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Myklebust LH, Lassemo E. The role of local inpatient psychiatric units and general practitioner on continuity of care in Northern Norway: A case-register study. Int J Methods Psychiatr Res 2021; 30:e1866. [PMID: 33248004 PMCID: PMC8170572 DOI: 10.1002/mpr.1866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 11/19/2020] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES The general practitioners' (GP) role in the care of mental health patients has received increased attention. The literature underlines the need for integration of primary and specialist services, but cross-boundary continuity for patients with severe conditions may be particularly poor. The aim of this study was to analyze the collaboration between primary care and different models of specialized psychiatric services for patients with severe conditions. METHODS We compared a local and a centralized model of mental health care. Service utilization over a 5-year period was studied. RESULTS Findings suggest that a local institution-based model of services positively affects the use of both GP and specialist outpatient care, with most inpatients utilizing both GP and specialist outpatient consultations. In the centralized model, a substantial proportion of inpatients only used GP outpatient care. Furthermore, inpatients that used both GP and specialist outpatient services received more of both services compared to those who did not enter specialist outpatient care at all. CONCLUSION Local inpatient units may positively affect continuity of care and collaboration between general practitioners and specialist psychiatric services compared to more traditional hospital units, probably because better functional integration of services, better facilitation of clinical alliances/relationships, or a more network-oriented treatment philosophy.
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Affiliation(s)
- Lars Henrik Myklebust
- Sykehuset Innlandet HF, Hamar, Norway.,Nord-Norsk Psykiatrisk Forskningssenter, Bodø, Norway
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Lassemo E, Myklebust LH, Salazzari D, Kalseth J. Psychiatric readmission rates in a multi-level mental health care system - a descriptive population cohort study. BMC Health Serv Res 2021; 21:378. [PMID: 33892715 PMCID: PMC8067649 DOI: 10.1186/s12913-021-06391-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 04/14/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Readmission rates are frequently used as a quality indicator for health care, yet their validity for evaluating quality is unclear. Published research on variables affecting readmission to psychiatric hospitals have been inconsistent. The Norwegian specialist mental health care system is characterized by a multi-level structure; hospitals providing specialized -largely unplanned care and district psychiatric centers (DPCs) providing generalized -more often planned care. In certain service systems, readmission may be an integral part of individual patients' treatment plan. The aim of the present study was to describe and examine the task division in a multi-level health care system. This we did through describing differences in patient population (age, sex, diagnosis, substance abuse comorbidity and length of stay) and admissions types (unplanned vs. planned) treated at different levels (hospital, DPC or both), and by examining whether readmission risk differ according to type and place of treatment of index-admission and travel-time to nearest hospital and DPC. METHODS In this population-based cohort study using administrative data we included all individuals aged 18 and older who were discharged from psychiatric inpatient care with an ICD-10 diagnosis F2-F6 ("functional mental disorders") in 2012. Selecting each individual's first discharge during 2012 as index gave N = 16,185 for analyses following exclusions. Analysis of readmission risk were done using Kaplan-Maier failure curves. RESULTS Overall, 15.1 and 47.7% of patients were readmitted within 30 and 365 days, respectively. Unplanned admission patients were more likely to be readmitted within 30 days than planned patients. Those transferred between hospital and DPC during index admission were more likely to be readmitted within 365 days, and to experience planned readmission. Patients with short travel time were more likely to have unplanned readmission, while patients with long travel time were more likely to have planned readmission. CONCLUSIONS DPCs and hospitals fill different purposes in the Norwegian health care system, which is reflected in different patient populations. Differences in short term readmission rates between hospitals and DPCs disappeared when type of admission (unplanned/planned) was considered. The results stress the importance of addressing differences in organisation and task distribution when comparing readmission rates between mental health systems.
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Affiliation(s)
- Eva Lassemo
- SINTEF Digital, Health Research, P.O. Box 4760 Torgarden, NO-7465, Trondheim, Norway.
| | | | - Damiano Salazzari
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Piazzale L.A. Scuro, 10, 37134, Verona, Italy
| | - Jorid Kalseth
- SINTEF Digital, Health Research, P.O. Box 4760 Torgarden, NO-7465, Trondheim, Norway
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Nickels SV, Campos Tomasino M, Flamenco Arvaiza NA, Hunter CA. Access to mental health care in El Salvador: a case study of progress toward decentralization. Rev Panam Salud Publica 2019; 42:e172. [PMID: 31093200 PMCID: PMC6385792 DOI: 10.26633/rpsp.2018.172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 06/06/2018] [Indexed: 11/24/2022] Open
Abstract
Objective To assess the need for decentralization of psychiatric services in El Salvador, based on country-specific evidence, and to generate baseline measures the government and researchers could use to monitor and measure future progress toward decentralization. Methods Observations were made and psychiatric outpatients and their families/caregivers (n = 453) surveyed with a cross-sectional instrument at the National Psychiatric Hospital (Hospital Nacional General y de Psiquiatría “Dr. José Molina Martínez”) in the capital city of San Salvador. Findings were compared with national census data to determine barriers to psychiatric care in a largely centralized system. The following data were collected: department of origin, travel time to hospital, time in hospital, costs, and qualitative comments about accessing services. Descriptive statistics and regression were used to assess the data. Government reports on all psychiatric outpatient consultations provided nationwide in 2015 (n = 61 010) at 10 regional hospitals were also reviewed and compared to population data to determine the proportion of the population of each hospital service area (department or group of departments) that received a psychiatric outpatient consultation. Results Households from the half of the country (7 out of 14 departments) farthest away from the National Psychiatric Hospital (42% of the general population) spent twice as much time and three times as much money to access the hospital's psychiatric outpatient services, resulting in severe hardship on both patients and families/caregivers. Conclusions This report estimates that 45% of those with mental health needs in the seven departments farthest away from the National Psychiatric Hospital departments are still not accessing services compared to the seven departments nearest the hospital. The results of this study support the World Health Organization's call for governments to fully implement community-based mental health systems. This is the first study to assess progress toward decentralization of psychiatric services in El Salvador.
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Affiliation(s)
- Samuel V Nickels
- Center for Health and Human Development, Harrisonburg, VA, United States of America
| | | | | | - Cynthia A Hunter
- Department of Social Work, College of Health and Behavioral Studies, James Madison University, Harrisonburg, Virginia, United States of America
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Myklebust LH, Sørgaard K, Wynn R. How mental health service systems are organized may affect the rate of acute admissions to specialized care: Report from a natural experiment involving 5338 admissions. SAGE Open Med 2017; 5:2050312117724311. [PMID: 28839939 PMCID: PMC5546644 DOI: 10.1177/2050312117724311] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 07/10/2017] [Indexed: 12/17/2022] Open
Abstract
Objectives: Studies on the dynamics between service organization and acute admissions to psychiatric specialized care have given ambiguous results. We studied the effect of several variables, including service organization, coercion, and patient characteristics on the rate of acute admissions to psychiatric specialist services. In a natural experiment-like study in Norway, we compared a “deinstitutionalized” and a “locally institutionalized” model of mental health services. One had only community outpatient care and used beds at a large Central Mental Hospital; the other also had small bed-units at the local District Psychiatric Centre. Methods: From the case registries, we identified a total of 5338 admissions, which represented all the admissions to the psychiatric specialist services from 2003 to 2006. The data were analyzed with chi-square tests and Z-tests. In order to control for possible confounders and interaction effects, a multivariate analysis was also performed, with a logistic regression model. Results: The use of coercion emerged as the strongest predictor of acute admissions to specialist care (odds ratio = 7.377, 95% confidence interval = 4.131–13.174) followed by service organization (odds ratio = 3.247, 95% confidence interval = 2.582–4.083). Diagnoses of patients predicted acute admissions to a lesser extent. We found that having psychiatric beds available at small local institutions rather than beds at a Central Mental Hospital appeared to decrease the rate of acute admissions. Conclusion: While it is likely that the seriousness of the patients’ condition is the most important factor in doctors’ decisions to refer psychiatric patients acutely, other variables are likely to be important. This study suggests that the organization of mental health services is of importance to the rate of acute admissions to specialized psychiatric care. Systems with beds at local District Psychiatric Centers may reduce the rate of acute admissions to specialized care, compared to systems with local community outpatient services and beds at Central Mental Hospitals.
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Affiliation(s)
- Lars Henrik Myklebust
- Psychiatric Research Centre of Northern Norway, Nordland Hospital Trust, Bodø, Norway
| | - Knut Sørgaard
- Psychiatric Research Centre of Northern Norway, Nordland Hospital Trust, Bodø, Norway.,Department of Clinical Medicine, UiT-The Arctic University of Norway, Tromsø, Norway
| | - Rolf Wynn
- Department of Clinical Medicine, UiT-The Arctic University of Norway, Tromsø, Norway.,Division of Mental Health and Addictions, University Hospital of North Norway, Tromsø, Norway
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Ala-Nikkola T, Pirkola S, Kaila M, Saarni SI, Joffe G, Kontio R, Oranta O, Sadeniemi M, Wahlbeck K. Regional Correlates of Psychiatric Inpatient Treatment. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2016; 13:ijerph13121204. [PMID: 27929403 PMCID: PMC5201345 DOI: 10.3390/ijerph13121204] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 11/13/2016] [Accepted: 11/30/2016] [Indexed: 11/16/2022]
Abstract
Current reforms of mental health and substance abuse services (MHS) emphasize community-based care and the downsizing of psychiatric hospitals. Reductions in acute and semi-acute hospital beds are achieved through shortened stays or by avoiding hospitalization. Understanding the factors that drive the current inpatient treatment provision is essential. We investigated how the MHS service structure (diversity of services and balance of personnel resources) and indicators of service need (mental health index, education, single household, and alcohol sales) correlated with acute and semi-acute inpatient treatment provision. The European Service Mapping Schedule-Revised (ESMS-R) tool was used to classify the adult MHS structure in southern Finland (population 1.8 million, 18+ years). The diversity of MHS in terms of range of outpatient and day care services or the overall personnel resourcing in inpatient or outpatient services was not associated with the inpatient treatment provision. In the univariate analyses, sold alcohol was associated with the inpatient treatment provision, while in the multivariate modeling, only a general index for mental health needs was associated with greater hospitalization. In the dehospitalization process, direct resource re-allocation and substituting of inpatient treatment with outpatient care per se is likely insufficient, since inpatient treatment is linked to contextual factors in the population and the health care system. Mental health services reforms require both strategic planning of service system as a whole and detailed understanding of effects of societal components.
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Affiliation(s)
- Taina Ala-Nikkola
- University of Helsinki and Helsinki University Hospital, Välskärinkatu 12, Helsinki FI-00029, Finland.
- Unit for Mental Health, National Institute for Health and Welfare (T.H.L.); Mannerheimintie 168, Helsinki FI-00270, Finland.
- Public Health Medicine, University of Helsinki and Helsinki University Hospital, Helsinki FI-000014, Finland.
| | - Sami Pirkola
- University of Tampere School of Health Sciences, and Tampere University Hospital, Lääkärinkatu 1, Tampere FI-33014, Finland.
| | - Minna Kaila
- University of Helsinki and Helsinki University Hospital, Välskärinkatu 12, Helsinki FI-00029, Finland.
- Public Health Medicine, University of Helsinki and Helsinki University Hospital, Helsinki FI-000014, Finland.
| | - Samuli I Saarni
- Turku University Hospital and University of Turku, Kiinanmyllynkatu 4-8, Turku FI-20520, Finland.
| | - Grigori Joffe
- University of Helsinki and Helsinki University Hospital, Välskärinkatu 12, Helsinki FI-00029, Finland.
| | - Raija Kontio
- University of Helsinki and Helsinki University Hospital, Välskärinkatu 12, Helsinki FI-00029, Finland.
- University of Turku, Turku FI-20014, Finland.
| | - Olli Oranta
- Turku University Hospital and University of Turku, Kiinanmyllynkatu 4-8, Turku FI-20520, Finland.
| | - Minna Sadeniemi
- Unit for Mental Health, National Institute for Health and Welfare (T.H.L.); Mannerheimintie 168, Helsinki FI-00270, Finland.
- Department of Social Services and Health Care, City of Helsinki, Helsinki FI-00099, Finland.
| | - Kristian Wahlbeck
- Unit for Mental Health, National Institute for Health and Welfare (T.H.L.); Mannerheimintie 168, Helsinki FI-00270, Finland.
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Myklebust LH, Sørgaard K, Wynn R. Local inpatient units may increase patients' utilization of outpatient services: a comparative cohort-study in Nordland County, Norway. Psychol Res Behav Manag 2015; 8:251-7. [PMID: 26604843 PMCID: PMC4630195 DOI: 10.2147/prbm.s94857] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES In the last few decades, there has been a restructuring of the psychiatric services in many countries. The complexity of these systems may represent a challenge to patients that suffer from serious psychiatric disorders. We examined whether local integration of inpatient and outpatient services in contrast to centralized institutions strengthened continuity of care. METHODS Two different service-systems were compared. Service-utilization over a 4-year period for 690 inpatients was extracted from the patient registries. The results were controlled for demographic variables, model of service-system, central inpatient admission or local inpatient admission, diagnoses, and duration of inpatient stays. RESULTS The majority of inpatients in the area with local integration of inpatient and outpatient services used both types of care. In the area that did not have beds locally, many patients that had been hospitalized did not receive outpatient follow-up. Predictors of inpatients' use of outpatient psychiatric care were: Model of service-system (centralized vs decentralized), a diagnosis of affective disorder, central inpatient admission only, and duration of inpatient stays. CONCLUSION Psychiatric centers with local inpatient units may positively affect continuity of care for patients with severe psychiatric disorders, probably because of a high functional integration of inpatient and outpatient care.
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Affiliation(s)
| | - Knut Sørgaard
- Psychiatric Research Centre of North Norway, Nordland Hospital Trust, Bodø, Norway ; Department of Clinical Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Rolf Wynn
- Department of Clinical Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
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Stuen HK, Rugkåsa J, Landheim A, Wynn R. Increased influence and collaboration: a qualitative study of patients' experiences of community treatment orders within an assertive community treatment setting. BMC Health Serv Res 2015; 15:409. [PMID: 26400028 PMCID: PMC4581043 DOI: 10.1186/s12913-015-1083-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Accepted: 09/21/2015] [Indexed: 11/24/2022] Open
Abstract
Background Since 2009, 14 assertive community treatment (ACT) teams have started up in Norway. Over 30 % of the patients treated by the ACT teams were subject to community treatment orders (CTOs) at intake. CTOs are legal mechanisms to secure treatment adherence for patients with severe mental illness. Little is known about patients’ views and experiences of CTOs within an ACT context. Methods The study was based on qualitative in depth interviews with 15 patients that were followed up by ACT teams and that were currently subjected to CTOs. The data were analyzed by using a modified grounded theory approach. Results While some participants experienced the CTO as a security net and as an important factor for staying well, others described the CTO as a social control mechanism and as a violation of their autonomy. Although experiencing difficulties and tensions, many participants described the ACT team as a different mental health arena from what they had known before, with another frame of interaction. Despite being legally compelled to receive treatment, many participants talked about how the ACT teams focused on addressing unmet needs, the management of future crises, and finding solutions to daily life problems. Assistance with housing and finances, reduced social isolation, and being able to seek help voluntarily were positive outcomes emphasized by many patients. Discussion The participants had different views of being on a CTO within an ACT setting. While some remained clearly negative to the CTO, others described a gradual transition toward regarding the CTO as an acceptablesolution as they gained experience of ACT. Many of the participants valued the supportive relationship withthe ACT team, and communication with the care providers and the care providers’ attitudes could make a significant difference. The study shows that the perception of coercion is context dependent, and that the relationship between care providers and patients is of importance to how patients interpret the providers’ behavior and the restrictive interventions. Conclusions Although some patients focused on loss of autonomy and being compelled to take medications, other patients emphasised the supportive relationships they had with the ACT teams and that they had received help with housing, finances, and other daily life problems. Thus, being on mandated community treatment could be acceptable in the opinion of several of the patients, provided that they received other services that they found beneficial.
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Affiliation(s)
- Hanne Kilen Stuen
- Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders, Innlandet Hospital Trust, Brummundal, Norway. .,Department of Clinical Medicine, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway.
| | - Jorun Rugkåsa
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway. .,Departement of Psychiatry, University of Oxford, Oxford, UK.
| | - Anne Landheim
- Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders, Innlandet Hospital Trust, Brummundal, Norway. .,Norwegian Centre for Addiction Research, University of Oslo, Oslo, Norway.
| | - Rolf Wynn
- Department of Clinical Medicine, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway. .,Divison of Mental Health and Addictions, University Hospital of North Norway, Tromsø, Norway.
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Omer S, Priebe S, Giacco D. Continuity across inpatient and outpatient mental health care or specialisation of teams? A systematic review. Eur Psychiatry 2014; 30:258-70. [PMID: 25278422 DOI: 10.1016/j.eurpsy.2014.08.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 08/08/2014] [Accepted: 08/09/2014] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND A central question for the organisation of mental health care is whether the same clinicians should be responsible for a patient's care across inpatient and outpatient settings (continuity of care) or if there should be separate teams (specialisation). Current reforms in Europe are inconsistent on which to favour, and are based on little research evidence. This review is the first systematic appraisal of the existing evidence comparing continuity of care and specialisation across inpatient and outpatient mental health care. METHOD A systematic search for studies of any design comparing mental health care systems based on continuity or specialisation of care was performed. Differences in clinical, social and cost-effective outcomes, and the views and experiences of patients and staff were assessed using narrative synthesis. RESULTS Seventeen studies met the inclusion criteria. All studies had methodological shortcomings, but findings point towards reduced length and number of hospitalisations, and faster or more flexible transitions between services in continuity systems. Survey and qualitative findings suggest advantages of both systems, whilst patients and staff appear to prefer a continuity system. CONCLUSION The evidence base suggests better outcomes and stakeholder preferences for continuity of care systems, but the quality of existing studies is insufficient to draw definitive conclusions. Higher quality comparative studies across various settings and population groups are urgently needed.
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Affiliation(s)
- S Omer
- Unit for Social and Community Psychiatry (WHO Collaborating Centre for Mental Health Service Development), Queen Mary University of London, London, United Kingdom
| | - S Priebe
- Unit for Social and Community Psychiatry (WHO Collaborating Centre for Mental Health Service Development), Queen Mary University of London, London, United Kingdom
| | - D Giacco
- Unit for Social and Community Psychiatry (WHO Collaborating Centre for Mental Health Service Development), Queen Mary University of London, London, United Kingdom.
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Myklebust LH, Sørgaard K, Wynn R. Local psychiatric beds appear to decrease the use of involuntary admission: a case-registry study. BMC Health Serv Res 2014; 14:64. [PMID: 24506810 PMCID: PMC3923252 DOI: 10.1186/1472-6963-14-64] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Accepted: 02/06/2014] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Studies on the effect of organizational factors on the involuntary admission of psychiatric patients have been few and yielded inconclusive results. The objective was to examine the importance of type of service-system, level of care, length of inpatient stay, gender, age, and diagnosis on rates of involuntary admission, by comparing one deinstitutionalized and one locally institutionalized service-system, in a naturalistic experiment. METHODS 5538 admissions to two specialist psychiatric service-areas in North Norway were studied, covering a four-year period (2003-2006). The importance of various predictors on involuntary admission were analyzed in a logistic regression model. RESULTS Involuntary admission to the services was associated with the diagnosis of psychosis, male sex, being referred to inpatient treatment, as well as type of service-system. Patients from the deinstitutionalized system were more likely to be involuntarily admitted. CONCLUSIONS Several factors predicted involuntary status, including male sex, the diagnosis of psychosis, and type of service-system. The results suggests that having psychiatric beds available locally may be more favourable than a traditional deinstitutionalized service system with local outpatient clinics and central mental hospitals, with respect to the use of involuntary admission.
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Affiliation(s)
- Lars Henrik Myklebust
- Psychiatric Research Centre of Northern Norway, Nordland Hospital Trust, Bodø N-8092, Norway
| | - Knut Sørgaard
- Psychiatric Research Centre of Northern Norway, Nordland Hospital Trust, Bodø N-8092, Norway
- Department of Clinical Medicine, University of Tromsø, Tromsø N-9037, Norway
| | - Rolf Wynn
- Department of Clinical Medicine, University of Tromsø, Tromsø N-9037, Norway
- Division of Addictions and Specialized Psychiatric Services, University Hospital of North Norway, Tromsø N-9291, Norway
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