Controversies: Coercion
Compulsory mental health care is controversial - some clinicians use coercion more frequently than others. What yields best results for the patients? And are you more or less likely to be hospitalised against your will, depending on where you live?
Compulsory mental health care, with or without hospital admission, is part of the treatment system for people with severe mental illness. For many, this also involves forced medication. But does more or less use of coercion lead to better long-term outcomes for these patients?
Compulsory care is a serious restriction on a person’s freedom and should only be used as a last resort—after voluntary treatment has been tried or is clearly pointless. Since changes to the Mental Health Act in 2017, compulsory care can only be used for people with severe mental illness who lack decision-making capacity, or if there is an immediate and serious risk to the person or others. The doctor requesting compulsory admission and the psychiatrist or psychologist making the final decision at the hospital must use significant clinical judgement to assess whether these legal conditions are met.
Nearly 40% of people referred for compulsory admission are not actually admitted against their will once they arrive at the hospital. One in three patients placed under compulsory observation (§3.2)—a period used to assess whether the criteria for coercion are met—are also not transferred to full compulsory care. This suggests uncertainty in these decisions, and differing opinions on how necessary coercion actually is. Previous research has shown persistent geographical differences in the use of coercion across community mental health centre (DPS) areas—differences that cannot be fully explained by variation in patient characteristics.
Due to ethical, economic, and practical concerns, randomised trials are not suitable for studying whether patients have better outcomes under high or low levels of coercion. It remains unclear whether coercion works as intended by lawmakers. At the same time, human rights concerns are pushing for reduced use of coercion. For patients, whether they are admitted involuntarily can depend on which side of a municipal border they live on—making the system feel like a lottery.
We will use this geographical variation as a natural experiment to study which approach leads to the best short- and long-term outcomes for patients.
The project is funded by the Research Council of Norway – HELSEVEL – Effective, high-quality health, care and welfare services – #326407.
Ethics approval: REK #2017/2436
Read more about the project in Cristin