Out-Patient Commitment Order Use in Norway: Incidence and Prevalence
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BJPsych Open (2019) 5, e75, 1–7. doi: 10.1192/bjo.2019.60 Out-patient commitment order use in Norway: incidence and prevalence rates, duration and use of mental health services from the Norwegian Outpatient Commitment Study Henriette Riley, Ekaterina Sharashova, Jorun Rugkåsa, Olav Nyttingnes, Tore Buer Christensen, Ann-Torunn Andersen Austegard, Maria Løvsletten, Bjørn Lau and Georg Høyer Background 889). Use of in-patient care decreased significantly in the 3 years Norway authorised out-patient commitment in 1961, but there is after out-patient commitment compared with the 3 years before. a lack of representative and complete data on the use of out- Use of antipsychotic medication through the whole out-patient patient commitment orders. commitment period and fewer in-patient episodes in the 3 years before out-patient commitment predicted longer time to Aims readmission. To establish the incidence and prevalence rates on the use of out-patient commitment in Norway, and how these vary Conclusions across service areas. Further, to study variations in out- Mechanisms behind the pronounced variations in use of out- patient commitment across service areas, and use of patient commitment between sites call for further studies. Use of in-patient services before and after implementation of out- in-patient care was significantly reduced in the 3 years after a patient commitment orders. Finally, to identify determinants first-ever out-patient commitment order was made. for the duration of out-patient commitment orders and time to readmission. Declaration of interest None. Method Retrospective case register study based on medical files of all Keywords patients with an out-patient commitment order in 2008–2012 in six catchment areas in Norway, covering one-third of the Outpatient commitment; community treatment order; involun- Norwegian population aged 18 years or more. For a subsample of tary out-patient treatment. patients, we recorded use of in-patient care 3 years before and after their first-ever out-patient commitment. Copyright and usage © The Royal College of Psychiatrists 2019. This is an Open Access Results article, distributed under the terms of the Creative Commons Annual incidence varied between 20.7 and 28.4, and prevalence Attribution licence (http://creativecommons.org/licenses/by/ between 36.5 and 48.9, per 100 000 population aged 18 years or 4.0/), which permits unrestricted re-use, distribution, and above. Rates differed significantly between catchment areas. reproduction in any medium, provided the original work is Mean out-patient commitment duration was 727 days (s.d. = properly cited. The legal possibility of subjecting out-patients to mandatory care an increasing proportion of resources to community services in has steadily increased in recent decades, especially in North recent years. Further details about the Norwegian out-patient com- – America, Oceania and Europe.1 4 Norway authorised out-patient mitment population, the Norwegian out-patient commitment commitment as early as in 1961, when patients discharged with framework and what being on an out-patient commitment entailed an out-patient commitment order could be recalled to in-patient for patients is described in our previous paper from the Norwegian care without any further formalities. In 1999, the Norwegian Outpatient Commitment Study (NOCS).6 Mental Health Act was amended, authorising out-patient commit- Internationally, out-patient commitment has raised questions ment without a prior in-patient period. The coercive power of out- about the justification and effect of the order: does out-patient com- patient commitment orders in Norway is restricted to an obligation mitment reduce the overall use of coercion in the care of people with to comply with all scheduled treatment appointments, if necessary severe mental disorders, or does it increase coercion by adding coer- with the assistance of the police and the use of force. The legal cri- cive care in the community to in-patient coercion?7,8 Another fre- teria for out-patient commitment are the same as for in-patient quently raised question concerns the impact of out-patient commitment, including a requirement to make a global assessment commitment on the use of mental health services, especially in- – as to whether the intervention is the best option for the patient or patient care.4,9 11 Further, perceived coercion of patients with not. Out-patient commitment orders are valid for 1 year, but can out-patient commitment orders has received increased attention be renewed by an independent review board an unlimited number in recent years.12,13 The aim of NOCS was to collect representative of times. It is also noteworthy that the Norwegian Mental Health and complete data on the use of out-patient commitment in Act requires separate orders for involuntary placement and invol- Norway. In this paper, we report on population-based incidence untary treatment, for both in- and out-patients. Norway is among and prevalence rates, and changes in the utilisation of mental the countries with the highest number of mental health workers health care services before and after patients were subjected to per capita (240 per 100 000 population).5 The majority of these out-patient commitment, as well as predictors for the duration of are in out-patient services, and there has been a drive to allocate out-patient commitment orders and time to readmission. 1 Downloaded from https://www.cambridge.org/core. 01 Oct 2021 at 02:38:11, subject to the Cambridge Core terms of use. Riley et al such cases, we closely examined patients’ entire records, including Method relevant referral notes, discharge notes, nurses’ notes, reports from out-patient services, and correspondence between services, Study design including out-patient clinics. All data were meticulously checked NOCS is a retrospective case register study based on the examination to resolve potential discrepancies in the data-set and we held of medical files of all patients with an out-patient commitment order regular team meetings. between 2008 and 2012 in six Norwegian catchment areas. For the For the total sample, we recorded a limited number of variables: subsample of those who received their first-ever out-patient commit- demography, current out-patient commitment status, number and ment order in 2008 and 2009, we recorded the use of in-patient ser- duration of out-patient commitment episodes in 2008–2012, and vices 3 years before and after the out-patient commitment order. whether patients received an involuntary treatment order in con- junction with the out-patient commitment order or not. For those Settings with their first-ever out-patient commitment order in 2008 and The six study sites were located in different geographical areas across 2009 we recorded more comprehensive data (58 variables), includ- Norway. Sites were strategically selected in order to include both rural ing their consumption of in-patient care 3 years before and after the 6 first-ever out-patient commitment order. The in-patient’s admis- and urban populations. The areas are described elsewhere. The sites ’ were the University Hospital of North Norway, Helse Bergen Trust, sion resulting in the patient s first-ever out-patient commitment Sørlandet Hospital Trust, Innlandet Hospital Trust, Akershus was included in the number of in-patient-episodes 3 years before University Hospital and Lovisenberg Hospital. The latter two are out-patient commitment. Total numbers of involuntary in-patient located in the Oslo area, the capital. The total population in the com- placements each year from 2008 to 2013 were obtained through bined catchment areas equals one-third of the total Norwegian popu- routine annual reports at each participating site. lation aged 18 years or over, which was 3 867 645 in 2012. Statistical analyses Participants Incidence rates and point prevalence rates were calculated per 100 000 population (18 years of age or above) for each study year All patients aged 18 years or above who were on an out-patient com- from 2008 to 2012. Poisson regression was used to test for overall mitment order at the beginning of 2008 were included in the study. difference in incidence and point prevalence rates between sites. Further, we added all new out-patient commitment orders made To describe the sample and subsamples, we calculated means from 1 January 2008 to 31 December 2012. The total population (standard deviations) and medians (first and third quartiles) for in the combined catchment areas was 867 645 people (aged 18 continuous variables, while proportions were calculated for categor- years or above, 2012 figures). We identified a total of 1414 patients, ical variables. The Mann–Whitney U-test, Kruskal-Wallis H-test, representing 1700 out-patient commitment orders; of these, 274 Wilcoxon signed-ranks test and Pearson’s chi-squared test were patients received their first out-patient commitment in 2008 and used to compare groups when appropriate. 2009. Of all patients, 226 (16.0%) had two out-patient commitment Kaplan–Meier survival analysis with log-rank tests was per- episodes and 30 (2.1%) had three out-patient commitment episodes. formed to estimate crude associations between duration of the first- More than half of the patients (52.8%) were in the 30- to 50-year age ever out-patient commitment order and the following variables: group, with a slight predominance of men (56.4%). Diagnoses were site, gender, age, diagnosis, time since first contact with psychiatric only recorded for a subsample of 274 patients, and showed that services, use of psychiatric services before out-patient commitment, 76.9% were diagnosed within the schizophrenia disorders spectrum, living alone or not, involuntary admissions before first-ever out- 16.5% with affective mood disorders and 6.6% other diagnoses. patient commitment order, reference to danger to self or others, involuntary depot medication and follow-up variables. The same ana- Exclusion criteria lysis was performed for time to readmission.