A form of compulsory psychiatric treatment has recently come under fire from leading mental health experts for being ineffective and potentially unethical. The practice also raises concerns about Australia’s obligations under international human rights law.
It is not common knowledge that Australian laws allow for compulsory psychiatric treatment in the community. Community treatment orders (or “CTOs”) permit involuntary psychiatric treatment outside the hospital, in people’s homes and residences.
CTOs allow authorised psychiatrists to impose medication on former inpatients. These are often fortnightly or monthly injections. If the person refuses to comply, they can be taken by police and detained in a psychiatric facility.
Australia reportedly has rates of involuntary community treatment that are among the highest in the world. One study estimated that 5,675 Victorians were subject to CTOs in 2012, with figures rising significantly. Today, more than 10,000 people are likely to be subject to CTOs across Australia.
CTOs are based on the logic that forced treatment reduces the suffering of people with profound mental illness and saves lives. From this view, CTOs offer an alternative to more restrictive detention in psychiatric facilities, freeing up resources elsewhere in the system.
While this might sound attractive to some, it is not supported by robust evidence. Instead, mounting research indicates CTOs are no more effective than standard care.
A recent editorial by leading psychiatrists in the UK called for CTOs in their current form to be scrapped. Members of an executive committee of the Royal College of Psychiatrists (UK) cited three large-scale randomised control trials, which failed to show the efficacy of CTOs. According to the authors, if this standard of evidence was applied in general health care, “no clinical procedure would have any support from any regulatory institution”.
What are the concerns?
In particular, three large-scale, randomised control trials and their meta-analyses have failed to support the view that CTOs are effective in achieving their principle aims. These are: lowering hospitalisation rates; improving service use, mental state, or quality of life, or satisfaction with care.
The use of CTOs also has a number of potential pitfalls. Views in the community that people with mental health issues are untrustworthy and somehow invite a system of control and coercion could be exacerbated.
The ease with which clinicians can compel treatment via CTOs potentially undermines therapeutic relationships based on trust.
Finally, some of those subject to forced treatment have reported the experience as being like torture. The intervention is generally agreed to be a significant curtailment of personal liberty.
CTOs appear to violate the human rights of an already marginalised group. Australia has ratified the United Nations Convention on the Rights of Persons with Disabilities. This states that:
persons with disabilities have the right to the enjoyment of the highest attainable standard of health without discrimination on the basis of disability […] including on the basis of free and informed consent.
Last year, the United Nations committee overseeing the convention directed Australia to:
repeal all legislation that authorises […] the imposition of compulsory treatment […] in the community via Community Treatment Orders.
Aside from these human rights concerns, CTOs are expensive. Costs include clinical administration and delivery, regulation by legal instruments such as mental health tribunals, and resources for ordering people to hospital. This may require multiple emergency services, such as police, ambulance and emergency departments.
CTOs are often favoured by family members and carers who may be concerned about a relative who is not taking medication. Concerns understandably arise over the potential for self-harm and suicide.
These arguments are emotionally appealing, especially if the doctors believe in the effectiveness of coercive care in the community, which some research shows to be the case. But given mounting evidence, CTOs may meet family members’ and clinicians’ interests, but not the interests of those subject to orders themselves.
So what is the alternative?
The Australian government recently announced its response to the National Mental Health Commission’s (NMHC) review. It suggested a major overhaul in the allocation of around A$10 billion of Commonwealth funding.
The NMHC requested the current focus of the system should shift toward personally tailored supports which meet a person’s needs rather than meeting what clinical professionals think a person needs.
An example is a community-based and family-oriented approach in Ballarat, Victoria. The program works with the person and their family to come up with treatment that supports the person’s whole life, not just their medical needs. According to the NMHC, this service reduced the number of inpatients to 63.3% for adults and 60.7% for aged care. This compares well with the state average of 91%.
To achieve the shift sought by NMHC and the federal government, and to help Australia meet its human rights obligations, the resources spent on CTOs would be better spent on voluntary, evidence-based and personalised support.