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Reducing compulsory admission at a psychiatry emergency outpatient clinic – Norway

A psychiatric emergency outpatient clinic in Storgata, Oslo, sought to reduce compulsory admission by providing ‘focused interventions’ for people experiencing acute mental health crises (Submission 17B), and improving the decision-making of staff who impose compulsory admission. Hence, the aim was to reduce (but not eliminate) compulsory admissions. The initiative was trialled between 2001-2013, after which it was implemented into regular practice at the clinic.

Service data indicated a 70 percent decrease in the number of admissions to acute hospital care from 2005-2013. The amount of compulsory admissions compared to voluntary admissions was reduced from 79 percent (hence, 21 percent voluntary) to 40 percent (hence, 60 percent voluntary) in the period 2000-2008. This result persisted to 2013. From 2013 to the time of writing, the percentage of compulsory admissions has varied from 43-53 percent.

The principles for admissions developed as part of the initiative are still used as guidelines for admissions. The interventions include a ‘a checklist, personal feedback, an audit of the journals, and abolishment of printed forms’ (Ness et al., 2016)

The project developed in four steps.

Step 1 (initiated in 2001) involved reducing the proportion of involuntary admissions from 80 percent to 50 percent. Various methods were used, including: admitting doctors being encouraged not to compulsorily admit patients who accepted the admission voluntarily; a ‘Handbook’ being produced which set out ideal referral practice; doctors being discouraged from compulsorily admitting patients with a diagnosis of personality disorders and patients where suicide was the primary indication for admission, and so on. (For more details, see).

Step 2 (initiated in 2006) involved removing templates for compulsory admissions so as to encourage individual consideration of each case and to raise awareness and accountability for decisions of the decision -makers, as well as the requirement for an inter-disciplinary team to make a determination to impose treatment.

Step 3 (introduced in 2007) required individual feedback for staff about their own practice, including their rates of compulsory admissions. They were further encouraged to discuss indication for compulsory admissions with a colleague every time before admission.

Step 4 (introduced in 2009) involved a review of admission records – with a focus on the staff’s role in the admission process – by three senior psychiatrists from three acute psychiatric wards. Each employee’s record was reviewed anonymously to assess the decisions they had made about admission. The same procedure was performed after one year by a senior psychiatrist who gave individual feedback to the employees. (The idea was that if one staff member was admitting people involuntarily at higher rates than others that they would be informed and the trend would be discussed and addressed where needed).

Most of the individual psychiatrists who authorised a higher percentage of compulsory admissions compared to other staff were not aware that they were doing so. When such facts were established, some psychiatrists were not pleased and criticized the project. Some were concerned that the suicide rate of patients would increase. No evidence was provided of any suicide rate increase (Submission 17B).

The initiative was reportedly cost neutral.

Service users were not involved in developing, implementing or monitoring the initiative, but reportedly, the leaders of the initiative were inspired by ‘user organizations who campaigned for a decrease in compulsory admissions’ (Submission 17B). During the project period, Norway had a clear policy aim to reduce involuntary psychiatric treatment. (For further information about the project, see Ness et al., 2016).