ABSTRACT Background Community Treatment Orders (CTOs) are contested practices in mental healthcare due to unresolved evidence of effectiveness and persistent human rights concerns. Despite this, Australia has high rates of CTO use internationally. Research from a lived and living experience (LLE) perspective remains limited. Methods This mixed methods research explored experiences of people with LLE of mental ill‐health and being on a CTO (‘consumers’). An online survey including Likert‐rated, categorical and open‐ended questions was disseminated across Australia in 2024 to consumers aged 18 years or over. Quantitative data were reported descriptively, and qualitative data were analysed using Latent Content Analysis. Results Forty‐three people completed the survey; most identified as female (86%); 51.2% were aged 30‐49 years; 7.2% were currently on a CTO; 40.5% had been on a CTO in the past 1‐5 years; and 45.2% had been on a CTO more than once. Automated data contamination (‘bot’) infiltration hampered inclusion of further data. Participant responses included: (1) experiences prior to being on a CTO; (2) experiences whilst on a CTO; (3) attitudes towards CTOs; (4) family involvement; and (5) views on mental health services. While some consumers reported experiencing positive care, many rejected use of CTOs, reporting coercion, exclusion from decision‐making and information, lack of alternative support options, and lack of compassion. Conclusions Policy and practice reforms, including focus on recovery and human rights, appear to have failed to improve experiences of CTOs. Further work to close the policy‐practice gap and translate policy into more inclusive, human rights‐based care is indicated. Lived Experience or Public Contributions This project has included considerable involvement and community engagement with people with lived and living experience (‘LLE’) of CTOs and/or mental health service use in all phases of the project. The project includes two Chief Investigators who identify as LLE leaders and researchers (VE and SL), and who have direct lived experience of CTOs, or as a family/caregiver of individuals who have direct lived experience of CTOs. The project manager (TZ) and some project staff (TS, TK, and PS) are LLE researchers, and the project is guided by a Lived Experience Advisory Panel (LEAP) with LLE experience of CTOs, including both service users and family/caregivers. We also have LLE experts on our project's international advisory panel. Together, their contributions have been vital in the project team's open and transparent reflections on their diverse perspectives and positioning which have grounded the project's focus on LLE perspectives.

Background Global initiatives to reduce restrictive practices in mental health settings have gained increasing attention. However, discrepancies in restrictive practice rates create uncertainties about whether these variations reflect true differences in clinical practices or arise from inconsistent classification and reporting methods. Aims This study investigated how healthcare professionals classify and report potential restrictive practice scenarios, and examined variations in classification and documentation across diverse facilities. Method This was an international survey conducted using an online questionnaire via the Qualtrics platform. Healthcare professionals working in adult mental health in-patient settings were recruited through multiple media platforms and snowball sampling. The questionnaire included 44 potential restrictive practice case scenarios. Participants rated each scenario as follows: (a) whether it should be classified as a restrictive practice; (b) whether it should be recorded as such; (c) whether it would be classified as a restrictive practice within their facility; and (d) whether it would be reported as a restrictive practice in their facility. Survey development was guided by systematic reviews and co-design work with stakeholders. Data were analysed using ordered regression models, with clustering by participant identity and country. Robust standard errors were applied to ensure accurate estimation of variability. Results A total of 491 healthcare professionals from 41 countries participated. Results indicated substantial inconsistencies in clinicians’ perspectives regarding what constitutes restrictive practices and whether a given action should be reported as a restrictive practice. Although participants frequently identified scenarios as restrictive practices, their intention to report them was considerably lower. Additional discrepancies were observed between clinicians’ individual perspectives and their expectations of how these practices were actually being classified and reported as restrictive practices within the in-patient facilities where they work. Conclusions Discrepancies between healthcare professionals’ classification of restrictive practices and their reporting intentions, as well as between their perspectives and actual institutional practices, highlight potential errors in current reporting systems. These findings underscore the need for standardised definitions, enhanced reporting frameworks and structured training programmes and monitoring mechanisms to improve consistency in the management of restrictive practices across mental health settings.

BACKGROUND:The effectiveness of Community Treatment Orders (CTO) and the variability with which they are used remains the subject of ongoing debate. AIMS:To examine the associations between discharge from psychiatric in-patient care on to a CTO in New South Wales (NSW), Australia, and hospital admissions and bed-days in the following 12 months. METHOD:Retrospective matched case-control study using linked administrative health data from NSW between 1 January 2017 and 31 December 2023. Cases were individuals discharged on to a CTO after their first psychiatric hospital admission during the study period. We attempted to match controls 2:1 on age, gender and hospital discharge within 6 months of each other. Data were from the NSW Mental Health Ambulatory and Admitted Patient Data Collections. RESULTS:There were 5506 individuals discharged on to CTOs and 9761 matched controls. Discharge on to a CTO did not affect the odds of hospital readmissions in the following 12 months (adjusted odds ratio (ORadj) = 1.06, 95% CI 0.97-1.14) though was associated with significantly greater bed-days (log βadj = 0.12, 95% CI 0.08-0.17, p < 0.0001). Individuals with a principal diagnosis of non-affective psychosis who were discharged on to a CTO had significantly lower odds of hospital readmissions in the following 12 months (ORadj = 0.67, 95% CI 0.59-0.77). CONCLUSIONS:Discharge on to a CTO did not significantly affect hospital readmissions across the full sample, but did significantly lower the odds for individuals with non-affective psychosis. This suggests that targeted use of CTOs in specific populations (e.g., non-affective psychosis) warrants greater consideration, as the benefit of their use otherwise - especially from a human rights point of view - is unclear. REGISTRATION:Australian and New Zealand Clinical Trials Registry (ACTRN12624000152527).

AIMS:Efforts to reduce restrictive practices (RPs) in mental health care are growing internationally. Yet, inconsistent definitions and perspectives often challenge the consistent implementation and evaluation of reduction strategies. This study explored which scenarios different mental health stakeholders classify as RPs, examined the contextual factors influencing these classifications and compared classification patterns across clinicians, researchers, service users and family caregivers. METHODS:An international cross-sectional survey was conducted using a multilingual online questionnaire hosted on the Qualtrics platform. A total of 851 stakeholders participated, including clinicians (n = 517), service users (n = 80), family caregivers (n = 89) and researchers (n = 165). Participants were presented with 44 potential RP case scenarios and asked to rate whether each scenario should be classified as an RP using a four-point Likert scale (Definitely yes, Probably yes, Probably no, Definitely no). The scenarios were organized into 22 paired comparisons, each sharing the same core context but differing in specific details. Paired comparisons were analyzed one pair at a time, allowing us to identify classification patterns between the scenarios and isolate the effects of particular contextual factors using ordered logistic regression. Interaction analyses were then conducted to assess how classification patterns varied across stakeholder groups. RESULTS:Substantial discrepancies exist both within and between stakeholder groups regarding whether a given action should be considered an RP or not. Physically visible actions were often identified as RPs across all groups, while less visible forms often went unrecognized. Contextual differences, such as the healthcare professional's intention, duration of the action, methods used, presence or absence of consent, door-locking status, and the severity of anticipated harm to be prevented influenced whether a given action was classified as an RP. Service users classified more scenarios as RPs than other groups; however, their decisions were more context-sensitive, shifting notably even with minor changes in scenario details. Among the 22 paired scenarios compared, 13 (59.09%) showed significant differences (p < 0.01) within at least one stakeholder group and eight demonstrated differences between groups. CONCLUSIONS:Mental health stakeholders' interpretations of RPs were often shaped not only by the inherent coercive nature of actions but also by the context in which they occurred and the professional role of the assessors. This underscores the need for harmonized definitions and classification frameworks for RPs, co-designed with diverse stakeholders. Addressing less visible forms of RPs in policy and clinical practice is also essential.

There is an urgent need in the delivery of mental health services to incorporate a more human-rights oriented approach, and promote supported decision-making, whereby individuals are supported their own mental health decisions based on their will and preferences. Aotearoa/New Zealand’s current Mental Health Act enables the use of compulsory treatment, which breaches both international obligations under the Convention of the Rights of Persons with Disabilities and the principles of Te Tiriti o Waitangi (the Treaty of Waitangi), the covenant between Māori and the Crown which demands partnership and equity and the principle of self-determination for Māori. Mental Health Advance Preference Statements (MAPS) have been identified as a tool to promote supported decision-making and allow people a voice in their own care. This paper examines the foundations of a new project which is Māori-centred and co-produced with stakeholders, including tāngata whaiora who experience mental distress and those who work and research mental health services. The aim of this project is to create and implement culturally appropriate and locally relevant MAPS-type tools and then evaluate the impact of implementation. It is posited this will lead to improvements in health and equity, particularly for Māori.

BACKGROUND:The use of community treatment orders (CTOs) has increased in many jurisdictions despite very limited evidence for their efficacy. In this context, it is important to investigate any differences in outcome by subgroup. AIMS:To investigate the variables associated with CTO placement and the impact of CTOs on admissions and bed-days over the following 12 months, including differences by diagnosis. METHOD:Cases and controls from a complete jurisdiction, the state of Queensland, Australia, were analysed. Administrative health data were matched by age, sex and time of hospital discharge (index date) with two controls per case subject to a CTO. Multivariate analyses were used to examine factors associated with CTOs, as well as the impact on admissions and bed-days over the 12 months after CTO placement. Registration: Australian and New Zealand Clinical Trials Registry (ACTRN12624000152527). RESULTS:We identified 10 872 cases and 21 710 controls from January 2018 to December 2022 (total n = 32 582). CTO use was more likely in First Nations people (adjusted odds ratio = 1.14; 95% CI: 1.06-1.23), people from culturally diverse backgrounds (adjusted odds ratio = 1.45; 95% CI: 1.33-1.59) and those with a preferred language other than English (adjusted odds ratio = 1.21; 95% CI: 1.02-1.44). When all diagnostic groups were considered, there were no differences in subsequent admissions or bed-days between cases and controls. However, both re-admissions and bed-days were significantly reduced for CTO cases compared with controls in analyses restricted to non-affective psychoses (e.g. adjusted odds ratio = 0.77, 95% CI: 0.71-0.84 for re-admission). CONCLUSIONS:Queenslanders from culturally or linguistically diverse backgrounds and First Nations peoples are more likely to be placed on CTOs. Targeting CTO use to people with non-affective psychosis would both address rising CTO rates and mean that people placed on these orders derive possible benefit. This has implications for both clinical practice and policy.

Background The use of compulsory community treatment (CCT) in Australia is some of the highest worldwide despite limited evidence of effectiveness. Even within Australia, use varies widely across jurisdictions despite general similarities in legislation and health services. However, there is much less information on whether variation occurs within the same jurisdiction. Aims To measure variations in the use of CCT in a standardised way across the following four Australian jurisdictions: Queensland, South Australia, New South Wales (NSW) and Victoria. We also investigated associated sociodemographic variables. Methods We used aggregated administrative data from the Australian Institute of Health and Welfare. Results There were data on 402 060 individuals who were in contact with specialist mental health services, of whom 51 351 (12.8%) were receiving CCT. Percentages varied from 8% in NSW to 17.6% in South Australia. There were also wide variations within jurisdictions. In NSW, prevalence ranged from 2% to 13%, in Victoria from 6% to 24%, in Queensland from 11% to 25% and in South Australia from 6% to 36%. People in contact with services who were male, single and aged between 25 and 44 years old were significantly more likely to be subject to CCT, as were people living in metropolitan areas or those born outside Oceania. Conclusions There are marked variations in the use of CCT both within and between Australian jurisdictions. It is unclear how much of this variation is determined by clinical need and these findings may be of relevance to jurisdictions with similar clinician-initiated orders.

BACKGROUND:We have previously analysed outcomes for all community treatment orders commenced during a 10-year period in New Zealand. Given Te Tiriti O Waitangi obligations to scrutinise health and consider equity for Māori, we completed this analysis to consider community treatment-order outcomes according to ethnicity. METHODS:Ministry of Health databases provided demographic, service use and medication dispensing data for community treatment-order recipients between 2009 and 2018. As non-Māori on community treatment orders are older, less deprived and less likely to be diagnosed with a Psychotic Disorder, data were categorised according to age (<35/⩾35 years), level of deprivation (New Zealand Dep levels ⩽3, 4-6 and ⩾7) and diagnosis (Psychotic Disorder/non-Psychotic Disorder). The incidences of key outcome measures (admissions, community care, medication dispensing) were calculated for periods on/off community treatment orders for Māori and non-Māori to consider the differential impact of community treatment orders according to ethnicity. RESULTS:Māori have high rates of community treatment order utilisation and are younger, more likely to be diagnosed with a Psychotic Disorder and spend longer receiving compulsory treatment than non-Māori. Non-Māori are more likely to receive more additional depot antipsychotic medication on-community treatment orders compared with periods off-community treatment order than Māori but other clear patterns of response distinguishing between Māori and non-Māori were not present. CONCLUSION:The differences between Māori and non-Māori for community treatment-order utilisation suggest the presence of structural inequity in underlying mental illness distribution and treatment provision. Māori cultural expertise at all levels of healthcare including healthcare planning and delivery is required to make advances and reduce disparity.

INTRODUCTION: An Australasian Airline’s Alcohol and Other Drug (AOD) Program demonstrates abstinence rates that exceed those of general AOD programs. The reasons for this are unclear. The purpose of this research was to develop a theory as to why this program is successful. METHODS: A qualitative examination following grounded theory methodology was undertaken. AOD program patients and healthcare professionals were interviewed until content saturation was reached. Data analysis followed grounded theory to identify the key concepts associated with the program’s success. RESULTS: The core theory that emerged highlighted the pivotal roles of a strong employee–company relationship, shared values, and a safety-focused culture in explicating the program’s success. This moves beyond the “carrot and stick” model of motivation, where belonging to this organization and safety consciousness serve as powerful drivers for abstinence. Challenges and barriers highlighted some unique challenges to the program in managing the coronavirus pandemic and the difference in approach to substance use in community spaces versus safety-critical employment. DISCUSSION: This research expands the understanding of this AOD program’s success in a safety-critical industry, emphasizing the elements of a working relationship that are beyond positive or negative reinforcement. Future research should work to quantify and test the generalizability of these findings. Nairn J, Bell E, Myers J, Higgins M, Johnston B, Newton-Howes G. A grounded theory exploration of addictions treatment within a commercial airline setting . Aerosp Med Hum Perform. 2024; 95(6):313–320.

We argue that editorial independence, through robust practice of publication ethics and research integrity, promotes good science and prevents bad science. We elucidate the concept of research integrity, and then discuss the dimensions of editorial independence. Best practice guidelines exist, but compliance with these guidelines varies. Therefore, we make recommendations for protecting and strengthening editorial independence.

Aim: To understand the themes for Māori subjected to compulsory community treatment orders. Background: The Mental Health (Compulsory Assessment and Treatment) Act 1992 has been utilised in Aotearoa New Zealand for more than three decades. Despite Māori having higher rates of being subject to community treatment orders, there is little research examining their perspectives of its benefits and harms. Methods: Thematic analysis of a purposive sample of Māori in Hawke’s Bay, New Zealand. Results: Five themes were developed. Māori described community treatment orders as restrictive and stigmatising. Some Māori described being poorly informed of the structures surrounding the use of community treatment orders and saw it as a mechanism to circumvent information-giving regarding treatment. Counterbalancing these, Māori described community treatment orders as mandating support and saw them as a mechanism to access care. Finally, some described their compulsory treatment status as unimportant and irrelevant. Conclusions: Thematic analysis identified five clear themes from interview participants. Conceptualisation of community treatment orders was largely negative, although Māori acknowledged that being subject to community treatment orders demanded more support from services. Themes of stigma and restriction are common in the literature, however, conception of the use of community treatment orders to bypass consent is novel. The literature describes community treatment orders as providing support, however, in this study, the interpretation suggests a need to lose personal autonomy to receive care, a potentially ‘slippery slope’ towards a two-tier type service. These findings remind services of the importance of attending to cultural elements of care, being clear around the process of consent. In terms of policy, weaving in cultural understanding appears to be important from an Indigenous perspective.

Purpose Previous research indicates that social support is protective for the mental health outcomes of exposure to childhood adversity. However, the impact of social support as a protective factor following exposure to cumulative childhood adversity is understudied with prospective longitudinal data. The aim of this present study was to examine how social support mediates the impact of cumulative exposure to childhood adversity on internalising disorder in adulthood. Methods The Christchurch Health and Development Study (CHDS) is a general population birth cohort, born in 1977 and representative of Christchurch, New Zealand at the time of the cohort members' birth. The present study used a generalised estimating equations (GEE) framework to analyse direct associations between a cumulative measure of childhood adversity (CA) and internalising disorders (major depression, and any anxiety disorder), and indirect associations through social support. Results Results indicated a dose-dependent relationship between increased exposure to CA and worsened odds of a diagnosis for major depression and any anxiety disorder, respectively. There was also a significant mediating effect of social support on the direct associations between CA and both major depression (OR (95%CI) =0 .98 (0.97, 0.99), p < 001) and any anxiety disorder (OR (95%CI) = .98 (0.97, 0.99), p < 001). Conclusion The findings indicate that social support reduces the impact of childhood adversity on adult mental health, and is therefore a target for future work examining potential interventions following CA.

Background Coercive or restrictive practices such as compulsory admission, involuntary medication, seclusion and restraint impinge on individual autonomy. International consensus mandates reduction or elimination of restrictive practices in mental healthcare. To achieve this requires knowledge of the extent of these practices. Aims We determined rates of coercive practices and compared them across countries. Method We identified nine country- or region-wide data-sets of rates and durations of restrictive practices in Australia, England, Germany, Ireland, Japan, New Zealand, The Netherlands, the USA and Wales. We compared the data-sets with each other and with mental healthcare indicators in World Health Organization and Organisation for Economic Cooperation and Development reports. Results The types and definitions of reported coercive practices varied considerably. Reported rates were highly variable, poorly reported and tracked using a diverse array of measures. However, we were able to combine duration measures to examine numbers of restrictive practices per year per 100 000 population for each country. The rates and durations of seclusion and restraint differed by factors of more than 100 between countries, with Japan showing a particularly high number of restraints. Conclusions We recommend a common set of international measures, so that finer comparisons within and between countries can be made, and monitoring of trends to see whether alternatives to restraint are successful. These measurements should include information about the total numbers, durations and rates of coercive measures. We urge the World Health Organization to include these measures in their Mental Health Atlas.

There is a global initiative to reduce the use of restrictive care practices in mental health settings. Variations in the reported rates across regions complicate the understanding of their use and tracking trends over time. However, it remains unclear whether these discrepancies reflect real differences in the implementation of these practices or are sourced from inconsistencies in incident classification and reporting methods. This study employed a co-design approach to identify contexts that would influence the classification and reporting of restrictive care practices. The research involved 29 mental health stakeholders, including 22 professional experts from 13 countries across Europe, Africa, North America, Asia and Australasia and seven service users and family carers from Australia. Recruitment was conducted through email invitations, snowball sampling and social media outreach. Six web-based panel meetings, each lasting 90-120 minnutes were held. These discussions focused on exploring various contexts that might lead to uncertainty among professionals when classifying and reporting actions whether or not as restrictive care practices. A final list of 23 contexts was identified and considered for the development of 81 case scenario items. Finally, all the 29 panel members selected 44 from 81 case scenarios for inclusion in an upcoming international survey to examine variations in the classification and reporting of restrictive care practices. The findings from this co-design work emphasise the involvement of a wide range of factors and contexts in the classification and reporting of restrictive care practices that may contribute to the observed variations in the in the reported rates of these practices. The case scenarios developed in this study will support future research and serve educational purposes, illustrating real-life situations in the mental healthcare context.

ABSTRACT Background Mental disorders and discrimination share common risk factors. The association between having a mental disorder and experiencing discrimination is well-known, but the extent to which familial factors, such as genetic and shared environmental factors, might confound this association, including gender differences in familial confounding, remains unexplored. Aims We investigated potential unmeasured familial confounding in the relationship between mental disorders and discrimination. Method We examined 2,044 same-sex twin pairs aged 16–25 years from the German population-based study ’TwinLife’ . We used a matched design and random-effects regression applied to within-individual and within-and-between pair models for the association between mental disorder and discrimination, and used likelihood ratio tests (LRTs) to compare these models. Multivariable models were adjusted for body-mass-index, educational attainment, and global life satisfaction. Results Mental disorder and discrimination were associated in the adjusted within-individual model (adjusted odds ratio=2.19, 95% Confidence Interval:1.42–3.39, P <0.001). However, the within-and-between pair model showed that this association was explained by the within-pair mean (aOR=4.24, 95%CI:2.17–8.29, P <0.001) and not the within-pair difference (aOR=1.26, 95%CI:0.70–2.28, P =0.4) of mental disorder. Therefore, this association was mostly explained by familial confounding, which is also supported by the LRTs for the unadjusted and adjusted models ( P <0.001 and P =0.03, respectively). This familial confounding was more prominent for males than females. Conclusions Our findings show that the association between mental disorder and discrimination is almost fully explained by unmeasured familial factors. Incorporating family members in interventions targeted at ameliorating mental ill-health and experiences of discrimination among adolescents may improve efficacy.

BackgroundCompulsory Community Treatment Orders (CTOs) enable psychiatric medication without the need for consent. Careful scrutiny of outcomes including mortality is required to ensure compulsory treatment is evidence-based and ethical. AimsTo report mortality for patients placed on CTOs and analyse data according to CTO status, mortality cause and diagnosis. MethodData for all patients placed under CTOs between 1 January 2009 and 31 December 2018 was provided by the Ministry of Health, New Zealand. Data included diagnostic and demographic information, dates of CTOs, and any dates and causes of death. Deaths were categorised into suicides, accidents and assaults, and medical causes. Mortality data are reported according to CTO status and diagnosis. ResultsA total of 14 726 patients were placed on CTOs over the study period, during which there were 1328 deaths. The mortality rate was 2.97 on and 2.31 off CTOs (rate ratio 1.29, 95% CI 1.14-1.45; P < 0.01). The mortality rate for accidents and assaults was 0.44 on and 0.25 off CTOs (rate ratio 1.73, 95% CI 1.23-2.42; P < 0.01). The mortality rate for medical causes was 2.33 on and 1.90 off CTOs (rate ratio 1.22, 95% CI 1.07-1.40; P < 0.01). The suicide rate was 0.20 on and 0.15 off of CTOs (rate ratio 1.33, 95% CI 0.81-2.12; P = 0.22). ConclusionsIncreased care and medication provided during compulsory treatment does not the modify the course of illness sufficiently to reduce mortality during CTOs. Higher mortality rates during CTO periods compared with non-CTO periods may reflect greater unwellness during CTOs.