Restrictive practice in mental health care

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Summary

Key points

  • Almost 1 in 5 (19.9%) residential mental health care episodes were for people with an involuntary mental health legal status during 2019–20.
  • Around 1 in 7 (14.7%) community mental health care contacts were for people with an involuntary mental health legal status during 2019–20.
  • 45.6% of hospitalisations and 55.6% of patient days in admitted hospital acute units were for people with an involuntary mental health legal status during 2019–20.
  • 7.3 seclusion events per 1,000 bed days were reported for acute specialised mental health hospital services during 2020–21, down from 13.9 during 2009–10.
  • 5.2 hours was the average seclusion duration during 2020–21.
  • 11.6 physical restraint events per 1,000 bed days and 0.7 mechanical restraint events per 1,000 bed days were reported during 2020–21.

In Australia, all states and territories collect data regarding the use of restrictive practices in public acute mental health services. Data include the provision of mental health treatment to persons on an involuntary basis, and the use of seclusion and/or restraint, under state and territory mental health legislation.

Nationally in 2019–20 mental health care was provided to people on an involuntary basis during:

  • 1 in 5 residential mental health care episodes (19.9%)
  • 1 in 7 community mental health care service contacts (14.7%)
  • almost 3 in 5 (55.6%) patient days in inpatient Acute units, and
  • 1 in 2 (49.7%) patient days in inpatient non-acute units.

People in acute hospital care in Australia were secluded 12,371 times during 2020–21 for 5.2 hours on average (excluding Forensic services). This represents 7.3 events per 1,000 bed days. The national seclusion rate has nearly halved over the last decade.

Nationally, during 2020–21 there were 19,690 physical restraint events and 1,108 mechanical restraint events, representing 11.6 and 0.7 events per 1,000 bed days respectively. Over the last five years (since data coverage began), the national physical restraint rate has not changed much, while mechanical restraint has more than halved.

Data on involuntary treatment in both community and residential mental health care settings have been available for almost two decades. The use of seclusion and restraint in acute admitted mental health care settings (first reported in 2016) and involuntary treatment in acute and non-acute admitted mental health care settings (first reported in 2019) are more recent data initiatives.

The collection and improvement of data on the use of restrictive practices in Australian mental health care is an ongoing initiative. Annual reporting continues through cooperative efforts in the mental health data sector under national priority endeavours, particularly through coordinated work with state/territory mental health authorities.

Spotlight data

Has the use of seclusion in public mental health hospital care changed over the last decade?

Line and area graph showing seclusion rate (events per 1,000 bed days) in Australia from 2009–10 to 2020–21. Seclusion is the confinement of a person alone in a room or area where they are prevented from free exit. The national seclusion rate nearly halved from 2009–10 to 2020–21. This is real change in how services use seclusion and how patients are treated during hospitalisation. Refer to Table RP.5. 

Involuntary treatment in hospital care and rates of seclusion and restraint are national indicators under the Key Performance Indicators for Australian Public Mental Health Services.

Introduction

Restrictive practices in care settings include any practices and interventions that restrict a person’s rights, including their freedom to move (Australian Government 2014; SQPSC 2016).

State and territory mental health-related legislation specifies the conditions under which restrictive practices may be used. These include the assessment, admission and treatment of people in health services on an involuntary basis in some circumstances, and the use of seclusion (when a person is confined alone in a room or area where free exit is prevented) and restraint (when a person’s freedom of movement is restricted by physical or mechanical means). Minimising the use of seclusion and restraint in mental health services is a key focus across multiple sectors – including consumers, carers, governments and services.

This section reports the latest available national data on the treatment of people on an involuntary basis in Australian public community mental health care services, residential mental health services, and acute and psychiatric hospitals. This section also reports data on the use of seclusion and restraint in Australian mental health acute hospital services.

Involuntary mental health care

All states and territories have legislation on the treatment of people with mental illness. These include provisions relating to the treatment of people on an involuntary basis, which means that under some specific circumstances, a treatment order can be applied to provide mental health treatment – including medication and therapeutic interventions – without the person’s consent being given.

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

In Australia, people can receive mental health treatment on an involuntary basis in community care, residential care, and/or admitted care settings.

Nationally, during 2019–20 around 1 in 7 community mental health care service contacts (14.7%) and 1 in 5 residential mental health care episodes (19.9%) were involuntary (Figure RP.1).

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.

Nationally, during 2019–20 around half of patient days in Acute admitted patient units (55.6%) and Non-acute admitted patient units (49.7%) were involuntary. This represents the proportion of time spent in hospital care under which people received involuntary treatment. People aged 35–39 years and 40–44 years had the highest proportion in Non-acute units, while people aged 25–29, 30–34 and 40–44 years had the highest proportion in Acute units.

Figure RP.1: Mental health care with involuntary mental health status, by states and territories and setting, 2019–20

Bar chart showing the proportion of involuntary mental health care by state/territory and service setting in 2019–20 for acute and non-acute inpatient days, community mental health care contacts and residential mental health care episodes. Refer to Tables RP.2 and RP.3.

Note: Direct comparison between settings is not possible due to different counting units and criteria. More information is in the data source section.

Sources: National Residential Mental Health Care Database, National Community Mental Health Care Database, State and territory governments; Tables RP.2 and RP.3.

Source data: Restrictive practices in mental health care tables

Involuntary care in admitted settings can also be reported for hospitalisations. During 2019–20, almost half (45.6%) of hospitalisations in Acute units and almost 1 in 3 (30.9%) hospitalisations in Non-acute (Other) units nationally were involuntary (Table RP.3). 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.

Involuntary treatment in hospital care is included in the Key Performance Indicators for Australian Public Mental Health Services. These indicators contribute to measuring the performance and progress of mental health services in Australia. The indicators are also reported in the Mental health indicators section. Refer to the data source section for more information.

Seclusion and restraint in mental health care

Seclusion is the confinement of a person at any time alone in a room or area from which free exit is prevented. The purpose, duration, structure of the area and awareness of the person are not considered in determining what constitutes seclusion.

Seclusion also applies if the person agrees to or requests confinement of their own accord. However, if voluntary isolation or time alone is requested and the person is free to leave at any time then this is not considered seclusion.

Restraint is the restriction of a person’s freedom of movement by physical or mechanical means. Physical restraint is the use of hands-on immobilisation techniques by health staff. Mechanical restraint is the application of devices on a person’s body to restrict their movement (for example, belts or straps).

Number of seclusion and restraint events

People receiving mental health care in hospitals were secluded 12,371 times nationally during 2020–21. On average, a seclusion event lasted for 5.2 hours (excluding Forensic services) (Figure RP.2).

Patients were restrained 19,690 times by physical means and 1,108 times by mechanical means nationally during 2020–21 (Figure RP.2.1).

Figure RP.2: Number and duration of seclusion events, average duration (2013–14 to 2020–21) and number of restraint events (2015–16 to 2020–21)

Figure RP.2: Bar graph showing the number of seclusion events in Australia from 2013–14 to 2020–21. A line overlaying the bars shows the average duration of seclusion in Australia for the same period. Refer to Table RP.5.

Figure RP.2.1: Bar graph showing the number of mechanical and physical restraint events in Australia from 2015–16 to 2020–21. Refer to Table RP.8.

Notes: Average duration of seclusion does not include South Australia prior to 2018–19.

Queensland did not collect information on physical restraint events prior to 2017–18.

Source: National Seclusion and Restraint Database, Tables RP.5 and RP.8

Source data: Restrictive practices in mental health care tables

Rates of seclusion and restraint over time

During 2020–21 there were 7.3 seclusion events per 1,000 bed days. This is a decrease from a rate of 8.1 the previous year, and from 15.6 during 2008–09 when data coverage begins (Figure RP.3).

There is an overall downward trend in seclusion rate observed from 2009–10, which marks the first year of data collection for all 8 jurisdictions (a rate of 13.9). Over the last 5 years (2016–17 to 2020–21) there has been an average annual decrease in the national seclusion rate of -0.4%.

Nationally, during 2020–21 there were 11.6 physical restraint events and 0.7 mechanical restraint events per 1,000 bed days (Figure RP.3.1).

The rate of physical restraint has remained between 10.1 and 11.6 in the period since 2015–16 when data coverage begins. The rate of physical restraint has increased from 10.3 in 2017–18, which marks the 1st year of collection for all eight jurisdictions.

The rate of mechanical restraint was 1.7 during 2015–16 when data coverage begins. Over the last 5 years (2016–17 to 2020–21) the average annual change in the mechanical restraint rate is -8.2%.

In keeping with the national priority to minimise the use of seclusion and restraint, rates are included in the Key Performance Indicators for Australian Public Mental Health Services national set (CHC 2017; National Mental Health Working Group 2005 as cited in NMHPSC 2013). These indicators contribute to measuring the performance and progress of mental health services in Australia. The indicators are also reported in the Mental health indicators section. Refer to the data source section for more information.

Rates of seclusion and restraint by states and territories

Figure RP.3: Rates of seclusion (2008–09 to 2020–21) and restraint events (2015–16 to 2020–21), by states and territories

Figure RP.3: Line graph showing seclusion events per 1,000 bed days for all states and territories from 2008–09 to 2020–21. There is an overall downward trend, with the exception of ACT. Refer to Table RP.5.

Figure RP.3.1: Line graph showing mechanical and physical restraint events per 1,000 bed days for all states and territories from 2015–16 to 2020–21. Mechanical restraint shows an overall downward trend, with the exception of NSW. Physical restraint shows an overall upward trend, with the exception of Vic where the rate has decreased over time. Refer to Table RP.8.

Note

Rates are not calculated where numerators are less than 5 or denominators are less than 100 due to the potential for unreliable statistics. Queensland did not collect information on physical restraint events prior to 2017–18. Comparisons between jurisdictions, between years, and for smaller jurisdictions should be undertaken with caution. More information is in the data source section.

Source: National Seclusion and Restraint Database, Tables RP.5 and RP.8

Source data: Restrictive practices in mental health care tables

Seclusion and restraint by target population

Seclusion and restraint data can also be presented by the target population of the service where the event occurred.

For seclusion data during 2020–21 around three-quarters (77.6%) of in-scope care (total number of bed days) was provided by General services. Older person services accounted for 13.9% followed by Forensic (4.4%) and Child and adolescent (4.0%) services.

The highest rate of seclusion during 2020–21 was for Forensic services with 27.3 seclusion events per 1,000 bed days, followed by Child and adolescent services (9.5), General services (7.3) and Older person services (0.3). Forensic services show an increase in the rate of seclusion events between 2009–10 and 2020–21, whilst General, Child and adolescent and Older person services show reductions. However, year on year variability is seen for all target populations (Figure RP.4).

For physical restraint during 2020–21, the rate for Forensic services (59.9 events per 1,000 bed days) was more than twice that of Child and adolescent services (27.2) and over 6 times that of General services (9.2). The rate of mechanical restraint was also highest for Forensic services (Figure RP.4.1). For the period 2015–16 to 2020–21, the use of physical and mechanical restraint was more common for Forensic services than other service types.

Figure RP.4: Rates of seclusion (2008–09 to 2020–21) and restraint (2015–16 to 2020–21), by target population

Figure RP.4: Line graph showing seclusion events per 1,000 bed days for General, Child and adolescent, Older persons, and Forensic target populations, from 2008–09 to 2020–21. Refer to Table RP.6.

Figure RP.4.1: Line graph showing mechanical and physical restraint events per 1,000 bed days for General, Child and adolescent, Older persons, and Forensic target populations, from 2015–16 to 2020–21. Refer to Table RP.9.

Note: Queensland did not collect information on physical restraint events prior to 2017–18.

Source: National Seclusion and Restraint Database, Tables RP.6 and RP.9

Source data: Restrictive practices in mental health care tables

Rates of seclusion and restraint by hospital

Rates of seclusion, physical restraint and mechanical restraint are available for hospitals containing in-scope specialised acute mental health units (excluding forensic units). During 2020–21, the highest rates by hospital were 54.1 for physical restrain, 47.1 for seclusion and 4.7 for mechanical restraint. Of the 134 reported hospitals, 86 (64.2%) had a rate of zero for mechanical restraint, 20 (14.9%) had a rate of zero for seclusion, and 9 (6.7%) a rate of zero for physical restraint.

Rates are presented for all reported hospitals and states and territories in Figure RP.5; to select a specific hospital refer to Figure RP.5.1.

Figure RP.5: Seclusion and restraint rates, by states and territories and hospital, 2020–21

Figure RP.5: Horizontal bar chart showing seclusion and mechanical and physical restraint events per 1,000 bed days in 2020–21 by hospital, excluding forensic units. Refer to Table RP.11.

Figure RP.5.1: Interactive text display showing seclusion and mechanical and physical restraint events per 1,000 bed days for each hospital in 2020–21. The user is able to select a particular hospital to display. Refer to Table RP.11.

Source: National Seclusion and Restraint Database, Table RP.11

Source data: Restrictive practices in mental health care tables

Key concepts

Key concept Description

Admitted patient mental health care

Admitted patient mental health care refers to a specialised mental health service in a psychiatric hospital or specialised mental health unit in an acute hospital that provides overnight care.

There are two types of admitted patient care. Acute care admitted patient programs involve short‑term treatment for individuals with acute episodes of a mental disorder, characterised by recent onset of severe clinical symptoms that have the potential for prolonged dysfunction or risk to self and/or others. Other or non‑acute care refers to all other admitted patient programs, including rehabilitation and extended care services.

Community mental health care

Community mental health care refers to government‑funded and operated specialised mental health care provided by community mental health care services and hospital‑based ambulatory care services, such as outpatient and day clinics.

Episodes of residential care

Episodes of residential care are defined as a period of care between the start of residential care (either through the formal start of the residential stay or the start of a new reference period (that is, 1 July)) and the end of residential care (either through the formal end of residential care, commencement of leave intended to be greater than 7 days, or the end of the reference period (that is, 30 June)). An individual can have one or more episodes of care during the reference period.

Hospitalisation

Hospitalisation is the term used to refer to the episode of admitted patient care, which can be a total hospital stay (from admission to discharge, transfer or death) or a portion of a hospital stay beginning or ending in a change of type of care (for example, from acute care to rehabilitation).

Mental health legal status

Mental health legal status is defined as whether a person is treated on an involuntary basis under the relevant state or territory mental health legislation, at any time during an episode of admitted patient care, an episode of residential care or treatment of a patient/client by a community based service during a reporting period.

Patient days

Patient day means the occupancy of a hospital bed (or chair in the case of some same day patients) by an admitted patient for all or part of a day. The length of stay for an overnight patient is calculated by subtracting the date the patient was admitted from the date of separation and deducting days the patient was on leave. A same-day patient is allocated a length of stay of 1 day. Patient day statistics can be used to provide information on hospital activity that, unlike separation statistics, account for differences in length of stay. The patient day data presented in this report include days within hospital stays that occurred before 1 July provided that the separation from hospital occurred during the relevant reporting period (that is, the financial year period). This has little or no impact in private and public acute hospitals, where separations are relatively brief, throughput is relatively high and the patient days that occurred in the previous year are expected to be approximately balanced by the patient days not included in the counts because they are associated with patients yet to separate from the hospital and therefore yet to be reported. However, some public psychiatric hospitals provide very long stays for a small number of patients and, as a result, would have comparatively large numbers of patient days recorded that occurred before the relevant reporting period and may not be balanced by patient days associated with patients yet to separate from the hospital.

Residential mental health care

Residential mental health care refers to residential care provided by residential mental health services. A residential mental health service is a specialised mental health service that:

  • employs mental health trained staff on‑site
  • provides rehabilitation, treatment or extended care to residents for whom the care is intended to be on an overnight basis and in a domestic‑like environment
  • encourages the residents to take responsibility for their daily living activities.

These services include those that employ mental health trained staff on-site 24 hours per day and other services with less intensive staffing. However, all these services employ on‑site mental health trained staff for some part of the day.

Restraint

Restraint is defined as the restriction of an individual's freedom of movement by physical or mechanical means.

Mechanical restraint

The application of devices (including belts, harnesses, manacles, sheets and straps) on a person's body to restrict his or her movement. This is to prevent the person from harming themselves or endangering others or to ensure the provision of essential medical treatment. It does not include the use of furniture (including beds with cot sides and chairs with tables fitted on their arms) that restricts the person's capacity to get off the furniture except where the devices are used solely for the purpose of restraining a person's freedom of movement.

The use of a medical or surgical appliance for the proper treatment of physical disorder or injury is not considered mechanical restraint.

Physical restraint

The application by health care staff of ‘hands-on’ immobilisation or the physical restriction of a person to prevent the person from harming themselves or endangering others or to ensure the provision of essential medical treatment.

Seclusion

Seclusion is defined as the confinement of a person at any time of the day or night alone in a room or area from which free exit is prevented.

Key elements include that:

  1. The person is alone.
  2. The seclusion applies at any time of the day or night.
  3. Duration is not relevant in determining what is or is not seclusion.
  4. The person cannot leave of their own accord.

The intended purpose of the confinement is not relevant in determining what is or is not seclusion. Seclusion applies even if the person agrees or requests the confinement.

The awareness of the person that they are confined alone and denied exit is not relevant in determining what is or is not seclusion. The structure and dimensions of the area to which the consumer is confined is not relevant in determining what is or is not seclusion. The area may be an open area, for example, a courtyard. Seclusion does not include confinement of people to High Dependency sections of gazetted mental health units, unless it meets the definition.

More information can be found in the data source section about jurisdictional consistency with this definition.

Service contacts

Service contacts are defined as the provision of a clinically significant service by a specialised mental health service provider for patients/clients, other than those admitted to psychiatric hospitals or designated psychiatric units in acute care hospitals and residents in 24‑hour staffed specialised residential mental health services, where the nature of the service would normally warrant a dated entry in the clinical record of the patient/client in question. Any patient can have one or more service contacts over the relevant financial year period. Service contacts are not restricted to face‑to‑face communication and can include telephone, video link or other forms of direct communication. Service contacts can also be either with the patient or with a third party, such as a carer or family member, other professional or mental health worker, or other service provider.

Target population

Some specialised mental health services data are categorised using 5 target population groups:

  • Child and adolescent services focus on those aged under 18 years.
  • Older person services focus on those aged 65 years and over.
  • Forensic health services provide services primarily for people whose health condition has led them to commit, or be suspected of, a criminal offence or make it likely that they will reoffend without adequate treatment or containment.
  • General services provide services to the adult population, aged 18 to 64, however, these services may also provide assistance to children, adolescents or older people.
  • Youth services target children and young people generally aged 16-24 years.

Note that, in some states, specialised mental health beds for aged persons are jointly funded by the Australian and state and territory governments. However, not all states or territories report such jointly funded beds.

 

Data coverage is 2019–20 for involuntary care, 2008–09 to 2020–21 for seclusion, and 2015–16 to 2020–21 for restraint. This section was last updated in May 2022.