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Forensic Psychiatric Organization in Finland
International Journal of Law and Psychiatry, Vol. 23, No. 5–6, pp. 541–546, 2000 Copyright © 2000 Elsevier Science Ltd Printed in the USA. All rights reserved 0160-2527/00 $–see front matter
PII S0160-2527(00)00059-5
Forensic Psychiatric Organization in Finland Markku Eronen,* Eila Repo,† Heikki Vartiainen,‡ and Jari Tiihonen§
Introduction In Finland, there are four national laws that deal with the forensic psychiatric services: criminal law on forensic psychiatric evaluations (1889), the mental health law (1990), Mental Health Act (1990), and the law about state mental hospitals (1987 and 1997) (Finnish Law, 1998). The mental health law deals with the general principles concerning mental health services and connections with health care in general. The ministry of social and welfare is responsible for organizing the health care system in Finland. Regionally, the provincial governments are responsible for this work. The communities are responsible for organizing health care, including mental health care, in their regions. The mental health law also supplies with basic guidelines for the work in state mental hospitals. According to the law, the main functions of state mental hospitals are performing forensic psychiatric evaluations and treating patients who have been found not guilty by reason of insanity as well as patients who are too dangerous or difficult to be treated in regional hospitals. The mental health law defines when and how patients can be committed into mental hospitals involuntarily. For an involuntary commitment, the patient has to (a) be psychotic and; (b) due to his/her psychosis, he or she has to be (1) in the need of immediate psychiatric care or (2) dangerous to his/her health or welfare or (3) dangerous to other people’s health or welfare; and (c) other treatment facilities are not satisfactory enough to give the patient treatment he or she needs. The above rules are valid both for the general psychiatric patients and for the forensic psychiatric patients. The mental health law defines also about the forensic psychiatric evaluations. According to the Finnish law, the courts decide if a forensic psychiatric *Medical Director, Vanha Vaasa Hospital, Vaasa, Finland. †Medical Director, Niuvanniemi Hospital, Kuopio, Finland. ‡Chief Physician, Helsinki University Central Hospital, Helsinki, Finland. §Professor and Chairman, Department of Forensic Psychiatry, University of Kuopio and Department of Clinical Physiology, Kuopio University Hospital, Kuopio, Finland. Address correspondence and reprint requests to Dr. Jari Tiihonen, M.D., Ph.D., Department of Forensic Psychiatry, University of Kuopio, Niuvanniemi Hospital, FIN-70240 Kuopio, Finland; E-mail: [email protected] 541
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M. ERONEN et al.
evaluation should be conducted. Basically, the evaluation can be ordered if the criminal offense committed by the accused is serious enough to result in at least a 1-year prison sentence. In reality, almost all forensic psychiatric examinations are conducted on offenders who have committed serious violent offenses or other serious criminal acts. In court, both the prosecutor and the defense are allowed to ask for a forensic psychiatric evaluation. However, it is the judge who makes the final decision. In most cases, when the offender is accused of serious violent acts, the judge agrees to the requests for evaluations. After deciding on the evaluation, the court asks the National Authority of Medicolegal Affairs (NAMA) to arrange the evaluation. The NAMA can, in some rather clear cases, make the evaluation on the basis of patient records. For example, in 1997, 11 cases, and in 1996, 18 cases were dealt in the NAMA without an actual forensic psychiatric evaluation. However, in most cases the NAMA asks special hospitals provided with forensic psychiatric experts to conduct the actual forensic psychiatric evaluation. In the whole country, on average, 200 to 250 forensic psychiatric evaluations per year have been conducted during the last decades (Annual Report of National Authority of Medicolegal Affairs, 1997; Eronen, Tiihonen, Ylitapio, & Hakola, 1995; Eronen, Tiihonen, & Hakola, 1996a). In the hospitals, a multidisciplinary team lead by a doctor specialized in forensic psychiatry evaluates the patient. The doctor is always a civil servant of the state (thus, he or she gets paid by the state and is expected to be as objective as possible). The evaluation is very thorough and includes exhaustive gathering of anamnestic data from various sources, thorough psychiatric evaluation, standardized psychological tests, interviews by a social worker and psychologist, evaluation of physical condition with laboratory testing and observation of the offender by the hospital staff, taking time in average for 5 weeks. The theoretical maximum time for the evaluation is 2 months. However, in some exceptional cases, 2 more months can be spent on the permission given by the NAMA. This extra time is used very rarely (e.g., in cases of suspected malingering). As a result of the forensic evaluation, a detailed report with medical diagnosis and an opinion on the criminal responsibility is given to the NAMA by the forensic psychiatrist. The forensic psychiatrist also has to estimate, if the offender fulfills the criteria for involuntarily psychiatric care and if he or she is able to stand trial. Based on this report, and the criminal files, the NAMA then gives its opinion to the court. In the NAMA, the reports are scrutinized by at least two independent psychiatrists and at least by one independent judge. If they find evident errors in the report, they can send it back to the forensic psychiatrists for modification. In most cases (90%), the NAMA’s and the forensic psychiatrist’s conclusions are in agreement. However, the NAMA can also disagree and give its own opinion. After this procedure, the court of law independently decides about the criminal responsibility and the criminal judgement of the offender. In the Finnish system, the courts can neglect the health-care specialist’s opinions. However, this happens only rarely, and in about 90% of the cases the courts have found the forensic psychiatric examination to be very reliable (Vartiainen & Hakola, 1992a). In Finland, there are three different stages in criminal responsibility. A person can be fully criminally responsible, have diminished criminal responsibil-
FORENSIC PSYCHIATRIC ORGANIZATION IN FINLAND
543
ity, or be found not criminally responsible. In the first case, a person considered to be mentally healthy enough to be convicted and judged normally. Most criminal offenders (55% of those who have been studied in forensic psychiatric evaluation in recent years) belong to this group. If a person suffers from a serious psychiatric disorder, but not an actual psychosis, or at least has not suffered from a psychosis during his or her offense, he or she may be considered to have diminished criminal responsibility. Also, if the person is mentally retarded with a Wechsler Adult Intelligence Scale (WAIS) (Wechsler, 1981) score between 55 and 70, he or she may be considered to be only partly criminally responsible for his or her acts. In these cases, the courts judge the offenders, but their sentences are 25% shorter than they would be if the person were fully criminally responsible for his or her acts. They are not convicted for a life sentence, either. This group of offenders is treated the same way as fully criminally responsible offenders. They are sentenced to prison. They do not get any specific psychiatric treatment unless they themselves ask for it. The third group of criminal responsibility in Finland (25% of those who have been studied in forensic psychiatric evaluation) consists of persons who are not found to be criminally responsible. They are either psychotic or mentally retarded (WAIS score ⬍55). The courts do not judge them, but instead, the NAMA may commit them to mental hospitals for treatment. In most of the cases the treatment at least starts on a involuntary basis. However, every year there are also a few cases in which a person is not judged because he or she is considered to be not criminally responsible, and yet, he or she no longer fulfills the criteria for involuntary commitment at the time of the forensic psychiatric evaluation. These persons may continue their treatment on a voluntary basis or may even have no treatment or conviction at all. The Forensic Inpatient Services in Finland If the court of law finds an offender to be not criminally responsible, the NAMA decides the hospital where the patient’s treatment starts. In most of the serious cases, the treatment starts in either of the two state mental hospitals in Finland; Niuvanniemi hospital provided with 284 beds or Vanha Vaasa hospital with 125 beds. After the first 6 months, the municipalities have a right to decide if they consider their local health-care organization to be capable of taking responsibility for the treatment or if they want to continue paying the state mental hospitals for the treatment. At least after every 6 months, the doctors at the hospital have to reevaluate the patient and give their opinion if he or she still fulfills the criteria for the involuntary treatment. If this is the case, the provincial court reinforces the commitment. However, the county administrative court also has the opportunity not to reinforce the decision made by the doctor. In such a case, the patient must immediately be let out of the hospital, if he or she wants to go. These kind of cases are, however, very rare. Ordinarily, the county administrative courts reinforce the doctor’s decisions. In this phase, the patient can appeal to the Supreme Administration Court, which makes the final decision concerning the involuntary hospitalization. Every 6 months this procedure is repeated, until the doctors think that the need for involuntary treatment has ended or the
544
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patient himself of herself agrees with the need for treatment, consequently having no need for involuntary treatment. The actual average treatment time in state mental hospital has varied between 4 and 8 years in Finland during this decade. However, in some cases the treatment may last much longer. Finnish law does not put any limit on the duration of the involuntary treatment; the law only requires a new evaluation about the need of the treatment every 6 months interval. How Forensic Patients Are Returned to General Mental Health Care in Finland When the doctor in charge considers that it is possible to discharge the patient and start outpatient treatment, he/she makes a proposal to the NAMA. The NAMA can then decide to stop the treatment or to continue the involuntary treatment. If the patient is discharged, there is a 6-month supervision period while the patient is considered to be still in need of involuntary treatment. During this time, he or she can be readmitted to the hospital, if the reports from the outpatient unit indicate that his or her mental condition warrants involuntary hospital treatment again. Theoretically, after this 6-month period, the NAMA can order another 6-month follow-up period for the patient. Until the last few years this has happened quite seldom. However, in Finland during 1996 there were eight such cases, and seven in 1997 (Annual Report of National Authority of Medicolegal Affairs, 1997). There is no specific forensic psychiatric outpatient treatment in Finland. However forensic psychiatric patients have to see a psychiatrist at least once a month during the first 6 months after their discharge from the hospital. Normally this happens in a municipal local mental health center. A psychiatrist from the mental health center writes a short report of the patient every month and sends it to the psychiatric hospital, where the patient has been discharged. When the 6-month period is over (one or more 6-month periods, if NAMA decides to order another follow-up period for the patient), the “criminal status” of the patient disappears, and the patient is in every way a common psychiatric patient having no special obligations to follow. If after this he or she fell more seriously ill, he or she would be treated and committed to a hospital with the same procedure as everybody else in Finland. All psychiatric outpatient care is voluntary in Finland. Research on the Forensic Populations in Finland Finland has a rich tradition in forensic psychiatric research. The two main centers for forensic psychiatric research in Finland are in Helsinki University Central Hospital and in Kuopio in Niuvanniemi Hospital. Helsinki’s unit is lead by Professor Virkkunen, who has concentrated his research on impulsive violent behavior, familial alcoholism, and neurotransmitter metabolism. Professor Virkkunen and his co-workers have published a large number of studies on the associations between impulsive, violent, and suicidal behavior with a deficiency or dysregulation in serotonergic functions. Virkkunen and Linnoila named it “low serotonin syndrome” to describe conditions characterized by
FORENSIC PSYCHIATRIC ORGANIZATION IN FINLAND
545
episodes of mood changes, impulsive behavior, or both. Other altered or dysfunctional biological parameters reported by Virkkunen’s team in patients with aggressive or impulsive syndromes include norepinephrine, dopamine, and glucose (Linnoila & Virkkunen, 1992; Nielsen et al., 1998; Virkkunen, Eggert, Rawlings, & Linnoila, 1996). The department of forensic psychiatry of University of Kuopio is situated in Niuvanniemi Hospital and lead by professor Tiihonen. He and his co-workers have done research in brain imaging with neurotransmitter specific ligands among forensic psychiatric populations (Tiihonen et al., 1994, 1997; Tiihonen, Kuikka, et al., 1995). This group has also done conducted numerous epidemiological studies in forensic psychiatry. They have calculated odds ratios for the risk increase for different specific mental disorders in large male and female populations of Finnish homicide offenders and homicide recidivistic offenders (Eronen, 1995; Eronen et al., 1996a, 1996b; Eronen, Hakola, & Tiihonen, 1996; Tiihonen, Isohanni, Räsänen, Koiranen, & Moring, 1998). This group has also found some extremely high odds ratios for risk increase for violent behavior among homicide offenders and state mental hospital patients during the first year after their discharge from the hospital or prison (Tiihonen, Hakola, Nevalainen, & Eronen, 1995; Tiihonen, Hakola, Eronen, Vartiainen, & Ryynänen, 1996). Niuvanniemi Hospital is—unlike Helsinki University Central hospital—responsible for the treatment of criminal patients. Researchers in Niuvanniemi have done research on various aspects of treatment and follow-up (Vartiainen & Hakola, 1992b, 1994; Vartiainen, Vuorio, Halonen, & Hakola, 1995; Vartiainen et al., 1995). References Annual Report of National Authority of Medicolegal Affairs. (1997). Helsinki: Kirjapaino Snellman Oy (in Finnish). Eronen, M. (1995). Mental disorders and homicidal behavior in female subjects. American Journal of Psychiatry, 152, 1216–1218. Eronen, M., Hakola, P., & Tiihonen, J. (1996). Factors associated with homicide recidivism in a 13-year sample of homicide offenders in Finland. Psychiatric Services, 47, 403–406. Eronen, M., Tiihonen, J., & Hakola, P. (1996a). Mental disorders and homicidal behavior in Finland. Archives of General Psychiatry, 53, 497–501. Eronen, M., Tiihonen, J., & Hakola, P. (1996b). Schizophrenia and homicidal behavior. Schizophrenia Bulletin, 22, 83–89. Eronen, M., Tiihonen, J., Ylitapio, J., & Hakola, P. (1995). Uusimpia tutkimushavaintoja rikoksista syytettyjen henkilöiden oikeuspsykiatrisista mielentilatutkimuksista. Lakimies, 4, 538–547. Finnish Law. (1998). Suomen Laki 2. Helsinki: Kauppakaari Oyj, Lakimiesliiton kustannus (in Finnish). Linnoila, V. M. I., & Virkkunen, M. (1992). Aggression, suicidality and serotonin. Journal of Clinical Psychiatry, 53(Suppl. Oct.), 46–51. Nielsen, D. A., Virkkunen, M., Lappalainen, J., Eggert, M., Brown, G. L., Long, J. C., Goldman, D., & Linnoila, M. (1998). A tryptophan hydroxylase gene marker for suicidality and alcoholism. Archives of General Psychiatry, 55, 593–602. Tiihonen, J., Hakola, P., Eronen, M., Vartiainen, H., & Ryynänen, O.-P. (1996). Risk of homicidal behavior among discharged forensic psychiatric patients. Forensic Science International, 79, 123–129. Tiihonen, J., Hakola, P., Nevalainen, A., & Eronen, M. (1995). Risk of homicidal behaviour among persons convicted of homicide. Forensic Science International, 72, 43–48. Tiihonen, J., Isohanni, M., Räsänen, P., Koiranen, M., & Moring J. (1998). Specific major mental disorders and criminality: A 26-year prospective study of the 1966 Northern Finland birth cohort. American Journal of Psychiatry, 154, 840–845.
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Tiihonen, J., Kuikka, J., Bergström, K., Hakola, P., Karhu, J., Ryynänen, O.-P., & Föhr, J. (1995). Altered striatal dopamine re-uptake site densities in habitually violent and non-violent alcoholics. Nature Medicine, 1, 654–657. Tiihonen, J., Kuikka, J., Bergström, K., Lepola, U., Koponen, H., & Leinonen, E. (1997). Dopamine reuptake site densities in patients with social phobia. American Journal of Psychiatry, 154, 239–242. Tiihonen, J., Kuikka, J., Hakola, P., Paanila, J., Airaksinen, J., Eronen, M., & Hallikainen, T. (1994). Acute ethanol-induced changes in cerebral blood flow. American Journal of Psychiatry, 151, 1505–1508. Vartiainen, H., & Hakola, P. (1992a). Mielentilalausunnon käyttökelpoisuus ja kehittämistoiveet. Lakimies, 4, 521–527. Vartiainen, H. T., & Hakola, H. P. A. (1992b). How changes in mental health law adversely affect offenders discharged from security hospital. Journal of Forensic Psychiatry, 3, 563–570. Vartiainen, H., & Hakola, P. (1994). The effects of TV monitoring on ward atmosphere in a security hospital. International Journal of Law and Psychiatry, 17, 443–449. Vartiainen, H., Tiihonen, J., Putkonen, A., Koponen, H., Virkkunen, M., Hakola, P., & Lehto, H. (1995). Citalopram, a selective serotonin reuptake inhibitor, in the treatment of aggression in schizophrenia. Acta Psychiatrica Scandinavica, 91, 348–351. Vartiainen, H., Vuorio, O., Halonen, P., & Hakola, P. (1995). The patients’ opinions about curative factors in involuntary treatment. Acta Psychiatrica Scandinavica, 91, 163–166. Virkkunen, M., Eggert, M., Rawlings, R., & Linnoila, M. I. (1996). A prospective follow-up study of alcoholic violent offenders and fire setters. Archives of General Psychiatry, 53, 523–529. Wechsler, D. (1981). Wechsler Adult Intelligence Scale–Revised Manual. New York, NY: Psychological Corporation.
PII S0160-2527(00)00059-5
Forensic Psychiatric Organization in Finland Markku Eronen,* Eila Repo,† Heikki Vartiainen,‡ and Jari Tiihonen§
Introduction In Finland, there are four national laws that deal with the forensic psychiatric services: criminal law on forensic psychiatric evaluations (1889), the mental health law (1990), Mental Health Act (1990), and the law about state mental hospitals (1987 and 1997) (Finnish Law, 1998). The mental health law deals with the general principles concerning mental health services and connections with health care in general. The ministry of social and welfare is responsible for organizing the health care system in Finland. Regionally, the provincial governments are responsible for this work. The communities are responsible for organizing health care, including mental health care, in their regions. The mental health law also supplies with basic guidelines for the work in state mental hospitals. According to the law, the main functions of state mental hospitals are performing forensic psychiatric evaluations and treating patients who have been found not guilty by reason of insanity as well as patients who are too dangerous or difficult to be treated in regional hospitals. The mental health law defines when and how patients can be committed into mental hospitals involuntarily. For an involuntary commitment, the patient has to (a) be psychotic and; (b) due to his/her psychosis, he or she has to be (1) in the need of immediate psychiatric care or (2) dangerous to his/her health or welfare or (3) dangerous to other people’s health or welfare; and (c) other treatment facilities are not satisfactory enough to give the patient treatment he or she needs. The above rules are valid both for the general psychiatric patients and for the forensic psychiatric patients. The mental health law defines also about the forensic psychiatric evaluations. According to the Finnish law, the courts decide if a forensic psychiatric *Medical Director, Vanha Vaasa Hospital, Vaasa, Finland. †Medical Director, Niuvanniemi Hospital, Kuopio, Finland. ‡Chief Physician, Helsinki University Central Hospital, Helsinki, Finland. §Professor and Chairman, Department of Forensic Psychiatry, University of Kuopio and Department of Clinical Physiology, Kuopio University Hospital, Kuopio, Finland. Address correspondence and reprint requests to Dr. Jari Tiihonen, M.D., Ph.D., Department of Forensic Psychiatry, University of Kuopio, Niuvanniemi Hospital, FIN-70240 Kuopio, Finland; E-mail: [email protected] 541
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M. ERONEN et al.
evaluation should be conducted. Basically, the evaluation can be ordered if the criminal offense committed by the accused is serious enough to result in at least a 1-year prison sentence. In reality, almost all forensic psychiatric examinations are conducted on offenders who have committed serious violent offenses or other serious criminal acts. In court, both the prosecutor and the defense are allowed to ask for a forensic psychiatric evaluation. However, it is the judge who makes the final decision. In most cases, when the offender is accused of serious violent acts, the judge agrees to the requests for evaluations. After deciding on the evaluation, the court asks the National Authority of Medicolegal Affairs (NAMA) to arrange the evaluation. The NAMA can, in some rather clear cases, make the evaluation on the basis of patient records. For example, in 1997, 11 cases, and in 1996, 18 cases were dealt in the NAMA without an actual forensic psychiatric evaluation. However, in most cases the NAMA asks special hospitals provided with forensic psychiatric experts to conduct the actual forensic psychiatric evaluation. In the whole country, on average, 200 to 250 forensic psychiatric evaluations per year have been conducted during the last decades (Annual Report of National Authority of Medicolegal Affairs, 1997; Eronen, Tiihonen, Ylitapio, & Hakola, 1995; Eronen, Tiihonen, & Hakola, 1996a). In the hospitals, a multidisciplinary team lead by a doctor specialized in forensic psychiatry evaluates the patient. The doctor is always a civil servant of the state (thus, he or she gets paid by the state and is expected to be as objective as possible). The evaluation is very thorough and includes exhaustive gathering of anamnestic data from various sources, thorough psychiatric evaluation, standardized psychological tests, interviews by a social worker and psychologist, evaluation of physical condition with laboratory testing and observation of the offender by the hospital staff, taking time in average for 5 weeks. The theoretical maximum time for the evaluation is 2 months. However, in some exceptional cases, 2 more months can be spent on the permission given by the NAMA. This extra time is used very rarely (e.g., in cases of suspected malingering). As a result of the forensic evaluation, a detailed report with medical diagnosis and an opinion on the criminal responsibility is given to the NAMA by the forensic psychiatrist. The forensic psychiatrist also has to estimate, if the offender fulfills the criteria for involuntarily psychiatric care and if he or she is able to stand trial. Based on this report, and the criminal files, the NAMA then gives its opinion to the court. In the NAMA, the reports are scrutinized by at least two independent psychiatrists and at least by one independent judge. If they find evident errors in the report, they can send it back to the forensic psychiatrists for modification. In most cases (90%), the NAMA’s and the forensic psychiatrist’s conclusions are in agreement. However, the NAMA can also disagree and give its own opinion. After this procedure, the court of law independently decides about the criminal responsibility and the criminal judgement of the offender. In the Finnish system, the courts can neglect the health-care specialist’s opinions. However, this happens only rarely, and in about 90% of the cases the courts have found the forensic psychiatric examination to be very reliable (Vartiainen & Hakola, 1992a). In Finland, there are three different stages in criminal responsibility. A person can be fully criminally responsible, have diminished criminal responsibil-
FORENSIC PSYCHIATRIC ORGANIZATION IN FINLAND
543
ity, or be found not criminally responsible. In the first case, a person considered to be mentally healthy enough to be convicted and judged normally. Most criminal offenders (55% of those who have been studied in forensic psychiatric evaluation in recent years) belong to this group. If a person suffers from a serious psychiatric disorder, but not an actual psychosis, or at least has not suffered from a psychosis during his or her offense, he or she may be considered to have diminished criminal responsibility. Also, if the person is mentally retarded with a Wechsler Adult Intelligence Scale (WAIS) (Wechsler, 1981) score between 55 and 70, he or she may be considered to be only partly criminally responsible for his or her acts. In these cases, the courts judge the offenders, but their sentences are 25% shorter than they would be if the person were fully criminally responsible for his or her acts. They are not convicted for a life sentence, either. This group of offenders is treated the same way as fully criminally responsible offenders. They are sentenced to prison. They do not get any specific psychiatric treatment unless they themselves ask for it. The third group of criminal responsibility in Finland (25% of those who have been studied in forensic psychiatric evaluation) consists of persons who are not found to be criminally responsible. They are either psychotic or mentally retarded (WAIS score ⬍55). The courts do not judge them, but instead, the NAMA may commit them to mental hospitals for treatment. In most of the cases the treatment at least starts on a involuntary basis. However, every year there are also a few cases in which a person is not judged because he or she is considered to be not criminally responsible, and yet, he or she no longer fulfills the criteria for involuntary commitment at the time of the forensic psychiatric evaluation. These persons may continue their treatment on a voluntary basis or may even have no treatment or conviction at all. The Forensic Inpatient Services in Finland If the court of law finds an offender to be not criminally responsible, the NAMA decides the hospital where the patient’s treatment starts. In most of the serious cases, the treatment starts in either of the two state mental hospitals in Finland; Niuvanniemi hospital provided with 284 beds or Vanha Vaasa hospital with 125 beds. After the first 6 months, the municipalities have a right to decide if they consider their local health-care organization to be capable of taking responsibility for the treatment or if they want to continue paying the state mental hospitals for the treatment. At least after every 6 months, the doctors at the hospital have to reevaluate the patient and give their opinion if he or she still fulfills the criteria for the involuntary treatment. If this is the case, the provincial court reinforces the commitment. However, the county administrative court also has the opportunity not to reinforce the decision made by the doctor. In such a case, the patient must immediately be let out of the hospital, if he or she wants to go. These kind of cases are, however, very rare. Ordinarily, the county administrative courts reinforce the doctor’s decisions. In this phase, the patient can appeal to the Supreme Administration Court, which makes the final decision concerning the involuntary hospitalization. Every 6 months this procedure is repeated, until the doctors think that the need for involuntary treatment has ended or the
544
M. ERONEN et al.
patient himself of herself agrees with the need for treatment, consequently having no need for involuntary treatment. The actual average treatment time in state mental hospital has varied between 4 and 8 years in Finland during this decade. However, in some cases the treatment may last much longer. Finnish law does not put any limit on the duration of the involuntary treatment; the law only requires a new evaluation about the need of the treatment every 6 months interval. How Forensic Patients Are Returned to General Mental Health Care in Finland When the doctor in charge considers that it is possible to discharge the patient and start outpatient treatment, he/she makes a proposal to the NAMA. The NAMA can then decide to stop the treatment or to continue the involuntary treatment. If the patient is discharged, there is a 6-month supervision period while the patient is considered to be still in need of involuntary treatment. During this time, he or she can be readmitted to the hospital, if the reports from the outpatient unit indicate that his or her mental condition warrants involuntary hospital treatment again. Theoretically, after this 6-month period, the NAMA can order another 6-month follow-up period for the patient. Until the last few years this has happened quite seldom. However, in Finland during 1996 there were eight such cases, and seven in 1997 (Annual Report of National Authority of Medicolegal Affairs, 1997). There is no specific forensic psychiatric outpatient treatment in Finland. However forensic psychiatric patients have to see a psychiatrist at least once a month during the first 6 months after their discharge from the hospital. Normally this happens in a municipal local mental health center. A psychiatrist from the mental health center writes a short report of the patient every month and sends it to the psychiatric hospital, where the patient has been discharged. When the 6-month period is over (one or more 6-month periods, if NAMA decides to order another follow-up period for the patient), the “criminal status” of the patient disappears, and the patient is in every way a common psychiatric patient having no special obligations to follow. If after this he or she fell more seriously ill, he or she would be treated and committed to a hospital with the same procedure as everybody else in Finland. All psychiatric outpatient care is voluntary in Finland. Research on the Forensic Populations in Finland Finland has a rich tradition in forensic psychiatric research. The two main centers for forensic psychiatric research in Finland are in Helsinki University Central Hospital and in Kuopio in Niuvanniemi Hospital. Helsinki’s unit is lead by Professor Virkkunen, who has concentrated his research on impulsive violent behavior, familial alcoholism, and neurotransmitter metabolism. Professor Virkkunen and his co-workers have published a large number of studies on the associations between impulsive, violent, and suicidal behavior with a deficiency or dysregulation in serotonergic functions. Virkkunen and Linnoila named it “low serotonin syndrome” to describe conditions characterized by
FORENSIC PSYCHIATRIC ORGANIZATION IN FINLAND
545
episodes of mood changes, impulsive behavior, or both. Other altered or dysfunctional biological parameters reported by Virkkunen’s team in patients with aggressive or impulsive syndromes include norepinephrine, dopamine, and glucose (Linnoila & Virkkunen, 1992; Nielsen et al., 1998; Virkkunen, Eggert, Rawlings, & Linnoila, 1996). The department of forensic psychiatry of University of Kuopio is situated in Niuvanniemi Hospital and lead by professor Tiihonen. He and his co-workers have done research in brain imaging with neurotransmitter specific ligands among forensic psychiatric populations (Tiihonen et al., 1994, 1997; Tiihonen, Kuikka, et al., 1995). This group has also done conducted numerous epidemiological studies in forensic psychiatry. They have calculated odds ratios for the risk increase for different specific mental disorders in large male and female populations of Finnish homicide offenders and homicide recidivistic offenders (Eronen, 1995; Eronen et al., 1996a, 1996b; Eronen, Hakola, & Tiihonen, 1996; Tiihonen, Isohanni, Räsänen, Koiranen, & Moring, 1998). This group has also found some extremely high odds ratios for risk increase for violent behavior among homicide offenders and state mental hospital patients during the first year after their discharge from the hospital or prison (Tiihonen, Hakola, Nevalainen, & Eronen, 1995; Tiihonen, Hakola, Eronen, Vartiainen, & Ryynänen, 1996). Niuvanniemi Hospital is—unlike Helsinki University Central hospital—responsible for the treatment of criminal patients. Researchers in Niuvanniemi have done research on various aspects of treatment and follow-up (Vartiainen & Hakola, 1992b, 1994; Vartiainen, Vuorio, Halonen, & Hakola, 1995; Vartiainen et al., 1995). References Annual Report of National Authority of Medicolegal Affairs. (1997). Helsinki: Kirjapaino Snellman Oy (in Finnish). Eronen, M. (1995). Mental disorders and homicidal behavior in female subjects. American Journal of Psychiatry, 152, 1216–1218. Eronen, M., Hakola, P., & Tiihonen, J. (1996). Factors associated with homicide recidivism in a 13-year sample of homicide offenders in Finland. Psychiatric Services, 47, 403–406. Eronen, M., Tiihonen, J., & Hakola, P. (1996a). Mental disorders and homicidal behavior in Finland. Archives of General Psychiatry, 53, 497–501. Eronen, M., Tiihonen, J., & Hakola, P. (1996b). Schizophrenia and homicidal behavior. Schizophrenia Bulletin, 22, 83–89. Eronen, M., Tiihonen, J., Ylitapio, J., & Hakola, P. (1995). Uusimpia tutkimushavaintoja rikoksista syytettyjen henkilöiden oikeuspsykiatrisista mielentilatutkimuksista. Lakimies, 4, 538–547. Finnish Law. (1998). Suomen Laki 2. Helsinki: Kauppakaari Oyj, Lakimiesliiton kustannus (in Finnish). Linnoila, V. M. I., & Virkkunen, M. (1992). Aggression, suicidality and serotonin. Journal of Clinical Psychiatry, 53(Suppl. Oct.), 46–51. Nielsen, D. A., Virkkunen, M., Lappalainen, J., Eggert, M., Brown, G. L., Long, J. C., Goldman, D., & Linnoila, M. (1998). A tryptophan hydroxylase gene marker for suicidality and alcoholism. Archives of General Psychiatry, 55, 593–602. Tiihonen, J., Hakola, P., Eronen, M., Vartiainen, H., & Ryynänen, O.-P. (1996). Risk of homicidal behavior among discharged forensic psychiatric patients. Forensic Science International, 79, 123–129. Tiihonen, J., Hakola, P., Nevalainen, A., & Eronen, M. (1995). Risk of homicidal behaviour among persons convicted of homicide. Forensic Science International, 72, 43–48. Tiihonen, J., Isohanni, M., Räsänen, P., Koiranen, M., & Moring J. (1998). Specific major mental disorders and criminality: A 26-year prospective study of the 1966 Northern Finland birth cohort. American Journal of Psychiatry, 154, 840–845.
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