pexels photo 675262 - Psychiatric coercion in Norway - Key figures

Psychiatric coercion in Norway – Key figures

Antall tvangsinnleggelser 1024x568 - Psychiatric coercion in Norway - Key figures

Compulsory commitment – National numbers of formal decisions (Blue) and numbers of patients (Orange)

Background

Norwegian Ministry of Health’s information page on the use of coercion in specialized mental health care in Norway.

Norway has two national quality indicators (NKIs) for the use of coercion in this area – one for compulsory commitment, and one for coercive measures. These indicators show a small number of variables, but data is available with approx. 6 months delay. More extensive numbers are available in a publishing solution called “SAMDATA”, but here the publishing delay about 1.5 years.

Links (pages in Norwegian):

Compulsory commitment

Coercive measures

SAMDATA, use of coercion in mental health care in Norway

 

Last reports on the use of coercion from the Norwegian Ministy of Health (in Norwegian):

Development in the period between 2013-2017,

Status after the amendment (capacity to consent) to the Norwegian Mental Health Care Act in 2017.


For 2018 – Last publicly available in-depth figures

Compulsory commitment:

Figures from the Norwegian Patient Register (NPR) showed that 5,707 patients were compulsory admitted a total of 8,076 times. About 150 of these were younger than 18 years (admissions to child and adolescent psychiatry). Half of the compulsory admissions start with a compulsory observation-period. The median duration of compulsory confinement was 14 days.

Compulsory treatment:

  • 1974 decisions on compulsory treatment, mainly antipsychotic drugs (56 decisions on compulsory nutrition)

Coercive measures:

  • Mechanical restraint:                               4047 decisions (for 1017 persons)
  • Isolation:                                                   1350 decisions (for 340 persons)
  • Chemical restraint:                                  1913 decisions (for 823 persons)
  • Manual restraint:                                      7708 decisions (for 1695 persons)

Incidence-rates, per 100 000 inhabitants  16 years and above:

  • Compulsory commitment (§3-2/ §3-3):             186/ 100 000
  • Seclusion (without isolation) (§4-3):                  65/ 100 000
  • Compulsory treatment (§4-4):                           46/ 100 000
  • Coercive measures (§4-8):                                 51/ 100 000

Commentary

The number of compulsory admissions has remained relatively stable over a number of years, both in terms of the number of admissions and the number of people being admitted.

Following the amendment to the Mental Health Care Act in mid-2017 (introduction of lack of competancy to consent as a condition for the use of coercion), the number of compulsory admissions was slightly reduced the same year.

Figures for 2018 and onwards show that the decline was temporary. A possible reason may be the tightening of the law-demand that patients without competence to consent must be compulsory admitted (stricter requirements for competence to consent as a basis for voluntariness).

In 2020, there was 12.7% more compulsory admissions nationally than in 2017.

For coercive measures, manual restraint in particular has increased in the years 2015-2018 (approximately doubled number of decisions). The number of decisions on chemical restraint and isolation has been relatively stable during the same period. The use of mechanical restraint increased in the period 2016-2017 (3559 to 4453 decisions), after which there has been a slight reduction (4047 decisions in 2018).

Compulsory commitment

If the conditions of the law are met, the patient can be committed to an institution against their will. The criteria for the continued use of compulsory commitment must be re-evaluated every 3 months. An independent Supervisory commitee at the hospital (1 judge, 1 GP and 2 laymen) makes the decision if compulsory commitment is prolonged after the first 3 months, and after a year, the decision must be renewed. In theory, there is no limitation on possible yearly renewals, and as such compulsory commitment can last indefinitely.

Compulsory observation is used when there is a predominant suspicion that the criteria for compulsory mental health care are present, but there is still some uncertainty. Decisions on compulsory observation mean that the patient can be kept in hospital for up to ten days to assess the patient’s condition.

Outpatient Commitment (TUD) Compulsory mental health care and -observation can be done in a community setting, where this is deemed in the patient’s best interests.

Coercive measures

According to the Mental Health Care Act § 4-8, coercive measures shall only be used on patients when this is absolutely necessary to prevent the patient from injuring himself or others, or to prevent significant damage to buildings, clothing, furniture or other material things. The law mentions four forms of coercive measures: Isolation, mechanical-, chemical- and manual restraint.

Seclusion is in Norway defined as keeping the patient away from fellow inpatients or staff not involved in the patient’s treatment. The patient shall be accompanied by a member of the staff at all times (unless the patient whishes to be alone, and this is justifiable). Isolation is not permitted when being secluded.

Compulsory treatment

Section 4-4 of the Mental Health Care Act allows patients to undergo examination and treatment, without their own consent, that is clearly in accordance with a professionally recognized psychiatric method and sound clinical practice. Compulsory treatment presupposes that the patient is subject to compulsory mental health care, either as an inpatient or as outpatient commitment. In reality, compulsory treatment is essentially about treatment with drugs. In recent years, some decisions have been made on compulsory nutrition. Decisions on compulsory nutrition are mainly made in child and adolescent psychiatry.