Do Low Rates of Coercion in Catchment Areas Predict Negative Effects for Persons With Severe Mental Disorders? A Register Study From Norway 2015-2017. Part of Reducing Coercion in Norway (ReCoN)

Involuntary mental health care is permitted because it is believed to make people with severe mental disorders (SMD) better and prevent them from getting worse or even dying. This study concerns whether low levels of coercion in an area is connected with poorer outcomes in Norway. Too little involuntary care could be expected to lead to the opposite outcomes to those intended by the Norwegian Mental Health Act.

The same law applies all over Norway, but the rate of involuntary care varies: there is an up to five-fold difference between the catchment areas of the 69 Community Mental Health Centers (CMHC).

This study will use national register data to test whether areas with low rates of involuntary care shows signs of failing to achieve the patient benefits of involuntary care as intended by the Norwegian Mental Health Act.

Data on involuntary care will be retrieved from the Norwegian Patient Registry (NPR) and combined with data on the general population and demographics from Statistics Norway, to study the hypothesized negative consequences of low rates of involuntary care. All of Norway's 21 Health Trusts and their 69 Community Mental Health Centers that provide specialist services are required to submit to NPR on an annual basis complete data of all service use from their hospitals' electronic patient administrative and clinical systems. The NPR conducts extensive data-quality checks, and publishes completeness data for all variables. The registry implemented a unique patient identifier in 2008, so that a patient's care can be followed across time. From the NPR database, information on all specialist mental health treatment activity for patients with set criteria (in our case diagnosis F20-31 and legal status) during a given time period (here 2015-18) can be extracted.

Both involuntary admissions and outpatient compulsion in the form of community treatment orders (CTO) are envisaged to contribute to the aims of the Mental Health Act, such as protection against harm, improvement, restoration of health, and recovery or cure for the patient. The variable of interest is low use of the combination of these two forms of involuntary care. To our knowledge, there is no established way to calculate a combined measure of inpatient and outpatient involuntary care, and it is not generally established how one form of involuntary care is associated with the other. In Norway, 31% of involuntary admissions continued as a CTO in 2018, and although permitted, CTOs are almost never initiated when the patient lives at home. When a patient is under involuntary admissions or a CTO, the care system has substantial influence and control over their treatment, and medication is a particular focus. Regardless of the form of involuntary care, control over treatment can be continued according to necessity criteria in the law in order to prevent deterioration. For these reasons, the rate of persons affected by involuntary admission and/or CTO per 100 000 capita will be used as an indicator of use of involuntary care in the catchment area and hence, the main covariate.