Mental Health Services In Norway Research Articles

COPSYC-19: The impact of early phase lockdown on mental health among people with psychotic disorders.

On March 12th 2020 extensive measures were implemented to prevent spread of the coronavirus disease-19 (COVID-19). These measures were commonly referred to as "lockdown". In this study we investigate the psychological impact associated with living under these circumstances among patients with psychotic disorders receiving care from specialized mental health services in Norway. During early phases of lockdown, patients and clinicians receiving and providing mental health care for psychotic disorders in specialized health services at Oslo University Hospital were asked to fill out questionnaires developed for the study. 129 participants from outpatient clinics (91 patients and 38 clinicians) and 89 from inpatient wards (15 patients and 74 clinicians) were recruited. Data regarding mental health and related symptoms were analysed using Wilcoxon signed rank tests and standard multiple regression. Outpatients reported significantly less extensive worrying, loneliness and hallucinatory experiences during early phase lockdown compared to the two weeks prior. Reductions in loneliness were predictive of experienced improvement in subjective mental health. However, the majority of clinicians from outpatient clinics believed their patients were experiencing more worrying and loneliness. The result of this study suggests that many patients with psychosis experienced less loneliness, excessive worrying and hallucinations during the first phase of lockdown. This contrasts the clinicians' perceptions, as the patients show signs of resilience during times of uncertainty. The limitation in the study timeframe should be noted.

Mental health services in Norway, 2023.

Norway has, according to the World Health Organization, more psychiatrists engaged in public health services per head of population than any other country, and the proportionate numbers of psychologists and others engaged in mental healthcare are also among the world's highest. Approximately 10% of Norway's gross domestic product is spent on health, expenditure per capita that is the fourth highest internationally. We discuss how this wealth of expertise translates into the delivery of services to the public.

Client predictors of therapy dropout in a primary care setting: a prospective cohort study

BackgroundTherapy dropout poses a major challenge. Considerable research has been conducted on predictors of dropout, however none in the context of primary mental health services in Norway. The purpose of this study was to investigate which client characteristics can predict dropout from the service Prompt Mental Health Care (PMHC).MethodsWe performed a secondary analysis of a Randomized Controlled Trial (RCT). Our sample consisted of 526 adult participants receiving PMHC-treatment in the municipalities of Sandnes and Kristiansand, between November 2015 to August 2017. Using logistic regression, we investigated the association between nine client characteristics and dropout.ResultsThe dropout rate was 25.3%. The adjusted analysis indicated that older clients had a lower odds ratio (OR) of dropping out compared to younger clients (OR = 0.43, [95% CI = 0.26, 0.71]). Moreover, clients with higher education had a lower odds ratio of dropping out compared to clients with lower levels of education (OR = 00.55, 95% CI [0.34, 0.88]), while clients who were unemployed were more likely to drop-out as compared the regularly employed (OR = 2.30, [95% CI = 1.18, 4.48]). Finally, clients experiencing poor social support had a higher odds ratio of dropping out compared to clients who reported good social support (OR = 1.81, [95% CI = 1.14, 2.87]). Sex, immigrant background, daily functioning, symptom severity and duration of problems did not predict dropout.ConclusionThe predictors found in this prospective study might help PMHC-therapists identify clients at risk of dropout. Strategies for preventing dropout are discussed.

Societal costs of personality disorders: A cross-sectional multicenter study of treatment-seeking patients in mental health services in Norway.

There is a relatively small body of research on the cost-of-illness of personality disorders (PDs). Most studies only include borderline PD. The aim of this study was to investigate mean societal costs, including its components, (direct) health service costs and (indirect) productivity loss, among treatment-seeking patients with the broad range of all PDs according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Cross-sectional data from 911 patients diagnosed with at least 1 PD were retrieved from the quality register of the Norwegian Network for Personality Disorders-a collaboration of PD treatment units within specialist mental health services. The patients were referred in the time period 2017-2020. Estimation of costs was based on a bottom-up approach, using information from a structured interview covering the 6-month period before assessment, whereas unit costs were retrieved from public reports, public records, or public agencies. The human capital approach was used to calculate productivity loss. Diagnoses were determined by semi-structured diagnostic interviews (Structured Clinical Interview for DSM-5-PD [SCID-5-PD]). The mean societal costs were €20.260 during the 6-month period before specialized treatment. The largest cost component was productivity loss (65%), whereas health service costs constituted 35%. The main contributors to societal costs from the underlying health service cost components were inpatient treatment (20.5%) and individual outpatient treatment (10.5%). Societal costs were substantial among treatment-seeking patients with the broad range of DSM-5 PDs, comparable to the societal costs of schizophrenia, and significantly higher than the societal costs of both depression and anxiety disorders. The cost estimates converged with recent, register-based cost-of-illness studies of different PDs but exceeded previous findings from other bottom-up studies. Furthermore, the results underscore the importance of implementing effective and specialized treatment for patients with a broad range of PDs, not only to alleviate individual suffering but also to reduce the level of societal costs. The emphasis on productivity loss as a main contributor to the overall societal costs is substantiated, hence underlining the relevance of interventions focusing on improving occupational functioning.

Service Characteristics and Geographical Variation in Compulsory Hospitalisation: An Exploratory Random Effects Within-Between Analysis of Norwegian Municipalities, 2015-2018.

Background: Compulsory hospitalisation in mental healthcare is contested. For ethical and legal reasons, it should only be used as a last resort. Geographical variation could indicate that some areas employ compulsory hospitalisation more frequently than is strictly necessary. Explaining variation in compulsory hospitalisation might contribute to reducing overuse, but research on associations with service characteristics remains patchy.Objectives: We aimed to investigate the associations between the levels of compulsory hospitalisation and the characteristics of primary mental health services in Norway between 2015 and 2018 and the amount of variance explained by groups of explanatory variables.Methods: We applied random-effects within–between Poisson regression of 461 municipalities/city districts, nested within 72 community mental health centre catchment areas (N = 1,828 municipality-years).Results: More general practitioners, mental health nurses, and the total labour-years in municipal mental health and addiction services per population are associated with lower levels of compulsory hospitalisations within the same areas, as measured by both persons (inpatients) and events (hospitalisations). Areas that, on average, have more general practitioners and public housing per population have lower levels of compulsory hospitalisation, while higher levels of compulsory hospitalisation are seen in areas with a longer history of supported employment and the systematic gathering of service users' experiences. In combination, all the variables, including the control variables, could account for 39–40% of the variation, with 5–6% related to municipal health services.Conclusion: Strengthening primary mental healthcare by increasing the number of general practitioners and mental health workers can reduce the use of compulsory hospitalisation and improve the quality of health services.

Mode of delivery of Cognitive Behavioral Therapy for Insomnia: a randomized controlled non-inferiority trial of digital and face-to-face therapy.

Study ObjectivesDigital Cognitive Behavioral Therapy for Insomnia (dCBT-I) has demonstrated efficacy in reducing insomnia severity in self-referred and community samples. It is unknown, however, how dCBT-I compares to individual face-to-face (FtF) CBT-I for individuals referred to clinical secondary services. We undertook a randomized controlled trial to test whether fully automated dCBT-I is non-inferior to individual FtF CBT-I in reducing insomnia severity.MethodsEligible participants were adult patients with a diagnosis of insomnia disorder recruited from a sleep clinic provided via public mental health services in Norway. The Insomnia Severity Index (ISI) was the primary outcome measure. The non-inferiority margin was defined a priori as 2.0 points on the ISI at week 33.ResultsIndividuals were randomized to FtF CBT-I (n = 52) or dCBT-I (n = 49); mean baseline ISI scores were 18.4 (SD 3.7) and 19.4 (SD 4.1), respectively. At week 33, the mean scores were 8.9 (SD 6.0) and 12.3 (SD 6.9), respectively. There was a significant time effect for both interventions (p < 0.001); and the mean difference in ISI at week 33 was −2.8 (95% CI: −4.8 to −0.8; p = 0.007, Cohen’s d = 0.7), and −4.6 at week 9 (95% CI −6.6 to −2.7; p < 0.001), Cohen’s d = 1.2.ConclusionsAt the primary endpoint at week 33, the 95% CI of the estimated treatment difference included the non-inferiority margin and was wholly to the left of zero. Thus, this result is inconclusive regarding the possible inferiority or non-inferiority of dCBT-I over FtF CBT-I, but dCBT-I performed significantly worse than FtF CBT-I. At week 9, dCBT-I was inferior to FtF CBT-I as the 95% CI was fully outside the non-inferiority margin. These findings highlight the need for more clinical research to clarify the optimal application, dissemination, and implementation of dCBT-I. Clinicaltrials.gov: NCT02044263: Cognitive Behavioral Therapy for Insomnia Delivered by a Therapist or on the Internet: a Randomized Controlled Non-inferiority Trial.

The Introduction of Medication-Free Mental Health Services in Norway: An Analysis of the Framing and Impact of Arguments From Different Standpoints.

Introduction: Debates about coercive practices have challenged a traditional biomedical hegemony in mental health care. The perspectives of service user organizations have gained considerable ground, such as in the development of the Convention on the Rights of Persons with Disabilities. Such changes are often contested, and might in practice be a result of (implicit) negotiation between stakeholders with different discursive positions. To improve understanding of such processes, and how discursive positions may manifest and interact, we analyzed texts published over a 10 year period related to the introduction of medication-free inpatient services in Norway.Methods: We conducted qualitative analyses of 36 policy documents related to the introduction of medication-free services and 75 opinion pieces from a subsequent debate. We examined discursive practices in these texts as expressions of what is perceived as legitimate knowledge upon which to base mental health care from the standpoints of government, user organizations and representatives of the psychiatric profession. We paid particular attention to how standpoints were framed in different discourse surrounding mental health care, and how these interacted and changed during the study period (2008–2018).Results: The analysis shows how elements from the discourse promoted by service user organizations—most notably the legitimacy of personal experiences as a legitimate source of knowledge—entered the mainstream by being incorporated into public policy. Strong reactions to this shift, firmly based in biomedical discourse, endorsed evidence-based medicine as the authoritative source of knowledge to ensure quality care, although accepting patient involvement. Involuntary medication, and how best to help those with non-response to antipsychotic medication represented a point at which discursive positions seemed irreconcilable.Conclusion: The relative authorities of different sources of knowledge remain an area of contention, and especially in determining how best to help patients who do not benefit from antipsychotics. Future non-inferiority trials of medication-free services may go some way to break this discursive deadlock.

Digital cognitive–behavioural therapy for insomnia compared with digital patient education about insomnia in individuals referred to secondary mental health services in Norway: protocol for a multicentre randomised controlled trial

IntroductionInsomnia is highly prevalent in outpatients receiving treatment for mental disorders. Cognitive–behavioural therapy for insomnia (CBT-I) is a recommended first-line intervention. However, access is limited and most patients with insomnia...

Community-based Mental Health Services in Norway.

Community-based mental healthcare in Norway consists of local community mental health centres (CMHCs) collaborating with general practitioners and primary mental healthcare in the municipalities, and with psychiatrists and psychologists working in private practices. The CMHCs were developed from the 1980s to give a broad range of comprehensive mental health services in local catchment areas. The CMHCs have outpatient clinics, mobile teams, and inpatient wards. They serve the larger group of patients needing specialized mental healthcare, and they also collaborate with the hospital-based mental health services. Both CMHCs and hospitals are operated by 19 health trusts with public funding. Increasing resources in community-based mental healthcare was a major aim in a national plan for mental health between 1999 and 2008. The number of beds has decreased in CMHCs the last decade, while there has been an increase in mobile teams including crisis resolution teams (CRTs), early intervention teams for psychosis and assertive community treatment teams (ACT teams). Team-based care for mental health problems is also part of primary care, including care for patients with severe mental illnesses. Involuntary inpatient admissions mainly take place at hospitals, but CMHCs may continue such admissions and give community treatment orders for involuntary treatment in the community. The increasing specialization of mental health services are considered to have improved services. However, this may also have resulted in more fragmented services and less continuity of care from service providers whom the patients know and trust. This can be a particular problem for patients with severe mental illnesses. As the outcomes of routine mental health services are usually not measured, the effects of community-based mental care for the patients and their families, are mostly unknown.

Do different traumatic events invoke different kinds of post-traumatic stress symptoms?

Background: Characteristics of the traumatic event may influence the levels of and specific manifestation of particular symptoms of post-traumatic stress (Grimm, Hulse, Preiss, & Schmidt, 2012). For example, sexual trauma has been found to be associated with higher levels of post-traumatic stress symptoms (PTSS) than both motor vehicle accidents and sudden loss (Kelley, Weathers, McDevitt-Murphy, Eakin, & Flood, 2009). Motor vehicle accidents were associated with higher levels of hypervigilance and physiological reactivity than sudden loss. A restricted range of affect/inability to love close others, avoidance of thoughts/feelings, and detachment/estrangement were more severe in sexual abuse and sudden loss than in motor vehicle accidents. This may reflect that aspects of some traumatic events (e.g. sudden, fast, life-threatening) may induce fear conditioning, whereas other traumatic events lasting over an extended time (e.g. repeated sexual abuse, bullying) may elicit other PTSS such as thoughts that the world is generally not a kind or safe place (Wilkinson, Dodgson, & Meares, 2017). To further understand the aetiology of PTSS, it may be helpful to identify similarities and differences in PTSS across more types of trauma exposure. Objective: To assess differential profiles of PTSS after sexual trauma, domestic violence, accidents/medical trauma, sudden loss/serious illness of a loved one, and bullying/threats. Method: We examined the severity and profiles of symptoms of post-traumatic stress according to worst trauma reported, in a clinical sample of 4873 children and adolescents (6–18 years old, M = 14.0, SD = 2.7, 63.7% girls) referred for any reason to the general Child and Adolescent Mental Health Services in Norway. We compared the 95% confidence interval (CI) for each symptom with the 95% CI for overall PTSS within each trauma type. Results: The overall severity of PTSS was higher for sexual trauma (n = 353) than for all other assessed traumas. Furthermore, the severity was significantly higher for domestic violence (n = 407) and bullying/threats (n = 648) than for accidents/medical trauma (n = 213) and sudden loss/serious illness of a loved one (n = 654). Across all assessed worst traumatic experiences, the most commonly endorsed symptoms were psychological cue reactivity, avoidance, and difficulties with sleeping and concentrating. In addition, sexual trauma, domestic violence and bullying/threats were associated with relatively higher levels of negative beliefs and emotions. Sudden loss/serious illness was associated with relatively higher levels of negative emotions. Accidents/medical trauma were not associated with other relatively higher symptoms than avoidance and sleeping and concentration difficulties. Conclusions: The manifestation of PTSS may differ according to the type of trauma exposure. This may have implications for responsiveness to treatment interventions. For example, interventions that target negative beliefs (e.g. cognitive restructuring) may be particularly potent for adolescents who have experienced sexual trauma, family violence, or bullying/threats.

Local, Early, and Precise: Designing a Clinical Decision Support System for Child and Adolescent Mental Health Services.

Mental health disorders often develop during childhood and adolescence, causing long term and debilitating impacts at individual and societal levels. Local, early, and precise assessment and evidence-based treatment are key to achieve positive mental health outcomes and to avoid long-term care. Technological advancements, such as computerized Clinical Decision Support Systems (CDSSs), can support practitioners in providing evidence-based care. While previous studies have found CDSS implementation helps to improve aspects of medical care, evidence is limited on its use for child and adolescent mental health care. This paper presents challenges and opportunities for adapting CDSS design and implementation to child and adolescent mental health services (CAMHS). To highlight the complexity of incorporating CDSSs within local CAMHS, we have structured the paper around four components to consider before designing and implementing the CDSS: supporting collaboration among multiple stakeholders involved in care; optimally using health data; accounting for comorbidities; and addressing the temporality of patient care. The proposed perspective is presented within the context of the child and adolescent mental health services in Norway and an ongoing Norwegian innovative research project, the Individualized Digital DEcision Assist System (IDDEAS), for child and adolescent mental health disorders. Attention deficit hyperactivity disorder (ADHD) among children and adolescents serves as the case example. The integration of IDDEAS in Norway intends to yield significantly improved outcomes for children and adolescents with enduring mental health disorders, and ultimately serve as an educational opportunity for future international approaches to such CDSS design and implementation.

A system analysis of the mental health services in Norway and its availability to women with female genital mutilation.

This article explores mental health services in Norway and their availability for women subjected to female genital mutilation/cutting (FGM/C). The article focus on the system of communication and referrals from the perspective of health workers, and aims to identify bottlenecks in the system, what and where they are to be found, and analyze how different mental health services deal with Sub Saharan African (SSA) women in general, but in particular with respect to FGM/C. The study was conducted in Oslo, Norway, using a qualitative fieldwork research design, with the use of purposeful sampling, and a semi-structural guideline. One hundred interviews were done with general practitioners (GPs), gynecologists, psychologists, psychiatrists, midwives and nurses. A system analysis is applied using socio-cybernetics as a tool to identify the flow of communication and referrals of patients. The study shows that borders of subsystems, silencing mechanisms, regulations and "attitudes" of the system can lead to women with SSA background having difficulty getting access to the specialist services. High standards for referral letters, waiting lists, out pushing to the lower levels, insecurities around treatment and deference rules silencing mental health issues during consultancies, have a negative impact on the accessibility of services. Consequences are that mental health problems due to FGM/C are under-investigated, under-referred, and under-treated and a silenced problem within the mental health services for women. A better integration of subsystems at the specialist level with the GP scheme is necessary, as well as providing competence on FGM/C to the different levels. It is also important to strengthen and integrating the services at the Municipal level and provide information to SSA women about the low threshold services.

Mode of Delivery of Cognitive Behaviour Therapy for Insomnia: A Randomized Controlled Non-Inferiority Trial of Digital or Face-to-Face Therapy

Background: Digital CBT-I (dCBT-I) has demonstrated significant efficacy in reducing insomnia severity in self-referred and community samples. It is unknown, however, how dCBT-I compares to individual face-to-face (FtF) CBT-I for individuals referred to clinical secondary care services. Methods: Parallel-group non-inferiority randomized controlled trial of fully automated dCBT-I versus FtF CBT-I. Eligible participants were adults with insomnia referred to a sleep clinic via public mental health services in Norway. The primary outcome measure was the Insomnia Severity Index (ISI). The non-inferiority margin was defined a priori as 2-points on the ISI at week 33 post-randomization i.e. dCBT-I is non-inferior if the 95% Confidence Interval (CI) for the mean difference is between -2 and ∞, whilst individual FtF CBT-I is superior if the 95% CI is between -∞ and 0. Secondary outcomes were tested using superiority analyses. These were sleep-wake variables, psychological distress and fatigue. Findings: Between October 2014 and January 2016, 101 patients from 288 potential participants were recruited. Individuals were randomized to FtF CBT-I (n=52) or dCBT-I (n=49); mean baseline ISI scores were 18·4 (SD 3·7) and 19·4 (SD 4·1) respectively. At week 33, 48 (92%) in the FtF CBT-I group and 41 (85%) in the dCBT-I group completed the ISI; the mean scores were 8·9 (SD 6·0) and 12·3 (SD 6·9) respectively. There was a significant time effect for both interventions (p<0·001); and the mean difference in ISI at week 33 was -2·8 (95% CI: -4·8 to -0·8; p=0·007). No significant differences were found on secondary outcomes. Interpretation: In a clinical sample, individual FtF CBT-I was superior to dCBT-I in reducing insomnia severity; however, both were associated with significant reductions in insomnia. These findings highlight the need for more clinical research to clarify the optimal application, dissemination, and implementation of dCBT-I. Trial Registration: ClinicalTrials.gov NCT02044263. Funding Statement: St. Olavs Hospital and SOVno. Declaration of Interests: Havard Kallestad, Jan Scott, Oystein Vedaa, Daniel Vethe, Gunnar Morken, Stian Lydersen, Tore C. Stiles, Borge Sivertsen, and Knut Langsrud: Declare no known conflicts of interest in relation to this research project and the submitted manuscript. Ethics Approval Statement: The protocol was approved by the Regional Ethical Committee of South-East Norway (Reference: 2013/1836).

Substance use among patients in specialized mental health services in Norway: prevalence and patient characteristics based on a national census

Purpose The aim of this study was to investigate the clinical and demographic variation in the prevalence of substance use among the general psychiatric population in Norway. Methods A national census in psychiatric institutions and outpatient clinics was conducted. Data were returned for 2358 inpatients (response rate, 65%) and 23,167 outpatients (response rate, 60%). Substance use was measured based on substance use disorder diagnosis or reported substance use in the last 4 weeks (alcohol 2–4 days a week or more frequently/illicit drug use). Regression analyses controlling for demographic and sociodemographic characteristics were carried out. Results Substance use was identified in 32.4% of inpatients and 13.9% of outpatients. The most frequently reported substances used were alcohol, sedatives and cannabis. Among inpatients, the prevalence of substance use was highest in patients with schizophrenia, personality disorders and anxiety disorders. Among outpatients, the prevalence was highest in patients with schizophrenia and other psychoses. Inpatients with anxiety disorders and outpatients with schizophrenia and other psychoses had a significantly higher risk of substance use than other patients. In both samples, the prevalence of substance use was higher among males, 24 to 29-year-olds and the most socially deprived. Conclusions This study provides further knowledge about patients at risk for co-morbid substance abuse and poor treatment outcomes. Clinicians may consider targeting patients with schizophrenia and other psychoses, young males and those who are socially deprived in efforts to prevent emerging substance abuse and improve outcomes.

An exploratory study of the experiences of being both a mental health professional and carer in mental health services in Norway.

WHAT IS KNOWN ON THE SUBJECT?: Many carers report feeling unrecognized by professional healthcare teams. Carers often report difficulty accessing mental health services for relatives. Carers who are also mental health professionals mayexperience role conflict as found for General Practitioners. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Carers who are mental health professionals are often not recognized for their professional knowledge and face similar communication barriers as other carers. Difficulties for carers who are mental health professionals are concerned with information sharing, decision-making and continuity of care. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Opportunity for services to learn from the experiences of mental health professional and carers to develop better communication and shared decision-making methods for carers Carers who are mental health professionals should be recognized by services for their dual role (and skills). Service development opportunity for training in supporting and engaging carers who are mental health professionals ABSTRACT: Introduction Around 60% of carers of relatives with mental health problems report feeling unrecognized by professional health care, and many report a lack of engagement, shared decision-making and information sharing. There is a paucity of research examining these issues for carers who are also mental health professionals. Aims This was an exploratory study to (a) explore the extent of this role among health service staff, (b) gather an indication of the issues faced by carers when interacting with the health system and (c) test the feasibility of conducting research. Methods Mental health professionals in mental health services completed an online survey that assessed the frequency, content and satisfaction of the experiences of carers. Results The sample comprised 453 mental health professionals (74% female), 52% being carers. Half of carers reported having therapist contact, and 25% were satisfied with the contact. Negative experiences were related to Information, Decision-making and Continuity of care. Discussion There was a high frequency of mental health professionals who were carers. The majority were dissatisfied, and this was primarily in relation to communication with services. Implications for practice Improving information sharing through training of staff and identification of the system barriers is likely to enhance experiences for service users and families.

Clinical psychologists in primary mental health care in Norway - what to do?

Abstract Background The past 20 years Norwegian health authorities have put significant effort into increasing the number of clinical psychologists in primary health care. By 2020, all Norwegian municipalities are required by law to have clinical psychologists available. In 2018, only about half of the 422 municipalities had fulfilled this requirement, and the number of vacant positions is growing. The purpose of this study was to investigate the usefulness of clinical psychologists in a primary care setting as perceived from primary mental health care leaders/employees and those who educate clinical psychologists at the universities. Methods We combined the use of open-ended questions in a survey (N = 456) among leaders and employees of primary mental health services in Norway, with data from semi-structured focus group and individual interviews (N = 15) with academic staff at the four universities in Norway that provides education for clinical psychologists. Results The discussion on utilisation and usefulness of clinical psychologists in Norwegian primary care often condensates into weighing time spent on a never-ending demand for individual therapy against time spent on health promotion, prevention and system level work. Traditionally, Norwegian psychologists have received education mostly focusing on treatment methodology and individual therapy most suitable for the specialist services. The curricula are now changing towards more health promotion/prevention in primary care, but still lacks focus on system level approaches like collaboration with and guidance of other professions - which are the qualities asked for from those who hire clinical psychologists in primary mental health care. Conclusions Interdisciplinary collaboration with a wide spectre of professionals and thereby ’working with and through others’ in the health and welfare services, was suggested to be the most efficient way of utilising psychological clinical competence. Key messages The Norwegian clinical psychologists’ education is becoming more primary care friendly. Psychologists in primary care must be part of interdisciplinary teams where they can work with and trough others.

Acting on audit & feedback: a qualitative instrumental case study in mental health services in Norway

BackgroundThe National Guideline for Assessment, Treatment and Social Rehabilitation of Persons with Concurrent Substance Use and Mental Health Disorders, launched in 2012, is to be implemented in mental health services in Norway. Audit and feedback (A&F) is commonly used as the starting point of an implementation process. It aims to measure the research-practice gap, but its effect varies greatly. Less is known of how audit and feedback is used in natural settings. The aim of this study was to describe and investigate what is discussed and thematised when Quality Improvement (QI) teams in a District Psychiatric Centre (DPC) work to complete an action form as part of an A&F cycle in 2014.MethodsThis was an instrumental multiple case study involving four units in a DPC in Norway. We used open non-participant observation of QI team meetings in their natural setting, a total of seven teams and eleven meetings.ResultsThe discussions provided health professionals with insight into their own and their colleagues’ practices. They revealed insufficient knowledge of substance-related disorders and experienced unclear role expectations. We found differences in how professional groups sought answers to questions of clinical practice and that they were concerned about whether new tasks fitted in with their routine ways of working.ConclusionActing on A&F provided an opportunity to discuss practice in general, enhancing awareness of good practice. There was a general need for arenas to relate to practice and QI team meetings after A&F may well be a suitable arena for this. Self-assessment audits seem valuable, particular in areas where no benchmarked data exists, and there is a demand for implementation of new guidelines that might change routines and develop new roles. QI teams could benefit from having a unit leader present at meetings. Nurses and social educators and others turn to psychiatrists or psychologists for answers to clinical and organisational questions beyond guidelines, and show less confidence or routine in seeking research-based information. There is a general need to emphasise training in evidence-based practice and information seeking behaviour for all professional groups.

The organisation of local mental health services in Norway: evidence, uncertainty and policy

This article addresses questions about health authorities’ recommendations on the local organisation of services for people with mental health disorders in Norway. Analysis is made of the dynamic relationship between different evaluations, national guidelines and other knowledge that influence the organisation of services. The analysis is based upon documents about how recommendations by health authorities have shifted during a period of 15 years. The relationship between policy guidelines, the role of scientific evidence and practical organisational models is characterised by ambiguity and pragmatism. Some theoretical implications of these findings and uses of knowledge in different policy areas are discussed.

Public attitudes towards involuntary admission and treatment by mental health services in Norway

PurposeThe role of compulsory treatment of serious mental disorders has been the topic of ongoing public debate involving among others mental health professionals, service providers, service user advocates, relatives of service users, media commentators and politicians. However, relatively little is known about general public attitudes towards involuntary admission and compulsory treatment of people with various mental disorders. This article examines the attitudes in a representative sample of Norway's population towards the use of involuntary admission and treatment, and under which circumstances does the general public consider compulsory treatment to be justified in the Norwegian mental health care services. MethodData were collected from a representative sample of the population in Norway aged 18 and older. The sample was stratified for gender, geographical region and age distribution (n=2001). The survey was performed in the months of May 2009 (n=1000) and May 2011 (n=1001), using Computer Assisted Telephone Interviews (CATI) by an independent polling company. All respondents were provided a general definition of coercive intervention before the interview was conducted. AnalysisUnivariate descriptions and bivariate analyses were performed by means of cross-tabulation, analysis of variance (one-way ANOVA) and comparing of group of means. Cohen's d was used as the measure for effect size. ResultsBetween 87% and 97% of those surveyed expressed strong or partial agreement with the use of involuntary admissions or compulsory treatment related to specified cases and situations. The majority of interviewees (56%) expressed the opinion that overall, current levels are acceptable. A further, 34% were of the opinion that current levels are too low, while only 9.9% of respondents supported a reduction in the level of involuntary treatment. Lower levels of education were associated with a more positive attitude towards involuntary admission and treatment.There was stronger support for admission to prevent suicide than the possibility of violence by the mentally ill. ConclusionThe Norwegian adult population largely supports current legislation and practices regarding involuntary admission and compulsory treatment in the mental health services.

Risk of violence among patients in psychiatric treatment: results from a national census

Background: Adverse media coverage of isolated incidents affects the public perception of the risk of violent behavior among people with mental illness. However, the risk of violence is studied most frequently among inpatients, which falsely exaggerates the prevalence of people with mental illness because the majority of individuals receive treatment as outpatients.Aim: To estimate the prevalence of the risk of violence among inpatients and outpatients in psychiatric treatment, as well as the associations with gender, age, socio-economic status and co-morbid substance use disorders in all major diagnostic categories.Methods: We conducted a national census of patients in specialist mental health services in Norway, which included 65% of all inpatients (N = 2,358) and 60% of all outpatients (N = 23,124).Results: The prevalence of the risk of violence was 32% among inpatients and 8% among outpatients, where 80% of the patients in specialist mental health services were outpatients. If we weight the prevalence rates accordingly, less than 2% of the patients in specialist mental health services had a high risk of violent behavior.Conclusions: The stigma attached to those with mental illness is not consistent with the absence or low to modest risk of violent behavior in 98% of the patient group. Substance use disorders must be given priority in the treatment of all patient groups. Mental health care in general and interventions that target violent behavior in particular should address the problems and needs of these patients better, especially those who are unemployed, have a low level of education and have a background of being a refugee or an immigrant.