Suicidal behaviour/self-destructiveness, psychosis, affective disorders (mania, serious depression) and substance abuse were the main problems on admittance (tab 2). A look at the discharge diagnoses for involuntary admittances in Østfold (6) shows that 14 % were admitted with a diagnosis related to substance abuse, 8 % with schizophrenia, 16 % with affective disorders, 11 % with personality and behavioural disturbances, and 18 % with a need-for-observation diagnosis. The studies are not however directly comparable. Our study comprises all admitted patients, but the Østfold study only included patients admitted under the former § 3 (observation section).
47 % were admitted involuntarily. Similar results are found in a previous study from the same hospital (7). The national average in 2005, according to SAMDATA (project aimed at providing, analysing and publishing data within mental health care, substance abuse and specialist health care), was 41 % (9). SAMDATA does however not consider acute psychiatry specifically or include internal transfers. After a professional assessment was done within 24 hours, 25 % were still under compulsory detention both in this study and according to a study by SINTEF Health. SINTEF’s study, however, included all institutional psychiatry (8). Within 24 hours 22 of 49 involuntary admittances (45 %) had been converted to the voluntary section. 18 of 30 patients (60 %), admitted for coerced observation, had their MHA section lifted after the statutory assessment. In the Østfold study (6) 54 % of the patients had their section lifted after assessment. The fact that more than half of those admitted for observation had their section lifted the day after, according to both studies, ought to lead to a systematic appraisal of the circumstances surrounding admittances. Four of 15 patients (27 %) admitted for coerced mental health care had their section lifted on assessment. There may have been no basis for using coercion or the situation may have changed within the first 24 hours.
If it is the case that there was no basis for using coercion, this represents a serious problem. We often observe that the situation changes within 24 hours on an acute psychiatric ward. On arrival, many of the patients had thoughts of suicide, were high on drugs or thought to be psychotic. It is very important in acute psychiatric treatment to give patients a sense of security, peace and quiet, sleep, care and conversation. Often, this will be sufficient for the situation to change. It is a goal that mental illness should be discovered by the patient’s regular GP and treated at the lowest possible level in the specialist health service. The reason why more are admitted from the out-of-hours service may be that the pressure of symptoms combined with possible substance abuse is higher in the evening and at night when the opportunities for action are limited. It might also be because the out-of-hours doctors do not know the patients so well. A regular doctor who cooperates with others and knows the patient well can find other solutions than hospitalization. It will also be important to see how much time out-of-hours doctors spend with the patients compared to the time spent by their regular GP and the specialist health service. More patients had shorter stays in hospital when admitted by out-of-hours doctors and this may indicate that the available time for assessment and treatment was short. This aspect should be studied further. 70 % of patients admitted under the observation and assessment section of the MHA (§ 3.6), and nearly half the patients admitted for coerced mental health care (§ 3.7) are admitted via the out-of-hours service (Table 3). Would there be more voluntary admissions if regular GPs and the specialist health service were able to a greater degree to manage patients with acute conditions during working hours in the daytime? Sufficient access to local psychiatric nurses on evening and night duty, an appointment with the regular GP or a specialist the following day and an emergency team in operation should be good preventative measures against the unnecessary use of coercion. It is important to do studies on the actual admittances themselves and to test out suggested measures empirically before concluding that the use of coercion on admittance can be reduced and the measures are working as intended.
11 patients were observed with an average observation time of 4.5 days. The aim of the ward was to assess at all times whether or not it was really necessary to use coercion. The average detention time in the Østfold study was 23 days for patients under the observation section (6). How much of this time was coerced observation is not given so a direct comparison is difficult. Reasons for a short coerced observation period may be several, for example, the new MHA (2) has reduced the observation time from three weeks to 10 days; and there is an increased awareness of the need to reduce the use of coercion (11,12). Earlier reports (8) - (10) also show a marked variation in the use of coercion among the different health institutions. We have not found other studies that look at the length of time taken for observation and assessment. Relatively few of our patients (16 %) were still involuntary after the assessment was complete. This finding requires further study. It is possible that one of the objectives of the new MHA has been achieved, which was to reduce the extent of coerced observation. The material is too small to draw definite conclusions and further investigation is needed. It should be assessed whether it should be mandatory to record the data assessed in this study on a regular basis. Records of these data would improve our knowledge of the actual use of coercion in all of Norway’s health institutions. One problem is that all psychiatric patients (wherever admitted or treated) are grouped together. Assessments of the use of coercion must consider which institution admitted them and the nature of the illness. 17 patients who remained involuntary had serious psychotic disorders. Five of these received follow-up in the municipalities after treatment and could be discharged. The remaining 12 had serious mental disease with loss of ADL (activities in daily life) functions requiring long-term treatment in psychotic and rehabilitation wards.
One of the main functions of the MHA Commission is to monitor whether the Responsible Medical Officer (RMO) follows the MHA in accordance with its intentions and thereby they have an important role in safeguarding patient rights. Seven patients used their right to complain; no appeals were upheld. A few chose to withdraw their complaint or let it rest till a later meeting. The fact that few patients had their complaint upheld can be interpreted in various ways. It may be that the RMO has made an assessment in line with how the Commission interprets the MHA. There were few form-filling errors on admittance, which indicates good acquaintance with the new law.
The strength of the study is that it comprises all patients discharged in the period. The author has made most of the MHA section assessments, met up with the Commission and been the RMO for all the patients. The variable comprising discharge diagnoses may be a weakness. One may wonder if the sample is representative for acute psychiatric wards in the entire country, but some studies (6) - (10) indicate that the investigated ward is not atypical. Further studies should however be undertaken in other places as previous studies do not give an adequate picture of the situation throughout Norway.