The use of outpatient commitment in Norway: Who are the patients and what does it involve?

Variations between, and within, jurisdictions in the use of community treatment orders and other compulsory community treatment: study of 402 060 people across four Australian states

BACKGROUND

The use of compulsory community treatment (CCT) in Australia is some of the highest worldwide despite limited evidence of effectiveness. Even within Australia, use varies widely across jurisdictions despite general similarities in legislation and health services. However, there is much less information on whether variation occurs within the same jurisdiction.

AIMS

To measure variations in the use of CCT in a standardised way across the following four Australian jurisdictions: Queensland, South Australia, New South Wales (NSW) and Victoria. We also investigated associated sociodemographic variables.

METHODS

We used aggregated administrative data from the Australian Institute of Health and Welfare.

RESULTS

There were data on 402 060 individuals who were in contact with specialist mental health services, of whom 51 351 (12.8%) were receiving CCT. Percentages varied from 8% in NSW to 17.6% in South Australia. There were also wide variations within jurisdictions. In NSW, prevalence ranged from 2% to 13%, in Victoria from 6% to 24%, in Queensland from 11% to 25% and in South Australia from 6% to 36%. People in contact with services who were male, single and aged between 25 and 44 years old were significantly more likely to be subject to CCT, as were people living in metropolitan areas or those born outside Oceania.

CONCLUSIONS

There are marked variations in the use of CCT both within and between Australian jurisdictions. It is unclear how much of this variation is determined by clinical need and these findings may be of relevance to jurisdictions with similar clinician-initiated orders.

Patients' experiences with coercive mental health treatment in Flexible Assertive Community Treatment: a qualitative study

BACKGROUND

Flexible Assertive Community Treatment (FACT) teams have been implemented in Norwegian health and social services over the last years, partly aiming to reduce coercive mental health treatment. We need knowledge about how service users experience coercion within the FACT context. The aim of this paper is to explore service user experiences of coercive mental health treatment in the context of FACT and other treatment contexts they have experienced. Are experiences of coercion different in FACT than in other treatment contexts? If this is the case, which elements of FACT lead to a different experience?

METHOD

Within a participatory approach, 24 qualitative interviews with service users in five different FACT teams were analyzed with thematic analysis.

RESULTS

Participants described negative experiences with formal and informal coercion. Three patterns of experiences with coercion in FACT were identified: FACT as clearly a change for the better, making the best of FACT, and finding that coercion is just as bad in FACT as it was before. Safety, improved quality of treatment, and increased participation were described as mechanisms that can prevent coercion.

CONCLUSION

Results from this study support the argument that coercion is at odds with human rights and therefore should be avoided as far as possible. Results suggest that elements of the FACT model may prevent the use of coercion by promoting safety, improved quality of treatment and increased participation.

The relationship between area levels of involuntary psychiatric care and patient outcomes: a longitudinal national register study from Norway

BACKGROUND

Mental health legislation permits involuntary care of patients with severe mental disorders who meet set legal criteria. The Norwegian Mental Health Act assumes this will improve health and reduce risk of deterioration and death. Professionals have warned against potentially adverse effects of recent initiatives to heighten involuntary care thresholds, but no studies have investigated whether high thresholds have adverse effects.

AIM

To test the hypothesis that areas with lower levels of involuntary care show higher levels of morbidity and mortality in their severe mental disorder populations over time compared to areas with higher levels. Data availability precluded analyses of the effect on health and safety of others.

METHODS

Using national data, we calculated standardized (by age, sex, and urbanicity) involuntary care ratios across Community Mental Health Center areas in Norway. For patients diagnosed with severe mental disorders (ICD10 F20-31), we tested whether lower area ratios in 2015 was associated with 1) case fatality over four years, 2) an increase in inpatient days, and 3) time to first episode of involuntary care over the following two years. We also assessed 4) whether area ratios in 2015 predicted an increase in the number of patients diagnosed with F20-31 in the subsequent two years and whether 5) standardized involuntary care area ratios in 2014-2017 predicted an increase in the standardized suicide ratios in 2014-2018. Analyses were prespecified (ClinicalTrials.gov NCT04655287).

RESULTS

We found no adverse effects on patients' health in areas with lower standardized involuntary care ratios. The standardization variables age, sex, and urbanicity explained 70.5% of the variance in raw rates of involuntary care.

CONCLUSIONS

Lower standardized involuntary care ratios are not associated with adverse effects for patients with severe mental disorders in Norway. This finding merits further research of the way involuntary care works.

Health professionals' experience of treatment of patients whose community treatment order was revoked under new capacity-based mental health legislation in Norway: qualitative study

BACKGROUND

Norway introduced capacity-based legislation in mental healthcare on 1 September 2017 with the aim of increasing patient autonomy and legal protection and reducing the use of coercion. The new legislation was expected to be particularly important for patients under community treatment orders (CTOs).

AIMS

To explore health professionals' experiences of how capacity-based legislation affects healthcare services for patients whose compulsory treatment order was revoked as a result of being assessed as having capacity to consent.

METHOD

Nine health professionals responsible for treatment and care of patients whose CTO was revoked owing to the new legislation were interviewed in depth from September 2019 to March 2020. We used a hermeneutic approach to the interviews and analysis of the transcripts.

RESULTS

The participants found that capacity-based legislation raised their awareness of their responsibility for patient autonomy and involvement in treatment and care. They also felt a need for more frequent assessments of patients' condition and capacity to consent and more flexibility between levels of care.

CONCLUSIONS

The study shows that health professionals found that capacity-based legislation raised their awareness of their responsibility for patient autonomy and involvement in treatment and care. They sought closer dialogue with patients, providing information and advice, and more frequently assessing patients' condition to adjust treatment and care to enable them to retain their capacity to consent. This could be challenging and required competence, continuity and close collaboration between personnel in different healthcare services at primary and specialist level.

Examining the health and criminal justice characteristics for young people on compulsory community treatment orders: An Australian birth cohort and data linkage study

BACKGROUND

Most studies on the predictors and effectiveness of community treatment orders (CTOs) are restricted to health-related variables and do not consider forensic contacts as established by criminal justice databases or predictors from birth. We used linked administrative health and criminal justice data for a birth cohort in Queensland, Australia to investigate the characteristics and outcomes of people placed on CTOs.

METHODS

CTOs were identified from administrative data for hospital admissions and community mental health service contacts for a population cohort of 45,141 individuals born in Queensland in 1990. These data were linked with administrative court records, with individuals followed up to age 23/24 years. Logistic regression analyses were used to examine characteristics associated with CTO placement and Tobit regression analyses to examine factors predicting health and criminal justice outcomes in the following year.

RESULTS

There were 211 CTO cases by age 23/24 years, for whom it was possible to identify 413 controls on voluntary treatment. Non-affective psychoses [F20-F29] were the strongest predictors of CTO placement (OR_adj = 4.07, 2.77-5.99) followed by a court appearance (OR_adj = 1.99, 1.28-3.09). CTOs were associated with greater, not lower, subsequent psychiatric hospital admissions, inpatient bed-days and community mental health service contacts, although on sensitivity analyses psychiatric hospital admissions were the same as voluntary controls. CTOs were not associated with more subsequent court appearances despite higher rates of offending before CTO placement.

CONCLUSIONS

Both clinical and forensic variables can determine CTO placement and, on adjustment for these covariates, CTOs were not associated with reductions in psychiatric hospital admission, time spent as an inpatient, or subsequent court appearances. The latter finding might mean that CTOs reduce the risk of offending to that of voluntary controls.

Increased autonomy with capacity-based mental health legislation in Norway: a qualitative study of patient experiences of having come off a community treatment order

Background

Capacity-based mental health legislation was introduced in Norway on 1 September 2017. The aim was to increase the autonomy of patients with severe mental illness and to bring mental health care in line with human rights. 

The aim of this study is to explore patient experiences of how far the new legislation has enabled them to be involved in decisions on their treatment after they were assessed as capable of giving consent and had their community treatment order (CTO) revoked due to the change in the legislation.

Method

Individual in-depth interviews were conducted from September 2019 to March 2020 with twelve people with experience as CTO patients. Interviews were transcribed and analysed using thematic analysis inspired by hermeneutics.

Results

Almost all interviewees were receiving the same health care over two years after their CTO was terminated. Following the new legislation, they found it easier to be involved in treatment decisions when off a CTO than they had done in periods without a CTO before the amendment. Being assessed as having capacity to consent had enhanced their autonomy, their dialogues and their feeling of being respected in encounters with health care personnel. However, several participants felt insecure in such encounters and some still felt passive and lacking in initiative due to their previous experiences of coercion. They were worried about becoming acutely ill and again being subjected to involuntary treatment.

Conclusion

The introduction of capacity-based mental health legislation seems to have fulfilled the intention that treatment and care should, as far as possible, be provided in accordance with patients’ wishes. Systematic assessment of capacity to consent seems to increase the focus on patients’ condition, level of functioning and opinions in care and treatment. Stricter requirements for health care providers to find solutions in cooperation with patients seem to lead to new forms of collaboration between patients and health care personnel, where patients have become more active participants in their own treatment and receive help to make more informed choices.

The therapeutic relationship in the context of involuntary treatment orders: The perspective of nurses and patients

WHAT IS KNOWN ON THE SUBJECT?: Involuntary treatment orders are increasingly being used around the world to allow the treatment of individuals living with a mental illness deemed incapable of giving consent and who are actively refusing treatment. The use of involuntary treatment orders can impact the nurse-patient therapeutic relationship, which is essential to offer quality care and promote recovery. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Nurses and patients do not agree on the possibility to develop a therapeutic relationship, with nurses believing they can build a bond with the patients despite the challenges imposed by the involuntary treatment order, and patients rejecting this possibility. Nurses caring for patients on involuntary treatment orders feel obligated to apply the conditions of this measure, even if it damages the relationship with their patients. This difficult aspect of their work leads them to question their role in relation to the management of involuntary treatment orders. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurses need to be aware of the reasons why patients on involuntary treatment orders do not believe in the possibility of building a therapeutic relationship. Nurses need to reflect on and express their concerns about the damaging effects that managing involuntary treatment orders conditions can have on the nurse-patient therapeutic relationship. ABSTRACT: Introduction Involuntary treatment orders (ITO) can impact the nurse-patient therapeutic relationship (TR) negatively. Despite the increasing use of ITOs around the world, few studies have explored their influence on the TR from the perspectives of nurses and patients. Aim To describe the TR in the context of ITOs as reported by nurses and individuals living with a mental illness. Method Secondary data analysis of qualitative interviews with nurses (n = 9) and patients (n = 6) was performed using content analysis. Results Participants described the TR as fundamentally embedded in a power imbalance amplified by the ITO, which was discussed through the conflicting roles of nurses, the legal constraints imposed on patients and nurses, the complex relation between the ITO and the TR, and the influence of mental healthcare settings' context. Discussion Nurses and patients' views were opposed, questioning the authenticity of the relationship. Implications for Practice Nurses should be aware of the patients' lack of faith in the TR to ensure that they are sensitive to patients' behaviours that may falsely suggest that a relationship is established. Further studies should explore ways to alleviate the burden of the management of ITOs on nurses and allow for a trusting relationship to be build.

Impact of introducing capacity-based mental health legislation on the use of community treatment orders in Norway: case registry study

BACKGROUND

In 2017, a capacity-based criterion was added to the Norwegian Mental Health Act, stating that those with capacity to consent to treatment cannot be subjected to involuntary care unless there is risk to themselves or others. This was expected to reduce incidence and prevalence rates, and the duration of episodes of involuntary care, in particular regarding community treatment orders (CTOs).

AIMS

The aim was to investigate whether the capacity-based criterion had the expected impact on the use of CTOs.

METHOD

This retrospective case register study included two catchment areas serving 16% of the Norwegian population (aged ≥18). In total, 760 patients subject to 921 CTOs between 1 January 2015 and 31 December 2019 were included to compare the use of CTOs 2 years before and 2 years after the legal reform.

RESULTS

CTO incidence rates and duration did not change after the reform, whereas prevalence rates were significantly reduced. This was explained by a sharp increase in termination of CTOs in the year of the reform, after which it reduced and settled on a slightly higher leven than before the reform. We found an unexpected significant increase in the use of involuntary treatment orders for patients on CTOs after the reform.

CONCLUSIONS

The expected impact on CTO use of introducing a capacity-based criterion in the Norwegian Mental Health Act was not confirmed by our study. Given the existing challenges related to defining and assessing decision-making capacity, studies examining the validity of capacity assessments and their impact on the use of coercion in clinical practice are urgently needed.

Insights into involuntary hospital admission procedures for psychiatric patients: A 3-year retrospective analysis of police records

The procedure of involuntary hospitalization has been an ongoing subject of study. Its implementation requires the systematic co-ordination between the Justice and Health Care systems around the globe. In the case of Greece, the procedure under discussion is regulated by Law 2071/1992, which designates the Police as the agent that links the aforementioned systems together. The present study aims to shed light upon the procedure of involuntary hospitalizations, regarding the preparatory stage and the Police involvement up to the individuals' admission to the on-call hospital for a mental health assessment (MHA). The entry data of two police stations in Athens was recorded by the respective Duty Officer responsible for each case. The police records were retrospectively inspected and information on socio-demographic, clinical and parametric characteristics was extracted. The data collection took place between March and July 2020 and included 324 cases, 80.3% of which referred to involuntary hospitalizations; 17.6% of sample cases did not meet the criteria of the procedure, as opposed to 1.9% of the cases in which the patients eventually ended up being voluntarily admitted and afterwards hospitalized for treatment. There was a statistically comparison of socio-demographic, clinical and parametric variables in relation to the status of hospitalization groups (involuntary, voluntary and no hospitalization). Additionally, statistical comparisons were made between parametric and clinical variables in relation to the type of prosecution order (written: standard route, oral: emergency route). Acute mental health deterioration accounted for around 45% of the total data and it has been identified as the main factor for informing the Hearings Prosecutor office mainly by the patient's family and subsequently proceeding to the issuance of an order (in either written or oral form) to the Police. This enables the Police to escort the individuals and lead them to a psychiatric unit for mental health assessment (MHA) and based on this, for involuntary hospitalization if deemed necessary. In 87.9% of the cases, the individual was transported by police vehicles over a time span ranging from the very same day to 22 days. In total, the written prosecution orders (63.6%) outnumbered the oral ones (36.7%). The findings of the present study demonstrate that the Prosecution order type varies significantly depending on the causes that instigated the involuntary hospitalization procedure. The psychiatric decision whether there should be hospitalization or outpatient therapy also significantly varies depending on the diagnosis. Lastly, the results point out that the need for improvement and further clarification of the aforementioned Greek Law is absolutely essential.

Outpatient commitment in mental health services from a municipal view

BACKGROUND

Outpatient commitment (OC) is a legal decision for compulsory mental health care when the patient stays in his or her own home. Municipal health-care workers have a key role for patients with OC decision, but little is known about how the legislation system with OC works from the municipality's point of view.

METHOD

The present study has a quantitative descriptive design using an electronic questionnaire sent to health-care workers in the municipalities that participated. The study included health-care workers from the mental health services in two counties in Norway who have experience with psychosis and OC decisions.

RESULTS

There were 230 people who received the questionnaire. The sample consisted of various health professionals from both small and large municipalities.The results show which tasks they have in follow-up of patients in the municipalities.

CONCLUSION

From the municipality's point of view, there are no significant differences in follow-up for patients with or without an OC decision, apart from conversations about medication. An individual plan is rarely used to facilitate follow-up, although this is the statutory right of patients with OC decisions. The health-care workers lack knowledge and education about the OC scheme. The cooperation between municipalities and the specialist health-care services is not clearly defined.

Community treatment orders in Western Switzerland: A retrospective epidemiological study

PURPOSE

Community treatment orders (CTOs) are legal procedures that authorise compulsory community mental health care to people affected by severe mental disorders. Nowadays, CTOs are regulated in 75 countries, with important variations in terms of legal criteria and practices. In Switzerland CTOs were introduced on the 1^st January 2013, following the amendment of the Swiss Civil Code. The aim of this study was to provide a first understanding of the use of CTOs in Western Switzerland in terms of incidence and prevalence rates, population profile, orders duration and reasons for discharge.

METHODS

Incidence and prevalence rates of CTOs between 2013 and 2017 were estimated. Survival analysis was used to investigate time to CTO discharge and associated factors. Logistic regression was performed to identify factors associated with CTOs' success as reason for discharge.

RESULTS

CTOs' incidence rates per 100'000 inhabitants ranged between 4.8 for 2013 and 9.6 for 2017, while their prevalence raised from 4.8 to 19.5. People placed under CTO were mainly male, in their forties, of Swiss origin, single and living independently. Primarily affected by Schizophrenia, schizotypal and delusional disorders (F20-F29), they frequently presented substance use problems, and severe danger for themselves. CTOs were mainly ordered by the guardianship authority as a form of conditional release. The estimated mean time to discharge was almost three years. Not being of Swiss origin and being prescribed to take a medication were associated with longer CTO while living in hospital, as a consequence of a long-lasting hospitalisation, and having a non-medical professional in charge of the order were associated with shorter time to discharge. Neither clinical factors nor legal criteria predicted time to discharge. Moreover, spending more days under CTO increased the likelihood of success at discharge, whereas not being of Swiss origin reduced it.

CONCLUSIONS

To the best of our knowledge, no previous studies have examined the CTOs' implementation in Switzerland. CTOs prevalence increased rapidly despite the lack of evidence on positive outcomes. Our results suggested that once under CTO, it takes a long time for a patient to be released, in case of both positive and negative outcomes.

Dementia and patient safety in the community: a qualitative study of family carers' protective practices and implications for services

BACKGROUND

Dementia is a cause of disability and dependency associated with high demands for health services and expected to have a significant impact on resources. Care policies worldwide increasingly rely on family caregivers to contribute to service delivery for older people, and the general direction of health care policy internationally is to provide care in the community, meaning most people will receive services there. Patient safety in primary care is therefore important for future care, but not yet investigated sufficiently when services are carried out in patients' homes. In particular, we know little about how family carers experience patient safety of older people with dementia in the community.

METHODS

This was an explorative study, with qualitative in-depth interviews of 23 family carers of older people with suspected or diagnosed dementia. Family carers participated after receiving information primarily through health professionals working in dementia care. A semi-structured topic guide was used in a flexible way to capture participants' experiences. A four-step inductive analysis of the transcripts was informed by hermeneutic-phenomenological analysis.

RESULTS

The ways our participants sought to address risk and safety issues can be understood to constitute protective practices that aimed to prevent or reduce the risk of harm and/or alleviate damage from harm that occurs. The protective practices relate to four areas: physical harm, economic harm, emotional harm, and relational harm. The protective practices are interlinked, and family carers sometimes prioritize one over another, and as they form part of family practice, they are not always visible to service providers. As a result, the practices may complicate interactions with health professionals and even inadvertently conceal symptoms or care needs.

CONCLUSIONS

When family caregivers prevent harm and meet needs, some needs may be concealed or invisible to health professionals. To recognize all needs and provide effective, safe and person-centered care, health professionals need to recognize these preventive practices and seek to build a solid partnership with family carers.

Out-patient commitment order use in Norway: incidence and prevalence rates, duration and use of mental health services from the Norwegian Outpatient Commitment Study

BACKGROUND

Norway authorised out-patient commitment in 1961, but there is a lack of representative and complete data on the use of out-patient commitment orders.

AIMS

To establish the incidence and prevalence rates on the use of out-patient commitment in Norway, and how these vary across service areas. Further, to study variations in out-patient commitment across service areas, and use of in-patient services before and after implementation of out-patient commitment orders. Finally, to identify determinants for the duration of out-patient commitment orders and time to readmission.

METHOD

Retrospective case register study based on medical files of all patients with an out-patient commitment order in 2008-2012 in six catchment areas in Norway, covering one-third of the Norwegian population aged 18 years or more. For a subsample of patients, we recorded use of in-patient care 3 years before and after their first-ever out-patient commitment.

RESULTS

Annual incidence varied between 20.7 and 28.4, and prevalence between 36.5 and 48.9, per 100 000 population aged 18 years or above. Rates differed significantly between catchment areas. Mean out-patient commitment duration was 727 days (s.d. = 889). Use of in-patient care decreased significantly in the 3 years after out-patient commitment compared with the 3 years before. Use of antipsychotic medication through the whole out-patient commitment period and fewer in-patient episodes in the 3 years before out-patient commitment predicted longer time to readmission.

CONCLUSIONS

Mechanisms behind the pronounced variations in use of out-patient commitment between sites call for further studies. Use of in-patient care was significantly reduced in the 3 years after a first-ever out-patient commitment order was made.

DECLARATION OF INTEREST

None.