Rugkåsa Jorun, Nyttingnes Olav, Šaltytė Benth Jūratė, Husum Tonje Lossius, Kjus Solveig Helene Høymork, Wormdahl Irene, Hofstad Tore, Hatling Trond
Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway.
Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway.
Soc Psychiatry Psychiatr Epidemiol. 2025 Apr 30. doi: 10.1007/s00127-025-02914-3.
Internationally, policies and legal changes seek to reduce the use of involuntary psychiatric admissions. Usually directed towards specialist services, these initiatives show little sustained progress. We tested whether an intervention at the level of primary mental health services has potential to reduce the use of involuntary admissions.
We conducted a two-arm cluster-RCT following Zelen's design (ClinicalTrials.gov:NCT03989765). Each cluster included the primary mental health service and their local collaborators in mid-sized Norwegian municipalities with rates of involuntary admissions above the national average. Five clusters were randomised to co-create and implement a comprehensive intervention. These could not be blinded, but the five control clusters were. Our primary hypothesis was that rates of involuntary admissions would be lower in the intervention arm when comparing change over time between arms, and that this would sustain. Secondary hypotheses were that rates of referrals for involuntary admissions and rates of referrals confirmed for involuntary status after the second statutory assessment, would be lower in the intervention arm.
Data obtained from the Norwegian Patient Registry included all events in the study period. The difference between trial arms in changes of rates of involuntary admissions from baseline to the intervention period was 6.8 (95% CI 1.8 to 11.7; effect size (EC) 2.7), and reduced to 3.0 (95% CI -3.8 to 9.7; ES 0.9) between baseline and the post-intervention period. The difference between arms regarding changes in referral rates between the baseline and intervention period was 1.7 (95% CI -4.6 to 8.1; ES 0.5), and for changes in the rate of referrals resulting in involuntary status it was 1.3 (95% CI -3.4 to 6.0; ES 0.8).
We found a clear difference between trial arms in our primary outcome of involuntary admissions during the intervention period, but not beyond that period, and not regarding referrals for involuntary admissions, although the consistent direction of change favoured the intervention. We interpret the results to constitute 'proof of concept' that adequately resourced primary mental health services might contribute to policy aims of reducing involuntary care. Further rigorous studies in heterogeneous contexts are required.
在国际上，政策和法律变革旨在减少非自愿精神科住院治疗的使用。这些举措通常针对专科服务，但成效甚微，进展难以持续。我们测试了在初级心理健康服务层面进行干预是否有可能减少非自愿住院治疗的使用。
我们按照泽伦设计开展了一项双臂整群随机对照试验（ClinicalTrials.gov:NCT03989765）。每个整群包括挪威中等规模城市的初级心理健康服务机构及其当地合作伙伴，这些城市的非自愿住院率高于全国平均水平。五个整群被随机分配共同创建并实施一项综合干预措施。这些整群无法设盲，但五个对照整群可以设盲。我们的主要假设是，比较两组随时间的变化时，干预组的非自愿住院率会更低，且这种情况会持续。次要假设是，干预组的非自愿住院转诊率以及第二次法定评估后被确认为非自愿状态的转诊率会更低。
从挪威患者登记处获得的数据包括研究期间的所有事件。从基线到干预期，试验组之间非自愿住院率变化的差异为6.8（95%置信区间1.8至11.7；效应量（EC）2.7），到基线与干预后期之间，该差异降至3.0（95%置信区间-3.8至9.7；效应量0.9）。基线与干预期之间转诊率变化的组间差异为1.7（95%置信区间-4.6至8.1；效应量0.5），导致非自愿状态的转诊率变化的组间差异为1.3（95%置信区间-3.4至6.0；效应量0.8）。
我们发现，在干预期内，试验组在非自愿住院这一主要结局上存在明显差异，但在此期间之后则不存在，在非自愿住院转诊方面也不存在差异，尽管变化的一致方向有利于干预措施。我们将这些结果解释为“概念验证”，即资源充足的初级心理健康服务可能有助于实现减少非自愿护理的政策目标。需要在不同背景下进行进一步的严格研究。
