Compulsory treatment in a psychiatric hospital. Compulsory treatment in a psychiatric hospital Grounds for the application of compulsory medical measures

In some cases, a person needs treatment, as he is a danger both to himself and to others. This happens not only with drug addiction or alcohol dependence, which lead to a loss of control over one's behavior, but also in the presence of contagious diseases that require isolation of the patient from society.

Legislation

The question of compulsory treatment is rather complicated. Indeed, in essence, a person is deprived of liberty, although he did not commit an unlawful act. In different countries of the world this issue is solved in different ways.

Compulsory medical measures in the legislation of the world

Measures of a medical nature are provided for by the legislation of most countries of the world. According to international law, criminals suffering from mental illness are required to undergo compulsory treatment. It is believed that a criminal who suffers from a mental disorder cannot be held responsible and fully aware of the significance of his acts.

Usually, treatment is seen as a “security measure”, that is, the ability to protect citizens from a person who poses a danger to them. In a similar sense, the law on compulsory treatment is interpreted by the legislation of most European countries.

Compulsory measures of a medical nature in the criminal law of Russia

In Russian legislation, the first mention of the compulsory treatment of insane criminals appeared in 1823. Criminals were to be placed in asylums for the mentally ill, where they were held separately from other patients.

In 1845, this law was amended: now people who were insane from birth, or sick people who committed murder, arson, or attempted suicide, had to undergo treatment.

In 1923, a law was passed that considered compulsory treatment as a "measure of social protection". In 1960, involuntary hospitalization was described in more detail. In particular, according to the new law, depending on the severity of the offense committed, criminals could be kept either in an ordinary psychiatric hospital or in a hospital that is part of the Ministry of Internal Affairs.

Compulsory measures of a medical nature, connected with the execution of punishment

Currently, the procedure for providing medical care under compulsion is considered by criminal, executive and procedural legislation, in particular, it is described in the law “On the Fundamentals of Protecting the Health of Citizens in the Russian Federation”. The decision to impose a sentence is made by the court: otherwise, the provision of medical care without the consent of the citizen is illegal.

The best developed legislation in the field of compulsory psychiatric care. Depending on the severity of the disorder and the committed act, either outpatient or inpatient treatment is prescribed. A stay in a specialized hospital may also be assigned. This is done if the offender must be under the round-the-clock supervision of specialists. At the same time, the time spent in the hospital is counted in the term of serving the sentence. If the need for detention in a medical institution disappears, the offender is discharged from the hospital, and an examination of his condition is carried out before discharge.

IMPORTANT! The decision to terminate therapy combined with punishment is made only by the court.

Principles of compulsory treatment

According to the Criminal Code, measures of compulsory treatment can be taken in the following cases:

• a person has committed a dangerous act, while being in an insane state, for example, in a state of passion, which must be proven in the course of a forensic psychological examination;
• mental disorder developed after the commission of the crime, as a result of which the punishment provided for by the Criminal Code of the Russian Federation is impossible;
• the person who committed the crime suffers from a mental illness that does not exclude sanity;
• the offender committed an infringement on the sexual inviolability of a person who has not reached the age of consent.

When making a decision, the court must take into account how dangerous the offender is to society and whether he is capable of committing similar acts in the future. The question of predicting the behavior of a criminal suffering from a mental disorder is rather complicated. Abroad, it is believed that involuntary hospitalization should be carried out in all cases when the offender shows an increased level of aggression. In this regard, compulsory treatment as a measure of punishment is used quite widely. In our country, judges and experts take into account the severity of the condition, prognosis, addiction to drugs or alcohol, the presence of a family, own housing, and a number of other factors. At the same time, as practice has shown, it is precisely social indicators that have the maximum value for predicting the behavior of a criminal (committing criminal acts in the past, relationships with loved ones, the level of social adaptation).

Compulsory treatment measures

On an outpatient basis, a criminal can be treated if a person does not need constant supervision by doctors. This usually happens if a person is aware of the presence of a mental disorder, follows the recommendations of a doctor, and also does not have pronounced deviations in behavior. Outpatient treatment is given to people whose mental disorder was of a transient nature and ended by the time the court decision was made.

Hospitalization in a hospital is required if the perpetrator's disorder requires constant monitoring. In this case, the type of hospital (general, specialized, with intensive supervision) is determined by the court.

IMPORTANT! As a rule, the choice of a hospital is carried out depending on the place of residence of the patient, which allows you to maintain social ties and receive the necessary support from relatives.

Types of compulsory treatment

The type of compulsory treatment depends on the disorder that the offender is diagnosed with.

Drug addicts

Compulsory rehabilitation of drug addicts is carried out in drug treatment clinics and rehabilitation centers. At the same time, treatment can be prescribed not only after the consideration of criminal cases: rehabilitation can also be prescribed after administrative offenses. In this case, the treatment is carried out both on an outpatient basis and inpatient.

The issue of compulsory treatment of drug addiction is rather controversial: experts argue that in order to achieve the desired effect, motivation is required on the part of the patient, which, as a rule, is absent in experienced drug addicts.

alcoholics

In the USSR, there was a system of dispensaries in which alcoholics who had committed administrative or criminal offenses underwent treatment and rehabilitation forcibly. However, at present, such a system has been abolished, in connection with which criminals suffering from alcoholism can be treated in drug treatment clinics or centers by court order. Compulsory treatment is possible only if the experts have established the fact of dependence on alcohol.

If the offender committed an illegal act while intoxicated, but does not suffer from alcoholism, it is impossible to send him for compulsory treatment.

Mentally ill

Most often, mentally ill criminals undergo compulsory treatment. At the same time, treatment does not cancel the fact of serving a sentence if the offender was found sane. The term of hospitalization may be counted towards serving the sentence.

TB patients

According to paragraph 2 of article 10 of the law "On Preventing the Spread of Tuberculosis in the Russian Federation", people suffering from open forms of tuberculosis and violating the sanitary and epidemiological regime, as well as evading examinations and therapy, can be hospitalized by force. Compulsory hospitalization of tuberculosis patients is carried out after a court decision, an application to which is submitted by the management of the organization in which the patient is under observation.

Compulsory treatment for tuberculosis in Russia is a rather acute issue. Can a TB patient refuse hospitalization? It depends on the form of the disease, the presence or absence of the allocation of Koch's sticks and the accuracy in performing medical appointments and examinations.

Other types

In a number of countries, chemical castration is used as punishment for rape and other sexual crimes. The offender is required to take drugs that reduce sexual desire or make sexual intercourse impossible. This practice is widespread in the United States, but it is not used in Russia.

Why is involuntary hospitalization needed?

Involuntary hospitalization is needed in the following cases:

• the offender poses a danger to others (due to the presence of a mental disorder, dependence on narcotic and psychotropic substances, etc.);
• the patient has a contagious disease (for example, an open form of tuberculosis), and hospitalization is necessary to prevent the spread of infection;
• the offender is not aware of his actions and cannot be punished while serving time in prison.

Grounds for the application of compulsory medical measures

Compulsory hospitalization may be prescribed in the following cases:

• committed a crime in a state of insanity;
• after the commission of the crime, the offender was found to have a mental disorder;
• the offender suffers from a disease that does not preclude sanity;
• a criminal over 18 years of age committed an act against the sexual inviolability of a person under the age of 14 years.

Application of compulsory treatment

The decision to cancel their compulsory treatment is taken by the court on the basis of a petition from the medical institution where the patient is kept. Treatment can also be given to criminals who are already serving their sentences in prison: a person may develop a mental disorder or tuberculosis while incarcerated.

The term of treatment is counted for the term of serving the sentence (one day of treatment for one day of imprisonment).

Complaint for involuntary hospitalization

A claim for involuntary hospitalization can only be filed by a representative of the medical institution where the person is being treated. This usually happens if the doctor detects that the patient is a danger to himself or others, is unable to care for himself, or has a serious mental disorder, without realizing this and refusing to be hospitalized.

The court made a positive decision: what's next

If the court decides in the affirmative, the involuntary hospitalization law requires the patient to go to an appropriate institution for treatment, or to start outpatient treatment.

Consequences of avoiding hospitalization

When evading hospitalization, the court may review its decision. For example, inpatient treatment may be prescribed instead of outpatient treatment. The duration of treatment may also be extended.

Deadlines for the application of compulsory medical measures

As a rule, the application of measures of compulsory treatment begins immediately after the pronouncement of the verdict by the court. Moreover, these measures are indefinite, that is, they can have any duration. Termination of treatment is possible when the patient's condition improves.

Extension, modification and termination of compulsory medical measures

It is possible to extend, change or terminate compulsory medical measures only at the request of a doctor who noted the positive dynamics in the patient's condition and filed a corresponding statement of claim. The issue of conversion of treatment is decided by the court.

Compulsory hospitalization of a criminal is possible only by a court decision. In all other cases, treatment without the consent of the patient is illegal. It is impossible to avoid hospitalization ordered by the court, especially if the offender is recognized as a danger to society.

Compulsory outpatient observation and treatment by a psychiatrist may be prescribed if there are grounds provided for in Article 97 of this Code, if the person, due to his mental state, does not need to be placed in a psychiatric hospital.

• 1. Outpatient compulsory observation and treatment by a psychiatrist may be prescribed if there are grounds provided for in Art. 97 of the Criminal Code, if a person, due to his mental state, does not need to be placed in a psychiatric hospital. Compulsory outpatient observation and treatment by a psychiatrist, as well as inpatient compulsory treatment, is prescribed by a court decision based on the recommendations of a forensic psychiatric expert commission, in which, along with a conclusion on the sanity or insanity of a person, an opinion should be expressed on the need to apply PMMC to him and the form such measures. The conclusion of expert psychiatrists is subject to careful evaluation by the court in conjunction with all the materials of the case. The recommendations of expert psychiatrists are not binding on the court, although, of course, they are taken into account when making a court decision.
• 2. When deciding on the appointment of outpatient compulsory observation and treatment by a psychiatrist, in addition to establishing the grounds for the use of PMMC, the court takes into account the nature of the mental disorder of the person, the social danger of the deed, as well as the possibility of carrying out his treatment and monitoring him on an outpatient basis. The mental state of a person, in particular, the nature of his mental disorder, must be such that treatment and rehabilitation measures can be carried out without being placed in a psychiatric hospital.

For example, by court order, R. was released from criminal liability for committing, in a state of insanity, a socially dangerous act under Part 3 of Art. 30, paragraph "c" part 2 of Art. 105 of the Criminal Code; she was assigned compulsory measures of a medical nature - outpatient compulsory observation and treatment by a psychiatrist. She, in a state of insanity, attempted to kill her infant. The public prosecutor raised the issue of canceling the ruling and sending the case for a new trial, believing that the court unreasonably applied compulsory outpatient observation and treatment by a psychiatrist, while, according to the conclusion of expert psychiatrists, R. needs compulsory treatment in a general psychiatric hospital. According to the public prosecutor, the court did not take into account the nature and degree of public danger of the act, the severity of the consequences, the likelihood of a repetition of unlawful behavior.

The Judicial Collegium for Criminal Cases of the Armed Forces of the Russian Federation left the ruling of the court unchanged, indicating the following. According to the conclusion of forensic psychiatrists, R. suffers from a mental disorder in the form of a depressive-paranoid syndrome. At the time of the offense, she could not realize the actual nature and social danger of her actions and manage them, she was recognized as insane, in need of compulsory treatment in a general psychiatric hospital. However, the resolution of issues of insanity, the appointment of the type of coercive measures of a medical nature falls within the competence of the court. As established in the case, R., being in a state of insanity, attempted to kill her infant, and then she herself tried to commit suicide. According to the testimony of the representative of the victim and witnesses, R. has been living with her family since the commission of the act, her health has improved, she is taking care of the child, she is aware of what has happened, and is under the supervision of her relatives. Taking into account the opinion of the doctor treating R., the court came to the correct conclusion about the possibility of curing R. without placing her in a psychiatric hospital (determination of the Supreme Court of the Russian Federation of 07.12.1999).

• 3. According to its content, outpatient compulsory observation and treatment by a psychiatrist involves monitoring the mental state of a person through regular examinations by a psychiatrist and providing this person with the necessary medical and social assistance, i.e. obligatory follow-up. Such observation is established regardless of the consent of the patient. The frequency of such examinations depends on the mental state of the person, the dynamics of his mental disorder and the need for mental health care. Dispensary observation also includes psychopharmacological and other treatment, including psychotherapy, as well as social rehabilitation measures.
• 4. The difference between the legal status of mentally ill patients who are under outpatient compulsory observation and other patients receiving outpatient psychiatric care lies in the impossibility of terminating such observation without a court decision. Patients to whom this coercive measure is applied do not have the right to refuse treatment: in the absence of their consent, treatment is carried out by decision of a commission of psychiatrists. In addition, it is possible to switch from outpatient compulsory treatment to inpatient treatment, which involves such a change in the mental state of a person when it becomes impossible to carry out compulsory treatment without being placed in a psychiatric hospital, as well as in cases of gross violations of the regime of outpatient compulsory treatment or when avoiding it.
• 5. Compulsory outpatient observation and treatment by a psychiatrist is associated with significantly less restrictions on the personal freedom of a person. It can be applied, firstly, as a primary measure of compulsory treatment, for example, when a socially dangerous act was committed in a state of temporary morbid mental disorder, the repetition of which is unlikely. Secondly, this measure may become the last step in the transition from inpatient compulsory treatment to the provision of psychiatric care necessary for a person suffering from a mental disorder in a general manner.

$1. Outpatient compulsory observation and treatment by a psychiatrist

Outpatient compulsory observation and treatment by a psychiatrist in accordance with the law (Article 100 of the Criminal Code) "may be prescribed if there are grounds provided for in Article 97 of this Code, if the person, due to his mental state, does not need to be placed in a psychiatric hospital."

The general basis for the appointment of coercive medical measures is "danger to oneself or other persons" or "the possibility of causing other significant harm" to insane, partially sane, alcoholics and drug addicts who have committed crimes, as well as persons whose mental disorder occurred after the commission of crimes. According to experts, outpatient compulsory observation and treatment by a psychiatrist can be prescribed to persons who, due to their mental state and taking into account the nature of the committed act, pose a low social danger or do not pose a danger to themselves and other people. The last statement clearly contradicts the prescription of the law (part 2 of article 97) that compulsory medical measures are prescribed only in cases where mentally ill persons can cause harm or are dangerous to themselves or others.

The legislator, as a circumstance allowing the court to prescribe compulsory outpatient treatment and treatment by a psychiatrist, provides for such a mental state in which a person who has committed a dangerous act does not need to be placed in a psychiatric hospital. The Criminal Code does not provide criteria for this mental state. Forensic psychiatrists believe that an outpatient form of compulsory treatment can be applied to persons who, due to their mental state, are able to independently satisfy their vital needs, have sufficiently organized and orderly behavior and can comply with the outpatient treatment regimen assigned to them. The presence of these signs allows us to conclude that a mentally ill person does not need inpatient compulsory treatment.

However, the legal criteria for a mental condition in which the patient does not need inpatient treatment are:

1. the ability to correctly understand the meaning and significance of the applied outpatient observation and treatment by a psychiatrist;

2. the ability to manage their behavior in the process of compulsory treatment.

The medical criteria for the mental state in question are:

1. temporary mental disorders that do not have a clear tendency to recur;

2. chronic mental disorders in remission due to compulsory treatment in a psychiatric hospital;

3. alcoholism, drug addiction, other mental disorders that do not exclude sanity.

In accordance with the law, to persons who have committed a crime in a state of sanity, but who suffer from alcoholism, drug addiction or another mental disorder within the framework of sanity, if there are grounds, the court may prescribe compulsory medical treatment only in the form of outpatient observation and treatment by a psychiatrist (part 2 of Art. 99 of the Criminal Code).

The place of compulsory outpatient treatment depends on the type of punishment imposed by the court:

o persons sentenced to deprivation of liberty undergo outpatient treatment at the place of serving their sentence, that is, in correctional institutions;

o Persons sentenced to non-custodial sentences receive compulsory treatment from a psychiatrist or narcologist at the place of residence.

In essence, compulsory outpatient observation and treatment by a psychiatrist is a special type of dispensary observation and, as such, consists in regular examinations by a psychiatrist (in a dispensary or other medical institution providing outpatient psychiatric care) and providing a mentally ill person with the necessary medical and social assistance (Part 3, Article 26 of the 1992 Law). Such observation and treatment by a psychiatrist is established regardless of the consent of the patient and is carried out on a compulsory basis (part 4 of article 19 of the 1992 Law). Unlike ordinary dispensary observation, compulsory observation and treatment is canceled only by a court decision, and, if necessary, can be changed by the court to another measure - compulsory treatment in a psychiatric hospital. The basis for replacing outpatient treatment with inpatient treatment is the submission of a commission of psychiatrists about the deterioration of the mental state of the person and the impossibility of carrying out compulsory treatment without placement in a hospital.

Outpatient compulsory observation and treatment by a psychiatrist in some cases can be used as a primary measure of compulsory treatment, in other cases this measure can act as the last stage of compulsory treatment following compulsory treatment in a psychiatric hospital.

As a primary measure, compulsory outpatient observation and treatment by a psychiatrist can be used against persons who have committed socially dangerous acts in a state of short-term mental disorder caused by pathological intoxication, alcohol, intoxication, exogenous or postpartum psychosis.

As the last stage of compulsory treatment, experts propose to apply outpatient supervision and treatment by a psychiatrist in relation to persons who have committed socially dangerous acts in a state of chronic mental disorder or dementia, after undergoing compulsory treatment in a psychiatric hospital due to the fact that these persons need medical supervision and supportive care regimen.

The introduction into the Criminal Code of such a compulsory medical measure as outpatient observation and treatment by a psychiatrist is aimed at reducing the number of persons subjected to compulsory treatment in psychiatric hospitals and maintaining their social adaptation during outpatient treatment by a psychiatrist in the patient's habitual living conditions.

Some people who have committed an illegal act are insane or mentally ill.

Naturally, in this state they cannot be sent to correctional institutions, but freedom to release seems dangerous to the life and health of respectable citizens.

What to do in such cases? Chapter 15 of the Criminal Code of the Russian Federation provides for the possibility of applying medical measures to them. There are several types of them, but in this article we will analyze in detail the features of compulsory treatment in a general psychiatric hospital.

general review

Compulsory psychiatric treatment is a measure of state coercion for persons suffering from any mental disorder and who have committed a crime.

It is not a punishment and is appointed solely by a court decision. The goal is to improve the condition or complete cure of patients in order to prevent them from committing new acts dangerous to society.

According to Art. 99 of the Criminal Code of the Russian Federation (as amended on 06.07.2020) There are 4 types of compulsory medical measures:

1. Compulsory outpatient observation and treatment by a psychiatrist.
2. Treatment in a general psychiatric hospital.
3. Treatment in a psychiatric hospital of a specialized type.
4. Treatment in a psychiatric hospital of a specialized type with intensive supervision.

Compulsory treatment is used when a person with a mental disorder requires maintenance, care and supervision that can only be provided in an inpatient setting.

The need for hospitalization arises when the nature of the disorder of a mentally ill person poses a danger both to him and to those around him. In this case, the possibility of treatment by a psychiatrist on an outpatient basis is excluded.

The nature of the mental disorder and the type of treatment are determined by the judge. He makes a decision based on the opinion of experts, which states what medical measure and for what reason is required for this person.

Psychiatric expert commissions act on the principle of sufficiency and necessity of the chosen measure to prevent new crimes by a sick person. It also takes into account what treatment and rehabilitation measures he needs.

What is a general psychiatric hospital

This is an ordinary psychiatric hospital or other medical organization that provides appropriate assistance in a hospital.

Here treated and ordinary patients in the direction of a specialist.

Compulsory treatment is carried out by patients who have committed an unlawful act that is not connected with an encroachment on the life of other people.

According to their mental state, they do not pose any danger to others, however, they need to be hospitalized. Such patients do not require intensive monitoring.

The need for compulsory treatment lies in the fact that there is a high probability that a mentally ill person will commit a repeated crime.

Being in a general hospital will help to consolidate the results of treatment and improve the mental state of the patient.

This measure is prescribed for patients who:

1. Committed an illegal act in a state of insanity. They do not have a tendency to break the regime, but there is a high probability of recurrence of psychosis.
2. Suffer from dementia and mental illness different origin. They committed crimes as a result of the influence of external negative factors.

Issues related to the extension, change and termination of treatment are also resolved by the court on the basis of the conclusion of the commission of psychiatrists.

The duration of the coercive measures is not indicated when the decision is made, since it is impossible to establish the period that is necessary for the patient to be cured. So the patient is examined every 6 months to determine your mental state.

Treatment in a general hospital, combined with the execution of a sentence

If the offender is serving a prison term and he has a deterioration in his mental state, then in this case The law provides for the replacement of the term with compulsory treatment.

This is enshrined in Part 2 of Art. 104 of the Criminal Code of the Russian Federation. In this case, the convicted person is not released from punishment.

The time spent in a psychiatric hospital is counted towards the term of serving the imposed sentence.. One day of hospitalization equals one day of imprisonment.

Upon recovery of the convict or improvement of his psyche, the court terminates treatment in a general hospital on the proposal of the executing body and on the basis of the conclusion of the medical commission. If the term has not yet expired, then the convicted person shall serve it further in a correctional institution.

Forced treatment in a psychiatric hospital

It is possible to send dangerous persons to a special clinic for such treatment only by court order. At the request of relatives or a call, a person cannot be put in a mental hospital. So in court, you need to provide serious and solid evidence.

Most alcoholics and drug addicts deny their addiction, while turning the lives of their loved ones into a nightmare. Naturally, they are confident in their adequacy and voluntarily refuse treatment.

Life with a dependent person brings a lot of problems, quarrels, material troubles. That is why relatives are wondering how to send him for compulsory treatment in a mental hospital.

If pronounced mental deviations are observed in drug and alcohol addictions, then only treatment is possible without the consent of the patient.

To be sent for compulsory treatment to a general psychiatric hospital the following documents are required:

• relatives statement;
• conclusion of doctors about the presence of signs of inadequacy.

How to send for treatment

First of all, the psychiatrist must determine whether there are mental disorders or not.

In addition, it must be established whether their actions endanger other people.

To determine the mental state of a person, you need to seek clarification from the local doctor. He will write a referral to a psychiatrist.

If the patient cannot go to him, then he is obliged to come to the house himself. If deviations are found, the doctor writes out a document that allows send a person for compulsory treatment involuntarily.

If the condition worsens, you should call an ambulance. They need to show a certificate from a psychiatrist. After that, the staff must take the patient to a mental hospital for further treatment.

Relatives have 48 hours from the moment a mentally ill person is placed in a general hospital to file a claim for referral to compulsory treatment.

So it goes dealt with on a special basis. The application is written in any form in compliance with the requirements of Art. 302, 303 Code of Civil Procedure of the Russian Federation.

The lawsuit is filed with the district court at the location of the psychiatric hospital. The applicant must indicate all the grounds for placement in a mental hospital, referring to the rule of law. The conclusion of the psychiatric commission must be attached to the claim.

The law defines special conditions for legal proceedings in such cases:

• the application is considered within 5 days;
• a mentally ill citizen has the right to be present at the trial;
• The decision of the court is made on the basis of a medical-psychiatric examination.

In the Constitution of Russia there are such rights as the inviolability of the person and freedom of movement. In order to comply with them, the law strictly prescribes place citizens for compulsory treatment in psychiatric hospitals only by court order. Otherwise, there is criminal liability.

Video: article 101. Compulsory treatment in a medical organization providing psychiatric care

Since 1997, Russia began to use outpatient compulsory observation and treatment by a psychiatrist, or APNL. Up to this point, only a stationary form of medical measures has been taken, although in countries such as Germany, Great Britain, Australia, the USA, the Netherlands, coercion is still used.

The first prerequisites for outpatient coercion were observed as early as 1988. In Ukraine, Uzbekistan, Kazakhstan, Azerbaijan, Georgia, the SSR in the Criminal Code considered the transfer of a patient to relatives or guardians under the supervision of a doctor as compulsory medical measures. But this was only a prerequisite, since the USSR Ministry of Health at that time believed that there was no need for outpatient practice.

Nikonov, Maltsev, Kotov, Abramov lawyers and psychiatrists theoretically substantiated the importance of compulsory outpatient treatment. They said that among the patients there are people who have committed socially dangerous acts, do not need inpatient treatment, but psychiatric control and various therapies are needed. The authors also emphasize that in some cases, after inpatient treatment, patients could not adapt to life, which led to an aggravation of their mental state and an increased risk of endangering the public, while it is impossible to resume compulsory treatment, since the court has already canceled. In this case, the replacement by the court of hospital for outpatient treatment is a trial discharge, in which the patient can be returned to compulsory inpatient care.

Specifics of APNL in different countries

The formation of the APNL in different countries has its own characteristics:

1. In Russia, this form is a norm of criminal law, which is applied to insane and less sane persons.
2. In the UK, the Mental Health Act, 1983, is used. It gives the court the right to send a patient to a hospital for up to 6 months. Patients can then be discharged under conditions of regular psychiatric and social monitoring. Also, outpatient monitoring is prescribed during a long vacation from the hospital.
3. In some US states, a conditional discharge is used in cases where the patient has been discharged from the hospital, and the term of punishment that could have been assigned to him in a sane state has not yet passed. The extension or cancellation of treatment is decided by the court.
4. In the Netherlands, APNL is received not only by hospital patients, but also by those who voluntarily agreed for the sake of a reduction and a suspended sentence. Such a proposal is put forward as an alternative for a less serious offence. Also, this measure is used in relation to complex and aggressive patients so that their condition does not worsen and there is no relapse.
5. In the provinces of Canada, patients are gradually being returned to the community. All are treated on an outpatient basis. They are observed under the jurisdiction of a special "observation commission", or Commission d "examen, Board of Review. Every year it checks the patient's status and sets the conditions under which the patient remains in society, and if they are not met, the subject returns to the hospital. The conditions include the following :
   • meetings with a psychiatrist;
   • taking medication;
   • life in a certain environment;
   • avoidance of alcohol and other harmful substances.

Essence of APNL in Russia

Article 100 of the Criminal Code of the Russian Federation and some by-laws describe the country's APNL: a person who has been released from criminal liability and punishment is sent to a dispensary or other psycho-neurological institutions, where either they are treated on an outpatient basis. The patient must:

• explain the meaning and significance of these actions;
• warn that in case of evasion from observation, he is transferred to a hospital.

The instructions of the Ministry of Health and the Ministry of Internal Affairs of the Russian Federation oblige a psychiatrist to visit a patient at least once a month. The police help

• in control of the patient's behavior;
• if necessary, determine the location;
• in hospitalization if there is a danger to society from this person.

Also, health and internal affairs authorities can exchange information about APNL patients. Benefits for facial outpatient treatment:

• contact with others;
• life with family;
• availability to go to work;
• leisure activities.

These advantages are characteristic only for persons who are in a stable mental state and follow the instructions of a psychiatrist.

APNL classification

All persons undergoing outpatient compulsory therapy are divided into two groups:

• patients with primary coercive measure;
• patients in the final stage of coercive measures after the hospital.

APNL can also be classified:

• adaptive-diagnostic stage;
• planned differentiated curation;
• final stage.

Let's consider each of them.

Characteristics of the adaptive-diagnostic phase

The first stage is recommended for people who have been diagnosed with a temporary mental disorder or mental exacerbation (attack, paroxysm) of a chronic mental disorder, provided that it ended by the time of examination and did not leave clinical manifestations that need only a doctor's control or preventive therapy. It is also necessary to take into account that the patient maintains social adaptation and the ability to comply with the regimen.

Sometimes APNL is prescribed for people with negative personality mechanisms of OOD. But it is applicable when the patient was provoked to act by the situation itself, which arose against his will and was resolved by the time of the examination. Also, such a measure is prescribed if the patient:

• does not have psychopathic manifestations;
• does not have a tendency to an alcoholic state;
• not prone to drug use;
• has little or no tendency to repeat the situation;
• has a predominance of persistent negative disorders with a decrease;
• maintains a relationship with the doctor.

The primary stage is not assigned to persons:

• capable of spontaneous frequent occurrence of mental relapses, which can be easily caused, for example, by alcohol, psychogenics, etc.
• with incomplete treatment of an attack;
• psychopathic disorders with irascibility, opposition, emotional coarseness, moral and ethical decline;
• with a recurrence of committing acts dangerous to society, for example, a crime, in a state of psychosis or remission.

In doing so, you need to take into account:

• degree of inability to social adaptation;
• social microenvironment;
• alcoholization;
• anesthesia.

An example of patient H., aged 40, who committed OOD in a state of temporary psychological disorder. He was accused of causing bodily harm to his relative.

Previous development was not observed. Electrician. While serving in the army, he received a head injury with loss of consciousness. After the patient complained of headaches, dizziness. Sometimes he drinks alcohol. In a state of intoxication, headaches intensify, the patient becomes irritable. A few days before the act, the wife of the patient was hospitalized in a somatic hospital. For 4 days he drank 150 grams of vodka. He experienced a deterioration in health, decreased appetite, poor sleep, and a sense of concern for his wife. Before committing an act at work, he drank 150 grams of vodka. After the evening shift came home. Communicated with the family and complained of feeling unwell, headache. For a long time he could not fall asleep, feelings of anxiety and anxiety did not leave him. According to the household members, he got up at 3 am and drank one tablet of diphenhydramine. At 6 o'clock in the morning the patient got up again and began to say something inarticulate. When the mother went to the neighbors, the patient caught up with her on the landing and pushed her hard. A relative who was trying to drag her mother home was hit, after which she fell down the stairs and received fractures. The patient then returned home, went to the kitchen, took a knife and stabbed himself in the chest, damaging his lung. Witnesses said that the patient behaved in silence, the view was terrifying, his eyes were bulging. The same condition was observed during the arrest of the man. In the police car, he did not contact anyone, did not pay attention to appeals, stared at one point with rounded eyes. After the operation, the patient regained consciousness, was able to adequately answer questions, referred to memory lapses, and could not believe what had happened.

During the examination, the experts made the following conclusion: at the time of the act against relatives, the patient had scattered residual neurological symptoms, signs of paroxysmal activity were detected on the EGG. Complaints are characteristic of a cerebrasthenic condition. The patient is depressed by the current situation, completely critical, intellectually preserved. There are no psychotic phenomena and paroxysmal disorders. This means that Kh., due to an organic brain lesion at the time of the offense, developed a twilight state of consciousness provoked by alcohol. The commission recommended sending him to compulsory outpatient observation and treatment by a psychiatrist.

The recommendation was made on the basis that X had no prior history of any mental disorder. This episode was the only one in her life, so there is no indication for inpatient treatment. However, the presence of a head injury does not allow to give a clear confidence that the disorder of consciousness may not recur. Therefore, the patient must be observed by a psychiatrist, periodically undergo examinations and EEG control, undergo appropriate absorbable and dehydration therapy.

During outpatient compulsory treatment at the first adaptive-diagnostic stage, the patient undergoes an additional examination to clarify the basic etiological factors that are the basis for the development of a psychotic state during OOD, paraclinical studies, or EEG, are also carried out. In addition, information is being collected on risk factors for relapse. After that, recommendations are given about the lack of contact with persons with whom experiences were associated during psychosis, and social problems that need a dispensary are established.

At the second stage, a complex of rehabilitation measures and therapy is determined for each patient, depending on the identified pathology. They do not need to be released from work, since at the time of the appeal they do not have grounds for this, but there are exceptions and they recommend light working conditions.

The patient must undergo drug therapy, psycho-corrective treatment, which explain the impact of adverse effects on the body and the importance of observing psycho-hygienic measures.

At the third stage, patients with organic brain damage are observed. For them, control studies are carried out by a neurologist, ophthalmologist, etc. in order to reveal the dynamics of pathological factors that are irritants for relapse. The following events take place here:

• discussion and compilation of favorable and pathogenic life situations;
• the process of learning, consolidating protection skills;
• auto-training;
• etc.

With the improvement of the EEG parameters and the overall state of the psyche, one can judge the positive dynamics and the achieved stable compensation of consciousness, which makes it possible for the court to note APNL. The continuation of APNL in this case is 6-12 months. With the manifestation of any form of pathology, the patient and relatives should immediately visit a psychiatrist on a regular basis due to the possibility of relapse.

For people with a negative-personal character at the first stage, the main tasks are:

• clarification of the structure of disorders;
• choice of biological therapy;
• the establishment of socio-psychological factors that promote or hinder adaptation in the conditions of APNL;
• diagnostics of structure and behavior;
• establishing functional links between cognitions (expectations, assessments, etc.) and features of the external manifestation of verbal and non-verbal behavior;
• assessment of the household environment to improve it in order to exclude relapse;
• undergoing psychotherapy.

The patient and relatives are explained the legal status of the patient, and they also talk about the importance of observing the regimen of observation and therapy. If there has been a decrease in working capacity, provided that there is no disability, then the person must undergo a medical and social examination. In addition, it is necessary to establish the forms of social assistance that the patient needs, for example:

• resolution of family conflicts;
• improvement of living conditions;
• etc.

At the first adaptive-diagnostic stage, with a stable state of mind, the patient can take part in cultural events and labor processes.

Definition of the second stage - planned differentiated curation

This phase contains a combination of biological therapy with therapeutic and corrective work on the psyche and the provision of social assistance.

Biological therapy is based on the principle of a differentiated approach, which should take into account:

• treatment of probable compensation of the condition;
• therapy of persistent psychopathological disorders;
• relapse prevention measures.

Behavioral therapy includes learning that:

• develops new coping skills;
• helps to improve communication skills;
• helps to overcome maladaptive stereotypes;
• helps to overcome destructive emotional conflicts.

The task of this stage is to smooth and replace as much as possible the features that led the patient to commit an offense, for this they improve the situation:

• in family;
• in a microsocial environment.

At the second and final stage, consultations and therapy are provided to the relatives of the patient.

If the treatment lasted more than 6 months, and the mental state was stable, and the patient constantly visited a psychiatrist and took the necessary medications, while there were no episodes of delinquency and bad deeds, and he was able to adapt, then withdrawal from APNL may be considered.

The nature of the final stage

This phase occurs after compulsory treatment, when the patient needs the help and control of a psychiatric service that promotes social adaptation. Treatment in a hospital and a psychiatrist is evidenced by the following signs:

• clinical picture of a chronic mental illness of delusional and / or psycho-like manifestation with a non-remission course or unstable remissions with frequent relapses;
• criticism of the disease and / or committed OOD, regardless of adequate long-term therapy;
• the need for continued treatment;
• collected information from the anamnesis, which indicates violations of social adaptation;
• in the past, there was a tendency to abuse drugs, alcohol, etc.;
• the presence of criminal experience;
• change in the microsocial environment at the place of residence.

All of the above signs are the basis for changing the type of compulsory medical measure.

At the first stage of APNL, patients undergo supportive therapy, during this period social and domestic problems are solved, neurotic layering is removed for those in need, and assistance is provided in adaptation.

The second stage is responsible for achieving mental stability and adaptation through the implementation of individual, differentiated treatment and rehabilitation measures. The frequency of meetings with a psychiatrist depends on:

• mental state of the patient;
• compliance with the constant intake of maintenance therapy from 1 time per week to a month, since during this time all the most significant social and domestic problems should be resolved.

At the second stage, in patients undergoing APNL treatment, deterioration is observed. For example, in schizophrenics, the manifestation of an attack is autochthonous, seasonal; in a patient with a brain injury, relapse is provoked by external stimuli. If a worsening of the mental state is detected early on, then a change in the APNL is not required, although in some cases it is still necessary.

Psychocorrective measures contribute to:

• the formation of communication skills, including cognitive, emotional and behavioral aspects;
• creating satisfactory self-control through social skills training.

The third stage is responsible for preparing the patient for the withdrawal of compulsory treatment. This stage is characterized by the following:

• achieving a stable state of mind;
• persistent reduction of residual psychopathological symptoms;
• maximum adaptation.

Before canceling the compulsory decision, conversations are held with the patient and relatives:

• about the possibility of recurrence:
• about the need to comply with the regime of dispensary observation.

Almost all patients after discharge from inpatient treatment have a disability of group II. Only 15% do not need it. Such people may return to their previous jobs. Usually, labor adaptation takes place in special medical and labor workshops.

The psychiatrist and the police are collaborating at this time to exchange information about the patient:

• about his whereabouts;
• about his place of residence;
• about labor status.

Also, the exchange of information provides for the assistance of the police at a time of increased threat to society.

The positive attitude of the patient to treatment, visits to a psychiatrist and various therapies, allow us to make a prediction about further cooperation with the patient after the withdrawal of APNL. Contact is also established with a relative who is critical of the state of health of the person. This contact gives:

• transfer of part of the responsibility;
• obtaining information about relapse.

All procedures are necessary in order to prevent a recurrence of a dangerous situation.

Termination of APNL does not guarantee a recurrence of mental state imbalance. Therefore, it is necessary to take into account the objective data that are obtained from:

• doctor;
• family members:
• neighbors;
• the police;
• social worker.

Achieving adaptation contributes to:

• loss of unfavorable microsocial environment;
• creating a satisfactory lifestyle;
• emergence of interests;
• emergence of worries.

But do not forget that the successful adaptation of patients in this group is often unstable, since minor difficulties, an antisocial environment, alcohol consumption can lead to a breakdown. Data of successful adaptation are considered:

• total control;
• long-term follow-up (up to 2 years or more).

The essence of coercive measures with the execution of punishment

This type of punishment can be applied by the court if a person commits a crime and needs treatment for a mental disorder, not excluding sanity - part 2 article 22, part 2 article 99, article 104 of the Criminal Code of the Russian Federation.

Article 62 of the Criminal Code of the RSFSR, 1960 states: it is necessary to use compulsory treatment and the application of punishment measures against persons suffering from alcoholism and drug addiction. This law was applied only in cases where it was provable. However, in the late 80s, the norm began to be criticized, referring to the infringement of human rights. But still in 1996 the Criminal Code retained this punishment. This was reflected in articles 97, 99, 104. In 2003, an amendment was made - the abolition of punishment (paragraph "d", part 1, article 97 of the Criminal Code). Now persons must undergo only compulsory treatment within the framework of the penitentiary system.

The above changes did not affect people who were in a state of mental disorder at the time of the commission of the crime (Article 22 of the Criminal Code). According to part 2 of article 97 of the Code, compulsory treatment is not used for all subjects, only for those whose mental disorder is capable of harming themselves and other people. For persons referred to in Art. 97 can only be used by a psychiatrist for APNL (according to part 2 of article 99). Two parts of article 104 of the Criminal Code state that when undergoing inpatient treatment or APNL, the patient's sentence is counted.

From all it follows that legal and medical relations consider this measure as:

• an independent type of compulsory treatment;
• responsibility for certain duties.

These aspects are specified in article 102 of the Criminal Code. Cancellation of punishment occurs after the conclusion of the commission of psychiatrists is presented to the court. It should be noted that this measure is quite fully described in part 3 of Article 97 of the Criminal Code.

But, despite this, the implementation of the measure has many legally unclear and controversial issues, which indicates the problematic nature of its application. Compulsory treatment should take place for a long time even at the first stage, in case of avoiding relapse. Otherwise, the resulting effect will disappear, and it will be impossible to resume the APNL. And to apply these measures throughout the entire term of punishment, which can exceed 10-25 years, is clinically and organizationally unjustified.

It is also not clear who will implement the coercion, as the Psychiatric Care Act does not allow medical institutions to perform such actions on persons whose disorder is not severe.

In modern times, the above is questionable, since coercive measures with the execution of punishment in all cases are executed properly and bring the desired effect.

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