Compulsory mental health care in Norway: the treatment criterion

Cooperation in the mental health treatment of patients with outpatient commitment

Background:

Patients with outpatient commitment have a decision on coercive treatment from the specialist health services even if they are in their own home and receive municipal health services.

Objective:

The aim of this study is to gain more knowledge about how the outpatient commitment system works in the municipal health service and specialist health services, and how they collaborate with patients and across service levels from the perspectives of healthcare professionals.

Methods:

This is a qualitative study collecting data through focus group interviews with health personnel from the municipal health service and specialist health services.

Results:

The results describe the health personnel’s experiences with follow-up and interactions with the patients with outpatient commitment decisions, and their experiences with collaboration between service levels.

Conclusion:

The study show that outpatient commitment makes a difference in the way patients with this decision are followed up. The legislative amendment with new requirements for consent competence was challenging. Collaboration between services levels was also challenging.

Nursing Perspectives: Reflecting History and Informal Coercion in De-escalation Strategies

Health professionals like nurses respond to aggression and violence with de-escalation techniques, and still often with coercive measures. Such measures applied by institutions are often rooted in historically grown traditions rather than evidence, reflection, or formation. In this article, we present de-escalation strategies integrating a high and critical awareness toward traditions and the practice of formal and informal coercion.

Compulsory Psychiatric Admissions in an Italian Urban Setting: Are They Actually Compliant to the Need for Treatment Criteria or Arranged for Dangerous Not Clinical Condition?

Background: Italy was one of the first European countries adopting the need for treatment criteria for compulsory admission (CA). The aim of the present study was to confirm whether CA in an urban setting in Italy was compliant with the requested clinical criteria. Methods: In this retrospective observational study, we retrieved all collected information regarding CA in Turin (Italy) from January 2006 to December 2013. All content and data reported in the CA forms, including diagnosis and clinical details, were gathered and analyzed. Comparisons between CA with and without a diagnosis of DSM-IV psychiatric disorders and between different diagnoses were performed using either parametric or non-parametric tests, depending on variable distribution. Results: Three hundred and two (10.5%) of 2,870 consecutive CAs made in Turin during a lag time of 8 years were due to unknown psychiatric diagnoses (113; 3.9%) or to psychomotor agitation (189; 6.6%). The most prevalent psychiatric disorders leading to CA were schizophrenia (729; 25.4%), brief psychotic disorder (627; 21.8%), bipolar disorder episode (396; 13.8%), delusional disorder (292; 10.2%), and personality disorder (237; 8.3%). The CAs due to psychiatric disorder were longer (U = 328,875.0; p < 0.001) and involved patients who were more likely to be compulsorily admitted during the study period (U = 357,012.5; p = 0.003), to have had prior contact with a psychiatrist [ χ ( 2 ) 2 = 28.34; p < 0.001], to have had previous admissions to a psychiatric ward [ χ ( 2 ) 2 = 33.06; p < 0.001], to be under the care of psychiatric services [ χ ( 3 ) 2 = 87.01; p < 0.001], and not to have concurrent alcohol [ χ ( 1 ) 2 = 23.06; p < 0.001] and/or drug use [ χ ( 1 ) 2 = 12.97; p < 0.001] than those due to psychomotor agitation/unspecified diagnoses. Conclusion: Despite a history of 35 years of CA made according to a strict need for treatment criteria, the evaluation of CA records shows that a certain proportion of CAs appears to have been due to brief, not psychiatric, alcohol/drug related behavioral conditions. Further studies should confirm the need for law reform leading to the integration between the need for treatment and the danger criteria for CAs.

Prevalence and management of patients with outpatient commitment in the mental health services

Background People with mental health problems are mostly treated within the community. The law allows for the use of compulsory mental health care both in hospital and in the community. Various forms of outpatient commitment (OC) have been adopted in much European legislation. To be subjected to OC is a serious intervention in a person's life. Aim The purpose of this study is to gain knowledge about patients who undergo OC. The study explores the incidence and prevalence of OC in a geographical area, the central characteristics of the sample, and how the framework for follow-up treatment for patients to resolve OC works. Methods The data were collected from a review of electronic patient records. The statistical methods used in this study were descriptive analysis, with frequency analysis and cross-tabulation analysis. Results The main finding in the present study is that the use of OC has increased. An important finding is that most of the patients have a decision made for OC that is justified by the treatment criterion. The present study shows that there is insufficient documentation on statutory responsibilities for follow-up treatment of patients with an OC. Conclusions This study shows that the use of OC has increased. It should be considered whether implemented measures to reduce the use of coercion have the desired effect.

Involuntary psychiatric admission: The referring general practitioners' assessment of patients' dangerousness and need for psychiatric hospital treatment

BACKGROUND

In Norway, GPs may decide to refer patients to involuntary psychiatric treatment. Internationally, there has been a discussion regarding criteria for involuntary admission. In Norway and in other countries where the treatment criterion is still used, some have suggested its removal.

AIMS

To examine which legal criteria GPs used to refer patients to involuntary admission, whether they had thought about using a different criterion, and on which information they based their decision.

METHODS

A total of 74 doctors who had referred patients to involuntary admission at one major Norwegian psychiatric hospital participated in semi-structured interviews.

RESULTS

In total, 38% (28) had applied the danger criterion only and 23% (17) had applied the treatment criterion only; 32% (24) had applied both criteria, while 7% (5) did not answer this question; 74% (55) said that they could not have chosen a different criterion; 45% (33) had based their decision on events/behaviour prior to and during the consultation, 43% (32) on events prior to the consultation only, and 8% (6) on information obtained during the consultation only; 4% (3) did not answer this question. None had used tools to aid in the assessment of danger.

CLINICAL IMPLICATIONS

The danger criterion was frequently used by the referring GPs. It is unclear how a removal of the treatment criterion from Norwegian legislation might impact clinical practice.

CONCLUSIONS

While the danger criterion was applied by a majority, the treatment criterion was also chosen by many and was of importance to the doctors' reasoning regarding referrals to involuntary admission. Most thought they could not have chosen a different criterion.

Interpretations of legal criteria for involuntary psychiatric admission: a qualitative analysis

BACKGROUND

The use of involuntary admission in psychiatry may be necessary to enable treatment and prevent harm, yet remains controversial. Mental health laws in high-income countries typically permit coercive treatment of persons with mental disorders to restore health or prevent future harm. Criteria intended to regulate practice leave scope for discretion. The values and beliefs of staff may become a determinating factor for decisions. Previous research has only to a limited degree addressed how legal criteria for involuntary psychiatric admission are interpreted by clinical decision-makers. We examined clinicians' interpretations of criteria for involuntary admission under the Norwegian Mental Health Care Act. This act applies a status approach, whereby involuntary admission can be used at the presence of mental disorder and need for treatment or perceived risk to the patient or others. Further, best interest assessments carry a large justificatory burden and open for a range of extra-legislative factors to be considered.

METHODS

Deductive thematic analysis was used. Three ideal types of attitudes-to-coercion were developed, denoted paternalistic, deliberative and interpretive. Semi-structured, in-depth interviews with 10 Norwegian clinicians with experience from admissions to psychiatric care were carried out. Data was fit into the preconceived analytical frame. We hypothesised that the data would mirror the recent shift from paternalism towards a more human rights focused approach in modern mental health care.

RESULTS

The paternalistic perspective was, however, clearly expressed in the data. Involuntary admission was considered to be in the patient's best interest, and patients suffering from serious mental disorder were assumed to lack decision-making capacity. In addition to assessment of need, outcome effectiveness and risk of harm, extra-legislative factors such as patients' functioning, experience, resistance, networks, and follow-up options were told to influence decisions. Variation in how these multiple factors were taken into consideration was found. Some of the participants' statements could be attributed to the deliberative perspective, most of which concerned participants' beliefs about an ideal decision-making situation.

CONCLUSIONS

Our data suggest how a deliberative-oriented ideal of reasoning about legal criteria for involuntary admission lapses into paternalism in clinical decision-making. Supplementary professional guidelines should be developed.