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Department of Forensic Psychiatry, University of Helsinki, and Vanha Vaasa Hospital, Vaasa, Finland
Neuroscience and Psychiatry Unit, University of Manchester, Stopford Building, Oxford Road, Manchester M13 9PT, UK, email: birgit.vollm{at}manchester.ac.uk
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Introduction |
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 Top Introduction Civil patientsPatients with intellectual...Patients with substance misuse...Forensic patientsDiscussionConclusionReferences |
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Finland has a population of approximately 5 255 580; a total of 4.3 million Finns (82.3%) live in urban communities, and Finland’s economic structure is that of a typical urbanised country. Primary production is now a source of employment for only 6% of the population, 27% work in industry and construction and 66% in trade and services. Unemployment rates have been high, between 10 and 15%, in the past 10 years (see http://virtual.finland.fi).
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Civil patients |
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TopIntroductionCivil patientsPatients with intellectual...Patients with substance misuse...Forensic patientsDiscussionConclusionReferences |
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The current Finnish Mental Health Act stipulates the following criteria for compulsory admission:
‘Psychotic illness’ in the context of this legislation is understood to include the diagnoses of delirium, severe forms of dementia, all types of schizophrenia and other psychoses, organic and other delusional disorders, major depressive disorder with psychotic features and bipolar disorder. These diagnostic criteria are comparatively restrictive and can cause practical difficulties in some situations, for example if suicidal patients clearly pose a risk to themselves but do not clearly fulfil criteria for admission because of the absence of psychotic symptoms. The dangerousness criteria on the other hand are interpreted in a rather broad way and can include risk to one’s own health as a result of poor standards of personal care, as well as endangering the development of one’s children.
The process of detention is initiated by a referral for observation (known as MI), which can be written by any physician if they consider it likely that the criteria for involuntary admission are fulfilled. In hospital, the patient is then examined by a second doctor who must be a psychiatrist. At this stage the patient can be admitted on a voluntary basis, or indeed not at all, if the psychiatrist does not consider the criteria for detention to be fulfilled. If compulsory admission is recommended by the psychiatrist, a written statement (MII) describing the patient’s condition, detention criteria, as well as the patient’s own views, has to be produced on the fourth day after initial admission at the latest. A third recommendation, MIII, the final decision, is then required by the psychiatrist in charge at the hospital to which the patient is admitted. This completes the procedure; the detention is then valid for 3 months. In Finland, involuntary admission of a psychiatric patient is therefore dependent on the opinion of three independent doctors but does not involve other professionals. Compared with other European countries this is a minority position only shared by Denmark, Sweden, Ireland and Luxemburg (Salize et al, 2002). The majority of EU member states require non-medical authorities (most commonly judges) to be part of the decision-making process or to make the final decision on compulsory detention.
If at the end of the 3-month period it is considered likely that detention criteria are still fulfilled, new recommendations MII and MIII are filed and the renewed detention is then valid for 6 months. However, this second period of detention has to be immediately confirmed by a local administrative court. After this 9-month period, if the patient needs further compulsory treatment the process has to start anew with a MI referral which can be initiated by any doctor outside the hospital at which the patient is currently treated.
There is no legislative distinction made between involuntary placement and treatment in Finnish mental health law. Medication and other treatments can be given against the patient’s will if the advantages clearly outweigh the disadvantages, and the treatment of the patient’s illness or their safety, or that of others, necessitates it. This includes electroconvulsive therapy which can be administered in an emergency (e.g. in a catatonic state, as a life-saving measure) but would not otherwise be given compulsorily to a non-consenting patient. There are, however, no specific safeguards such as the requirement of a court order or a second opinion in relation to any compulsory treatments. However, every restriction has to be clearly documented and filed, and the patient can file a complaint to the chief executive officer of the hospital, to the courts, or even to the parliamentary ombudsman. However, restrictions of other liberties are regulated in much detail, and the law makes specific reference to restricting patient’s possessions, limiting contacts, seclusion and restraint. Every case of seclusion and mechanical restraint has to be documented and reported to the responsible authorities (the state provincial office). Compulsory out-patient treatment is not presently permitted in Finland.
Patients can appeal against their detention at a local administrative court within 14 days of notification of their compulsory admission (MIII). Decisions by the local administrative court can be appealed against at the Supreme Administrative Court. In appeals cases independent psychiatric reports are commissioned. Appeals can also be lodged with the medical director of the detaining hospital.
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Patients with intellectual disability |
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TopIntroductionCivil patientsPatients with intellectual...Patients with substance misuse...Forensic patientsDiscussionConclusionReferences |
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Patients with substance misuse disorders |
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TopIntroductionCivil patientsPatients with intellectual...Patients with substance misuse...Forensic patientsDiscussionConclusionReferences |
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Forensic patients |
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TopIntroductionCivil patientsPatients with intellectual...Patients with substance misuse...Forensic patientsDiscussionConclusionReferences |
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The level of responsibility depicts the evaluated mental state of the offender at the time of the crime; the concept can be applied regardless of the type of offence. The court makes the decision of criminal responsibility, and in 99% of cases the perpetrators are considered fully responsible. The court decides whether or not a psychiatric examination is required to assess the criminal responsibility of the perpetrator. The examination can be ordered if the criminal offence can lead to at least a 1-year prison sentence. In practice, the more serious the crime, the more likely that the offender will undergo a forensic psychiatric assessment. The court may also ask the National Authority for Medicolegal Affairs, a division of the Ministry of Social Affairs and Health, for an assessment of the need for treatment in cases where no forensic psychiatric examination took place. Criteria for a finding of no criminal responsibility are that the offender, owing to severe mental illness, mental retardation or another severe mental disorder, did not understand the true nature of the act, or its unlawfulness, or was unable to control their behaviour. The sentencing court plays no further part in the case after the finding of no criminal responsibility.
In 2004, 168 forensic psychiatric assessments were made; 82% of the offenders had committed homicide or another serious violent offence (excluding arson), 14% were women and 2% under 18 years of age (Terveydenhuollon Oikeusturvakeskus, 2005). Forensic psychiatric examinations are arranged by the National Authority of Medicolegal Affairs, and are carried out on an in-patient basis in a special hospital or in prison. During a 2-month period, a thorough assessment is conducted, which includes extensive information gathered from various sources, standardised psychological tests, physical examinations, laboratory tests, behavioural observation and repeated interviews by a forensic psychiatrist and the multidisciplinary team. The final forensic psychiatric report includes an opinion on the level of criminal responsibility, a psychiatric diagnosis according to ICD–10 criteria (World Health Organization, 1992) and an assessment as to whether the offender fulfils criteria for involuntary psychiatric care. The National Authority of Medicolegal Affairs prepares an independent statement for the court and in most cases recommendations are found to be in agreement with the forensic psychiatric report.
In 2004 (Terveydenhuollon Oikeusturvakeskus, 2005), 63% of offenders who had undergone a forensic psychiatric assessment were found to be fully responsible and were therefore sentenced in the usual way. In cases of diminished responsibility the prison sentence can be lowered by 25% at the court’s discretion (until recently this reduction was mandatory). Offenders in this category may have serious psychiatric disorders, but not psychoses, or may have intellectual disability. They are dealt with by the criminal justice system without conditions of psychiatric treatment imposed. Substance use and personality disorders are not generally considered sufficient to warrant diminished responsibility. Offenders deemed to have no criminal responsibility are not sentenced but are usually committed to a psychiatric hospital (Eronen et al, 2000); in 2004 about 18% of offenders fell into this group. These patients can only be admitted to hospital if they fulfil the criteria for detention as discussed above. The National Authority of Medico-legal Affairs decides on the admission, and the need for treatment is reassessed every 6 months; this decision must be reinforced by the local court similar to the process adopted with civil patients. Patients can also appeal to the local administrative court.
There are two state hospitals in Finland dedicated primarily to the care of offenders with mental illness (although they also admit other patients who cannot be treated anywhere else): Vanha Vaasa Hospital, Vaasa and Niuvanniemi Hospital, Kuopio. The former has 147 beds, the latter 296. The average length of treatment for the discharged criminal patient is 5 years (Niuvanniemi Hospital, 2005). The decision of where the treatment of the offender with mental illness initially takes place lies with the National Authority of Medicolegal Affairs. Most patients in these two hospitals have schizophrenia or schizoaffective disorder (82%); other diagnoses include other psychoses (10%) and bipolar disorder (2%) (information from Vanha Vaasa Hospital website; http://www.vvs.fi/statsfin.html PÄÄDIAGNOOSIT). After 6 months in a forensic hospital, local psychiatric services can take patients back into their care if this is regarded as safe, which is rarely the case in practice. Patients are rehabilitated gradually through less secure wards and rehabilitation units (which may include local psychiatric services), before being reintegrated into the community. After discharge from in-patient treatment, patients are supervised for 6 months during which they are regularly seen by a psychiatrist. If necessary, this period can be extended and the patient can also be recalled to hospital. Final discharge from supervision is decided by the National Authority of Medicolegal Affairs.
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Discussion |
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TopIntroductionCivil patientsPatients with intellectual...Patients with substance misuse...Forensic patientsDiscussionConclusionReferences |
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Standards of forensic assessment and care are high in Finland. Unlike in the UK, the concept of criminal responsibility is applied to all offences and its assessment is one of the main purposes of the forensic examination. Access to forensic psychiatric care is restricted to those patients who are found to lack criminal responsibility (i.e. having mental illness at the time of the crime, and needing care for ongoing psychotic illness. It is not surprising therefore that a larger number of offenders are found to lack responsibility compared with the UK where this is not one of the admission requirements for forensic care.
Finnish mental health law is generally seen to work well in practice. It has been suggested, however, that clearer definitions regarding psychiatric disorders in relation to different levels of criminal responsibility are needed. Other problems are the perceived need for involuntary out-patient care to better prevent recidivism of criminal patients, and inequality of care received depending on where patients live. A multi-professional group was set up at the beginning of 2004 to review current legislation in relation to forensic patients. This expert committee presented its final recommendations in 2006 (Lankinen et al, 2006). These include a revision of the Mental Health Act so that offenders with a personality disorder found criminally irresponsible can also be compulsorily admitted for psychiatric treatment. Furthermore, compulsory out-patient treatment was recommended for mentally disordered offenders.
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Conclusion |
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TopIntroductionCivil patientsPatients with intellectual...Patients with substance misuse...Forensic patientsDiscussionConclusionReferences |
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References |
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TopIntroductionCivil patientsPatients with intellectual...Patients with substance misuse...Forensic patientsDiscussionConclusionReferences |
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LANKINEN, S., PAJUOJA, J., KOTILAINEN, J., et al (2006) Consolidation of the Penal Code and the Mental Health Act. Provisions on criminal patients (in Finnish with summary in English). Finnish Ministry of Social Affairs and Health.)
NIUVANNIEMI HOSPITAL (2005) Patients and Treatment [Potilaat ja hoito]. http://www.niuva.fi (In Finnish)
SALIZE, H. J., DRESSING, H. & PEITZ, M. (2002) Compulsory Admission and Involuntary Treatment of Mentally Ill Patients – Legislation and Practice in European Union Member States. European Commission Health & Consumer Protection Directorate.
TERVEYDENHUOLLON OIKEUSTURVAKESKUS (2005) Toimintakertomus 2004. http://www.teo.fi/Hakemistot/h10/10x.pdf (In Finnish.)
WORLD HEALTH ORGANIZATION (1992) The ICD–10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. WHO.
ZINKLER, M. & PRIEBE, S. (2002) Detention of the mentally ill in Europe – a review. Acta Psychiatrica Scandinavica, 106, 3 –8.[CrossRef][Medline]
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
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