Introduction
The indigenous inhabitants of the Australian continent arrived approximately 65 000 years ago. Treatment for schizophrenia prior to European arrival is not well known by current professionals. The Commonwealth of Australia, a parliamentary democracy, was established in 1901. The Commonwealth is a federation of six states and two territories that were originally colonies of Britain. Australia has a population of 26.8 million people, 30% of whom are born overseas. Indigenous Australians make up 3.8% of the population. Schizophrenia is a complex disorder of brain functioning, which the World Health Organization describes as a “disturbance involving the most basic functions that give the normal person a feeling of individuality, uniqueness and self-direction.” 1 Schizophrenia affects up to 1% of the populationReference Simeone, Ward, Rotella, Collins and Windisch 2 and is among the top 10 disorders in the global burden of disease and disability.Reference Mathers and Loncar 3 Australian surveys show similar prevalence results to international studies.Reference Jablensky, McGrath and Herrman 4
Treatment of schizophrenia includes staging of the disorder, psychological interventions (such as Cognitive Behavioral Therapy), addressing co-morbid conditions such as substance use and interpersonal deficits, psychoeducation, and antipsychotic medications.Reference Castle, Galletly and Dark 5 Treatment guidelines detail the management of acute and chronic psychotic symptoms, as well as ongoing evaluation of efficacy, adherence, and addressing co-morbid issues.Reference Castle, Galletly and Dark 5 Indigenous Australians show higher rates of schizophrenia, which may be explained by higher rates of substance useReference Ogilvie, Tzoumakis, Allard, Thompson, Kisely and Stewart 6 disorders, although other elements such as poverty, racism, and inequitable access to health care also play a role.Reference Ogilvie, Tzoumakis, Allard, Thompson, Kisely and Stewart 6
Overview of legislation
In Australia, individual states have their own Mental Health Acts to guide decision-making around involuntary treatment and admission. Each piece of legislation falls under the jurisdiction of the State or Territory government. Mental Health Acts guide admission of all civil involuntary admissions, based on current (and future) mental state and risk of harm to self or others.Reference Kirkby and Henderson7 Currently, variations between the definition of mental illnesses and disorders and differing criteria for involuntary treatment are found within the Acts. 8
The below table details current legislation for the states and territories in Australia for involuntary commitment and treatment. 8
All states and territories include a similar definition of “mental illness”; however, only the Australian Capital Territory (ACT) and New South Wales (NSW) have a definition for “mental disorder.” Other differences include a “continuing condition” in NSW, which includes potential deterioration or likely deterioration in their care. South Australia (SA) requires a person to have impaired decision-making capacity. As mentioned by Tosson et al.,Reference Tosson, Lam and Raeburn 9 “Criteria for mental health treatment is too diversely defined in each jurisdiction. While the criteria adhere to the ethical principles of beneficence and non-maleficence, they vary widely in implementation, which may result in differing treatments between States and Territories.”
Mental Health Acts are also used to determine acute treatment in inpatient settings and involuntary longer-term treatment in the community, under the provision of compulsory Community Treatment Orders (CTOs). Research of the reporting process of involuntary treatment both in hospitals and in the community is different among jurisdictions and uses differing data (incidents of treatment versus number of individuals affected).Reference Clugston, Young and Heffernan 10 There are clear differences regarding the reporting of involuntary treatment across states and territories within Australia and this should be rectified in order to inform current and future practice.
Australia is signatory to the Convention on the Rights of Persons with Disabilities (CRPD) and the Optional Protocol to the Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment (OPCAT). The Australian Government interprets the CRPD as allowing for “compulsory assistance or treatment of persons, including measures taken for the treatment of mental disability, where such treatment is necessary, as a last resort and subject to safeguards.” Although signatory to OPCAT, Australia has refused entry to international regulatory observers to review facilities where persons are detained (prisons, psychiatric hospitals, and locked community homes).Reference Ouliaris, Gill, Castan and Sundram 11
There are forensic provisions for diversion of persons with mental illness charged with criminal offenses into health systems, with each state administering services in varying fashion.Reference Ellis 12 This includes persons who meet legal criteria for not having criminal responsibility for their acts, not being capable of performing trial tasks, or for prisoners who require involuntary treatment of their condition. Lower order offences may be dealt with summarily by diversion to mental health treatment.Reference Davidson, Heffernan, Greenberg, Butler and Burgess 13 These provisions are not consistently applied across the country,Reference Carroll, Ellis, Aboud, Scott and Pillai 14 and persons who may be eligible for diversion can remain in prison settings which is not recommended or effective.
Services for people with schizophrenia
One of the unique health-care differences within Australia is the split between Commonwealth and state funding for health services. The Commonwealth government oversees the broad delivery of health care and funds Medicare (a universal safety net for outpatient care), whereas the individual states and territories are responsible for their hospital care and budget. This impacts the treatment of a chronic and complex illness like schizophrenia, which requires coordinated inpatient and outpatient services for integrated management.
The National Mental Health Service Planning Framework (NMHSPF)Reference Diminic, Gossip, Page and Comben 15 is one model that the Commonwealth government has introduced which assists with providing services for their local community. The broad principles are (i) mental health promotion, (ii) mental illness prevention, (iii) primary and specialized clinical ambulatory mental health services, (iv) specialized mental health community support services, (v) specialized bed-based mental health-care services, and (vi) medications and procedures.
Different jurisdictions within Australia broadly offer models of care that include inpatient treatment, community, and outreach treatment. The specific needs of an individual should guide treatment.Reference Castle, Galletly and Dark 5 Typically, patients needing acute admissions (due to symptoms and risk) might be treated in an inpatient ward. After some time, they might transition into community care. Some will be managed with community treatment orders (CTOs), as per local legislation and policies.
From a treatment perspective, there has been criticism that the legislative requirements requiring patients to be a danger to others or themselves delay treatment and lead to worsened outcomes.Reference Large, Nielssen, Ryan and Hayes 16 This is because delays in treatment ultimately lead to a longer duration of untreated psychosis, which might be linked to both suicideReference Altamura, Bassetti, Bignotti, Pioli and Mundo 17 –Reference Melle, Johannesen and Friis 19 and violence riskReference Milton, Amin and Singh 20 , Reference Verma, Poon, Subramaniam and Chong 21 as well as worsen the prognosis of the illness itself.Reference Marshall, Lewis, Lockwood, Drake, Jones and Croudace 22 , Reference Perkins, Gu, Boteva and Lieberman 23 The ethical issues of autonomy and beneficence are raised in this setting, which are keenly monitored in both medical and legislative frameworks.
The current system of having patients present to their local emergency departments for assessment also places pressure on the departments themselves. Poor access to community care flows into increased pressure being placed on emergency departments when dealing with acute presentations of mentally unwell individuals. Poor planning, coordination, and accountability mechanisms need to be addressed to improve equitable access for people who present with mental health concerns to their local hospital. As highlighted by emergency clinicians, the mental health system is ‘highly fragmented, with unclear roles and responsibilities’.Reference Duggan, Harris, Chislett and Calder 24
Effectiveness of treatment
Funding for mental health conditions across the Commonwealth and state/territories varies. Additionally, funding addresses both high- and low-prevalence disorders, as well as preventive strategies. 25 It is difficult to find the overall money spent on treatment of schizophrenia within the Australian context. The term “mental health” encompasses many disorders, as well as prevention strategies. This may lead to legislative and service reforms that reflect advocacy from groups representing high-prevalence conditions and neglect the special concerns faced by persons with schizophrenia and their families.
Treatment of mental health conditions should always be individualized and catered to the individual. Individuals suffering from more common disorders such as anxiety and depression tend to have greater insight and adherence to treatment than people suffering from schizophrenia. Management plans that address higher prevalent conditions might not adequately meet the treatment needs of people suffering from schizophrenia.
Treatment measures such as CTOs are often used to manage complex clients with schizophrenia in the community. However, CTOs should not be purely used to gain access to services, nor are they effective when services are non-existent or inadequate.Reference Light, Robertson and Boyce 26 Research also highlights that people with culturally and linguistically diverse backgrounds – including Indigenous Australians – are more likely to be placed on compulsory community treatment.Reference Kisely, Moss, Boyd and Siskind 27
Small studies that have evaluated the experience of people suffering from schizophrenia highlight universal goals – including having a stable place to live, remaining independent, and keeping physically healthy. Additionally, having autonomy and being able to collaborate with their treating team was very important.Reference Fifer, Keen, Newton, Puig and McGeachie 28
Conclusion
Long-term management of complex conditions such as schizophrenia requires individualized and highly specialized care. Current models of care and associated funding arrangements by both Commonwealth and state/territory governments do not adequately address the needs of this vulnerable community. Specialized models of care for people with severe mental illnesses would ensure that breakdowns in treatment provision were minimized and crisis presentations were not the mainstay of obtaining care within the public health system. Schizophrenia is often a forgotten disorder, where the lack of advocacy leads to poorer outcomes – for both the individual and our society.
Overall, the legislative regimes and health systems provided for persons with schizophrenia show confusion, perhaps reflecting the disorganization and lack of insight characteristic of the condition itself. It has been long noted that people without schizophrenia find the condition difficult to understand.Reference Rümke 29 On the one hand, legislation for compulsory treatment of mental disorders in general places schizophrenia as no different from other forms of mental disorder and distress and thereby makes compulsory hospitalization difficult to achieve, placing greater weight on autonomy and personal choice around treatments. On the other, hurdles to achieve diversion from justice systems are also high. When involuntary treatment or imprisonment does occur, international scrutiny of practice is then reduced. Services developed around these seemingly divergent objectives can then fail to develop and provide services relevant to the minority of mental health patients with the arguably more severe condition of schizophrenia. The end result is high rates of persons with schizophrenia in prisons,Reference Browne, Korobanova and Yee 30 high and increasing rates of homelessness,Reference Buhrich, Hodder and Teesson 31 and mortality.Reference Lawrence, Hancock and Kisely 32
Author contribution
Conceptualization: A.E., K.M.; Writing – review & editing: A.E., K.M.; Writing – original draft: K.M.
