Georg Høyer

“Life on Hold”: A Qualitative Study of Patient Experiences with Outpatient Commitment in Two Norwegian Counties

In recent decades, outpatient commitment orders have been increasingly used in the follow-up of persons with serious mental disorders. Most studies on outpatient commitment orders have focused on compliance and consumption of health care services; there is little research on the content of outpatient commitment orders from a patient perspective. The aim of this study is to examine patients’ experiences of living with outpatient commitment orders, and is based on qualitative interviews with 16 persons in two Norwegian counties. The data were analysed using a constructivist, interpretive approach to the grounded theory method. The main finding was that patients with outpatient commitment orders felt that their lives were on hold. The feeling of being seen only as patients prevented them from taking responsibility for their own lives. The medical context was perceived as an obstacle to recovery and transition to a more normal life. Patients’ daily lives were dominated by the agenda set by health care providers and many said they were subjected to control measures that resulted in a reduced quality of life. However, informants also spoke of positive experiences as outpatient commitment order patients, such as feeling safe and secure and having easy access to health care staff and services.

Involuntary hospitalization in contemporary mental health care. Some (still) unanswered questions

Background: Published figures on civil commitment rates in Europe show large differences between countries. All such rates are based on public register data, and it has been questioned to what extent such data can be trusted. Aims: To present an update on our current knowledge about involuntary hospitalization, with special emphasis on research issues related to time trends in its use, the impact of legislation, and that of service structure and ideology on variations in involuntary hospitalization rates. Methods: Literature review. Results: How civil commitment rates have been computed is rarely accounted for in the literature, and rates will vary substantially according to the methods used. The quality of public register data does also vary, and few studies have looked at the quality of public registers. Conclusions: We still have insufficient knowledge about the use of involuntary hospitalization. Given the varying quality of the data, it is problematic to draw any firm conclusions about the extent, time trends and variations in the use of civil commitment. Comparison of civil commitment rates between countries should for this reason be interpreted with caution.

Sleeping problems at 78 degrees north: the Svalbard Study

The aim of this study was to compare the prevalence of sleeping problems in two ethnically different populations living under the same extreme arctic climate. A total of 453 Norwegians (319 males and 134 females) were compared with 450 Russians (317 males and 133 females), all aged 18 years or older, living on Svalbard, the northernmost regular settlement in the world. Among Russians, 81% of the male subjects and 77% of the female subjects reported sleeping problems lasting for at least 2 weeks. The corresponding figures for the Norwegians were 22% (for males) and 25% (for females). Among Russians, sleeping problems decreased with increasing age, but no such age trend was found in Norwegians. Whereas sleeping problems among Norwegians were approximately equally frequent throughout the year, the Russians reported more problems during the polar night. ‘Problems falling asleep’, ‘not feeling rested in the morning’ and ‘waking up several times during the night’ were the most frequent types of sleeping problems in both groups. Depression, shift work, loneliness, ability to concentrate, alcohol consumption and quality of life were associated with sleeping problems in Norwegian subjects, whereas depression, shift work, ability to concentrate, and worry were associated with sleeping problems in Russians. The prevalence of sleeping problems was nearly fourfold higher among Russian subjects than among Norwegians living on Svalbard. As the Russians were recruited from a lower latitude than the Norwegians, we postulate that their problems should be interpreted in terms of inadequate acclimatization after migration to the north.

Rates for civil commitment to psychiatric hospitals in Norway. Are registry data accurate

Civil commitment rates to psychiatric hospitals in Norway are among the highest in Europe. However, published rates are based on registry data of uncertain quality. Civil commitment at four psychiatric hospitals were examined and the quality of registry data assessed. We examined 2043 admissions, recorded the duration of deprivation of liberty and calculated incidence rates for civil commitment. The overall study generated incidence rate for civil commitment based on “involuntary referrals”, “treatment periods” and persons involved were 259, 209 and 186 per 100,000 adults/year, respectively. For patients admitted for involuntary observation only, the mean duration of deprivation of liberty was 8.5 days, compared with 34.3 days for those admitted for long-term detention, representing 37.8% and 86.6% of the total inpatient period, respectively. The submitted records to the Norwegian Patient Registry (NPR) were incomplete and had missing information at two of the four hospitals. Moreover, when official civil commitment rates based on the NPR data were computed, almost 30% of all admissions were routinely excluded. Civil commitment in this study was higher than corresponding figures based on registry data. In general, civil commitment rates as reported by the NPR seem to be an underestimate.

Tvangsinnleggelser og tvangsretensjon i psykiatriske institusjoner-en sammenligning av regelverk og praksis i de skandinaviske land

The present paper deals with compulsory admissions to psychiatric institutions in Scandina via. In the first part, some historical reflections are given. It seems that the mental health acts occur and are revised simultaneously in each country. Major reforms seem to follow periods of progress in medicine and are based on optimistic attitudes towards treatment possibilities. What the actual situation concerns, admission rates are discussed in relation to the existing mental health acts in the different countries. It is shown that these admission rates vary considerably between the Scandinavian countries, regarding total admissions and compulsory admissions. In Sweden the number of compulsorily admitted patients per 100,000 inhabitants is 248, in Norway 109 and in Denmark 26 (1982 figures). It is difficult to explain the differences demonstrated without including cultural aspects as well as different attitudes towards compulsion.Furthermore, procedures for carrying out compulsion as well as requirements for...

‘Responsible, but Still not a Real Treatment Partner’: A Qualitative Study of the Experiences of Relatives of Patients on Outpatient Commitment Orders

The aim of this study was to explore relatives’ experiences when their family member is under an outpatient commitment order. A descriptive and exploratory approach was used based on qualitative interviews with 11 relatives. The relatives felt they had responsibility for the patient, but experienced a lack of recognition for their contribution to the treatment. Relatives paid little attention to coercion, but were more concerned about whether the follow-up care improved the patients social functioning. They further reported an unmet need for information and guidance from healthcare staff to improve cooperation in the patients care and treatment.

Social Services Necessary for Community Treatment Programmes Designed to Prevent Crime and Violence Among Persons with Major Mental Disorders

Treatment programmes designed to prevent crime and violence among persons with major mental disorders should result in reduced crime rates and violent episodes among patients in these programmes, compared to those in other programmes or in none at all. The relationship among crime rates, violence, and specific programmes is problematic for a number of reasons, primary among them the almost endless number of factors that contribute to the outcome in a given case. Problems related to the design of studies in this field also seriously limit our ability to draw firm conclusions about the effects of specific programmes or interventions. This chapter will focus on some of the theoretical and methodological problems that arise when the effectiveness of specially designed treatment programmes is examined. It will then review, in the light of this theoretical framework, some of the studies that have looked at the role of social services in outpatient rehabilitation programmes.

Community treatment orders – what are the views of decision makers?

Abstract Background: Community treatment orders (CTOs) are being increasingly used in Western countries. The scheme implies that mental health patients can live outside a hospital, but still be subject to coercive care to ensure compliance with their treatment. There is limited knowledge of how the scheme is practised. Aims: To gain knowledge of how decision makers weigh and evaluate various considerations when making decisions on CTOs. Method: Qualitative in-depth interviews with decision makers responsible for CTOs in Norway. Results: Decision makers viewed CTOs as a useful scheme to ensure control, continuity and follow-up care in the treatment of outpatients with a history of poor treatment motivation. They had varied interest in and knowledge of the patient’s life situation and how the scheme affects the patient’s everyday life. Little attention was devoted to patient experiences of formal and informal coercion. Conclusion: When deciding on CTOs, decision makers should pay more attention to the negative consequences that patients may experience. In many cases, decision makers are probably not aware of these coercive factors.

“Care or control?”: a qualitative study of staff experiences with outpatient commitment orders

PurposeOutpatient commitment orders are being increasingly used in many countries to ensure follow-up care of people with psychotic disorders after discharge from hospital. Several studies have examined outpatient commitment in relation to use of health care services, but there have been fewer studies of health professionals’ experiences with the scheme. The purpose of this study was to examine health professionals’ experiences with patients subject to outpatient commitment.MethodsThis was a focus group study using a descriptive and exploratory approach. The study was based on three focus group interviews with a total of 22 participants. Data were analysed using qualitative content analysis.ResultsThe study showed that health professionals had a positive attitude towards outpatient commitment and considered it necessary for patients with psychosis who lacked insight and did not collaborate on treatment. At the same time their attention to patients’ lack of insight could lead to a paternalistic approach more than measures to enhance patient autonomy. This challenged their therapeutic relationship with the patient.ConclusionHealth professionals found it difficult to combine control with therapeutic care, but gave greater emphasis to patients’ need for treatment and continuity of care than to their autonomy. This dilemma indicates a need to discuss whether increased attention to patients’ autonomy rather than insight into their illness would improve treatment cooperation and reduce the use of coercion.

Patients on outpatient commitment orders in Northern Norway

BackgroundIn recent years, an increasing number of countries have introduced outpatient commitment orders (OC), which imply that patients can be subject to compulsory follow-up and treatment while living in the community. However, few studies on how OC is practised have been published.MethodRetrospective case register study based on medical files of all patients receiving an OC order in 2008–2012. We used a pre/post design, recording the use of inpatient services three years before and three years after for those patients who received their first ever OC order in 2008 and 2009.ResultsA total of 345 OC orders applying to 286 persons were identified in the study period 2008–2012. Incidence and prevalence rates were relatively stable, but decreased during the last years of the study period. For all the 54 patients receiving their first ever OC order in 2008 and 2009, need for treatment was the reason for imposing OC, and all received psychotropic medication. The number of inpatient admissions and inpatient days was greater, while the number of days for each admission was lower three years after the OC order than three years before. The first ever OC lasted under a year for 76% of the patients. Receiving depot medication and follow-up by psychiatrists predicted longer OC durations than such treatment and care by psychologists. Only nine patients were not hospitalized during the three-year follow-up after the first ever OC order.ConclusionPatients on first ever OC orders in Northern Norway used inpatient services more after OC orders than before. Further studies are needed to explore whether increased use of inpatient services by OC patients is beneficial or a failure of OC.