Countries were selected based on a geographical definition of Europe, following the Standard Country or Area Codes for Statistical Use (Series M, No. 49) established by the United Nations Statistics Division. This classification led to the inclusion of 44 European countries.

The following inclusion criteria were applied:

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  The country has a standalone national Mental Health Law or Act; or

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  The country has a distinct chapter or section on mental health within a broader legislative framework (e.g., General Health Acts).

Exclusion criteria:

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  The country does not have a national MHL, with mental health governance regulated instead by interstate or regional legal frameworks.

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  In cases where a national MHL exists but regional differences in application are present, only provisions explicitly defined at the national level were considered for statistical purposes.

Data collection process: Relevant legislation was identified and collected between 21 November and 5 December 2024.

Primary sources and legal search strategy: The primary method of data collection involved a systematic search of official government websites for each of the 44 countries to locate the applicable MHL. Three possible scenarios were considered:

• 1. Laws available in English, Portuguese or Spanish - these documents were reviewed and analysed directly in their original language.

• 2. Laws available in other languages - in these cases, automatic translation tools were used to translate the texts into English for analysis purposes.

• 3. Law not found through official channels - where legislation could not be located through primary sources, secondary confirmation was sought using country profiles from the World Health Organization Mental Health Atlas 202,018 to verify the presence or absence of a national MHL or equivalent framework. Each law identified was1 cross-referenced with secondary sources, such as international reports and treaties, to ensure accuracy and comprehensiveness, and2 discussed between experts (CA in law and LM in psychiatry).

The criteria analysed were as follows:

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  Existence of legal criteria for involuntary admission.

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  Authority entitled to request a formal psychiatric evaluation.

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  Deciding authority for admission.

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  Legal definition of mental disorder.

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  Responsible professional for initial assessment.

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  Distinction between admission and treatment procedures.

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  Possibility of compulsory outpatient treatment.

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  Existence of a mandatory patient council or oversight body.

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  Time frame between assessment and legal decision.

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  Maximum duration permitted for emergency admission.

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  Deciding authority for emergency admission.

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  Maximum legal duration of initial placement.

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  Re-approval or renewal period for compulsory treatment.

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  Legal prohibition of specific practices.

These criteria were grouped into four thematic categories, each addressing different aspects of the national mental health legal framework.

• 1.General legal definitions: covering the foundational concepts and definitions that determine that structure the scope and applicability of mental health legislation.

• 2. Procedural requirements for involuntary admission: addressing legal procedures and decisions, and the responsible authorities.

• 3. Emergency procedures and exceptional circumstances: focusing on expedited admission procedures, often operating outside standard legal safeguards.

• 4. Consent and best practice: examining provisions that regulate the treatment of individuals lacking capacity to consent.

Firstly, while a systematic approach was employed to identify and review mental health laws, reliance on automatic translation tools for non-English, non-Portuguese, and non-Spanish sources introduces the possibility of semantic inaccuracies and may compromise legal nuances of certain terms and provisions. These translations are not equivalent to certified legal interpretations, and as such, the findings should be viewed as indicative rather than definitive.

A further limitation lies in the exclusion of subnational legal frameworks in federal or decentralised systems, such as Germany, and Switzerland. In these cases, national-level legislation was prioritised to maintain cross-country comparability, but this inevitably overlooks significant legal variation within those jurisdictions.

Additionally, although this study provides a broad mapping of legal provisions, it does not undertake a detailed policy or contextual analysis. Legal texts provide the formal framework, but real-world applicability depends on a country’s judicial practices, healthcare infrastructure, and cultural context, factors which fall outside the scope of this analysis. Future research should engage in-depth, country-specific legal and policy analyses to complement and extend our findings.

All the MHLs considered refer to mental disorder as a prerequisite for their application, either in the preambles of the documents or in later articles (Table 1).

All MHL except those of Iceland, Italy and Spain (92 %) define dangerousness as a criterion. Only 1 country (Portugal) includes active refusal of treatment. "Understanding" is explicitly mentioned 8 times and "need for treatment" 23 times.

Regarding the existence of definitions of mental disorder, 42 % do not provide a definition. Of the 21 countries that provide definitions, 11 refer to international standards or criteria (e.g. ICD or DSM) and 6 mention that diagnoses are made according to general medical/scientific criteria.

Of the 38 MHL analysed, only Macedonia, Sweden and Spain do not mention who can initiate the evaluation process (Table 2).

The most common vector was "health care providers", mentioned in 68 % of the MHLs. "Public safety" includes mentions of the police, gendarmerie or fire brigade, with 12 countries allowing this.

14 countries mentioned "family" (including words such as relatives or next of kin), with some specifying certain proximity requirements.

It should also be noted that 21 % of the laws allow any person to request a formal assessment, regardless of their role or relationship to the person being assessed.

In the majority of countries (68 %), the initial psychiatric assessment is legally required to be carried out by a mental health professional, most commonly a psychiatrist, who is specifically mentioned in 22 national laws (Table 3). In contrast, 24 % of MHLs allow any medical practitioner to carry out the initial assessment, without the need for specific mental health qualifications. Although some countries refer to the need for mental health training, these provisions often lack a clear definition or specification of the training standards involved.

Only Switzerland, Italy, Spain and North Macedonia do not explicitly state in their legislation who is responsible for carrying out the initial assessment.

Regarding the number of professionals involved in the assessment, only 27 % of countries (10 MHL) specify that more than one expert must be involved in order to produce a legally valid opinion for the purposes of formal decision-making procedures.

With respect to the maximum duration of emergency or short-term detention, 26 % of national MHLs set a maximum duration of less than 48 h, while 37 % allow emergency detention for periods between 2 days and 1 week. In contrast, six countries do not set a specific time limit for emergency detention, either because there is no reference to emergency detention procedures or because there is no time limit in the legal framework (Table 4).

Regarding the authority to decide on emergency detention, 42 % of MHLs assign this responsibility to psychiatrists. In addition, general practitioners and senior health managers - including chief physicians and directors of hospitals or regional health authorities - are also frequently named as responsible decision-makers, with 8 and 7 mentions respectively in the laws analysed.

Although the maximum duration of initial placement is not necessarily part of emergency procedures, it is often linked to them and, in some legislative contexts, constitutes a direct extension of emergency detention. This parameter is not specified in 30 % of countries, while 32 % of MHLs provide for an initial placement period of less than one month. The remaining legislation shows greater variability, with maximum periods ranging from one month to up to two years.

According to the legislations analysed 58 % of countries distinguish between involuntary admission and involuntary treatment, treating them as separate legal modalities. In contrast, 29 % of countries integrate both provisions within a single legal framework, without making a clear distinction between the two procedures. Regarding the legal provision for outpatient treatment, 61 % of countries allow for compulsory outpatient treatment, often under specific conditions that are explicitly defined in the legislation. Conversely, 29 % of countries restrict involuntary treatment exclusively to inpatient settings, without allowing for alternative forms of compulsory community treatment. Less than half of the MHLs examined provide explicit definitions of coercive measures and the legal contexts in which such measures are permitted. While several countries refer to limiting or regulating coercive practices, many do not specify which measures are permitted or under what circumstances they may be used. Mandatory patient councils - legal provisions ensuring that patients can be heard by a judge or other decision-making authority - are explicitly required in 51 % of the MHLs analysed, unless waived by the patient. With regard to reauthorisation periods - defined as the interval after which a mandatory treatment order must be reviewed and renewed - the study found considerable variation between national laws. Most countries (76 %) require the first reauthorisation decision to be taken within six months of the initial authorisation. Only Poland and Belgium allow a longer initial reauthorisation interval. Notably, seven countries do not specify in their legislation the timeframe or periodicity of re-authorisation procedures (Table 5).

Most of the national MHLs analysed include a preamble or general provision emphasising the protection of human rights, explicitly stating that mental health care should not interfere with individual liberties and that involuntary measures must be non-discriminatory and taken only in the best interests of the patient. These provisions often emphasise the principle of proportionality and the need to respect dignity and autonomy throughout the treatment process. A common legal clause is the prohibition of research or experimental treatment on persons who are unable to give informed consent, which reinforces internationally recognised ethical standards in clinical practice. In terms of prohibited practices, 14 countries explicitly identify specific interventions that are categorically prohibited within their legal framework. The most common prohibited practice is psychosurgery, but several laws also restrict or prohibit the use of electroconvulsive therapy (ECT) and sterilisation, particularly in involuntary or non-consensual contexts (Table 6). These bans reflect broader ethical concerns about the historical misuse of such interventions and the prioritisation of patients' rights and bodily integrity.

In all 38 MHLs analysed in this study, the presence of a mental disorder remains a core criterion for involuntary admission, often supplemented by the requirement of danger to self or others - except in Iceland and Italy, where this is not specified. Notably, only 21 % of countries explicitly mention lack of insight as a criterion, despite its clinical relevance in assessing decision-making capacity and treatment compliance.28,29 Insight, although controversial and primarily used in the context of psychotic disorders, continues to influence perceptions of patient autonomy. However, it is crucial to recognise that most people with serious mental disorders retain the capacity to make informed healthcare decisions and should not be subjected to unnecessary paternalism.30

There is also a lack of consensus on the appropriate criteria for involuntary treatment. While the ECHR requires a finding of mental disorder through medical expertise, its severity and persistence to justify detention,31 the Council of Europe includes dangerousness, insight and need for treatment as relevant factors.32 In addition, 42 % of MHLs do not define what constitutes a mental disorder or provide diagnostic criteria, creating a risk of inconsistency and abuse. In contrast, 45 % include definitions and 29 % adhere to international standards such as the ICD or DSM,33,34 which can promote diagnostic accuracy and safeguard patients' rights. To align with the CRPD, some scholars advocate a shift from diagnosis-based models to decision-making capacity-based frameworks, thereby reducing discrimination and increasing legal coherence.35

Our findings show that legislation regarding the initiation of formal, mandatory mental health assessments vary widely between countries. In most cases (66 %), healthcare providers are the primary initiators, highlighting the role of the clinical sector in early detection and response.31 However, other actors such as emergency services (e.g. police, fire brigade) and family members - mentioned in 37 % of laws - are also empowered to initiate such processes. This diversity reflects the wider societal and institutional responsibilities in responding to mental health crises and requires robust supportive frameworks and community guidance.2,35 As disability perspectives evolve towards de-medicalisation, there is an increasing emphasis on non-medicalised crisis interventions that respect legal capacity and minimise coercion.1,9,36 Legislation plays a crucial role in shaping crisis response systems and ensuring adequate training for first responders, particularly in human rights-based approaches, de-escalation techniques and trauma-informed care.9,18 The initial assessment, typically carried out by psychiatrists in 68 % of countries, can also be carried out by general practitioners (24 %). However, the lack of international training standards raises concerns about diagnostic consistency.1,36,37,47 The ECtHR has affirmed that deprivation of liberty without medical expertise is incompatible with the CRPD,31 which further reinforces the need for specialised knowledge in such procedures.

Despite the importance of clinical expertise, our study found that in 68 % of countries a single evaluator is allowed to determine involuntary treatment, a practice contradicting international recommendations for multidisciplinary evaluations that increase objectivity and minimise bias.1,9 In addition, 76 % of countries vest final decision-making authority in the courts, underscoring the role of the legal system in ensuring transparency, oversight and protection of individual liberties.6,9,27,38 In contrast, a few countries delegate this authority to non-judicial or undefined roles. In Norway, decisions are made by a 'mental health expert', although the qualifications for this role are not specified. In Malta, a Commissioner appointed by the Prime Minister has this responsibility, with no requirement for legal or clinical expertise. In the Netherlands, the Head of Establishment assumes this role, raising concerns about potential institutional bias and conflicts of interest. Such models, while culturally contextual, pose risks in the absence of formal legal or ethical safeguards. The SPT warns that any involuntary detention not ordered by a competent and independent judicial authority constitutes arbitrary detention.38 Legislative reforms must therefore address training and standardisation, with organisations such as the EPA advocating for improved professional training, despite the challenges posed by cultural heterogeneity, and proposing a European board examination as a possible harmonisation mechanism.35,39

The ethical and legal tensions surrounding involuntary treatment remain a key challenge in MHL. The Madrid Declaration (1996) emphasised that 'no treatment should be provided against the patient's will, unless withholding treatment would endanger the life of the patient and/or others", and reiterated that care must be in the best interests of the patient.16 This distinction between admission and treatment is crucial, with important ethical complications, but is often blurred in many MHLs, where both are treated as a single legal process. While more than half of European MHLs distinguish between admission and treatment, others do not, leading to legal ambiguity and gaps in interpretation. For example, Iceland's legislation applies 'dangerousness' only to admission criteria, not to treatment. The Optional Protocol to the Convention against Torture also states that involuntary admission should never imply an automatic right to administer medication without consent.38 In contrast, the ECtHR asserts that all interventions must have a therapeutic purpose,31 further challenging the use of admission solely as a security measure. Although trends towards deinstitutionalisation are encouraged, they need to be carefully managed as underfunded transitions can lead to increased involuntary admissions.36,40 Legislation needs to adapt and promote rights-based frameworks that balance safety, autonomy and ethical standards of treatment.

An important aspect of this development is outpatient commitment (OPC), which is legally permitted in only 61 % of countries. OPC typically involves a court-ordered commitment to engage in community-based treatment while remaining socially integrated. Although OPC models vary, evidence suggests that they can reduce rehospitalisation and improve treatment adherence, particularly when embedded in long-term community-based services.41–43 The WHO Mental Health Atlas (2020) reports that over 35 % of mental health budgets in high-income countries continue to be allocated to psychiatric hospitals,18 despite community-based care being more cost-effective and ethical. However, not all countries have implemented OPC frameworks, often due to restrictive legislation. Legal systems therefore play a crucial role in enabling or hindering this structural change. The distinction between admission and treatment must be clearly defined in law to ensure the appropriate application of the OPC.

Although some countries (e.g. Mexico) have enacted complete bans on coercive measures, most MHL continue to allow them, interpreting the CRPD in different ways. France and the Netherlands, for example, justify restraint as a last resort and emphasise the need for accountability, clear clinical guidelines and ethical oversight where such measures are permitted.6,8,31,44

While coercive practices remain prominently debated in global ethical and legal discourse, several interventions once considered commonplace are now unequivocally deemed ethically unacceptable. In 2015, Juan E. Méndez, the United Nations Special Rapporteur on Torture, explicitly advocated for an absolute prohibition of coercive medical interventions, with particular reference to psychosurgery, highlighting its irreversible nature and potential classification as torture.1,27,32,36,38 Similarly, coercive sterilisation, frequently linked to violations of women’s reproductive and human rights, has been explicitly condemned by the European Parliament’s Committee on Women’s Rights and Gender Equality, which demands rigorous safeguards and independent verification of informed consent.27,36,45,46 On a related but distinct front, contemporary electroconvulsive therapy (ECT)—a medically reversible intervention with demonstrated safety and clear clinical indications—necessitates further regulatory clarification. Certain clinical circumstances preclude patient consent yet yield significant therapeutic benefit, raising complex ethical questions. Nonetheless, international psychiatric bodies, including the World Psychiatric Association (WPA), offer limited guidance concerning non-consensual ECT administration,47 and five existing mental health laws explicitly prohibit its involuntary use.27,32,36

Enhancing legal agency is central to ethical reform, yet only half of MHLs require the presence of patient councils, reflecting a persistent gap in patient participation and procedural justice.1,15 Legal Capacity, a cornerstone of the CRPD, needs to be actively protected by legislation.1,14,15,48 Equal representation in legal proceedings should be more than symbolic - systems must ensure that people with mental disorders can meaningfully exercise their rights. Finally, timelines for assessments and decisions vary, with many countries allowing up to a week, others extending to a month or more, and some, such as Greece, requiring more rigorous review mechanisms after six months.

Our study showed that the maximum duration of involuntary emergency detention varies widely between national laws, with 39 % of countries limiting it to between three and seven days, while six countries do not specify a time limit at all. Such omissions raise critical concerns, potentially allowing indefinite detention or rendering early decisions legally invalid if no final procedure follows. Although there are no uniform international standards for review periods, regular evaluations are essential to assess the continuing need for care and to develop appropriate follow-up plans.1,38

Emergency procedures, originally designed as protective and public health measures, are particularly vulnerable to misuse, overuse and violation of individual rights.1 Even though their use in specific acute situations can be acknowledged, the focus should shift towards minimizing them in favour of more effective, rights-based preventive mechanisms. Research consistently shows that voluntary care produces better outcomes than involuntary admission, and that preventive strategies such as rehabilitation can reduce reliance on emergency interventions.49,50 Capacity building for health professionals, first responders and legal staff is essential, including training in de-escalation, prevention of violence, legal representation and discrimination.1,14,15,48 Models such as crisis intervention teams and mental health co-response units have been shown to reduce involuntary admissions and police use of force.50 Furthermore, emergency detention is often carried out without a comprehensive psychiatric assessment by inadequately trained professionals. According to the ECtHR, an immediate examination by a medical expert is required after detention, with a psychiatric evaluation always mandatory.31,38

This is the first study to compare European MHL in a centralized and autonomous manner, systematically analysing primary legal sources without reliance on third-party interpretations and directly assessing alignment with key international human rights instruments such as the CRPD, ECHR, and WHO guidelines. However, the study has some limitations. Firstly, the reliance on official government websites and publicly available documents means that the availability and completeness of data varied considerably between countries. In cases where automatic translation tools were used, it may have introduced interpretive inaccuracies and compromised the legal nuances of certain terms and provisions. Secondly, while secondary confirmation through the WHO Mental Health Atlas 2020 (as well as other studies) provided useful verification, this source is itself based on self-reported data from national authorities, which may be subject to reporting bias, decentralisation, or discrepancies between de jure legislation and de facto implementation.18,20,24,27 In addition, the exclusion of subnational legislative variations - particularly relevant in federal or decentralised systems - may have limited the scope of the analysis. The lack of historical or political contextual analysis also limits the understanding of how these laws have evolved and are currently operationalised. Furthermore, the study focused on the presence or absence of legal provisions without assessing the effectiveness, enforcement or ethical quality of these laws in practice.