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Picture two people, both suffering from a serious mental illness requiring hospital admission. One was born in Australia, the other in Asia.
Hopefully, both could be treated on a voluntary basis, taking into account their individual needs, preferences and capacity to consent. If not, you might imagine they should be equally likely to receive treatment against their will (known colloquially as being "sectioned" or "scheduled").
However, our research published in British Journal of Psychiatry Open suggests this is not the case.
In the largest study globally of its kind, we found Australians are more likely to be treated in hospital for their acute mental illness against their will if they are born overseas, speak a language other than English, or are unemployed.
What we did and what we found
We examined more than 166,000 episodes of voluntary and involuntary psychiatric care in New South Wales public hospitals between 2016 and 2021.
Most admissions (54 per cent) included at least one day of involuntary care.
Being brought to hospital via legal means, such as by police or via a court order, was strongly linked to involuntary treatment.
While our study does not show why this is the case, it may be due to mental health laws.
In NSW, which has similar laws to most jurisdictions in Australia, doctors may treat a person on an involuntary basis if they present with certain symptoms indicating serious mental illness (such as hallucinations and delusions) which cause them to require protection from serious harm, and there is no other less-restrictive care available.
Someone who has been brought to hospital by police or the courts may be more likely to meet the legal requirement of requiring protection from serious harm.
The likelihood of involuntary care was also linked to someone's diagnosis. A person with psychosis or organic brain diseases, such as dementia and delirium, were about four times as likely to be admitted involuntarily compared to someone with anxiety or adjustment disorders (conditions involving a severe reaction to stressors).
However, our data suggest non-clinical factors contribute to the decision to impose involuntary care.
Compared with people born in Australia, we found people born in Asia were 42 per cent more likely to be treated involuntarily.
People born in Africa or the Middle East were 32 per cent more likely to be treated this way.
Overall, people who spoke a language other than English were 11 per cent more likely to receive involuntary treatment compared to those who spoke English as their first language.
Some international researchers have suggested higher rates of involuntary treatment seen in people born overseas might be due to higher rates of psychotic illness. But our research found a link between higher rates of involuntary care in people born overseas or who don't speak English regardless of their diagnosis.
We don't know why this is happening. It is likely to reflect a complex interplay of factors about both the people receiving treatment and the way services are provided to them.
People less likely to be treated involuntarily included those who hold private health insurance, and those referred through a community health centre or outpatients unit.
Our findings are in line with international studies. These show higher rates of involuntary treatment among people from black and ethnic minority groups, and people living in areas of higher socioeconomic disadvantage.
A last resort? Or should we ban it?
Both the NSW and Australian mental health commissions have called involuntary psychiatric care an avoidable harm that should only be used as a last resort.
Despite this, one study found Australia's rate of involuntary admissions has increased by 3.4 per cent per year and it has one of the highest rates of involuntary admissions in the world.
Involuntary psychiatric treatment is also under increasing scrutiny globally.
When Australia signed up to the UN Convention on the Rights of Persons with Disabilities, it added a declaration noting it would allow for involuntary treatment of people with mental illness where such treatments are "necessary, as a last resort and subject to safeguards".
However, the UN has rejected this, saying it is a fundamental human right "to be free from involuntary detention in a mental health facility and not to be forced to undergo mental health treatment".
Others question if involuntary treatment could ever be removed entirely.
Where to from here?
Our research not only highlights concerns regarding how involuntary psychiatric treatment is implemented, it's a first step towards decreasing its use. Without understanding how and when it is used it will be difficult to create effective interventions to reduce it.
But Australia is still a long way from significantly reducing involuntary treatment.
We need to provide more care options outside hospital, ones accessible to all Australians, including those born overseas, who don't speak English, or who come from disadvantaged communities.
This includes intervening early enough that people are supported to not become so unwell they end up being referred for treatment via police or the criminal justice system.
More broadly, we need to do more to reduce stigma surrounding mental illness and to ensure poverty and discrimination are tackled to help prevent more people becoming unwell in the first place.
Our study also shows we need to do more to respect the autonomy of someone with serious mental illness to choose if they are treated. That's whether they are in NSW or other jurisdictions.
And legal reform is required to ensure more states and territories more fully reflect the principal that people who have the capacity to make such decisions should have the right to decline mental health treatment in the same way they would any other health care.
Amy Corderoy is a medical doctor and PhD candidate at the School of Psychiatry, University of NSW Sydney. This article originally appeared on The Conversation.