Better control needed for out-patients?

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By Anna-Stina Nykänen
     
      It happened on Wednesday morning on the Helsinki Metro. A man grabbed an axe and hit a stranger in the head. The assailant had long been known to suffer from schizophrenia. He had previously been sentenced for smaller crimes committed under diminished capacity. Last year he had undergone treatment against his will.
      How can a man who is known to be as ill as he was, be allowed to walk the streets if he is in such bad condition? Why was he not given adequate care?
      There are many possible answers.
      "He certainly had to be sick, to do something like that. It was a mindless, paranoid act", says Dr. Markku Eronen, a specialist in forensic psychiatry, after hearing what had been reported in the media on the case. He is the director of the Vanhan Vaasan Hospital - an institution specialised in forensic psychiatry. He does not know all of the details of the case - at least not yet. It is very likely that the man will be sent to Eronen’s hospital, or to the Niuvanniemi Hospital in Kuopio.
     
One might have wished  that the man could have ended up Eronen’s hospital before the incident. It is not a completely implausible scenario; in recent years the man was in court facing charges of larceny and possession of amphetamines. At that time a medical report on him was presented to court. He has not undergone an actual psychiatric examination, but according to a doctor’s statement, he was quite ill already then. Because of his illness, he had been treated against his will at a prison mental hospital.
      If the court had decided at that time that the man was mentally incapacitated when committing the crimes he was charged with, he would have been sent to the state mental institution for the criminally insane, where the average time of treatment is 6 - 8 years, and even after release, the patients are subject to long-term surveillance.
      Eronen feels that the doctors’ statements would have allowed the man to be acquitted and committed to mental care. However, for some reason this was not done. "Perhaps the court disagreed with the doctors, when it convicted him", Eronen ponders.
     
The man had been treated at the Prison Mental Hospital. It is not yet known what condition he was in when he left the prison, or if he was in some kind of out-patient care.
      "Nobody can be kept in the Prison Mental Hospital for a single day beyond their sentence", Eronen points out. We do not know if the man’s treatment continued after he left the hospital. Eronen can only tell us what the alternatives are.
      If a prisoner requires coercive treatment after release, that treatment is arranged in the person’s home community. Otherwise continuing treatment is voluntary.
      Patients who are released from prison are often quite motivated, when becoming an out-patient. Eronen thinks that perhaps the treatment was simply not successful. Sometimes patients stop taking their medication, or start using intoxicants.
      For instance, amphetamine in itself has been known to trigger a psychosis long after a person has stopped using it. For some, the substance can cause symptoms of schizophrenia.
      "The illness can be kept under control by living a well-organised life -  in a mental hospital,  for isntance - but once a patient starts partying, the disease can break out", Eronen explains.
      If an out-patient starts using drugs and stops attending treatment, there is nothing that anyone can do about it, because treatment is voluntary.
     
Nobody in Finland can be compelled to accept out-patient treatment - at least not yet. The Ministry for Social Affairs and Health has set up a working group that is to consider the possibility of a system of obligatory out-patient treatment, in which the patient would be required to take part in regular checkups. Such a system already exists in some countries. This would allow medical personnel to make sure that the patient is not taking intoxicants, and that he or she is taking the right medication.
      "If it is carried out well, obligatory out-patient treatment increases freedom by eliminating the need for long periods of hospitalisation", Eronen says. He is a member of the working group which is drawing up the plan.
      Eronen says that now, especially in prison hospitals, patients tend to get stuck in the institution, because it is difficult to get treatment anywhere else. "They engender more fear than before, even though they commit homicides less frequently than before", Eronen says.
      It is not easy to get into out-patient care from a prison hospital. In the last stages officials check to see how well the patients cope with long furloughs. If things do not go well, the patients are quickly taken back into the hospital. In out-patient care this possibility does not exist.
      Supervision has proved necessary. In hospital some patients can be in quite good condition in the doctors’ opinion, but while on furlough, or after moving to another hospital, they can deteriorate in just a couple of weeks.
      On the practical level long furloughs work something like mandatory out-patient care. However, it is questionable how long it is legal to continue such surveillance while fulfilling the rules of forced mental care. A system of mandatory out-patient care would clarify the situation somewhat.
      In some countries mandatory out-patient care can be extended for five years after release from hospital. In Germany, for instance, there is no limit to the extensions.
     
"Coercion can and should be seen as a type of care - not just a means of official control", Eronen says. He heads a research project, in which patients released from prison hospitals have voluntarily allowed themselves to be examined every six months. Results have been generally quite positive in every way.
      "If it is arranged in a clumsy and forced manner, there is a feeling that big brother is watching. If it succeeds, it is only one means of giving support. But coercion is coercion. It is always different from voluntary participation. Now patients are pleased, since they get to tell head physicians that they have succeeded well, and that life has been successful", Eronen says.
      Mandatory out-patient care will probably be used only for patients convicted of crimes. Other mental health patients would continue to be left out of out-patient care with no possibilities of having their physical condition followed.
      "Can a person be left without care to live a bad life? It is a question of values and drawing lines", Eronen says.
      However, he does not want to extend obligatory out-patient care to patients other than those within the criminal justice system. "They are dangerous to others, which gives more justification for interfering in their lives."
      Therefore, obligatory out-patient care would not have applied to the man swinging the axe in the Metro. "Perhaps it would have been wisest to make him a patient of a prison hospital. But no system is completely flawless", Eronen says.
     
Would obligatory out-patient care have been enough to keep the man, who has many other problems, in shape? He was homeless, and apparently used drugs. According to numerous studies, men like him are the biggest threats to Finnish social peace, says MP Ilkka Taipale (SDP), a doctor by profession, and an expert in the field.
      In his view, more attention should be given to those with a double problem: those who both suffer from schizophrenia and abuse drugs. They have fallen behind others. In addition, those mental patients who are unable to fend for themselves would need to have apartments with round-the-clock help available. Those being released from prison hospitals should have supervised housing, because society cannot get along with them otherwise. That way, they would constantly be under scrutiny.
      In Taipale’s view, it would not be bad to keep watch on how things are going with people with problems. He feels that prisoners should also have supervised housing where they could have freedom on a trial basis, as long as they keep to the straight and narrow. However, that would require money.
      But could society accept such measures, even if there were money? Or has the notion of individual freedom gone so far that no interference in anyone’s life is allowed any more?
      "On a general level, that is the case, but the people do understand. Those living in (the affluent Espoo suburb of) Westend understand that they need to look at those living in Vesala (a working-class neighbourhood in the east of Helsinki comprising mainly public housing) in the eye. If they do not look them in the eye, they will have to face each other eye to eye. The black sheep need to be cared for", Taipale says.
      And yet, "These kinds of acts can never be completely eliminated", he says.
     
Helsingin Sanomat / First published in print 21.4.2004


Previously in HS International Edition:
  Metro axe-attack victim dies in hospital (27.4.2004)
  Man attacks metro passenger with an axe; victim in critical condition (22.4.2004)

ANNA-STINA NYKÄNEN / Helsingin Sanomat
anna-stina.nykanen@hs.fi