Background
In recent decades, the majority of jurisdictions in North America, Australia and Europe have introduced legal measures that can compel patients to comply with outpatient treatment [
1‐
3]. The coercive powers of outpatient commitment (OC) vary between jurisdictions, as do the procedures and services offered to patients under an OC order [
4,
5]. A variety of names, such as community treatment orders, conditional release, preventive commitment, involuntary outpatient treatment, aggressive or assisted community treatment have been applied to OC in the literature. In this paper, we use the term OC to cover all forms of involuntary outpatient orders.
Norway introduced OC in 1961, as one of the first countries in Europe. The other Scandinavian countries, Sweden and Denmark, first sanctioned OC in 2008 and 2010 respectively [
6,
7]. In spite of the long use of OC in Norway, the scheme has never been assessed. The present paper presents results from one of the five sites participating in the larger Norwegian Outpatient Commitment Study, exploring the implementation of OC orders in different catchment areas.
OC in Norway
According to the earlier Norwegian 1961 Mental Health Act, patients discharged from inpatient care with an OC were obliged to attend their treatment appointments, if necessary by use of force. In addition, readmissions to inpatient care were facilitated for patients on an OC order, as no new independent assessment of the patient was needed for readmission. If a patient on an OC order refused to comply with the treatment, the law required a separate order for compulsory treatment. The Norwegian Mental Health Act was revised in 1999 and 2006, but few fundamental changes were made concerning OC, except for the introduction of the possibility to issue an OC order without a prior period as an inpatient, an option that is rarely used.
The criteria for OC in Norway are the same as those required for patients subject to inpatient involuntary psychiatric care. The decision to place a patient on an OC order is valid for one year, and only authorized psychiatrists or clinical psychologists employed by the specialized mental health services can make such decisions. A special feature of the legal framework governing OC in Norway is that the order continues to run during inpatient periods taking place within the valid period of the OC order. OC orders may be renewed for one year at a time by application to an independent review board (the Control Commission). There is no limit to the number of times the order may be renewed. In addition, the patient must be assessed every three months, by either a psychiatrist or a psychologist authorized to make OC decisions, to determine whether the legal criteria for OC are still fulfilled; if not, the order must immediately be lifted.
Patients and their next of kin can appeal the decision to place the patient under an OC order to the independent Control Commission, and the decision of the Control Commission can, in turn, be further appealed in court. OC legislation also requires a treatment plan to be drawn up, unless the patient refuses such a plan.
According to the latest available governmental mental health statistics, there were 2364 patients on an OC order in 2013 [
8], corresponding to an OC prevalence rate of 61.1 per 100,000 inhabitants aged 18 years and above. These figures should be read with caution, as there are concerns about the quality of OC statistics in Norway [
8].
Aim of the study
The aim of the study was threefold: Firstly, we wanted to produce reliable incidence and prevalence data on OC in the catchment area. Secondly, we aimed to explore how OC is practised in a region in Northern Norway, and thirdly, we wished to determine whether OC had an impact on the use of inpatient services.
Methods
The study was a retrospective case register study combined with an uncontrolled before/after design for the consumption of health care services by patients receiving OC orders in the two northernmost counties in Norway (Troms and Finnmark). The catchment area had a total population of 232,437 on 1 January 2012, of which 180,394 were aged 18 years or above, and covers approximately 71,000 sq. km (27,413 sq. miles). By comparison, the whole of Denmark is 43,000 sq. km (16,500 sq. miles). There is only one mental hospital serving the two counties, and it is also the only institution authorized to make OC decisions. The catchment area is generally scarcely populated with only three towns of more than 10,000 inhabitants. Many patients have to travel long distances, up to nearly 1000 km by road, and travel is often difficult due to harsh weather conditions.
All patients on an OC order at the beginning of 2008 and living in the catchment area were included in the study. Further, all new OC orders made from 1 January 2008 until 31 December 2012 were added to the study file. We identified 286 patients, representing 345 OC orders, during the period. Among those 286 patients, we further identified all patients with a first ever OC order (index OC) from 1 January 2008 to 31 December 2009 (n = 54). For those patients we gathered more comprehensive data, including their consumption of mental health inpatient care three years before and after the first ever OC decision was made. All data were recorded based on information in the patients’ electronic medical files. We searched all files in all mental health care institutions in the study catchment area where OC orders potentially could be made, but found that OC orders were only made by authorized staff at the only psychiatric hospital serving the two counties included in the study. To identify those with an OC order we searched summary reports of all patients discharged from inpatient care. The data extracted from the patient files were recorded onto a specially prepared registration form. Two different persons proofread all data once, while all variables on the use of inpatient services, forced medication and complaints were proofread twice. In addition, a random sample of case files was proofread for all variables for a third time. As no errors were identified in the random sample, we did not proceed to a third proofreading of all records. Patients that did not live in the catchment area and those who received an OC order issued solely for the purpose of a short-term stay in e.g. a somatic hospital or for transport to other institutions were excluded (n = 10).
Analysis
The data were analysed using the SPSS statistical package 22. The statistical analysis included the chi-square test, the T-test, and one sample Kolmogorov-Smirnov non-parametric test. Significance levels are indicated by asterisks in the tables. The main analysis was based on survival analysis methods with time starting at first OC decision and end of first OC period as the censoring event. Follow-up of those with a first ever OC order took place until 31 December 2012.
The following variables were evaluated as possible factors influencing the duration of OC by Kaplan-Meier analysis and log-rank tests: sex, age, diagnosis, time since first contact with psychiatric services, use of psychiatric services before OC, living alone or not, place of residence, involuntary admissions before first ever OC order, reference to danger to self or others, treatment compliance, medication (forced, voluntary and depot), and follow-up variables during OC. We first made a bivariate analysis entering all variables that could have any possible influence on the duration of the OC order, and then entered all variables with high correlations as independent variables in the final multiple regression analysis. The independent variables included in the final Cox regression model are accounted for in the results section.
Ethical considerations
The study was approved by the Regional Committee for Medical and Health Research Ethics, Region North (REC North) (Project No. 2010/2268), and conducted in accordance with the Declaration of Helsinki. To be able to produce reliable data on incidence and prevalence of OC in the study catchment area, completeness of the data was crucial. For this reason, REC North granted access to the medical files, without obtaining individual consent by the patients. All data were de-identified before being stored and used in the analysis.
Conclusions
Annual incidence and prevalence rates were relatively stable over the five-year period covered by the study (2008–2012), corresponding to an average of 53 new OC decisions a year and 118 persons on OC at a given time each year. OC orders were made in 8 % of all involuntary admissions in the same period. Patients on OC were dominantly middle-aged men with a schizophrenia spectrum diagnosis. Males were significantly younger, and had significantly shorter history as inpatients, than their female counterparts. In all but one case, OC orders were justified by the need for treatment, specified as the need for medication. Dangerousness was mentioned as an additional issue in only seven cases. All patients received psychotropic medication during their OC period, whereof 39% as depot injections. The OC order was lifted within one year for the majority of patients (76%). Being on depot medication and being followed up by psychiatrists compared to psychologists predicted longer durations of OC. Patients on their first time ever OC order had significantly more inpatient episodes and a greater mean total number of inpatient days in the three years after the order compared to the three years before, but the mean duration of stay per admission decreased from 26 days before the OC order to 15 days after. The validity of the use of inpatient services as an outcome measure in studies of OC can be questioned. In particular, the common interpretation of re-hospitalization as a failure of OC should be reconsidered.
Acknowledgements
We would like to thank Lisbeth Mørch and Heidi Magnussen who assisted with data collection.
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