Forensic Psychiatry in the Nordic countries Iceland, problems or possibilities Sigurður Páll Pálsson MD PhD

Problems or possibilities History: The first inpatient unit for forensic psychiatric patients was established in Before that time these individuals were placed in farms, prisons but for some years before 1992 they were sent to Sweden, Västervik (Bogi Melsted). Administered by the department of Justice the first years but since 2002 the department of Welfare became responsible* In 2009 the forensic unit was finally made part of the psychiatric section of Landspitali-University Hospital* We have 7 beds and the ward is located 45 km from Reykjavik called Sogn í Ölfusi. Approximately 0-2 patients are sentenced each year (pop. Iceland ). Deaths caused by murder or by physical assault, mean = 2 each year in Iceland. range 0-6 *

Problems or possibilities Legal system: If a patient is judged unaccountable by reason of insanity (severe mental disorder) the court has to rule the patient innocent of his crime and no punishment is possible. In another verdict the court decides on his placement. Usually this is Sogn if it is a serious crime like murder but placement can be in another facility depending on the case. The laws concerning forensic psychiatric patients are since 1940 in the General Penalty Act (similar: “Brottsbalken”, Sweden). No special law exists. Patients can after one year get their case revalued by the court.* The court can then oppose or rule for release with special restrictions or none at all. In this court the judges are 3 one of them a psychiatrist.

Problems or possibilities Outpatients are now 5 (6). Outpatient unit part of our general outpatient unit at Kleppur When a patient is permitted by the court to be released the court sets up different but usually strict follow-up criteria: 1) Concerning use of illegal drugs and alcohol, regular monitoring 2) Regular visits to the psychiatrist or other health professionals 3) Patients if needing antipsychotics has to follow the psychiatrist advice, concerning medication. 4) Time-frame for our supervison, surveilance* 5) In these sentences, court ruling, usually demanded that the patient will be sent back to Sogn if not compliing.* Or if become mentally ill again, threatening or thought to be dangerous again In essence the old verdict for forensic psychiatric ward is demanded to be re- initated as stated in the release verdict. Release verdict expires.

The problems Small unit, old unit, no unit in Reykjavik We have still no step down units Housing after discharge, service units lacking The rehabilitation process versus security aspects How the courts understand these cases How the public understands our cases How psychiatric investigations are conducted* The meaning of,,insanity” and thus unaccountable

Problems or possibilities Most penal codes include a requisite of accountability for a person to be considered legally responsible for his or her deeds. Accountability is usually defined in terms of the M'Naghten rules that state that in order to be legally responsible for a criminal act, the perpetrator must have: (i) known what he was doing, and (ii) known that what he did was wrong No person is criminally responsible for an act committed or an omission made while suffering from a mental disorder that rendered the person incapable of appreciating the nature and quality of the act or omission or of knowing that it was wrong A person must also be able to control his or her actions. The offender is not criminally responsible if at the time of the act, due to mental illness, severe mental deficiency or a serious mental disturbance or a serious disturbance of consciousness, thus is not able to understand the factual nature or unlawfulness of the act, or his/ her ability to control his/her behaviour is decisively weakened

Laws, codes concerning forensic psychiatry in Iceland !! 15. gr. Þeim mönnum skal eigi refsað, sem sökum geðveiki, andlegs vanþroska eða hrörnunar, rænuskerðingar eða annars samsvarandi ástands voru alls ófærir á þeim tíma, er þeir unnu verkið, til að stjórna gerðum sínum. The offender is not criminally responsible, will not be punished if at the time of the act, due to mental illness, severe mental deficiency or a serious mental disturbance or a serious disturbance of consciousness, thus was not able to control his/her behaviour 16. gr. Nú var maður sá, sem verkið vann, andlega miður sín, svo sem vegna vanþroska, hrörnunar, kynferðilegs misþroska eða annarrar truflunar, en þetta ástand hans er ekki á eins háu stigi og 15. gr. getur, og skal honum þá refsað fyrir brotið, ef ætla má eftir atvikum og eftir að læknisumsagnar hefur verið leitað, að refsing geti borið árangur If mental state milder than 15, medical evaluation concerning if prison sentence does have any purpose

Laws, codes concerning forensic psychiatry in Iceland 62. gr. Nú er maður sýknaður samkvæmt ákvæðum 15. gr., eða niðurstaða dóms verður sú, samkvæmt ákvæðum 16. gr., að refsing sé árangurslaus, og má þá ákveða í dómi, ef nauðsynlegt þykir vegna réttaröryggis, að gerðar skuli ráðstafanir til að varna því, að háski verði að manninum. Ef ætla má, að vægari ráðstafanir, svo sem trygging, bann við dvöl á ákveðnum stöðum eða svipting lögræðis, komi ekki að notum, má ákveða, að honum sé komið fyrir á viðeigandi hæli… Says what the court can do if the individual is jugded unacountable Prevent the individual to become dangerous but the mildest alternative should be used. Example insurance, forbidden to go to some places or use the law concerning statutary In the serious cases send to an institution 17. code says act under influence of alcohol or drugs should be punished for

Possibilities Statutable, statutory Special law in Iceland, “Lögræðislög” In these laws given possibilities to bring mentally ill to hospital for treatment Since 2004 a special unit for those patients needing longer stay than some weeks Postive experience having a special unit for these individuals. Clinically similar as those that come to Sogn. CBT used, special emphasis in most cases on drug abuse problems* Observation usually makes things fall into place.

It is worth the effort Since 1992, 47 individuals* have been admitted to Sogn None has yet committed a serious crime again! Two have commited suicide and one died of natural causes