Application to coercive in-patient treatment

Coercive in-patient treatment involves practices such as involuntary admission to hospital, locked environments, seclusion, forced medication and physical or chemical restraint. These measures are often used to manage patients at acute risk of harm to themselves or others, but raise significant ethical and human rights concerns. Studies have shown that coercive measures can worsen mental health outcomes, highlighting the need for alternative approaches. ^{Reference Kersting, Hirsch and Steinert3,Reference Chieze, Hurst, Kaiser and Sentissi4} By mapping and evaluating the impact of laws and policies, researchers can then identify best practices and recommend reforms to ensure that mental healthcare respects individuals’ rights and promotes their well-being. For instance, an evaluation of a change from a closed to an open in-patient environment showed that although unauthorised absences increased, there was a reduction in the time spent in seclusion and no increases in violent incidents. ^{Reference Beaglehole, Beveridge, Campbell-Trotter and Frampton5}

In one BJPsych Open paper, Savage et al compared coercive practices in mental healthcare across nine countries, revealing significant variations and the need for standardised measures to evaluate and reduce coercion. ^{Reference Savage, Lepping, Newton-Howes, Arnold, Staggs and Kisely6} The study recommended international collaboration to develop and implement standardised measures, supported by continuous monitoring and reporting.

A further BJPsych Open study explored factors associated with involuntary admission in New South Wales, Australia, given uncertainty as to what these were. ^{Reference Corderoy, Large, Ryan and Sara7} A greater knowledge of these factors might help in reducing coercion in psychiatry. It found that involuntary in-patient treatment had increased despite efforts to decrease its use. The strongest associations with involuntary care were referrals from the legal system and diagnoses of psychosis or organic mental disorders. ^{Reference Corderoy, Large, Ryan and Sara7} Moderate associations included substance use disorders, affective disorders, comorbid cannabis and amphetamine use disorders, unmarried status and being born in Asia, Africa or the Middle East. Conversely, individuals over 75 years old, those with comorbid personality disorders or those with private health insurance were less likely to receive involuntary care. ^{Reference Corderoy, Large, Ryan and Sara7}

There are also potential harms from in-patient treatment with qualitative research highlighting fear and distress during detention, particularly related to the use of force and restraint. ^{Reference Akther, Molyneaux, Stuart, Johnson, Simpson and Oram8} Although this was mitigated by staff efforts to form caring and collaborative relationships and provide clear information, negative impacts on self-worth and emotional state remained.

A final BJPsych Open study highlighted the impacts of involuntary admission on carers. ^{Reference Stuart, Akther, Machin, Persaud, Simpson and Johnson9} This included feelings of relief mixed with distress and anxiety about their loved one’s well-being. Carers emphasised the importance of timely and accessible information, supportive relationships with mental health professionals and involvement as partners in care.

Application to community treatment orders

CTOs allow compulsory treatment in the community for individuals with mental illness. Legal epidemiology can evaluate the effectiveness of CTOs in managing aggression and criminal behaviour among individuals with mental illness. Research has shown mixed results, with some studies indicating that CTOs may not significantly reduce violent or criminal behaviour. ^{Reference Kisely, Bull and Gill10} This suggests that the risk of violence may be influenced by factors beyond the scope of CTOs, such as substance use and environmental conditions. A comprehensive approach involves addressing the social and public health factors that contribute to violence and criminal behaviour. ^{Reference Kisely, Bull and Gill10} Legal epidemiology therefore allows for a broader and deeper understanding of the impact of interventions, potentially informing the development of policies that focus on the whole person and their community, rather than solely relying on legislative control of individuals. This includes integrating social services, community support and preventive measures to create a more holistic and effective mental health system.

Kisely et al (2025) explored variations in CTO use across four Australian jurisdictions using administrative data, where percentages varied from 8% of people in contact with mental health services in New South Wales to 17.6% in South Australia. ^{Reference Kisely, Bull, Zirnsak, Edan, Gould and Lawn11} Use varied widely even within the same jurisdiction. For instance, there was a six-fold difference between services with high and low levels of use in New South Wales and South Australia, while in Victoria it was four-fold. ^{Reference Kisely, Bull, Zirnsak, Edan, Gould and Lawn11} There were also significant disparities in use by gender, place of birth and metropolitan versus rural residence. ^{Reference Kisely, Bull, Zirnsak, Edan, Gould and Lawn11} It therefore seems unlikely that variations in clinical acuity can explain all these differences.

Another BJPsych Open study was a systematic review and meta-regression of 35 papers from 16 epidemiological studies across Australia and New Zealand. This indicated that higher rates of CTO use were associated with worse outcomes, suggesting that better targeted CTO placement that was restricted to use in non-affective psychosis might improve mental health outcomes. ^{Reference Kisely, McMahon and Siskind12} There was a similar finding in a third BJPsych Open paper, which evaluated the outcomes of CTO use for all New Zealanders placed on CTOs over a ten-year period.¹³This compared periods on CTOs with periods off CTOs. CTOs were associated with reduced admissions in people with psychotic disorders, but the opposite occurred for those with dementia disorders, bipolar disorders, major depressive disorder and personality disorders. These findings again raised questions about the appropriate use of CTOs and whether they are sufficiently targeted. The finding that higher rates of medications, including depot antipsychotic medications, were used on CTOs for all diagnostic groups similarly questions the use of compulsory treatments if they are not associated with improved clinical outcomes.

Another study by the same research group evaluated mortality rates on and off CTOs in New Zealand. ^{Reference Beaglehole, Newton-Howes, Porter and Frampton14} There were higher mortality rates on CTOs for deaths by accidents and assaults, as well as medical causes, possibly because CTOs were used at times of greater unwellness and risk. There was no significant effect on suicide. The authors concluded that increased care and medication while on a CTO did not the modify the course of illness sufficiently to reduce mortality.

These BJPsych Open papers therefore suggest that legal and policy frameworks should focus on reducing unnecessary CTO use and ensuring effective use for those who would benefit most.

Application to child maltreatment

Legal epidemiology can also be applied to the prevention of child maltreatment. Several BJPsych Open articles have highlighted the long-term adverse consequences and impacts on public health of child abuse and neglect. For instance, a study by Kisely et al (2024) showed significant associations between substantiated maltreatment and increased emergency department presentations and hospital admissions for common mental disorders up to 40 years old. ^{Reference Kisely, Bull, Trott, Arnautovska, Siskind and Warren15} The paper formed part of a larger project on the consequences of childhood maltreatment on outcomes in adulthood that linked data from a birth cohort to administrative health databases that was described in a further BJPsych Open paper. ^{Reference Kisely, Leske, Arnautovska, Siskind, Warren and Northwood16} This measured emergency department presentations and admissions for a wide range of mental and behavioural conditions, including severe mental illnesses, substance use disorders, suicidal ideation and self-harm.

In contrast to coercive or involuntary psychiatric treatment, there has been less emphasis on analysing the implementation and impact of interventions such as mandatory reporting, child protection services and family support programmes. Concerningly, two recent systematic reviews reported that suspected maltreatment was inconsistently reported to child protection services and, when it was, responses were limited or lacked evidence of efficacy in either the short or long term. ^{Reference Viswanathan, Rains, Hart, Doran, Sathe and Hudson17,Reference Garrison, Gillen, King, Cutshall and Howitt18} This included a broad range of health, psychosocial, academic and behavioural outcomes.