Lars Henrik Myklebust

Factors of importance to involuntary admission.

Background: Most countries allow for the use of involuntary admission of patients. While some countries have stable or declining rates of involuntary admission, this type of coercion is now on the increase in several European countries. Aims: To increase understanding of the antecedents of involuntary admission. Methods: The importance of various predictors of involuntary admission were analysed in univariate analyses and in a logistic regression model, involving approximately 2000 admissions to a Norwegian hospital. Results: Involuntary admission was positively associated with the diagnostic category of psychosis and negatively associated with the category of anxiety. Emergency referrals were also more likely to be coerced. Conclusions: Diagnostic category seems to be a central factor with respect to involuntary admission. Patients that were admitted in an emergency were also more likely to be coerced. Clinical implications: Certain groups of patients are more likely to be admitted involuntarily. Increasing attention to these groups could possibly also contribute to the reduction of coercion.

Local psychiatric beds appear to decrease the use of involuntary admission: a case-registry study

BackgroundStudies on the effect of organizational factors on the involuntary admission of psychiatric patients have been few and yielded inconclusive results. The objective was to examine the importance of type of service-system, level of care, length of inpatient stay, gender, age, and diagnosis on rates of involuntary admission, by comparing one deinstitutionalized and one locally institutionalized service-system, in a naturalistic experiment.Methods5538 admissions to two specialist psychiatric service-areas in North Norway were studied, covering a four-year period (2003-2006). The importance of various predictors on involuntary admission were analyzed in a logistic regression model.ResultsInvoluntary admission to the services was associated with the diagnosis of psychosis, male sex, being referred to inpatient treatment, as well as type of service-system. Patients from the deinstitutionalized system were more likely to be involuntarily admitted.ConclusionsSeveral factors predicted involuntary status, including male sex, the diagnosis of psychosis, and type of service-system. The results suggests that having psychiatric beds available locally may be more favourable than a traditional deinstitutionalized service system with local outpatient clinics and central mental hospitals, with respect to the use of involuntary admission.

The factor structure and psychometric properties of the Clinical Outcomes in Routine Evaluation--Outcome Measure (CORE-OM) in Norwegian clinical and non-clinical samples.

BackgroundThe Clinical Outcomes in Routine Evaluation - Outcome Measure (CORE-OM) is a 34-item instrument developed to monitor clinically significant change in out-patients. The CORE-OM covers four domains: well-being, problems/symptoms, functioning and risk, and sums up in two total scores: the mean of All items, and the mean of All non-risk items. The aim of this study was to examine the psychometric properties of the Norwegian translation of the CORE-OM.MethodsA clinical sample of 527 out-patients from North Norwegian specialist psychiatric services, and a non-clinical sample of 464 persons were obtained. The non-clinical sample was a convenience sample consisting of friends and family of health personnel, and of students of medicine and clinical psychology. Students also reported psychological stress. Exploratory factor analysis (EFA) was employed in half the clinical sample. Confirmatory (CFA) factor analyses modelling the theoretical sub-domains were performed in the remaining half of the clinical sample. Internal consistency, means, and gender and age differences were studied by comparing the clinical and non-clinical samples. Stability, effect of language (Norwegian versus English), and of psychological stress was studied in the sub-sample of students. Finally, cut-off scores were calculated, and distributions of scores were compared between clinical and non-clinical samples, and between students reporting stress or no stress.ResultsThe results indicate that the CORE-OM both measures general (g) psychological distress and sub-domains, of which risk of harm separates most clearly from the g factor. Internal consistency, stability and cut-off scores compared well with the original English version. No, or only negligible, language effects were found. Gender differences were only found for the well-being domain in the non-clinical sample and for the risk domain in the clinical sample. Current patient status explained differences between clinical and non-clinical samples, also when gender and age were controlled for. Students reporting psychological distress during last week scored significantly higher than students reporting no stress. These results further validate the recommended cut-off point of 1 between clinical and non-clinical populations.ConclusionsThe CORE-OM in Norwegian has psychometric properties at the same level as the English original, and could be recommended for general clinical use. A cut-off point of 1 is recommended for both genders.

Bed utilization in two differently organized community mental health services in Northern Norway: the VELO-project.

BackgroundThe literature on the dynamics between community- and hospital services concerning utilization of psychiatric beds is inconclusive. The Norwegian VELO-project provides an opportunity to study this in a natural experiment. Two service-systems are compared. The “central-bed system” have mainly outpatient- and day-hospital services locally, with psychiatric beds at a central mental hospital. The “local-bed system” have only one outpatient clinic, with beds at three local inpatient units. Also utilization of sheltered homes was studied. Hypotheses were predicted from Goldberg and Huxley’s’ stage theory and the Thornicroft and Tansella’s’ hydraulic model.Materials and methodsThe case-registries of 2005 were linked across service levels by patients’ 11-digit Social Security Number. From 1,865 single treatment episodes, 1,348 continuous courses by 1,253 individual patients were extracted.ResultsFor overall utilization of psychiatric beds there was only a small difference, were the central-bed system utilized 10% less than the other. For utilization of emergency inpatient admissions and acute hospital beds, the rate was more than twice in the central-bed system compared to the other. For utilization of municipalities sheltered homes, the rate was three times higher in the local-bed system.DiscussionThere may be bedrock of need for psychiatric beds regardless of system-organization. Distance may in general be a minor issue for utilization of psychiatric beds, and may primarily interact with patient- or contextual characteristics associated with acute situations. Activity of day-hospital services rather than outpatient consultations may affect utilization of sheltered homes. The main theoretical models are conceptually useful, although more research is needed to specify mechanisms.

Decentralization matters – Differently organized mental health services relationship to staff competence and treatment practice: the VELO study

BackgroundThe VELO study is a comparative study of two Community Mental Health Centres (CMHC) in Northern Norway. The CMHCs are organized differently: one has no local inpatient unit, the other has three. Both CMHCs use the Central Mental Hospital situated rather far away for compulsory and other admissions, but one uses mainly local beds while the other uses only central hospital beds. In this part of the study the ward staffs level of competence and treatment philosophy in the CMHCs bed units are compared to Central Mental Hospital units. Differences may influence health service given, resulting in different treatment for similar patients from the two CMHCs.Methods167 ward staff at Vesterålen CMHCs bed units and the Nordland Central Mental Hospital bed units answered two questionnaires on clinical practice: one with questions about education, work experience and clinical orientation; the other with questions about the philosophy and practice at the unit. An extended version of Community Program Philosophy Scale (CPPS) was used. Data were analyzed with descriptive statistics, non-parametric test and logistic regression.ResultsWe found significant differences in several aspects of competence and treatment philosophy between local bed units and central bed units. CMHC staff are younger, have shorter work experience and a more generalised postgraduate education. CMHC emphasises family therapy and cooperation with GP, while Hospital staff emphasise diagnostic assessment, medication, long term treatment and handling aggression.ConclusionThe implications of the differences found, and the possibility that these differences influence the treatment mode for patients with similar psychiatric problems from the two catchment areas, are discussed.

How mental health service systems are organized may affect the rate of acute admissions to specialized care: Report from a natural experiment involving 5338 admissions

Objectives: Studies on the dynamics between service organization and acute admissions to psychiatric specialized care have given ambiguous results. We studied the effect of several variables, including service organization, coercion, and patient characteristics on the rate of acute admissions to psychiatric specialist services. In a natural experiment-like study in Norway, we compared a “deinstitutionalized” and a “locally institutionalized” model of mental health services. One had only community outpatient care and used beds at a large Central Mental Hospital; the other also had small bed-units at the local District Psychiatric Centre. Methods: From the case registries, we identified a total of 5338 admissions, which represented all the admissions to the psychiatric specialist services from 2003 to 2006. The data were analyzed with chi-square tests and Z-tests. In order to control for possible confounders and interaction effects, a multivariate analysis was also performed, with a logistic regression model. Results: The use of coercion emerged as the strongest predictor of acute admissions to specialist care (odds ratio = 7.377, 95% confidence interval = 4.131–13.174) followed by service organization (odds ratio = 3.247, 95% confidence interval = 2.582–4.083). Diagnoses of patients predicted acute admissions to a lesser extent. We found that having psychiatric beds available at small local institutions rather than beds at a Central Mental Hospital appeared to decrease the rate of acute admissions. Conclusion: While it is likely that the seriousness of the patients’ condition is the most important factor in doctors’ decisions to refer psychiatric patients acutely, other variables are likely to be important. This study suggests that the organization of mental health services is of importance to the rate of acute admissions to specialized psychiatric care. Systems with beds at local District Psychiatric Centers may reduce the rate of acute admissions to specialized care, compared to systems with local community outpatient services and beds at Central Mental Hospitals.

Local inpatient units may increase patients' utilization of outpatient services: a comparative cohort-study in Nordland County, Norway

Objectives In the last few decades, there has been a restructuring of the psychiatric services in many countries. The complexity of these systems may represent a challenge to patients that suffer from serious psychiatric disorders. We examined whether local integration of inpatient and outpatient services in contrast to centralized institutions strengthened continuity of care. Methods Two different service-systems were compared. Service-utilization over a 4-year period for 690 inpatients was extracted from the patient registries. The results were controlled for demographic variables, model of service-system, central inpatient admission or local inpatient admission, diagnoses, and duration of inpatient stays. Results The majority of inpatients in the area with local integration of inpatient and outpatient services used both types of care. In the area that did not have beds locally, many patients that had been hospitalized did not receive outpatient follow-up. Predictors of inpatients’ use of outpatient psychiatric care were: Model of service-system (centralized vs decentralized), a diagnosis of affective disorder, central inpatient admission only, and duration of inpatient stays. Conclusion Psychiatric centers with local inpatient units may positively affect continuity of care for patients with severe psychiatric disorders, probably because of a high functional integration of inpatient and outpatient care.

Inpatients´ utilization of GP and psychiatric outpatient care. A comparison of a central-institution versus a local-institution based system of psychiatry. A case-register study

Introduction: The deinstitutionalization of psychiatry has in its essence been a downsizing of central psychiatric institutions in favor of outpatient- and community-based services. ‘Continuity of care’ has been a key concept from the onset in these ever more complex systems, both used as a measure of outcome and processes as well as a strategic priority (1). Recent research advocates systems that facilitate continuous clinical relationships between patients and clinicians rather than collaboration between specialized teams, but findings are limited (2-4). At the same time, the international literature has seen an increasing interest of the General Practitioners` (GP) role in the care of mental health patients, and underlines the need for integration of primary care and psychiatric services (5, 6). Recent studies suggest that for patients with severe conditions, cross boundary continuity are poor, and many are not seen in specialized care (7, 8). Purpose and methods: We review and discuss findings from studies on continuity of care in North Norway, focusing on the collaboration in the total of mental health services. We now want to focus on the continuity of care for individual patients with severe conditions between primary care and specialized mental health services: 1. Municipality (GPs), 2. Community mental health centers (CMHC), and 3. Central Mental hospitals (CMH). The two neighboring CMHCs of Vesteralen and of Lofoten, County of Nordland, North-Norway represent an interesting opportunity for mental health services research, because they are organized quite differently in spite of almost identical catchment-area characteristics. The one may be termed a central institution based model, the other a local institution based model. Both operate in concert with the county’s` CMH. These two models compared, particularly whether if local psychiatric beds rather than at a central hospital affects the utilization of GPs and municipality care. It is a retrospective cohort study of the total psychiatric care for all patients in two areas in North Norway, based on a prevalence sample from the routine case-registries of general practice and specialist services over the five years 2008-2012. Results and discussion: The most interesting result is that model of services exert at profound effect on the collaborative care between primary and specialist care. From a total of 971 inpatients included in the study, a majority in the local institution based model also utilized GPs- as well as specialist outpatient consultations. This was not the case in the centralized model, where a substantial proportion of inpatients did not receive specialist outpatient care at all. Further, those patients did neither use GP-care to the same extent as those who utilized both in- and outpatient services. Condition (diagnosis) and length of inpatient stay modified these findings, but system model still exerted an independent and profound effect on whether patients received collaborative care or not. Demographic and clinical variables like gender, age, or diagnosis did not alter these effects. The distinction between ‘continuity systems’ and ‘specialization systems’ described in recent literature may at least partly explain this (2). It may be that our two models facilitate continuous clinical contact between a therapist and patient to a different degree, and that this exerts an effect at both the primary and specialist level of services. In our local institution based system, one therapist may keep continuous contact with the patients over the transition from inpatient to outpatient care, whereas the central institution based model is more specialized and that patients may establish new relationships depending on in need of inpatient or outpatient services. Conclusion: The results suggests that smaller local inpatient units rather than central mental institutions might represent one way of achieving better continuity of care between primary and specialist services for patients with severe conditions. Further, utilization of both in-and outpatient services predicts also more use of general practitioners care. This relationship should be examined further in future research involving the North Norwegian psychiatric health services. References: 1- Myklebust LH, Olstad R, Bjorbekkmo S, Eisemann M, Wynn R, Sorgaard K. Impact on continuity of care of decentralized versus partly centralized mental health care in Northern Norway. International journal of integrated care. 2011;11:e142. 2- Omer S, Priebe S, Giacco D. Continuity across inpatient and outpatient mental health care or specialisation of teams? A systematic review. European psychiatry : the journal of the Association of European Psychiatrists. 2015;30:258-270. 3- Myklebust LH, Sorgaard K, Rotvold K, Wynn R. Factors of importance to involuntary admission. Nordic journal of psychiatry. 2012;66:178-182. 4- Myklebust LH, Sorgaard K, Wynn R. Local psychiatric beds appear to decrease the use of involuntary admission: a case-registry study. BMC health services research. 2014;14:64. 5- Fleury MJ IA, Aube D, Farand L, Lambert Y General practitioners`management of mental disorders: A rewarding practice with considerable obstacles. BMC Family Practice. 2012;13. 6- Mykletun A KA, Tangen T, Overland S. General practitioners`opinions on how to improve treatment of mental disoders in primary helath care. Interviews with one hunders Norwegian general practitioners. BMC Health Service Research. 2010;10. 7- Reilly S PC, Hann M, Reeves D, Nazareth I, Lester H. The Role of Primary Care in Service Provision for People with Severe Mental Illness in the United Kingdom. PLoS ONE. 2012;7. 8- Myklebust LH SK, Wynn R. Local inpatient units may increase patients’ utilization of outpatient services. A case-register study. Submitted.

P02-184 Continuity of care, systems integration and patient transitions: Central or local psychiatric beds? The VELO-project

Background Although scientifically controversial, continuity of care for patients with serious mental illness has long been a key-concept in the evaluation of deinstitutionalized mental health services. It is associated with systems integration, and particularly relevant in transitions from in- to outpatient status at the individual level. The theme is highlighted in a close to natural experiment that was part of the VELO-project, were two neighboring mental health service-systems diverge concerning their organization of in- and outpatient services. Aim To investigate the significance of systems integration of inpatient and outpatient services on continuity of care for individual patients. Method 244 inpatients from the services case-registry (2005) were followed concerning their pattern of both inpatient and outpatient service use. The results were controlled for length of hospitalization, diagnosis and demographical variables. Results Overall for inpatients, the low-integrated system shows significantly less outpatient activity than the high-integrated system. This pattern is not associated with differences in general service profile of the systems, and holds up for patients suffering from schizophrenia and anxiety, but not for affective disorders. Discussion The results may be explained by differences in geographical and managerial organization of the two systems. Conclusion High level of systems integration is important in reducing the risk of discontinuity of care for patients suffering from severe mental health problems. Level of integration may interact with differences in vulnerability for transitions of individual patients.