Impact of introducing capacity-based mental health legislation on the use of community treatment orders in Norway: case registry study

Background In 2017, a capacity-based criterion was added to the Norwegian Mental Health Act, stating that those with capacity to consent to treatment cannot be subjected to involuntary care unless there is risk to themselves or others. This was expected to reduce incidence and prevalence rates, and the duration of episodes of involuntary care, in particular regarding community treatment orders (CTOs). Aims The aim was to investigate whether the capacity-based criterion had the expected impact on the use of CTOs. Method This retrospective case register study included two catchment areas serving 16% of the Norwegian population (aged ≥18). In total, 760 patients subject to 921 CTOs between 1 January 2015 and 31 December 2019 were included to compare the use of CTOs 2 years before and 2 years after the legal reform. Results CTO incidence rates and duration did not change after the reform, whereas prevalence rates were significantly reduced. This was explained by a sharp increase in termination of CTOs in the year of the reform, after which it reduced and settled on a slightly higher leven than before the reform. We found an unexpected significant increase in the use of involuntary treatment orders for patients on CTOs after the reform. Conclusions The expected impact on CTO use of introducing a capacity-based criterion in the Norwegian Mental Health Act was not confirmed by our study. Given the existing challenges related to defining and assessing decision-making capacity, studies examining the validity of capacity assessments and their impact on the use of coercion in clinical practice are urgently needed.

S132. SAMPLING BIAS IN STUDIES OF FIRST-EPISODE PSYCHOSIS – A FOLLOW-UP STUDY

Background Attrition rates and sampling bias in controlled clinical studies are a concern when evaluating the relevance of the results to a specific patient population in a real-life clinical / treatment setting. Dropout rates in studies on psychotic disorders are high and many eligibility criteria may lead to bias in study samples. We wanted to analyze how representative are the patient samples typically included in first-episode psychosis studies such as the Turku Early Psychosis (TEPS) study by using a platform of 3772 consecutive admissions to clinical psychiatric services of Turku Psychiatry. Methods TEPS study was started in 2011 as a part of a larger study on psychosis treatment processes in Turku Psychiatric services. Each patient, inpatient and outpatient, went through initial clinical screening by the treatment group which was followed by a structured evaluation if the screen for first-episode psychosis was positive. Between Oct 2011 and June 2016 there were 195 patients with first-episode psychosis (FEP) suitable to the TEPS study. Of them 102 were willing and 93 were not willing to participate or were not reached in a baseline structured evaluation. Using patient records, we compared if these two groups differed in terms of clinical variables, treatment or prognosis during a 1-year follow-up. Time of hospital stay, involuntary vs. voluntary admission, coercive measures during the hospital care, re-hospitalizations and drop-out from the clinical care during the follow-up were used as outcomes. Results Non-participating (NTP) group had higher rate of involuntary care than participating (TP) group (70 % vs 62 %) as well as higher rate of coercion during the treatment and higher rate of re-admissions during the follow-up than the TP group (36 % vs 22 % and 41 % vs 34 %, respectively) but these differences did not reach statistical significance. During the one-year follow-up NTP group had a significantly higher rate of dropping out from the clinical care than participating TP group (48 % vs 30 %, p=0.01). NTP group had also higher rate of dropping out of clinical treatment mainly because of patient non-adherence (33 % vs 16 %, p=0.03). Discussion Nearly half (47 %) of the intent-to-study FEP patients were not reached or declined to participate in our study. Non-participating patients had a slightly more severe illness and poorer treatment adherence during one-year follow-up. The clinical differences were not as marked as we expected. E.g. involuntary care, inpatient care and more coercion during the follow-up were not significantly different between NTP and TP groups. Nevertheless, the data suggest considerable differences between participating and non-participating patients with first-episode psychosis which should be taken in to account when evaluating the generalizability of the results for an unselected group of psychotic patients in ‘real-life’ clinical care.

Commentary on “Implementation of policy regarding restrictive practices in England”

Purpose In the Netherlands, as in England, concerns exist about the extent of and frequency with which freedom-restricting measures are applied. The view is that use of these measures needs to decrease. The purpose of this paper is to outline new legislation that is expected to come into force in the Netherlands in 2020. Design/methodology/approach This paper provides a description of legislation entering into force on 1 January 2020. Findings Many of the new legislation’s practical implications remain unclear, including the definition of involuntary care. Research limitations/implications The new legislation will start being monitored directly after coming into force, and only then the authors will make out what works well and what does not. Practical implications Introducing new legislation on coercion is not sufficient. Careful implementation of the legislation is important, including the way it defines involuntary care. Originality/value In 2020, the Netherlands is introducing new legislation on involuntary care for people with an intellectual disability. This includes a definition of involuntary care.

MENTAL HEALTH ACT, MALTA 2012 - A personal reflection on 5 years working with a new legal framework

The Commissioner for the Promotion of Rights of Persons with Mental Disorders (CMH) was established in Article 5 of the Mental Health Act approved by the Maltese Parliament in December 2012. The whole Act was completely in force on 10th October 2014. The involuntary care process is being closely monitored. Patients are being followed up within the time-frames established by the new law. Although not strictly comparable, length of stay in involuntary care has diminished radically. Patients are being discharged from compulsory treatment orders or transferred to community treatment orders rather than being left on “leave of absence”. Community involuntary care is the preferred option of following up difficult cases. This shift requires commitment to strengthen community support services and render them sustainable. The applications for involuntary care are progressively being better completed and the quality of the information backing requests for involuntary detention of persons is improving. Care plans are being submitted, but their completeness and their quality merits revision. The issue of availability of human resources is a critical issue which regularly features in feedback with care teams. Evidence of greater involvement of patients and responsible carers in the care planning process should be better documented if it is indeed happening. The level of awareness of patients’ rights in terms of the Act merits deeper evaluation. The CMH must continue to provide a voice to vulnerable persons with mental disorders and their loved ones. Maximization of the potential of persons with mental disorders is not only a question of social justice but also critical for the sustainability of our health system and the prosperity of our society. The burden of mental disorders is increasing exponentially with the modernization of our society and those who are not coping with this burden merit active consideration and support. Key messages Public health advocacy and the improvement of patient rights. The use of legislative tools in reforming service delivery.

Forty years of the Law 180: the aspirations of a great reform, its successes and continuing need

Aim.Italy pioneered deinstitutionalisation over the past 60 years and enforced a famous mental health (MH) reform law in 1978. Deinstitutionalisation has been completed with the very closure of all psychiatric hospitals over two decades.Methods.After 40 years of implementation, this article presents the main achievements and challenges of the Italian MH reform law, including its long-term effect and impact in Italy and abroad.Results.The Legislation of 1978 was based on the discovery of rights as a key tool in mental healthcare. At the climax of crisis of psychiatric hospitals as total institutions in this country, through the new community-based system of care, it has fostered the lowest rate of involuntary care and gave back the full citizenship to people with MH disorders. This act was also part of a social movement for expanding civil and social rights, and a promise of a true paradigm shift not only in psychiatry, but also in the way of providing an adequate welfare community for all citizens. According to the WHO, the Italian city of Trieste, together with its region, is a practical example of how the Italian movement achieved deinstitutionalisation, intended as a complex process resulting in the gradual relocation of the economic and human resources and subsequent creation of 24 h services together with the development of social inclusion programmes.Conclusions.Even if the great principles of the Italian reform law were anticipatory (e.g., the UN Convention on Rights of Persons with Disabilities – CRPD), the law application has been poorly provided with resources and did not follow those avant-garde experiences as models. Limitations are evident today especially at the organisational levels, such as services capable to take up the challenge and transforming the field, left free from the imprint of total institutions. These endemic critical aspects concerning to implementation policies, together with the financial crisis of the Italian healthcare system, must be taken into consideration for a re-launch of this historical law. The rights-based approach opened by the Law 180 should now take into consideration the new legal situation caused by the CRPD worldwide in the area of individuals’ human rights, especially about the issue of legal capacity and related involuntary care.

Return of the asylum

SummaryRates of involuntary admission are increasing in England. Personality disorder should be excluded as a criterion for involuntary admission; stronger restraint reduction programmes should be instigated; and involuntary care should be based on treating illness (something we can do) and not on predicting violence (something we cannot).Declaration of interestNone.