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Objective: There is debate regarding the use of coercion in the psychiatric services and how to minimize its use. We examine changes in the use of coercion in one Norwegian psychiatric service area during a nine-year period. Methods: All patients receiving psychiatric services during the periods 2003–2006 and 2008–2012 in the study area were identified, subsequently also only those who had been involuntarily admitted or subjected to involuntary outpatient treatment. Yearwise rates of patients admitted to coercion and coercive treatment-episodes throughout the study period were calculated. Results: The overall number and the rate of coerced patients decreased to the total patient population. Most of the reduction were initially of the observational period. However, the number of coercive episodes per coerced patient increased. The pattern of outpatient versus inpatient modes of coercion both reflected this main trend. Conclusion: The use of coercion seem to be reduced overall, although the increase in treatment-episodes per patient may indicate a complex pattern in use and registration of coercion. The results may be related to legislative changes, restructuring of psychiatric services, or/and modified attitudes of health-personnel to coercion following a range of efforts to reduce it.

BackgroundReadmission rates are frequently used as a quality indicator for health care, yet their validity for evaluating quality is unclear. Published research on variables affecting readmission to psychiatric hospitals have been inconsistent. The Norwegian specialist mental health care system is characterized by a multi-level structure; hospitals providing specialized -largely unplanned care and district psychiatric centers (DPCs) providing generalized -more often planned care. In certain service systems, readmission may be an integral part of individual patients’ treatment plan.The aim of the present study was to describe and examine the task division in a multi-level health care system. This we did through describing differences in patient population (age, sex, diagnosis, substance abuse comorbidity and length of stay) and admissions types (unplanned vs. planned) treated at different levels (hospital, DPC or both), and by examining whether readmission risk differ according to type and place of treatment of index-admission and travel-time to nearest hospital and DPC.MethodsIn this population-based cohort study using administrative data we included all individuals aged 18 and older who were discharged from psychiatric inpatient care with an ICD-10 diagnosis F2-F6 (“functional mental disorders”) in 2012. Selecting each individual’s first discharge during 2012 as index gaveN = 16,185 for analyses following exclusions. Analysis of readmission risk were done using Kaplan-Maier failure curves.ResultsOverall, 15.1 and 47.7% of patients were readmitted within 30 and 365 days, respectively. Unplanned admission patients were more likely to be readmitted within 30 days than planned patients. Those transferred between hospital and DPC during index admission were more likely to be readmitted within 365 days, and to experience planned readmission. Patients with short travel time were more likely to have unplanned readmission, while patients with long travel time were more likely to have planned readmission.ConclusionsDPCs and hospitals fill different purposes in the Norwegian health care system, which is reflected in different patient populations. Differences in short term readmission rates between hospitals and DPCs disappeared when type of admission (unplanned/planned) was considered. The results stress the importance of addressing differences in organisation and task distribution when comparing readmission rates between mental health systems.

Objectives The general practitioners' (GP) role in the care of mental health patients has received increased attention. The literature underlines the need for integration of primary and specialist services, but cross‐boundary continuity for patients with severe conditions may be particularly poor. The aim of this study was to analyze the collaboration between primary care and different models of specialized psychiatric services for patients with severe conditions. Methods We compared a local and a centralized model of mental health care. Service utilization over a 5‐year period was studied. Results Findings suggest that a local institution‐based model of services positively affects the use of both GP and specialist outpatient care, with most inpatients utilizing both GP and specialist outpatient consultations. In the centralized model, a substantial proportion of inpatients only used GP outpatient care. Furthermore, inpatients that used both GP and specialist outpatient services received more of both services compared to those who did not enter specialist outpatient care at all. Conclusion Local inpatient units may positively affect continuity of care and collaboration between general practitioners and specialist psychiatric services compared to more traditional hospital units, probably because better functional integration of services, better facilitation of clinical alliances/relationships, or a more network‐oriented treatment philosophy.

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.

Introduction: Psychiatric patients may be subjected to coercion in many different forms, including involuntary admission to psychiatric hospital, involuntary outpatient treatment, and involuntary treatment with medications [1]. The use of coercion in the psychiatric services involves a range of ethical, clinical, and legal issues [2,3]. The Norwegian authorities have stated that it is a goal to reduce the use of coercion in the psychiatric services, as it is believed that this will improve the services and increase the quality of care [4]. Purpose and methods: We review and discuss findings from studies on coercion in North Norway, focusing on the relationship between the services available to patients in primary care and at local psychiatric clinics and the use of coercion. Results and discussion: A lack of services at the municipal level might increase the use of coercion. For instance, approximately half of the involuntary admissions had been referred from doctors working at municipal out-of-hours clinics [5]. These doctors often felt pressured to commit patients to psychiatric hospital, as few other options were available at nights and week-ends [5-7]. The increased availability of other services at nights and week-ends could therefore possibly result in reduced levels of coercion. Having sufficient resources available at the secondary level might also reduce the amount of coercion patients are subjected to. For instance, an area that had beds available for emergencies at local psychiatric clinics had significantly fewer (95% CI for EXP(B)=1.133-2.206, p=0.005) involuntary admissions than a comparable area without such beds [8]. While much of the coercion of psychiatric patients takes place at the tertiary/hospital level, this study suggests that the availability of services at the primary and secondary levels might influence the level of coercion at the tertiary/hospital level. Conclusion: The present study suggests that increasing the availabilty of voluntary psychiatric services at the primary and secondary levels might represent one way of achieving the goal of reducing coercion in the psychiatric services. This relationship should be examined further in future research involving the North Norwegian psychiatric health services. References: 1. Wynn R, Myklebust LH, Bratlid T. Psychologists and coercion: decisions regarding involuntary psychiatric admission and treatment in a group of Norwegian psychologists. Nordic Journal of Psychiatry 2007;61:433-437. 2. Wynn R. Coercion in psychiatric care: clinical, legal, and ethical controversies. International Journal of Psychiatry in Clinical Practice 2006;10:247-251. 3. Wynn R. The use of physical restraint in Norwegian adult psychiatric hospitals. Psychiatry Journal 2015; 2015: 347246. 4. Stuen HK, Rugkasa J, Landheim A, Wynn R. Increased influence and collaboration: a qualitative study of patients’ experiences of community treatment orders within an assertive community treatment setting. BMC Health Services Reserach 2015;14:409. 5. Rotvold K, Wynn R. Involuntary psychiatric admission: Characteristics of the referring doctors and the doctors' experiences of being pressured. Nordic Journal of Psychiatry 2015;69:373-379. 6. Rotvold K, Wynn R. Involuntary psychiatric admission: how the patients are detected and the general practitioners’ expectations for hospitalization. An interview study. International Journal of Mental Health Systems 2016; 10: 20. 7. Myklebust LH, Sorgaard K, Rotvold K, Wynn R. Factors of importance to involuntary admission. Nordic Journal of Psychiatry 2012;66:178-182. 8. 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.

IntroductionMental illness are among the most prevalent causes of death [1]. Larger population based studies are needed in order to control the high mortality rates for psychiatric patients [2].ObjectiveTo examine the relationship between psychiatric disease and somatic illness.MethodData from health-related databases and registries are cross-matched by social security number for all psychiatric patients in North-Norway for 2008–2016/2017. n = 4000–6000.(Table 1)Mortality is considered multifactorial, and risk factors may appear as both direct and indirect causes. A high number of demographic, somatic, psychiatric and service related variables allow the study to control for interactions and confounding associations by multivariate analyses.Results/planned papersA case-register study of the comorbidity of mental and somatic disorders in North Norway: Research protocol.Increased mortality in psychiatric patients: A case-registry study.Comorbidity of cancer and psychiatric illness: Findings from North Norway.Cardiovascular disease is prevalent among people suffering from depression and anxiety.The importance of the use of antipsychotic medication for physical health.Coercion and general health among psychiatric patients. The importance in continuity of care.Substance-use among psychiatric patients. Implications for general health and care pathways.Psychiatric patients use of general practitioner medical treatment.Table 1An overview of the information that will be retreived from the registries.Disclosure of interestThe authors have not supplied their declaration of competing interest.

While the use of coercion, such as involuntary medication and physical restraints, is widespread in psychiatric treatment, little is known about the outcomes of the use of these interventions. Nineteen patients who had been involuntarily medicated, physically restrained, or secluded from other patients, were matched to 19 controls. Outcome variables were overall satisfaction with treatment, self-rated improvement, recommendation of treatment to others, satisfaction with information about treatment, and degree of influence over own treatment. Data were analysed with paired t tests. There were no statistically significant differences between the patients who had been subjected to the coercive interventions and their controls. Overall satisfaction with treatment was poor for both groups, while self-rated improvement was rated as neither poor nor good. It is possible that other factors, such as the nature of the disorder and the duration of treatment, are of greater importance than the use of coercive interve...

Source at https://doi.org/10.1177/2050312117724311 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.

Introduction : During the last 20 years, there has been a shift in Norway, with an increase in services provided at local district psychiatric units and in municipalities and a reduction in centralized hospital services [1]. Simultaneously, attention has been directed to the negative effects of use of coercion within the services [2]. While it has been pointed out that rates of coercion in Norway are relatively high, few have examined the implications of this organizational change for the use of coercion [3]. Methods : Drawing on data obtained from the Norwegian Patient Register, we analyzed all episodes of specialized psychiatric care given in the area of Vesteralen and Lofoten, North Norway, for the periods 2003-2006 and 2008-2012 (data from 2007 were unavailable). Patients subjected to involuntary admission and involuntary outpatient treatments were identified. Results : The number of patients being treated in the study area increased from 886 in 2003 to 1347 in 2012. The number of involuntarily admitted patients and patients in involuntary outpatient treatment fell from 110 in 2003 to 30 in 2012. Discussion, limitations and lessons learnt : Our data suggest that while the number of patients in treatment increased with more than 50% during the study period, the number of patients being coerced was reduced with more than 70%. Several factors (on which we lack data here) may be of importance to rates of involuntary admission and treatment, including patients’ diagnoses [4, 5] and staffs’ attitudes [5, 6]. However, the increased provision of decentralized psychiatric services is likely to be one important factor in the reduction of coercion [3]. Local and low-threshold psychiatric services increase access and give patients the opportunity to get help at an earlier stage, which may reduce the need for coercion [3, 5]. Further studies are needed to examine the importance of psychiatric services organization on rates of coercion. 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. Int J Integr Care. 2011;11:e142. 2. Wynn R. Coercion in psychiatric care: clinical, legal, and ethical controversies. Int J Psychiatry Clin Pract. 2006;10(4):247-51. 3. Myklebust LH, Sorgaard K, Wynn R. Local psychiatric beds appear to decrease the use of involuntary admission: a case-registry study. BMC Health Serv Res. 2014;14:64. 4. Myklebust LH, Sorgaard K, Rotvold K, Wynn R. Factors of importance to involuntary admission. Nord J Psychiatry. 2012 Jun;66(3):178-82. 5. Rotvold K, Wynn R. Involuntary psychiatric admission: The referring general practitioners' assessment of patients' dangerousness and need for psychiatric hospital treatment. Nord J Psychiatry. 2015;69(8):637-42. d 6. Wynn R, Kvalvik AM, Hynnekleiv T. Attitudes to coercion at two Norwegian psychiatric units. Nord J Psychiatry. 2011;65:133-7.

Background The 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. Methods A 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. Results The 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. Conclusions The 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. Keywords: Outcome measure; CORE-OM; Translation; Reliability; Confirmatory factor analysis

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.To increase understanding of the antecedents of involuntary admission.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.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.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.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.

Background: The issue of continuity of care is central in contemporary psychiatric services research. In Norway, inpatient admissions are mainly to take place locally, in a system of small bed-units that represent an alternative to traditional central psychiatric hospitals. This type of organization may be advantageous for accessibility and cooperation, but has been given little scientific attention.Aims: To study whether inpatients' utilization of outpatient services differ between an area with a decentralized care model in comparison to an adjacent area with a partly centralized model. Method: The study was based on data from a one-year registered prevalence sample, drawing on routinely sampled data supplemented with data from medical records. Service-utilization for 247 inpatients was analyzed. The results were controlled for diagnosis, demographic variables, type of service system, localization of inpatient admissions, and length of hospitalization. Results: Most inpatients in the area with the decentralized care model also utilized outpatient consultations, whereas a considerable number of inpatients in the area with a partly centralized model did not enter outpatient care at all. Type of service system, localization of inpatient admission, and length of hospitalization predicted inpatients' utilization of outpatient consultations. The results are discussed in the light of systems integration, particularly management-arrangements and clinical bridging over the transitional phase from inpatient to outpatient care. Conclusion: Inpatients' utilization of outpatient services differed between an area with a decentralized care model in comparison to an adjacent area with a partly centralized care model. In the areas studied, extensive decentralization of the psychiatric services positively affected coordination of inpatient and outpatient services for people with severe psychiatric disorders. Small, local-bed units may therefore represent a favourable alternative to traditional central psychiatric hospitals.

Little is known about how different groups of health-care workers compare to each other and to the general public in their opinions about involuntary admission and treatment. In the present study, 1,094 people in Norway responded to a questionnaire containing three cases with patients suffering from schizophrenia. They were asked in which cases they would admit involuntarily and treat involuntarily with neuroleptics. An overwhelming majority would coerce when the patients were violent. Between a third and a half would coerce when the patients had problems coping with activities of daily life, or when the patients were in an early schizophrenic development with few symptoms. In all the cases, significantly more would accept involuntary admission than involuntary treatment with neuroleptics. The results suggest that health-care workers' attitudes to coercion in psychiatric care are in line with the attitudes of the general public. Prior experience with coercion, female sex, not having a college/university education, having a profession other than social worker, and not currently being employed in the psychiatric services, were positive predictors of willingness to coerce.