Compulsory outpatient treatment with a psychiatrist. Outpatient compulsory observation and treatment by a psychiatrist. Consequences of avoiding hospitalization

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LETTER from the Ministry of Health of the Russian Federation dated 07/23/99 25108236-99-32 (2020) Relevant in 2018

4. Organization of outpatient compulsory observation and treatment by a psychiatrist

4.1. Outpatient compulsory observation and treatment by a psychiatrist is carried out by a psychoneurological dispensary (dispensary department, office) at the patient’s place of residence.

If necessary, by decision of the chief psychiatrist of the relevant health authority, this medical measure can be carried out at the place of residence of the guardian or family members of the patient with whom he temporarily resides. A psychoneurological dispensary (dispensary department, office) sends written information to the internal affairs body at the person’s place of residence about his acceptance for outpatient compulsory observation and treatment by a psychiatrist. In the future, similar information is sent to the internal affairs body immediately upon receipt of a court ruling on the extension, modification or cancellation of a compulsory medical measure.

4.2. Control cards of dispensary observation (form N OZO-I/U) for persons undergoing outpatient compulsory treatment are located in the general file cabinets of psychoneurological dispensaries with a mark in the upper right corner of the front side of the card “PL” (compulsory treatment) and color markings or are formed separately an array with the same mark.

4.3. When accepted for outpatient compulsory treatment, the patient is explained the procedure for its implementation, the obligation to follow medical recommendations, and is also prescribed a regimen appropriate to his condition, the necessary treatment, diagnostic and rehabilitation (restorative) measures.

The patient must be examined by a doctor at a dispensary (dispensary department, office), and if indicated, at home, with a frequency that ensures the possibility of carrying out treatment, rehabilitation and diagnostic measures indicated for his mental state, but at least once a month. The implementation of medical recommendations is monitored by employees of the psychoneurological dispensary (dispensary department, office), if necessary, with the involvement of family members, guardians, and other persons in the patient’s immediate environment, and in cases of behavior of an antisocial nature, as well as evasion of the prescribed compulsory measure of a medical nature - and with with the help of police officers.

4.4. If the patient’s condition and behavior make it difficult to examine him (prolonged absence from his place of residence, resisting and committing other actions that threaten the life and health of medical workers, attempts to hide from them), as well as when outsiders create obstacles to his examination and treatment family members, guardians or other persons, medical personnel resort to the help of police officers.

The latter, acting in accordance with the Law of the Russian Federation “On the Police” and the Law of the Russian Federation “On Psychiatric Care and Guarantees of the Rights of Citizens in its Provision,” provide the necessary assistance in searching for, detaining a person and providing safe conditions for his examination.

4.5. In relation to a person undergoing outpatient compulsory observation and treatment, any medical means and methods permitted in accordance with the procedure established by law, as well as various types of treatment, rehabilitation and socio-psychiatric care provided for by the Law of the Russian Federation "On Psychiatric Care and Guarantees" may be used. rights of citizens during its provision." For this purpose, it can be sent to any treatment and rehabilitation unit of the dispensary (specialized offices, medical and industrial (labor) workshops, day hospital, etc.), and also placed in a psychiatric hospital without changing the form of compulsory treatment, if hospitalization is not caused by an increase in danger that is persistent. This person enjoys the right to free drug treatment and other rights and benefits provided for by the legislation of the Russian Federation, constituent entities of the Russian Federation and other regulations in relation to the corresponding category of persons suffering from mental disorders.

4.6. If there are indications, a person undergoing compulsory outpatient treatment may be sent to a psychiatric hospital (hospital, department) either voluntarily or through involuntary hospitalization. In the latter case, hospitalization is usually carried out with the assistance of the police. The psychiatric hospital (hospital, department) in which the patient is placed is notified in writing by the doctor who issued the referral for hospitalization that this person is undergoing compulsory outpatient treatment.

4.7. Able-bodied patients during compulsory outpatient treatment can, taking into account the state of their health, work both in normal conditions and in the conditions of medical and production specialized enterprises and workshops that employ the labor of persons suffering from mental disorders. In such cases, visits for official reasons are coordinated with the attending physician of the psychoneurological dispensary (dispensary department, office). If there is a change in their condition that makes them temporarily unable to work, they receive a sick leave certificate; if there is a permanent loss or reduction in their ability to work, they are sent to MSEC<*>and if they are recognized as disabled, they have the right to pension benefits.

<*>Medical and social expert commission.

4.8. If grounds arise for changing a medical measure to inpatient compulsory treatment, a psychoneurological dispensary (dispensary department, office) may also resort to involuntary hospitalization. In this case, simultaneously with hospitalization, by decision of the commission of psychiatrists, a petition is filed with the court to change the compulsory measure, of which the hospital administration is notified in writing. The issue of discharge of such a patient can only be resolved if a court ruling is received to refuse to change the compulsory medical measure.

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

Naturally, in this state they cannot be sent to correctional institutions, but releasing into freedom 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 imposed solely by court decision. The goal is to improve the condition or completely cure 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 July 6, 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 specialized psychiatric hospital.
  4. Treatment in a specialized psychiatric hospital with intensive supervision.

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

The need for treatment in a hospital arises if the nature of the disorder of a mentally ill person poses a danger to both him and others. In this case, the possibility of treatment with a psychiatrist on an outpatient basis is excluded.

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

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 inpatient care.

Here Ordinary patients are also being treated according to the direction of a specialist.

Compulsory treatment is given to patients who have committed an unlawful act that does not involve an attack on the lives of other people.

Due to their mental state, they do not pose any danger to others, but they require compulsory hospitalization. Such patients do not require intensive monitoring.

The need for compulsory treatment lies in the fact that there remains a high probability of a mentally ill person committing a repeat crime.

Staying in a general hospital will help consolidate the results of treatment and improve the patient’s mental state.

This measure is prescribed to patients who:

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

Issues regarding extension, change and termination of treatment are also resolved by the court based on the conclusion of a commission of psychiatrists.

The duration of compulsory measures is not indicated when making a decision, since it is impossible to establish the period necessary to cure the patient. That's why the patient undergoes examination every 6 months to determine your mental state.

Treatment in a general hospital combined with execution of punishment

If the offender is serving a prison sentence and there is 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 assigned sentence.. One day of hospitalization is equal to one day of imprisonment.

When the convicted person recovers or his mental health improves, the court terminates treatment in a general hospital on the recommendation of the body executing the punishment and on the basis of the conclusion of the medical commission. If the term has not yet expired, the convicted person will continue to serve it in a correctional institution.

Compulsory treatment in a psychiatric hospital

Dangerous persons can be referred to a special clinic for such treatment only by a court ruling. Based on a statement from relatives or a call, a person cannot be admitted to a mental hospital. That's why In court you need to provide serious and compelling evidence.

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

Living with a dependent person brings many problems, quarrels, and material problems. That is why relatives are wondering how to send him for compulsory treatment to a mental hospital.

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

To be sent for compulsory treatment to a general psychiatric hospital The following documents are needed:

  • statement from relatives;
  • doctor's conclusion about the presence of signs of inadequacy.

How to send for treatment

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

In addition, it must be established whether their actions pose a danger to other people.

To determine a person’s mental state, you need to seek clarification from your 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 detected, 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 this, the staff must take the patient to a mental hospital for further treatment.

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

So it goes are considered as special proceedings. 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 claim is filed in the district court at the location of the psychiatric hospital. The applicant must indicate all the reasons for placement in a mental hospital, citing the rules of law. The claim must be accompanied by the conclusion of a psychiatric commission.

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

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

The Russian Constitution includes rights such as personal integrity 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 decision. Otherwise, criminal liability arises.

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

Outpatient compulsory observation and treatment by a psychiatrist may be prescribed if there are grounds provided for in Article 97 of this Code, if the person’s mental state does not require placement 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. Outpatient compulsory 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 must be expressed on the need to apply PMMH to him and the type such measures. The conclusion of psychiatric experts is subject to careful evaluation by the court in conjunction with all the materials of the case. The recommendations of psychiatric experts are not binding for the court, although, naturally, they are taken into account when making a judicial 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 PMMH, the court takes into account the nature of the person’s mental disorder, the social danger of the crime, as well as the possibility of carrying out his treatment and observation 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 placement in a psychiatric hospital.

For example, according to the court's ruling, R. was exempt from criminal liability for committing a socially dangerous act in a state of insanity, provided for in Part 3 of Art. 30, paragraph "c" part 2 art. 105 CC; She was prescribed compulsory medical measures - outpatient compulsory observation and treatment by a psychiatrist. She, in a state of insanity, attempted to kill her infant child. The state 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, whereas, according to the conclusion of psychiatrist experts, R. needs compulsory treatment in a general psychiatric hospital. According to the state prosecutor, the court did not take into account the nature and degree of social danger of the act, the severity of the consequences, and the likelihood of a repetition of the unlawful behavior.

The Judicial Collegium for Criminal Cases of the Armed Forces of the Russian Federation left the court's ruling unchanged, indicating the following. According to the conclusion of forensic psychiatrists, R. suffers from a mental disorder in the form of depressive-paranoid syndrome. At the time of the offense, she could not understand the actual nature and social danger of her actions and control them; she was declared insane and in need of compulsory treatment in a general psychiatric hospital. However, resolving issues of insanity and imposing a type of compulsory medical measures falls within the competence of the court. As established in the case, R., being in a state of insanity, attempted to kill her infant child, and then herself attempted to commit suicide. According to the testimony of the victim’s representative and witnesses, R. has been living with her family since the crime was committed, her health has improved, she is taking care of the child, is aware of what happened, and is under the supervision of 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 RF Armed Forces dated December 7, 1999).

  • 3. In terms of 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. mandatory medical observation. Such observation is established regardless of the patient's consent. 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 ending such observation without a court decision. Patients to whom this compulsory measure is applied do not have the right to refuse treatment: in the absence of their consent, treatment is carried out according to the decision of a commission of psychiatrists. In addition, a transition from outpatient compulsory treatment to inpatient treatment is possible, which involves such a change in the mental state of a person when it becomes impossible to carry out compulsory treatment without placement in a psychiatric hospital, as well as in cases of gross violations of the regime of outpatient compulsory treatment or when evading it.
  • 5. Outpatient compulsory observation and treatment by a psychiatrist is associated with significantly fewer restrictions on a person’s personal freedom. It can be used, firstly, as a primary measure of compulsory treatment, for example, when a socially dangerous act was committed in a state of temporary painful 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.

Compulsory observation and treatment by a psychiatrist on an outpatient basis may be prescribed if there are grounds provided for in Article 97 of this Code, if the person’s mental state does not require placement in a medical organization providing psychiatric care in an inpatient setting.

Comments to Art. 100 of the Criminal Code of the Russian Federation


1. Outpatient compulsory observation and treatment by a psychiatrist is prescribed to persons who have committed a crime and suffer from mental disorders that do not exclude sanity, as well as to persons who have committed socially dangerous acts in a state of insanity. In both cases, this compulsory measure of a medical nature is applied to persons who, due to their mental state, are capable of complying with the treatment and observation regime. Their behavior is orderly, they are able to understand the significance of the medical measures applied to them.

2. When deciding whether to impose this compulsory measure, the court takes into account: a) the nature and degree of mental disorder; b) the possibility of achieving the goals of using compulsory medical measures through outpatient compulsory observation and treatment; c) the influence of a mental disorder on the patient’s behavior (is it aggressive, does it pose a real threat to himself and others, does it indicate the likelihood of a repetition of a socially dangerous act, etc.).

According to Art. 27 of the Law of the Russian Federation “On psychiatric care and guarantees of the rights of citizens during its provision”, dispensary observation can be established for a person suffering from a chronic and protracted mental disorder with severe persistent or often exacerbating painful manifestations.

4. Persons sentenced to imprisonment, arrest or restriction of freedom undergo outpatient treatment in institutions that execute these types of punishments (Article 18 of the Penal Code of the Russian Federation).

Persons sentenced to punishments not related to imprisonment or restriction of freedom undergo outpatient compulsory observation or treatment by a psychiatrist in a medical institution at their place of residence. A court ruling on the application of this measure is sent to the specified institution; this is also reported to the internal affairs body, whose task is to control and ensure the person’s attendance at the psychiatrist at the frequency established by it.

Since 1997, Russia began to use outpatient compulsory observation and treatment with a psychiatrist, or APNL. Until this moment, only stationary medical measures were used, although in countries such as Germany, Great Britain, Australia, the USA, and the Netherlands, coercion is still used.

The first prerequisites for outpatient coercion were observed back in 1988. In Ukraine, Uzbekistan, Kazakhstan, Azerbaijan, and Georgia, the SSR in the Criminal Code included 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 and do not need hospital treatment, but at the same time they need psychiatric control and various therapies. The authors also emphasize that in some cases, after inpatient treatment, patients could not adapt to life, which led to a deterioration of their mental state and an increased risk of endangering the public, while compulsory treatment cannot be resumed, since the court has already canceled it. In this case, the court’s replacement of inpatient treatment with 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 APNL in different countries has its own characteristics:

  1. In Russia, this form is a norm of criminal law that applies to insane and less sane persons.
  2. In the UK, they use the Mental Health Act, or Mental Health Act, 1983. It gives the court the right to send a patient to hospital for up to 6 months. Afterwards, patients can be discharged under regular psychiatric and social supervision. Outpatient observation is also prescribed during long-term leave from the hospital.
  3. In some US states, conditional discharge is used in cases where the patient has been discharged from the hospital, and the sentence that he could have been given in a sane state has not yet expired. The extension or cancellation of treatment is decided by the court.
  4. In the Netherlands, APNL is received not only by inpatients, but also by those who voluntarily agreed for the sake of a reduced and suspended sentence. Such a proposal is put forward as an alternative to a less serious offense. This measure is also used in relation to complex and aggressive patients so that their condition does not worsen and there is no relapse.
  5. In Canadian provinces, patients are gradually being reintroduced into society. All are treated on an outpatient basis. They are observed under the jurisdiction of a special “supervisory 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 is returned to the hospital. The conditions include the following :
    • meetings with a psychiatrist;
    • taking medications;
    • life in a certain environment;
    • non-use of alcohol and other harmful drugs.

The 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 psychoneurological institutions, where they are treated on an outpatient basis. The patient must:

  • explain the meaning and significance of these actions;
  • They warn that if he evades observation, he will be 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 the patient at least once a month. The police help:

  • in controlling the patient's behavior;
  • if necessary, locate;
  • in hospitalization if there is a danger to society from this person.

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

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

These benefits are typical only for individuals who are in a stable mental state and comply with the psychiatrist's instructions.

APNL classification

All persons who undergo outpatient compulsory therapy are divided into two groups:

  • patients with a primary compulsory measure;
  • patients in the final stage of compulsory measures after hospitalization.

APNL can also be classified:

  • adaptation-diagnostic stage;
  • planned differentiated supervision;
  • final stage.

Let's look at each of them.

Characteristics of the adaptation-diagnostic phase

We recommend the first stage for people who have been diagnosed with a temporary mental disorder or a mental exacerbation (attack, paroxysm) of a chronic mental disorder, provided that it has ended by examination and has not left clinical manifestations that only require medical supervision 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 to people with negative personality mechanisms of OOD. But it is applicable when the patient was provoked to act by the situation itself, which arose not of his will and was resolved by the time the examination was carried out. This measure is also prescribed if the patient:

  • does not have psychopathic-like manifestations;
  • has no tendency to become alcoholic;
  • has no tendency to use drugs;
  • has a low probability 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, psychogenism, etc.
  • with unfinished treatment of an attack;
  • psychopathic disorders with short temper, oppositionality, emotional roughness, moral and ethical decline;
  • with relapse into committing actions dangerous to society, for example, a crime, in a state of psychosis or remission.

In this case, you need to take into account:

  • degree of inability to social adaptation;
  • social microenvironment;
  • alcoholism;
  • drug addiction.

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

No development was observed previously. Electrician. While serving in the army, he suffered a traumatic brain injury with loss of consciousness. Afterwards the patient complained of headaches and dizziness. Sometimes drinks alcohol. In a state of alcohol intoxication, headaches intensify, the patient becomes irritable. A few days before the crime was committed, the patient’s wife was hospitalized in a somatic hospital. For 4 days he drank 150 grams of vodka. He experienced deterioration in health, loss of appetite, poor sleep, and a feeling of concern for his wife. Before committing the act at work, he drank 150 grams of vodka. After the evening shift I came home. He talked with his family and complained of feeling unwell and having a headache. For a long time he could not sleep; feelings of anxiety and restlessness did not leave him. According to family members, he got up at 3 am and took one tablet of diphenhydramine. At 6 o'clock in the morning the patient stood 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. Then the patient returned home, went to the kitchen, took a knife and stabbed himself in the chest, damaging his lung. Witnesses said that the patient behaved silently, his appearance was terrifying, his eyes were bulging. The same condition was observed when the man was detained. In the police car he made no contact with anyone, did not pay attention to calls, and looked 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 commission of the act against relatives, the patient had scattered residual neurological symptoms, and signs of paroxysmal activity were revealed on the EGG. Complaints are characteristic of a cerebrasthenic state. The patient is depressed by the current situation, completely critical, and intellectually preserved. There are no psychotic phenomena or paroxysmal disorders. This means that X., due to organic brain damage at the time of the offense, developed a twilight state of consciousness provoked by alcohol. The commission recommended that he be sent for compulsory outpatient observation and treatment by a psychiatrist.

The recommendation was made on the basis that X had no previous history of mental health problems. This episode was the only one throughout his life, so there is no indication for inpatient treatment. However, the presence of a head injury does not allow us to give clear confidence that the disorder of consciousness may not recur. Therefore, the patient needs to be observed by a psychiatrist, periodically undergo examinations and EEG monitoring, and undergo appropriate resorption and dehydration therapy.

During outpatient compulsory treatment at the first adaptation-diagnostic stage, the patient undergoes further 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. Afterwards, recommendations are given about the lack of contact with persons with whom experiences during psychosis were associated, and social problems that require a dispensary are identified.

At the second stage, a set of rehabilitation measures and therapy is determined for each patient, depending on the identified pathology. They do not need release from work, since at the time of their application they have no grounds for this, but there are exceptions and easier working conditions are recommended.

The patient must undergo drug therapy and psychocorrective treatment, which explain the impact of adverse effects on the body and the importance of observing psychohygienic 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 identify the dynamics of pathological factors that are irritants for relapse. The following events are held here:

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

With the improvement of EEG indicators 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. If any form of pathology occurs, the patient and relatives should immediately regularly visit a psychiatrist due to the possibility of relapse.

For people with negative personalities, at the first stage the main tasks are:

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

The patient and relatives are explained the legal status of the patient, and are also told about the importance of compliance with the observation and therapy regime. If there is a decrease in working capacity, provided 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;
  • and so on.

At the first adaptation-diagnostic stage, with a stable mental state, the patient can take part in cultural events and work processes.

Definition of the second stage - planned differentiated supervision

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

Behavioral therapy includes training that:

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

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

  • in family;
  • in a microsocial environment.

At the second and final stage, consultation and therapy are provided to the patient’s relatives.

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

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 with a psychiatrist shows the following signs:

  • clinical picture of a chronic mental illness of delusional and/or psycho-like manifestations with a non-remission course or unstable remissions with frequent relapses;
  • criticism of the disease and/or complete OOD, regardless of adequate long-term therapy;
  • need for continued treatment;
  • collected medical history information that indicates violations of social adaptation;
  • in the past there was a tendency to abuse drugs, alcohol, etc.;
  • having criminal experience;
  • changes 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 everyday problems are solved, neurotic layers are 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:

  • the patient's mental state;
  • 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 everyday problems must be resolved.

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

Psychocorrectional 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 abolition of compulsory treatment. This stage is characterized by the following:

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

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

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

Almost all patients after discharge from hospital treatment have group II disability. Only 15% do not need it. Such people can return to their previous jobs. Typically, labor adaptation occurs in special occupational therapy workshops.

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

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

The exchange of information also provides for assistance to the police in times of increased threat to society.

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

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

All procedures are necessary to ensure that a dangerous situation does not reoccur.

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

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

Achieving adaptation contributes to:

  • loss of an unfavorable microsocial environment;
  • creating a satisfying lifestyle;
  • emergence of interests;
  • the appearance of worries.

But we should not forget that successful adaptation of patients in this group is often unstable, since minor difficulties, an antisocial environment, and alcohol consumption can lead to a breakdown. Successful adaptation data is considered:

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

The essence of compulsory 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.

The Criminal Code of the RSFSR, Article 62, 1960, states: it is necessary to use compulsory treatment and the application of punitive 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, citing infringement of human freedom 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 (clause “d”, part 1, article 97 of the Criminal Code). Now individuals must undergo only compulsory treatment within the penal system.

The above changes did not affect people who were in a state of mental disorder at the time the crime was committed (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 causing harm to themselves and other people. To persons related to Art. 97 can only be used by a psychiatrist (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 everything 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 the punishment occurs after the conclusion of a commission of psychiatrists is provided to the court. It is worth noting that this measure is described quite fully in Part 3 of Article 97 of the Criminal Code.

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

It is also unclear who will implement the coercion, since the Law on Psychiatric Care does not allow medical institutions to carry out such actions against persons whose disorder is not severe.

In modern times, this is questionable, since compulsory measures with the execution of punishment in all cases are carried out properly and bring the desired effect.

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