THE VELO-2 STUDY. A COMPORATIVE STUDY OF TWO MENTAL HEALTH SERVICE-SYSTEMS: COLLABORATION, COSTS, UTILIZATION AND OUTCOMES.

The modern mental health care of the western world has developed through several stages. One major reform has been the closure of institutions and subsequent development of community mental health services - the deinstitutionalisation of psychiatry. In Norway, the "District psychiatric Centers" (DPS) has been the cornerstone in this development from the 1990s. The VELO-project is a comparative study based on two such centers, one in Vesterålen and one in Lofoten in the northwestern region of Norway. They are very dissimilar in outline and organization, although with the same catchment-area characteristics. One has many local psychiatric beds, while the other has mainly outpatient clinics and day-hospitals. The main scientific question from the project were to what extent this differences had for the treatment and care for patients with similar disorders and needs. The study population was based on data from the national Norwegian Patient Register from the psychiatric services in the years of 2008-2012. A total sample of 20 000 patients were further linked to other national registers such as the Cancer-register, the Death-register and various social registers at the Statistics Central of Norway. The study were granted permission by the national Data Protection Agency, and financed by The Norwegian Research Council. Various types of statistical modeling and the longitudinal design allowed for higher degree of causal explanations of results than is common in mental health services research. Initial results indicated that geographic distance to psychiatric beds did not affect the utilization, were both models used about 1 bed per 1000 inhabitants. Modern communication and health insurance may explain this. We also found that a reduction in bed-use were associated with an increase in out-patient care. This was also associated with a higher rate of mental health services use by the general population. There were no differences in the costs of the two models, by the comparison of key economical parameters of the services. The absolute sizes of main budgets may be of more relevance than the organization of the services. Local beds were also associated with higher continuity of care for patients with severe psychiatric disorders. Locally integrated health systems may enhance clinical alliances over time between therapist and individual patients. This also had relevance for the utilization of care at general practitioners (GPs). Increase individual relations between local personnel may be of importance for this finding. Local beds were also associated with less frequency of incidents with coercion and emergency/acute care. It may be that local-bed units have a treatment philosophy that emphasize more collaboration with other local resources, or that local beds may be more flexible than traditional central hospitals. This may be preventive before the condition of the patient becomes too grave. A side-result of the study indicates a falling rate of patients due to coercion over the period (2003-2012), but an increased incidence of coercive episodes. Changes in legislation and attitudes, and shorter length of inpatient treatment may be of relevance for these findings. In sum may the organization of mental health services have a profound effect the on care and outcomes of psychiatric patients. The study is somewhat negative to contemporary systems that require smooth coordination and collaboration from an array of units and services. A side-branch of the study concentrated on disability and psychiatric conditions. From a sample of 1230 persons in the observational period of 1991-2001, the results indicates that that depression increased in the period, with a rate of 3 to 1 for men to women, and that it increases the risk of disability. An extrapolation of the results from a sample of 1600 persons in the same period indicates that a point prevalence of 55 000 person in Norway may suffer from post-traumatic stress disorder, with about 2500 in annual increase. The results from the project are made publicly available in local and national media, to personnel and decision-makers at the services, and to the international scientific community by international journals.

The VELO?2 is a health-service research project. By means of a close to natural experiment, it explores the utilization and costs of a total set of services in a catchment area served by two models of decentralized mental health services. It describes lon gitudinal care-pathways of severely mentally ill persons, explores cooperation between all three levels of the Norwegian mental health services as well as outcomes of treatment at individual level of patients. It employs the novel concept of integrated ca re-pathways, in relation to individual outcomes of psychiatric health care. It also calculates costs of treatment, by total costs of services, cost of severely mental illness, and cost-benefit analyses. It is built upon the ongoing VELO-project when it co mes to methodology, sets of data, and scientific personnel. Materials and methods. Care-patways, health-service utilization and costs of services for severe mentally ill patients will be studied by the use of case-registries collected from the specialist services, in addition to municipality level of services. Outcome-analysis will be based on linkage to deat-, and social security registers as wll as data available from the health services systems ( need of specialist health services, sivil status and emp loyment status. Cost of health-services will be calculated for specialist services as well as for municipality services. Cost-benefit-analyses will be done for a 1-year cohort of patients recruited by informed consent. Analysis will be done at the level o f system of services, units of services, and service-modalities. For patients, analysis will be done for all psychiatric patients in cathcment-areas, at the level of categories of patients, and at individual level.