Voluntary and involuntary hospitalizations in acute psychiatric wards in Norway

Background and aim

The use of coercion in mental health care services has been widely debated, and it is agreed that the level of coercive hospitalizations should be as low as possible. In 2004-2005, SINTEF Health was commissioned by the Norwegian Directorate of Health and Social Affairs to build up, establish and lead an Evaluation Network for Acute Psychiatry. SINTEF Health invited all local health trusts in Norway to participate. The purpose was for the local health trusts in Norway to come together and establish new knowledge about acute psychiatry - an area that so far had too little focus with regard to quality assurance and research in Norway. Thus, the Multi-Center Study for Acute Psychiatry (MAP) was established. This dissertation takes a closer look at the use of involuntary hospitalizations and the factors that influence this process.

Study One: - Predictors of involuntary hospitalizations to acute psychiatry

Rates of involuntary hospitalized (IH) patients and involuntary psychiatric treatment of people with mental illness reflect characteristics

of national mental health care and laws or other legal frameworks. International studies on the rates of IH in psychiatric hospitals show great variability in results. It is, however, very difficult to compare figures due to differences in methodology of studies and legislation between countries.

The aims of Study One were to examine to (i) the rates of patients admitted to 20 acute psychiatric ward units in Norway for IH, (ii) compare voluntary hospitalized (VH) with IH patients’ and (iii) describe the predictors of IH.

Study Two: - Voluntary and involuntary acute psychiatric hospitalization in Norway: A 24h follow up study

The Norwegian Mental Health Care Act states that patients who are

involuntarily admitted to a hospital must be reassessed by a psychiatrist or a specialist in clinical psychology within 24 hours to assess whether the patient fulfils the legal criteria of the psychiatric status and symptoms. International research on the process of reassessment of IH in psychiatry is scarce, and an investigation of Norway's routine re-evaluation of IH patients may increase knowledge and understanding of this aspect of psychiatric treatment.

The aims of Study Two were to (i) investigate the rate of conversion from IH to a VH status; and (ii) identify the predictors of conversion from IH to VH.

Study Three: - Patients’ attitudes to psychiatric hospitalization: A national multicentre study in Norway.

Being IH raises a number of issues: attitudes from family and society, stigma of being hospitalized against patients own will, and the conflict of autonomy versus need for treatment. Law/policymakers, governments and the public want a reduction in IH. The aims of Study Three were to (i) investigate to what degree do patients referred for VH and IH state that they want admission or not; and (ii) what are the predicting factors for IH patients who stated they wanted admission.

Methods

The Multi-centre study of Acute Psychiatry (MAP) included all cases of acute consecutive psychiatric admissions in 20 acute psychiatric units in Norway, representing about 75% of the Norwegian acute psychiatric units during 2005–2006. Data included an Admission registration form describing admission variables and the rating scales of Global

Assessment of Functioning and Health of the Nation Outcome Scales. Of the full sample of 3.326 referred patients for admission, 3.051 patients provided data on wanting admission or not. We studied demographics and characteristics of the two groups (VH and IH). We then did a logistic regression analysis by using generalized linear mixed modelling based on data from 1.231 IH patients to calculate predictors of IH who wanted admission.

Results

Study One: Fifty-six percent of the sample were VH and 44% were IH. Regression analysis identified contact with police, referred by physicians who did not know the patient, contact with health services within the last 48 hours, not living in own apartment or house, high scores for aggression, level of hallucinations and delusions, and contact with an out-of office hours / emergency primary health care clinic within the last 48 hours and low GAF symptom score as predictors for IH. IH patients were older, more often male, non-Norwegian, unmarried and had a lower level of education. They were more likely to have a disability pension or received social benefits, and were more often admitted during evenings and nights, found to have more frequent substance abuse, less often responsible for children and were less frequently motivated for admission. IH patients had less contact with psychiatric services before admission. Most patients were referred because of a deterioration of their psychiatric illness.

Study Two: Out of 1468, admissions who were IH (44%), 1148 (78.2%) remained on IH status, while 320 patients (21.8%) were converted to VH. The predictors of conversion from IH to VH (IH → VH) after re evaluation of a specialist included patients wanting admission, better scores on Global Assessment of Symptom scale (GAF), fewer hallucinations and delusions and higher alcohol intake.

Study Three: 69.5% of the patients stated they wanted admission. As expected, 96.5% of the VH stated they wanted admission. However, nearly one-third (29.7%) of IH patients also expressed a need for hospitalization. In a multivariate analysis, we found that being IH and wanting admission were predicted by not being transported by police, having less aggression and using less drugs.

Conclusions

IH seems to be guided by the severity of psychiatric symptoms and characteristics of the referred patient such as male gender, substance abuse, contact with GP or not, aggressive behaviour, low level of social functioning and lack of motivation. There was a need for assistance by the police in a significant number of cases. This complexity challenges the organization of primary health care and psychiatric health services and highlights a need to consider better pathways to care.

The 24-hour re – assessment period for patients referred for IH, as stipulated by the Norwegian Mental Health Care Act, appeared to give adequate opportunity to reduce unnecessary IH, while safeguarding the patient's right to VH.

It is important to explore the attitude of a patient who has been referred to involuntary hospitalization. This can form the basis for a future dialogue about alternative ways of dealing with the patient's serious mental condition, and as far as possible preserve the patient's autonomy and co-determination, and if possible reduce unnecessary involuntary hospitalizations.Some patients who expressed the need for admission are still being admitted to acute psychiatric units under IH rather than VH. Thus, it is imperative that more effort should be made in the process of referral and admission by communication with patients in order to achieve a VH. By allowing more time for the referral and admission process, the referring physician may gain more knowledge of the patient such that an IH would not be necessary.

It is not within the study to establish causality concerning wrongful involuntary admission, but it is important to focus on the patient’s wishes in such complicated hospitalization processes. It is conceivable that coercion is used too much in some places. However, at the same time patients may need to receive treatment in a psychiatric hospital when this is necessary despite not being in agreement with the referral physician. Coercion should only be used based on Mental Health Care Act criteria and when it is strictly necessary for the treatment.

NORWEGIAN ABSTRACT

Bakgrunn og mål Bruken av tvang i psykisk helseverntjeneste er omdiskutert, og det er enighet om at nivået av tvangsinnleggelser skal være så lavt som mulig. I 2004 - 2005 fikk SINTEF Helse i oppdrag fra Sosial- og helsedirektoratet å bygge opp, etablere og lede et Evalueringsnettverk for akuttpsykiatri. SINTEF Helse inviterte alle helseforetak i landet til å delta. Hensikten var at helseforetakene kom sammen og etablerte ny kunnskap om akuttpsykiatri – et område som så langt hadde et for lite fokus med hensyn til kvalitetssikring og forskning i Norge. Dermed ble Multi - senter studiet for Akutt Psykiatri (MAP) etablert. Denne avhandlingen ser nærmere på bruken av tvangsinnleggelser og hvilke faktorer som påvirker dette.

Består av

Paper 1: Predictors of involuntary hospitalizations to acute psychiatry. Hustoft Kjetil, Larsen T.K., Auestad B., Joa I., Johannessen J.O., Ruud T. International Journal of Law and Psychiatry Volume 36, Issue 2, March–April 2013, Pages 136-143. https://doi.org/10.1016/j.ijlp.2013.01.006

Paper 2: Voluntary or involuntary acute psychiatric hospitalization in Norway: A 24 hour follow up study. Hustoft K., Larsen T.K., Brønnick K., Joa I, Johannessen J.O., Ruud T. International Journal of Law and Psychiatry Volume 56, January–February 2018, Pages 27-34. https://doi.org/10.1016/j.ijlp.2017.10.011

Paper 3: Patients’ attitudes to psychiatric hospitalization: A national multicentre study in Norway. Hustoft K., Larsen T.K., Brønnick K., Joa I, Johannessen J.O., Ruud T. Journal: BMC Psychiatry Submitted: May 2022