Out-patient commitment order use in Norway: incidence and prevalence rates, duration and use of mental health services from the Norwegian Outpatient Commitment Study.

BACKGROUND: Norway authorised out-patient commitment in 1961, but there is a lack of representative and complete data on the use of out-patient commitment orders. AIMS: To establish the incidence and prevalence rates on the use of out-patient commitment in Norway, and how these vary across service areas. Further, to study variations in out-patient commitment across service areas, and use of in-patient services before and after implementation of out-patient commitment orders. Finally, to identify determinants for the duration of out-patient commitment orders and time to readmission. METHOD: Retrospective case register study based on medical files of all patients with an out-patient commitment order in 2008-2012 in six catchment areas in Norway, covering one-third of the Norwegian population aged 18 years or more. For a subsample of patients, we recorded use of in-patient care 3 years before and after their first-ever out-patient commitment. RESULTS: Annual incidence varied between 20.7 and 28.4, and prevalence between 36.5 and 48.9, per 100 000 population aged 18 years or above. Rates differed significantly between catchment areas. Mean out-patient commitment duration was 727 days (s.d. = 889). Use of in-patient care decreased significantly in the 3 years after out-patient commitment compared with the 3 years before. Use of antipsychotic medication through the whole out-patient commitment period and fewer in-patient episodes in the 3 years before out-patient commitment predicted longer time to readmission. CONCLUSIONS: Mechanisms behind the pronounced variations in use of out-patient commitment between sites call for further studies. Use of in-patient care was significantly reduced in the 3 years after a first-ever out-patient commitment order was made. DECLARATION OF INTEREST: None.

The use of outpatient commitment in Norway: Who are the patients and what does it involve?

PURPOSE: Despite one of the longest histories of using Outpatient Commitment (OC), little is known about the use in the Norwegian context. Reporting from the Norwegian Outpatient Commitment Study, this article aims to: establish the profile of the OC population in Norway; ascertain the legal justification for the use of OC and what OC involves for patients; investigate possible associations between selected patient and service characteristics and duration of OC, and; explore potential differences based on gender or rurality. METHODS: A retrospective multi-site study, extracting data from the medical records of all patients on OC in six large regional hospitals in 2008-12, with detailed investigation over 36 months of the subsample of patients on first ever OC-order in 2008-09. We use descriptive statistics to establish the profile of the OC population and the legal justification for and the content of OC, and logistic regression to examine factors associated with duration of OC over 36 months. RESULTS: 1414 patients were on OC over the 5 years, and 274 had their first OC in 2008-09. The sample included more men than woman, and three-quarters were diagnosed with schizophrenia. They had long service histories, including involuntary admissions. The legal justification for all OC-orders was the need for treatment, and 18% were additionally justified by dangerousness. The option to initiate OC directly from the community was not used in any of the 274 first ever OC-orders. While 98% of patients were prescribed psychotropic medication, under half had an Involuntary Treatment Order, which under the Norwegian OC regime is required in addition to the OC-order to oblige patients to accept treatment (usually medication). 60% of patients had ≥2 clinical contacts monthly. There were some gender differences in descriptive analyses with men generally being worse off, but no clear pattern in terms of rurality. Patients in the sample had been on OC between one week and 20 years. The median duration of OC over 36 months was 365 days. Three factors contributed to longer duration: the use of the dangerousness criterion; a diagnosis of schizophrenia disorder, and; considerable problems with substance abuse. CONCLUSION: The characteristics of the OC population in Norway are very similar to that reported in other jurisdictions. Medication seems to be the central focus of OC, yet additional Involuntary Treatment Orders are imposed for less than half of patients. While all OC-orders were justified by the need to ensure treatment, risk seems to be a concern for a subgroup of patients who are kept on for longer. How the 2017 amendment to the mental health act, which precludes compulsion for competent patients unless danger is present, will affect OC use, remains to be seen. Further studies should specifically focus on variation in the use of OC, including at the level of individual clinicians.