Norway struggles to help self-harming patients
A new study of patients with severe self-harming behaviour shows that poor collaboration within the Norwegian Health System itself is associated with major problems in patient care.
A survey of 61 psychiatric departments in 2017 shows that Norway’s health care system has difficulty helping patients with very serious self-harming behaviour.
A national project group is behind the study, which is published in the Nordic Journal of Psychiatry.
The project group was established by a national advisory unit after repeated requests from clinicians for help.
The advisory unit “received inquiries from clinicians at psychiatric inpatient departments who sought advice on a patient group with very serious self-harm problems and long-term hospitalisation,” says Elfrida Hartveit Kvarstein from the Section for Personality Psychiatry at Oslo University Hospital. She was also head of the project group.
Read More: Young people use self-harm to share emotions
An alarming number of patients self-harm
There are relatively few studies of patients with very serious self-harming behaviour. For this reason, the researchers conducted a first-step screening survey to determine the extent of the problem.
"The study confirms a remarkable number of patients, which may indicate that the health care system has problems diagnosing and working with these patients," says Kvarstein.
The researchers contacted 83 department heads at Norwegian psychiatric inpatient centres and interviewed 61 of them.
“As a result of the interviews, we identified 427 patients who had either unusually frequent admissions in 2016, or unusually long admissions due to serious self-harming behaviour,” says Kvarstein, who describes the number of patients involved as alarmingly high.
“This extensive level of inpatient care suggests that these patients are not being helped by the system in a good way," she says and adds, "the situation was described as very resource-intensive."
Self-harming behaviour may or may not be related to suicide attempts, and can range from superficial cutting to life-threatening injuries. It is most common among young people.
Read More: Self-harm links to violence against others
Patients may have long stays in acute care
Kvarstein emphasizes that the study is a preliminary survey and does not represent all departments in Norway.
The new research shows that patients with self-harming problems were found in all health regions across the country, confirming that the problem is national and not a local phenomena.
Some of these patients stay in acute psychiatric inpatient units for weeks at a time. The researchers wrote of one patient who had been in an inpatient unit for several years.
“These kinds of services are often not staffed for prolonged therapeutic treatment, although they have access to ways to shield the patient or control self-harming behaviour. That means they can take care of the patient, but an acute psychiatric department will usually not be suitable in treating the underlying mental disorder," says Kvarstein.
The interviews revealed examples of very serious and repeated self-harming actions with major consequences. Among the 427 patients admitted in 2016, 5 committed suicide.
Read More: Self-harm is not only for troubled teens
Disagreements about patient treatment
Several department managers experienced major problems coordinating patient treatment with other units. These problems were found both internally within individual departments as well as between hospital departments, District Psychiatric Centres, outpatient services, and first-line services, says Kvarstein.
Norway’s District Psychiatric Centres (DPS) offer specialised health services to adults with psychiatric problems, including examinations, counselling, drug treatment, and crisis help. Most people treated at a DPS are offered outpatient treatment.
The researchers found several examples of disagreements over where the patient should be treated.
“The disagreement was primarily about the capacity to accept the patient, and justification for the admission,” she said.
The hospital department might want to refer patients for treatment at a DPS, while the DPS had problems accepting the patient due to lack of resources, says Kvarstein.
“Prolonged hospitalisation was particularly associated with the combination of severe medical sequelae and collaboration problems within health services,” the researchers wrote.
Hard to find the correct diagnosis
Clinicians could also have different opinions on the patient's diagnosis, and consequently on how the patient should be treated.
Kvarstein points out that self-injury occurs as a result of many different mental illnesses.
“In severe situations, the causes can be difficult to assess. Self-harm can result from everything from psychosis to personality disorders and is very often a combination of multiple psychiatric diagnoses. Self-harm may also complicate other disorders such as mental retardation and autism,” she says. “But if you don’t take into account both the underlying disorder and the severity of the problem, it can be hard to find the best approach,” she says.
The interviews revealed that health professionals were concerned about the quality of the diagnoses and treatments offered to this patient group. The researchers are now in the process of initiating the next step of the research.
“The plan is to conduct a systematic, national survey in 2019 of patients with extensive hospitalisation and serious self-harm. We will survey the patients’ mental health and functioning, as well as experiences and cooperation within the health care system,” says Kvarstein.
Read more in the Norwegian version of this article at forskning.no
- Elfrida Hartveit Kvarstein et al.: Extreme challenges: psychiatric inpatients with severe self-harming behavior in Norway: a national screening investigation, Nordic Journal of Psychiatry, October 2018