Mental Health Services in Norway and statistics on use of coercion

Tonje Lossius Husum, Phd, Clinical Psychologist Post doc researcher- Centre for medical ethics in UiO

Norwegian network for research on coercion in mental health services

Tonje Lossius Husum 2

Plan for presentation:

• The Norwegian Mental health services• The Norwegian Mental health law• Coercive interventions used in Norway• Statistics on coercion • Geographical variation • Message from the UN• Mention The Norwegian Action-plan for

reduced and quality-insured used of coercion in MH

Tonje Lossius Husum 3

4

Regional special Services

HospitalDepartements

Mental health services in the

community

General Practitioners

Psychologists/Psychiatrics on

“contract

«District» mental health service

DPS

Hospital services (Specialist health services)Community services

Forensic departementsEating disordersEtc…

Outpatient andWards with beds andDifferent kind of outpatient teams (ACT etc)

Out-patient services, also different kind of teams and some crisis-bed services

Involuntary treatment outside institution (TUD)

Involuntary observation and treatment, involuntary treatment and coercive means

Health regions in Norway (RHF)

5

Regionale helseregioner (RHF)Helsefortak (HF)

Use of Coercion….

Pictures from Google 6

Lov om etablering og gjennomføring av psykisk helsevern (psykisk helsevernloven) – 1999 (Norwegian Mental Health Law)

Most important sections about which regulate use of coercion:§ 2.1. The general rule of consent (voluntary)§ 3.1. Medical Examination§ 3.2. Decision on compulsory observation§ 3-3. Decision on compulsory mental health care (in institution and outside institution) § 3-4. Prohibition against transfer from voluntary to compulsory mental health care§ 3.4. Shielding§ 4-4. Treatment without consent§ 4-5. Connection with the outside world§ 4-6. Examination of the rooms and property and personal search§ 4-7. Seizures of assets (belag av eiendeler) § 4.7 Urine sample§ 4-8. The use of coercive means

7

Coercive means (Tvangsmidler) a. mekaniske tvangsmidler som hindrer pasientens bevegelsesfrihet, herunder belter og remmer samt skadeforebyggende spesialklær (mechanical restraints)

b. kortvarig anbringelse bak låst eller stengt dør uten personale til stede (isolation)

c. enkeltstående bruk av korttidsvirkende legemidler i beroligende eller bedøvende hensikt (acute use of sedative medication)

d. kortvarig fastholding (physical restraint)

Tonje Lossius Husum 8

Coercive means in Norway (Tvangsmidler) Mechanical

(Isolation)

Acute sedativemedication

Physical restraint+ skjerming/shielding

Official statistics on coercion

Unfortunately, data on the extent of compulsory treatment are incomplete and partly poor quality. This are the best approximations possible to provide on the basis of existing data….

…fra www.tvangsforskning.no

Tonje Lossius Husum 10

Total admissions in mental health hospital in 2012- official health statistics

Tonje Lossius Husum 11

Involuntary admissions:

Calculations based on patient data from the NPR show that about 5,400 people were involountary hospitalized a total of 7,800 times in 2012. This means that 16 percent of admissions to mental health services for adults occurred under coercion and that one in five inpatients had been involountary hospitalized at least once during the year.

Tonje Lossius Husum 12

Short admissions ?

Tonje Lossius Husum 13

Short admissions: For involuntary admissions where compulsory mental health care was established, half of patients were discharged or transferred to voluntary treatment within three weeks after the forced admission took place.

Tonje Lossius Husum 14

Reduction:

Number of compulsory admissions were reduced by approximately four percent from 2011 to 2012, and adjusted for population growth, the decline was six percent.

….it’s mowing in the right direction

Tonje Lossius Husum 15

Stabile geographical variations !! The analyzes show consistent and significant differences in the extent of forced hospitalizations both between and within health regions, but the difference appears to be somewhat reduced last year.

Tonje Lossius Husum 16

….it’s mowing in the right direction

Variation in coercive interventions between acute psychiatric wards – percent of patients (31 wards)

17Akuttavdelinger

  

0

88

83

64

60

53

4847

4443424241

36

333333

28

2525

23222222

19

171716

14

8

54

0

31

22

9

14

18

7

3

13

1716

6

14

9

22

8

0

6

13

10

88

11

6

2

6

3

14

0

5

0 0

3

Tvangsinnleggelser per 100 000 innbyggere 18 år og eldre. Fordelt etter pasientensbosted og beregnet som avvik i prosent fra gjennomsnittsrate for landet.

18

Omfang og varighet av tvangsinnleggelser i 2012, fordelt etter pasientens bosted19

Coercive means 2001 – 2007 (n)

Ragnild Bremnes, Trond Hatling og Johan Håkon Bjørngaard (2008): Bruk av tvangsmidler i psykisk helsevern 2001, 2003, 2005 og 2007, SINTEF Helse rapport A8231.

20

Use of coercive means 2001 – 2007

Samlet tvangsmiddelbruk samt skjerming. Antall ganger, timer (mekaniske tvangsmidler, isolering og holding) og pasienter totalt. Alle institusjoner. 2001, 2003, 2005 og 2007.

21

Coercive means in numbers in 2009 • From : Innsamling og analyse av data om bruk av tvangsmidler og vedtak om

skjerming i det psykiske helsevernet 2009 – Bjøkly, Knutzen, Furre & Sandvik (SIFER) (analyzing the coercive means protocols)

• 10 939 vedtak («juridical” decisions) (total) about coercive means and shielding towards 2432 persons

• Involuntary pharmacological treatment: 1875 times towards 712 persons (mean=2.63 times pr. patient)

• Mechanical restraints: 4426 times towards 1065 persons (mean duration time: 3.25 hours)

• Isolation: 269 decisions towards 114 persons (mean duration time: 0.53 hours)

• Psychical restraints: 1680 times towards 574 patients (mean=0.17 hours)

• Shielding: 2689 times towards 1406 patients (mean= 139.5 hours) Tonje Lossius Husum 22

Sammenligning av funn i 2009 med funn fra 2001–2007 (Bjørkly et al. 2011)

Tonje Lossius Husum 23

Number of decisions 2001-2009

Tonje Lossius Husum 24

Norway beeing observated from the UN:

Tonje Lossius Husum 25

UN’s conclusive remark towards Norway: • The Committee is concerned about the high frequency of compulsory

treatment and confinement in the mental health system of persons with psycho-social disabilities, as well as the inadequate legal framework regulating the application of coercive treatment. (art. 12).

• The Committee calls upon the State party to ensure full respect for human rights of persons with psycho-social disabilities in cases of treatment in a psychiatric institution, including through ensuring that treatment is based on the free and informed consent of the individual concerned or his or her legal representative. It recommends that the State party amend the Mental Health Act to introduce stricter procedural requirements to ensure that persons with psycho-social disabilities have adequate legal protection against the use of coercion. It also recommends that the State party incorporate into the law the abolition of the use of restraint and the enforced administration of intrusive and irreversible treatments such as neuroleptic drugs and electroconvulsive therapy (ECT). It further recommends that the State party increase the number of community-based services, including peer support and other alternatives to the medical model, for persons with psycho-social disabilities and allocate the necessary financial and human resources for the effective functioning of these services.

Tonje Lossius Husum 26

• Tiltaksplan for redusert og kvalitetsikret bruk av tvang i psykisk helsevern (Action plan for reduced and quality insured use of coercion) 2006

Tonje Lossius Husum 27

Tonje Lossius Husum 28

Takk for oppmerksomheten