Restrictive practices in mental health care

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.

Data downloads

Restrictive practices in mental health care tables 2020–21 (78KB XLXS)

Restrictive practices in mental health care section 2020–21 (1MB PDF)

Data source and key concepts related to this section

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.

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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 (78KB XLSX)

 

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 on Mental health services in Australia. 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 (78KB XLSX).

 

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 on Mental health services in Australia. 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.

Notes:
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 (78KB XLSX).

 

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 (78KB XLSX).

 

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 (78KB XLSX).