title: The importance of the patients deemed not guilty by reason of insanity for the psychiatric reform.
abstract: According to the Greek Penal Law if someone "because of a morbid disturbance of his mental functioning" (article 34) is acquitted of a crime or misdemeanour that the law punishes with more than 6 months imprisonment, then the court orders that this individual should be kept in a public psychiatric institution if the court reaches the conclusion that this person poses a threat to public safety.1 Individuals who have broken the law and deemed "not guilty by reason of insanity" are treated in psychiatric units of Psychiatric Hospitals according to the article 69 of the Penal Code. In Athens, in the Psychiatric Hospital of Athens and the Dromokaiteion Psychiatric Hospital, and in Thessaloniki in the Unit for "Not guilty by reason of insanity (NGRI)". The person who is deemed not guilty by reason of insanity following a crime is facing double stigmatisation and marginalisation from both the legal and the health system. He/she is usually treated initially with fear and later since there is no therapeutic aim but only the court instruction for "guardianship", with indifference. The patient who is committed by the courts in a psychiatric unit for being "NGRI" is facing a unique legal and psychiatric status.2 In this respect he/she is disadvantaged when compared to either convicted criminals or psychiatric inpatients. If the patient was not found "NGRI" (ie innocent as far as sentencing is concerned) he would have been punished with loss of liberty for a certain (specific) amount of time, and like all individuals convicted in court he/she would have the right to appeal and reduce his/her sentence in a higher court and maybe released from prison earlier for good behaviour etc. In this respect the individual found to be "NGRI" is disadvantaged when compared to a convicted felon since he/she is kept for an undefined period of time. Additionally, he/she will be allowed to leave the psychiatric unit following a subjective assessment of a judge with no psychiatric knowledge who will decide that this certain individual has "ceased to be dangerous". These problems are accentuated by the difficulties that the Greek justice system is facing. On the other side, from the psychiatric point of view, the "NGRI" patient who is an inpatient is not receiving the holistic, (bio psycho social) treatment and assessment of needs he/she requires. The psychiatric team looking after him, once the acute symptomatology is controlled is just getting used to a patient who will not be discharged in the immediate future. These patients form the "new chronic asylum psychiatric inpatients" for whom the treating psychiatrists are not allowed to discharge back into the community whilst it is unclear whether they can be transferred to supported rehabilitation units. It is a medical but also legal paradox to assign to contemporary psychiatric units aiming mainly to treat patients in the community to "keep and guard" inpatients whilst these psychiatric units should focus on care and rehabilitation of the patients (including the "NGRIs").3 Keeping patients like these in psychiatric units creates problems in the functioning of the units. These patients are "kept" in acute beds for long periods of time (5 to 6 years minimum) with patients treated voluntarily or against their will and cannot be discharged without a court's decision. The problems are obvious if one realises that the average time of hospitalisation is not exceeding 2 months for the vast majority of psychiatric patients. With the prolonged stay patients of the "article 69" (NGRIs) they not only burden the already limited resources (there is an established lack of psychiatric beds nationwide) but also this prolonged hospitalisation increases their stigmatisation and marginalisation. Thus the prolonged hospitalisation for "safety" reasons according to the court decision leads to the absence of a therapeutic aim other than maintaining the patient on the ward. Greece has agreed that there is an urgent need in developing community psychiatry services and closure/transformation of the big psychiatric hospitals (asylums). It is impossible to close hospitals where "NGRIs" are kept. The decision to move them into the community is not a medical-psychiatric but a legal one. In this respect it is imperative to establish a Forensic Psychiatric Unit for these patients. In our country as the "Psychargos" external evaluation highlighted, there are great gaps in the provision of Forensic psychiatric services.3 It must be emphasised that these gaps affect negatively psychiatric reform and social reintegration not only for the forensic psychiatric patients but for the whole of mentally ill individuals. Given that forensic Psychiatric services are developed in Athens and Thessaloniki and that training in Forensic Psychiatry has moved forward, it is imperative that the state should build upon the existing knowledge and experience and create specialist forensic units aiming to treat and rehabilitate this special and important group of patients.4 Only when the patients found "not guilty by reasons of insanity" have their own (safe for the society and them) therapeutic and rehabilitative services the aim of de-institutionalisation will be visible and realistic to implement.
authors.affiliation: Associate Professor in Psychiatry-Forensic Psychiatry, Director 2nd Psychiatry Department Athens University Medical School, "Attikon" Hospital.
authors.forename: Athanasios
authors.initials: A
authors.lastname: Douzenis
mesh_terms: D003134:Commitment of Persons with Psychiatric Disorders / Q000331:legislation & jurisprudence*; D003156:Community Mental Health Services / Q000331:legislation & jurisprudence; D003617:Dangerous Behavior; D005602:France; D018166:Health Care Reform / Q000331:legislation & jurisprudence*; D006301:Health Services Needs and Demand / Q000331:legislation & jurisprudence; D006742:Hospital Bed Capacity; D006778:Hospitals, Psychiatric / Q000331:legislation & jurisprudence; D006801:Humans; D007298:Insanity Defense; D010351:Patient Discharge / Q000331:legislation & jurisprudence; D011361:Professional Competence / Q000331:legislation & jurisprudence