Geographical Variation In Compulsory Hospitalisation In Norway 2014-2018

Abstract

Perspectives from psychiatric epidemiology and medical ethics are combined in a comprehensive analysis of geographical variation in compulsory hospitalisation in mental health care. The thesis contains important new knowledge that can help reduce unwarranted geographical varia­tion and compulsion. The magnitude of variation is quantified by analysing registry data spanning the whole population who were compulsorily hospitalised in Norway during 2014 - 2018. Different patterns of variation appear when counts are based on events, individuals and duration. Variations are large and stable over time. These variations suggest that some areas use more compulsion than necessary. They also question if some areas manage with less compulsion than expected due to efficient local services. We ex­plore how municipal mental health services re­late to compulsory hospitalisation by applying hierarchical models to panel data, specifically Random Effects Within-Between models. Fewer compulsory hospitalisations were seen when the number of general practitioners, mental health nurses and public housing was higher, compared to the area average. This indicates that situations where compulsory hospitalisation is considered necessary can hinge on supply of local services. The thesis includes an ethical inquiry of how geographical variation in compulsory hospitalisation can challenge principles of medical ethics. Supply-driven use of compulsion, due to lack of less restrictive alternatives, infringes on the principle of justice. Geographical variation in compulsory hospitalisation can also infringe on the principles of respect for autonomy and non-maleficence, since the principles are challenged differently, depending on area. Uncertainty surrounding beneficial outcomes makes it hard to identify overuse and underuse, but the right level of compulsory hospitalisation would never be higher than minimally necessary in a service system with good practices that promotes voluntariness.