Involuntary treatment in mental health care Print this page

This report presents information about involuntary treatment in Australian public mental health services. It includes community (day) services, residential (overnight) services, and hospital services.

Data from community and residential service settings have been available for almost two decades. Data from mental health hospital settings were first reported in 2019 and include acute (short-term) and non-acute (rehabilitation and extended care) programs. Where trend data are available, the 10-year change of the use of involuntary treatment varies by setting of care.

• In community services, the proportion of involuntary treatment has remained stable over the past 10 years.
• In residential services, the proportion of involuntary treatment has decreased slightly over the past 10 years.
• Hospital services have the highest proportion of involuntary treatment.

Involuntary treatment in hospital mental health care is used more often for:

• males compared with females
• adults aged 25 to 64
• Aboriginal and/or Torres Strait Islander peoples compared with non-Indigenous people.

In Australia, community and residential services for people with a diagnosis of Schizophrenia or Schizoaffective disorder have the highest rate of involuntary treatment compared to other common mental disorders in public mental health services.

Globally, and in Australia, involuntary treatment practices are an area of focus for health service improvement. The World Health Organisation (WHO) and the Organisation for Economic Co-operation and Development (OECD) have position documents on its use, but international differences in definitions and counting methods means that comparative reporting is challenging. Australia was second among countries with the highest rates of involuntary hospitalisation in a study of 22 countries across Europe, Australia, and New Zealand (Rains et al. 2019).

The National Mental Health Consumer and Carer Forum's stated position is that the rate of involuntary treatment in Australia remains too high (NMHCCF 2020).

While Australian states and territories have different legal criteria and data collection systems, it is possible to report on the use of involuntary treatment due to the coordinated efforts of state/territory mental health authorities and national government agencies. The collection and improvement of data on the use of involuntary treatment in Australian mental health services continues with ongoing collaboration.

All Australian states and territories have legislation relating to the rights and treatment of people with mental illness in medical and health care. There are conditions that must be met for health services and staff to provide assessment, admission and treatment to people on an involuntary basis. Treatment includes medication and other therapeutic interventions.

Legal approval is needed to order involuntary treatment. It must be shown:

• the person has a mental illness, and
• there is serious risk of harm to the health of the person or the safety of the person or public, and
• there is no less restrictive way to provide treatment (RANZCP 2017a).

Legislation varies between states and territories and the Royal Australian and New Zealand College of Psychiatrists notes “this variation is a barrier to pursuing best practice and reducing the incidence of involuntary treatment” (RANZCP 2017b).

Involuntary treatment is an example of a restrictive practice in a care setting. A restrictive practice is any practice or intervention that restricts a person's rights (Australian Government 2014; SQPSC 2016).

The National Mental Health Consumer and Carer Forum maintains that involuntary treatment and other restrictive practices are avoidable and preventable, and that involuntary treatment remains too high (NMHCCF 2020). 

Other examples of restrictive practices are:

• Seclusion. When a person is put alone in a room or area and they cannot get out by themselves. An example is a room with a door that locks and unlocks from the outside.
• Physical restraint. When staff use their hands or body to stop a person moving their body freely.
• Mechanical restraint. When items are used on a person’s body to stop them moving their body freely. Examples are belts or straps on a person’s hands or arms.

More information about these is in the Seclusion and restraint report.

Involuntary treatment in hospital mental health care is included in the Key Performance Indicators for Australian Key Performance Indicators in Public Mental Health Services. These indicators contribute to measuring the performance and progress of mental health services in Australia. Data on these indictors are also reported on AIHW's Mental Health Online Report. Refer to the data sources section for more information.

In a number of data collections, mental health legal status is used to identify if a person’s treatment was on an involuntary basis. Figure 1 shows Australian public mental health care provided under involuntary treatment arrangements.

Figure Invol.1 Involuntary treatment in Australian public mental health care

Hospital services provide specialised mental health care for people who are admitted to a psychiatric hospital or mental health unit in a hospital. In Australia, nearly half of hospitalisations in acute units and one third of hospitalisations in non-acute units are involuntary. Acute units provide short-term care and non-acute units include rehabilitation and extended care.

Community services provide specialised mental health care for people who are living in the community. Around 1 in 7 community service contacts across Australia is provided on an involuntary basis. This rate has not changed over the past decade.

Residential services provide specialised mental health care for people who are staying overnight in a domestic-like environment. The rate of involuntary residential care episodes in Australia has decreased from around 1 in 3 to around 1 in 6 over the past decade.

Western Australia has consistently reported a lower rate of involuntary community contacts over time compared to other states and territories. Although year to year numbers show some variability, around 1 in 32 community service contacts in Western Australia is involuntary. Western Australia has also reported the lowest rate of involuntary residential episodes and hospitalisations in mental health care.

The measure of patient days provides an indication of the number of days that the person received care during a mental health-related hospitalisation.

Nationally, people spend more than half of patient days under involuntary treatment. Most jurisdictions report a proportion of involuntary patient days above 50% in both acute and non-acute units (Figure 2).

Figure Invol.2 Patient days spent under involuntary treatment in Australian public hospital mental health care

Guidance on the use of involuntary treatment 

Involuntary hospitalisation and treatment are controversial practices (OECD 2021). For situations where involuntary care is considered necessary, international human rights documents have been developed to guide legal frameworks and good practice standards to avoid the inappropriate use of involuntary hospitalisation and treatment. These include the European Convention for the Protection of Human Rights and Fundamental Freedoms (European Court of Human Rights 1950) and the Mental Health Care Law: Ten Basic Principles (WHO 1996).

Efforts to develop international reporting on involuntary treatment 

Comparable reporting on the use of involuntary treatment across different countries is challenging due to:

• limited data availability and partial supply in some countries
• differences in how data on involuntary treatment are counted and collected
• differences in definitions of involuntary treatment
• differences in practice guidelines and legal conditions for use of involuntary treatment (WHO 2021a, 2021b; OECD 2021).

Internationally, reporting on mental health care performance and quality have improved since performance indicators were introduced by the OECD (Organisation for Economic Co-operation and Development) in 2013.

The EUNOMIA project , conducted from 2003 to 2006 (European Evaluation of Coercion in Psychiatry and Harmonisation of Best Clinical Practice), assessed the clinical practice of involuntary mental health hospitalisations in 12 European countries. The study found:

• the frequency of involuntary hospital treatment varied greatly between countries
• this was partly because of individual country’s sociocultural differences
• factors such as hospital structures or staffing levels did not influence rate of involuntary treatment (Raboch et al. 2010; Kalisova et al. 2014).

How does Australia compare? 

Data collection on involuntary treatment is one objective of the World Health Organisation's Comprehensive Mental Health Action Plan 2013–2030 (WHO 2021a). Data are collected globally under the Mental Health Atlas. For 2020:

• 171 out of the 194 member states (88%) at least partially contributed data
• 10% of the total number of admissions to inpatient facilities across countries were involuntary
• Australia, Canada, and New Zealand did not report the number of involuntary admissions in hospital mental health care (WHO 2021b).

In a study of 22 countries across Europe, Australia, and New Zealand, data were drawn from multiple sources including national organisations, peer-reviewed literature, and the WHO Mental Health Atlas.

• Australia was second among countries with the highest rates of involuntary hospitalisation.
• Australia’s involuntary hospitalisation rate was 227 per 100,000 people in 2016.
• The rate in Australia was more than double the mid-point of 106 among the 22 countries studied, with the highest rate in Austria (282) and the lowest in Italy (15) (Rains et al. 2019).

How long can a person be held involuntarily without review? 

The OECD (2021) reported the number of days a person can be held involuntarily under mental health legislation without review of a judge in 22 countries.

• In some countries (including Belgium), people can be held for 24 hours or less.
• In almost half (10 out of 22) of the countries (including Canada), people can be held for 1–3 days.
• In some countries (including Japan), there is no limit for the duration of involuntary hospitalisation.
• In countries with federated governments, such as Australia, there is no national legislation and states/territories have their own legal frameworks for how long a person can be held without review (OECD 2021).

Data on involuntary treatment for key demographics are only currently reported for hospital mental health care (Figure 3).

Figure Invol.3 Demographics of people who received involuntary treatment in Australian public hospital mental health care

The relationship between involuntary mental health legal status and demographic factors for people in hospital care varies globally (Curley et al. 2016). In Australia, people aged 30 to 44 years have the highest proportion of involuntary hospitalisations. People of this age are also among the age groups with the highest rates of hospitalisations in mental health care (AIHW 2022, Figure AC.3).

While people aged 18 to 24 have the highest rate of hospitalisations in mental health care (AIHW 2022, Figure AC.3), they have a lower rate of involuntary treatment in hospital mental health care compared to most other adult age groups. People aged 85 years and over have the lowest rate of involuntary treatment in hospital mental health care of all adult age groups.

In Australia, males have higher rates of involuntary hospitalisations in mental health care and patient days spent in involuntary care in hospital mental health units than females.

The rate of hospitalisations in mental health care for Aboriginal and/or Torres Strait Islander peoples is more than twice the rate for non-Indigenous patients (AIHW 2022, Figure AC.3). Indigenous people also have the highest rate of involuntary hospitalisations in mental health care and patient days spent in involuntary care in hospital mental health units. For more information about Aboriginal and/or Torres Strait Islander mental health refer to the Indigenous Mental Health & Suicide Prevention Clearinghouse. To learn more about ongoing initiatives visit the Aboriginal and Torres Strait Islander Health Performance Framework.

The non-specific category Mental disorder not otherwise specified is the most frequently recorded mental health-related principal diagnosis for mental health community services. Excluding this, the most commonly reported diagnoses in community and residential services are shown in Table 1.

Table 1: Most commonly reported mental health-related diagnoses in public mental health community and residential services

Principal Diagnoses	Proportion of community mental health care contacts	Proportion of residential mental health care episodes
Schizophrenia	21%	23%
Specific personality disorders	5%	16%
Depressive episode	6%	10%
Schizoaffective disorders	6%	9%
Bipolar affective disorders	5%	7%
Reaction to severe stress and adjustment disorders	5%	7%

Source data: Community mental health care services (Table CMHC.15) and Residential mental health care services (Table RMHC.15)

Figure 4 shows the proportion of involuntary treatment for each of the five most common mental health-related diagnoses. In community and residential care, people with a diagnosis of Schizophrenia or schizoaffective disorders have the highest proportions of involuntary treatment.

Figure Invol.4 Involuntary treatment for five common mental health-related diagnoses in Australian public mental health care

Psychotic disorders (such as schizophrenia) are characterised by disturbances in thinking and impairments in the way reality is perceived. This may include persistent delusions and/or hallucinations, disorganised speech and/or behaviour, and psychomotor disturbances (WHO 2022).

It is estimated that 5 per 1,000 people with a psychotic illness aged 10 to 64 were in contact with public specialised mental health services in a year (Morgan et al. 2012).

The use of compulsory treatment orders is more common for people who experience severe and persistent mental disorders than other types of mental disorders. People with major psychotic disorders such as schizophrenia are more likely to receive involuntary treatment than people with other mental disorders (Plahouras et al. 2020). Studies on involuntary treatment found that a history of a severe mental disorder is a predictor of involuntary mental health care (Kelly et al. 2004; Xiao et al. 2004).

Similarly, the EUNOMIA international study identified that diagnosis and severity of symptoms were found to be significant risk factors of involuntary treatment. People with a psychotic disorder were more likely to receive compulsory treatment (Kalisova et al. 2014).

Currently New South Wales, Victoria and Queensland are the only jurisdictions that report data for the Your Experience of Service (YES) survey which collects information from people receiving public mental health care about their experience of care. Data from survey respondents shows a positive experience of service is more likely for people who received care under Voluntary status than Involuntary and Not reported status (Figure 5). For more information, visit the Consumer perspectives report.

Figure Invol.5: Consumer-reported positive experience of service by people who received involuntary treatment in Australian public mental health care

Involuntary mental health treatment can often shape the therapeutic relationship between consumers and providers (Saya et al. 2019; Wyder et al. 2015). The National Mental Health Consumer and Carer Forum has published accounts from people who have described their experiences of involuntary treatment. The Forum states that involuntary treatment "precludes the development of trust and respect between consumers and families/carers and clinical staff, leading to fear and distress among consumers and a breakdown of therapeutic relationships" (NMHCCF 2020).

Research has identified that where there is no clear communication between providers and consumers about the use of involuntary treatment, it is difficult for consumers to understand why they are receiving involuntary treatment. This can contribute to negative experiences of involuntary treatment and of mental health care generally (Dawson et al. 2021).

Legally, coercive practices such as treatment orders can only be used in the most limited and regulated instances:

• where the person has a mental illness, and
• where there is serious risk of harm, and
• where there is no less restrictive way to provide treatment.

The Forum suggests that treatment orders are sometimes used as a threat to ensure compliance (a practice they refer to as 'emotional restraint') (NMHCCF 2020). Australia has some of the highest rates of involuntary treatment in mental health care. Involuntary treatment, especially if used without best practice arrangements, can negatively impact on consumers' experiences of mental health care.

A person's mental health legal status indicates if their treatment was on an involuntary basis.

Information on mental health legal status data is collected by state and territory governments and supplied to the AIHW for national reporting. Mental health legal status is recorded for service contacts, episodes, hospital separations, or hospital patient days, depending on the service setting as specified in the data source section.

In Australia, people can receive mental health treatment on an involuntary basis in community care (involuntary service contacts), residential care (involuntary episodes of care), and/or hospital care settings (involuntary hospitalisations).

In community mental health services, care is recorded as involuntary if the person is receiving care on an involuntary basis at the time of contact.

For residential services, care is recorded as involuntary if the person received involuntary treatment at any time during their period of mental health care—the person may not have been given treatment involuntarily for the entire period of care.

Like residential care, a hospitalisation is coded as involuntary if the person received involuntary treatment at any time during the care period—patients may not be given involuntary treatment for their entire hospitalisation.

Direct comparison between settings is not possible due to different counting units and criteria.

A treatment order is a legal order for compulsory assessment or treatment of a person in a mental health service. The legislation for treatment orders varies by state or territory, but in general, treatment orders involve a process of application, review, and approval/rejection from a legal authority such as a tribunal, magistrate or office of the Chief Psychiatrist.

Each state and territory government reports information on activity of treatment orders in public annual reports. Reporting of service contacts with a mental health legal status of Involuntary will differ from reporting of treatment orders in the community by state and territory Chief Psychiatrists due to differences in statistical unit, collection scope and jurisdictional data systems.

Note that time series comparisons should be interpreted with care and comparisons between states and territories should be made with caution. Changes to state and territory legislation and data collection methods can result in changes in the recording of contacts or episodes with involuntary legal status.

Apparent increases in Involuntary legal status in community and residential mental health care settings in New South Wales in 2018–19 is a reflection of poorer data quality in previous years. Information system transition and changed business practices impacted legal status from 2015–16. Similarly, improved data collection practices in government-operated services in Tasmania have led to an increase in the reported number of involuntary episodes in 2014–15.

The volume of residential episodes with involuntarily mental health legal status is likely to be understated for South Australia for the 2013–14 year due to a known data and reporting issue with also affects the national total.

More information can be found in the Community mental health care NMDS 2020–21: National Community Care Database, 2022; Quality Statement and the Residential mental health care NMDS 2020–21: National Residential Mental Health Care Database, 2022; Quality Statement.

Mental health legal status information is collected for the National Community Mental Health Care Database (NCMHCD)—which has coverage from 2000—and is collected for each service contact. Mental health legal status is recorded as involuntary if the person was given legislated involuntary treatment at the time of the service contact. It does not collect how much of their care involved involuntary treatment.

Data for the NCMHCD are supplied under the Community Mental Health Care National Minimum Data Set (CMHC NMDS) agreement. Data Quality Statements are published annually on the Metadata Online Registry (METEOR). Statements provide information on the institutional environment, timelines, accessibility, interpretability, relevance, accuracy and coherence. Refer to the CMHC NMDS Data Quality Statement. Previous years' data quality statements are also accessible via METEOR. Data from this collection are published online annually on AIHW’s Mental Health Online Report under Community mental health services.

Mental health legal status has been collected for the National Residential Mental Health Care Database (NRMHCD) since 2004 and is collected for each episode of care. Mental health legal status is recorded as involuntary if the resident was given legislated involuntary treatment at any time during an episode of care. It does not collect how much of their care involved involuntary treatment.

Data for the NRMHCD are supplied under the Residential Mental Health Care National Minimum Data Set (RMHC NMDS) agreement. Data Quality Statements are published annually on METEOR. Statements provide information on the institutional environment, timeliness, accessibility, interpretability, relevance, accuracy and coherence. Refer to the RMHC NMDS Data Quality Statement. Previous years' data quality statements are also accessible in METEOR. Data from this collection are published online annually on AIHW's Mental Health Online Report, under Residential mental health services.

Under the Fifth National Mental Health and Suicide Prevention Plan (2017–2022) the proportion of involuntary hospitalisations to specialised mental health services was introduced as national Performance Indicator (PI) 23: Rate of involuntary hospital treatment (NMHC 2020).

To facilitate a better understanding of the amount of involuntary treatment occurring in mental health hospitals, two involuntary treatment indicators under PI 23 were developed.

• Involuntary hospital treatment measures the proportion of public­­ hospital mental health separations in which a person was given involuntary treatment under existing legislation at any time during their treatment (proportion of separations with a mental health legal status of involuntary). Distinction between acute and non-acute units is possible. It does not measure how much of the care received was involuntary.
• Involuntary patient days measures the proportion of public mental health admitted patient days in which a person received care on an involuntary basis (NMHC 2020). Distinction between acute and non-acute units is possible.

All types of treatment orders are in scope for admitted care under these indicators, regardless of the setting of the treatment order. For example, admitted patients who are under a community treatment order will be included in the counts of involuntary hospitalisations.

These indicators were developed by pertinent committees of the day under the former Australian Health Ministers' Advisory Council (AHMAC) structure. The indicators were developed and established by the former Safety and Quality Partnership Standing Committee (SQPSC) and former Mental Health Information Strategy Standing Committee (MHISSC), with MHISSC's former National Mental Health Performance Subcommittee (NMHPSC) having undertaken the technical development of the indicator specifications (NMHPSC 2013).

The two involuntary indicators have been included in the Key Performance Indicators for Australian Public Mental Health Services (Jurisdictional level) indicator set since 2021.

For more detail on the indicators, refer to KPIs for Australian Public Mental Health Services: PI 17aJ – Involuntary hospital treatment, 2022 and KPIs for Australian Public Mental Health Services: PI 17bJ – Involuntary patient days, 2022. Data from these indicators are published online annually on AIHW’s Mental Health Online Report, under Performance Indicators for mental health care.

The Your Experience of Service (YES) survey is offered by public mental health services to people who have received care. The survey comprises 26 questions to collect data on perceptions of their treatment and the care they received. The survey includes an item on whether the person received involuntary treatment during the last 3 months.

Data are supplied under the YES National Best Endeavours Data Set (YES NBEDS) agreement. New South Wales, Queensland and Victoria currently supply data under this agreement and this is published online annually on AIHW's Mental Health Online Report under Consumer perspectives in mental health care. More information about the survey instrument, data methodology, and data quality over time can also be found in the report.

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