Long term outcomes and causal modelling of compulsory inpatient and outpatient mental health care using Norwegian registry data: Protocol for a controversies in psychiatry research project

Abstract

Objectives: Compulsory mental health care includes compulsory hospitalisation and outpatient commitment with medication treatment without consent. Uncertain evidence of the effects of compulsory care contributes to large geographical variations and a controversy on its use. Some argue that compulsion can rarely be justified and should be reduced to an absolute minimum, while others claim compulsion can more frequently be justified. The limited evidence base has contributed to variations in care that raise issues about the quality/appropriateness of care as well as ethical concerns. To address the question whether compulsory mental health care results in superior, worse or equivalent outcomes for patients, this project will utilise registry-based longitudinal data to examine the effect of compulsory inpatient and outpatient care on multiple outcomes, including suicide and overall mortality; emergency care/injuries; crime and victimisation; and participation in the labour force and welfare dependency.

Methods: By using the natural variation in health providers' preference for compulsory care as a source of quasi-randomisation we will estimate causal effects of compulsory care on short- and long-term trajectories.

Conclusions: This project will provide valuable insights for service providers and policy makers in facilitating high quality clinical care pathways for a high risk population group.

Keywords: causal inference; coercion; compulsion; compulsory mental health care; geographical variation; instrumental variables; psychiatric epidemiology.

FIGURE 1

Clinician preference for or against compulsion.

FIGURE 2

Theoretical illustration of the controversy on the use of compulsory mental health care for people with severe mental illness.

FIGURE 3

Geographical variation in compulsory hospitalised patients in Europe and Norway. Average rates per 100.000 inhabitant. Map based on data from (Hofstad et al., ; Sheridan Rains et al., 2019).

FIGURE 4

Trajectories observed in longitudinal registry data to be used in the project.

FIGURE 5

Themes of outcomes and/or baseline characteristics, including potential operationalisation.

FIGURE 6

The Norwegian Mental Health Care Act regulates compulsory inpatient and outpatient mental health care. Decisions for compulsory care are made at referral; within 24 h of admission; within 10 days (for compulsory observation); at least every third month, and 1 year after referral for compulsory mental health care, but discharge can be decided at any time.