Good Practices in Mental Health Care in Norway – connecting health and social services. A glimpse from inside Arne Repål

I wasn’t that interested in those early years

The early years No District Psychiatric Centres or other kinds of systematic after care The average stay in hospital in 1950 was 3 year Hospitals was overcrowded They were the home for many patients, not a place for psychiatric treatment. The patients were taken care of, given medical support and kept.

Neevengården psychiatric hospital 1910

Sandviken hospital 2012

White Paper on health policy In 1975 the government published a White Paper on the health policy partly as a response to the growing costs of health institutions. The Paper outlined that health services should be based on well-developed primary care services and that treatment should be provided at the lowest effective level.

District Psychiatric Centre In 1991 I moved to Vestfold County and was involved in building up a new DPC there. Vestfold is a geographically small county with inhabitants. It had been decided to build up four DPCs beside the psychiatric hospital.

The District Psychiatric Centre Central tasks: Outpatient clinics/ambulant services Daytime treatment Short-time inpatient treatment Long term treatment and rehabilitation Consultation, supervision and support for staff in primary care services Acute services and crisis intervention Education

The psychiatric hospital Urgent psychiatric care where hospitalisation is needed Treatment for patients needed to be held in closed sections Patients with complicated psychiatric illness

Organization In the National Mental Health Program the District Psychiatric Centres was described as autonomous with their own leadership. This was wrong I think. It made it difficult to establish a good relationship with the acute ward in the psychiatric hospital. There was no continuity when patients were discharged from the hospital.

Akuttilbudet:A

Primary Care Services The local councils are responsible for social support and primary health services. The local community are often small and differs in the way they have organized the primary care services. Most of the health personnel are psychiatric nurses or social workers Patients also have their local doctor.

Improving Access to Psychological Therapies project in Norway The main focus here are patients with depression and anxiety. They represent a large number of people; the mental health problem placing a significant burden on their wellbeing, their families, the health cervices and the wider economy. 12 communities are involved. Health personnel are given education within the Cognitive Therapy model. They shall be able to offer guided self-help, educational groups for anxiety and depression and individual treatment. People can attend without referral. The project is to be evaluated and if the results are good the model will be implemented in the rest of Norway.

Legal aspects During the last decade there have been increased emphasis on patients ´ own view and preferences both on the individual level and on the on the organisational level. Patients are also given a legal right to receive treatment within a given time. This is positive, but it must be right to say that this not always have been followed by the same concern about the treatment itself. The authorities has focused on reducing the compulsory mental health care.

National Guidelines for Treatment There are National guidelines for treatment of the most common diagnosis. These guidelines are meant to be evidence-based. There have been some discussion on this topic, and the level of evidence for choosing one specific treatment method varies. All in all I think the introduction of guidelines are positive as far as they are used in a sober way. They can help the leaders adopt programs for strategic competence development. These guidelines should also be a central part of the education of health personnel.

Advices (1) Thinking of the patient as part of the local society as well as an individual is important. This means that both the specialised services; the primary services and the patient have to cooperate. Often the relatives also are important co-operators.

Advices (2) The great challenge is maybe how to get most out of the recourses available. Keeping patients in hospitals are expensive, and often unnecessary. It’s cheaper, and often better for the patient, to give outpatient treatment of some kind. How to do this depends on local conditions.

Advices (3) De-institutionalisation means building up an alternative. Only reducing number of beds in the psychiatric hospital will not be a good solution. This can be a serious problem because it requires a period were you have to increase the resources spent on health services before you see the effect.

Advices (4) I think we in many cases have moved from thinking we should cure the patient’s condition to making it able for him or her to live with it. Accepting deviant behaviour and experiences is part of this and involves the whole society.

Advices (5) In choosing what treatment to offer I would recommend you to consider the scalability of the method. It is better to chose a method that relatively easy can be learned by many, have elements of guided self-help, not require to many consultations and does not require to much time spent on maintenance.

Advices (6) Coordinate the resources. Don't quarrel about who are going to do what If resources are limited, decide what should be the priority. For those with serious problems like psychosis you could consider giving education to health personnel across levels. In Norway this have been done on a large scale, enhancing the cooperation between the DPC and the primary health care.

Advices (7) Ambulant services are important for patients who are not able to receive other kinds of outpatient treatment.

Advices (8) Consider the possibility of self-help in various forms for mild to moderate depression and anxiety. Especially guided self-help witch combines the use of self-help materials and a few consultations have shown to have effect. Self-help materials can consist of books or Internet based programs. This can be part of a stepped care program. If assisted self-help does not help, the person can be offered participation in self-help groups witch focuses on psychoeducation. The third level is individual therapy.