How Can We Reduce The Use Of Compulsion Of People With Severe Mental Illness

BACKGROUND:

In Norway, as in other parts of the Western world, there have been concerns about increase in the use of compulsory mental health care for patients with severe mental illness. There is growing public concern, however, despite the explicit instruction from the Norwegian government that health services should reduce the use of compulsion, rates have not decreased. The Reducing Coercion in Norway study (RECON) is designed to develop and test an intervention, at the municipal level, to reduce the use of compulsion.

Most referrals to compulsory treatment come from primary care. In Norway, it is the 400+ municipalities who hold responsibility for primary care. This includes multi-disciplinary municipal mental health teams, substance abuse services, social care and GP services. At the Specialist level, four Regional Health Authorities Commission a number of Health Trusts to deliver specialist mental health care through acute hospitals and District Psychiatric Centres. These centres often collaborate, in different ways, with municipal services.

Municipal service providers are often those in most frequent contact with patients with severe mental illness, and will commonly be those detecting early signs of relapse. Importantly, municipal services (usually GPs or out of hours emergency services) will serve as gatekeepers for involuntary admissions, as they refer to specialist services who then may invoke the Mental Health Act that sanctions compulsion. This suggests a potential for developing strategies within municipal services to intervene early and possibly prevent some episodes of compulsion. Very little research has investigated the role municipal services play in the compulsion or on relevant cross-sectoral collaborations. There is also limited research on out-patient interventions designed to reduce compulsion. A systematic review could only include 15 experimental studies internationally. Joint crisis plans, risk assessments and counselling of staff were identified as promising interventions. However, most studies had insufficient samples or were of too poor quality to draw conclusions. Moreover, all included studies were based in specialist out-patient services.

The 'Six Core Strategies' intervention, developed to reduce seclusion and restraint in psychiatric hospitals, has shown positive effects. The six strategies involved are: structured efforts to improve leadership and organisational change; use of data to inform practice; workforce development; use of seclusion and restraint reduction tools; involvement of peers, and; rigorous debriefing techniques. It has been implemented in six countries, with positive results. No equivalent has been developed for municipal services. Service users and clinicians in Norway have, however, suggested potential strategies for municipal services to impact on compulsion rates. These include crisis plans; structured meetings of patients' networks, spaces for informal contact; key contact persons for patients; improved skills for early detection of relapse and; improved local collaboration. Given the potential role of municipalities for reducing the use of compulsion, it seems clear that further research is needed. RECON takes the Six Core Strategies model as a starting point for developing and testing a municipality-based intervention for reducing the use of compulsion.