Psychiatry - O. K. Napryeyenko 2001

General Psychiatry
Medico-social, military, and forensic psychiatric examination

Ensuring the expertise of working capacity and fitness for military service, as well as determining an individual's mental state and sanity when necessary, is one of the most critical Functions of psychiatric institutions.

The evaluation of working capacity in individuals with mental disorders is conducted by medical advisory commissions (MACs) of psychoneurological dispensaries, policlinics, hospitals, centers, clinics, and institutes, as well as by psychiatric medical and social expert commissions (MSECs) operating under municipal and regional healthcare authorities. The activities of MACs and MSECs are regulated by relevant legislative acts.

A MAC includes a ward or district psychiatrist and a department HEAD, and is chaired by the head of the institution or their deputy. The competence of a MAC encompasses establishing temporary disability, as well as issuing or extending sick leave certificates for a period not exceeding the total duration of the illness (4 months, or no more than 5 months within a calendar year). Additionally, a MAC decides on referring a patient to an MSEC, including before the expiration of the aforementioned period in cases of a pessimistic clinical and occupational prognosis.

A psychiatric MSEC operates under municipal (in large cities) or regional healthcare departments. It primarily conducts medical and social expertise regarding the level of functioning of patients referred by a MAC. In its work, it is guided by the relevant resolution of the Government of Ukraine. The Main Functions of an MSEC include determining the degree of a person's functional limitation based on their health status and establishing The Need for social assistance, as well as developing measures for individual medical and social rehabilitation of individuals with disabilities and monitoring their Structure/175.html">Implementation. The expert decision of an MSEC is not limited to assessing a patient's loss of working capacity, but is based on determining the overall degree of functional limitation according to criteria such as the loss or reduction of The ability to care for oneself, move, orient oneself, communicate, control one's behavior, and perform work activities.

Based on these criteria, the grounds for establishing Group I disability are a severely pronounced limitation in functioning According to the specified criteria or some of them, resulting in the need for outside care or assistance; Group II disability involves the same, except that the patient does not constantly require outside care; Group III disability involves functional limitations accompanied by a pronounced decrease in the ability to communicate, move, and participate in work activities.

Constant outside care or assistance is recommended when a patient is incapable of self-care. This occurs in cases of dementia (regardless of Etiology, including congenital idiocy and imbecility), and clearly pronounced prolonged psychotic states accompanied by behavioral disorganization.

Disability groups are subject to review every 1–3 years.

Military medical examinations are provided by the MACs of psychiatric institutions in accordance with orders issued by healthcare authorities. Examinations are commissioned by military medical boards at military enlistment offices to determine the fitness for military service of citizens called up for active military duty. The occupational fitness of service members is determined by the relevant commissions of military formations whenever doubts arise regarding their mental health or if Complaints are raised by individuals subject to inspection or conscription. A psychiatrist is a mandatory member of the MAC at military enlistment offices. When conducting military medical expertise, the MAC is guided by the "Regulations on Military Medical Expertise and Medical Examination in the Armed Forces of Ukraine," approved by the order of the Minister of Defense of Ukraine (No. 2 dated January 4, 1994). This document outlines the list of mental and behavioral disorders whose presence indicates: unfitness for military service with removal from military registration; unfitness for military service in peacetime or limited fitness in wartime; temporary unfitness; or fitness in cases of stable compensation or minor, short-term mental disorders that have not led to relevant negative consequences and have not significantly impacted the psyche.

Mental and behavioral disorders regulated by this list include: psychotic and non-psychotic mental disorders caused by organic Brain damage; endogenous psychoses, symptomatic psychoses, and other mental disorders; personality disorders; chronic alcoholism, drug addiction, and substance abuse; mental retardation; and stuttering. MAC Conclusions are made individually in each specific case, depending on the expert Assessment of the individual's health status.

Forensic psychiatric examinations are conducted by forensic psychiatric expert commissions or forensic psychiatric experts from medical or psychiatric institutions subordinate to healthcare authorities.

The main tasks of forensic psychiatric examination are:

1. Determining the mental state and providing a Conclusion regarding the sanity of individuals who are suspected, accused, or standing trial, whenever investigative and judicial authorities have doubts regarding their mental health and their ability to be accountable for their actions and control their behavior.

2. Determining the mental state and legal capacity of witnesses, victims, plaintiffs, and defendants when judicial or investigative authorities have doubts regarding their mental health and their ability to understand the meaning of their actions and deeds.

Forensic psychiatric examination is based on the principles of legality, independence, objectivity, and comprehensiveness of the study, and is appointed pursuant to rulings by an investigator or prosecutor, or by a court decision. It may be conducted on an outpatient or inpatient basis, in court, before an investigator, in absentia, or posthumously. The conclusion is drawn up as a report signed by all members of the forensic psychiatric commission, who bear criminal responsibility for its objectivity. Conclusions are made based on the results of clinical psychological and psychiatric examinations following the study and analysis of information about the individual and the circumstances of the offense committed. In doing so, experts are guided by Materials provided by the judicial-investigative body and objective data obtained by experts during the examination (medical documentation, observation, additional materials). If the expert conclusion is insufficiently substantiated, if doubts arise regarding the objectivity of the forensic psychiatric examination, if the individual's mental state changes, if new critical information previously unknown is obtained, or in particularly complex cases (to prevent errors, for example, in malingering), a repeat examination is appointed. It is conducted by a different expert or expert commission.

Among all types of forensic psychiatric examinations, outpatient examinations account for nearly 90% of all cases. Outpatient forensic psychiatric commissions are established by healthcare authorities in one of the psychiatric institutions of an oblast or a city under republican subordination. They comprise at least 3 psychiatrists, including a chairperson, a commission member, and a rapporteur physician who directly studies the case, analyzes information, and participates in the patient's examination. If an outpatient forensic psychiatric examination is unable to answer the questions posed by judicial or investigative bodies, it may issue a decision on the necessity of conducting an inpatient psychiatric examination, and a corresponding conclusion is drawn up.

Inpatient psychiatric examinations are conducted in psychiatric wards of hospitals, dispensaries, and specialized centers within forensic psychiatric departments. Security of the premises and territory, as well as the detention regime for individuals in custody, is provided by police authorities. The duration of an inpatient examination is limited to 30 days, but can be extended if necessary. The results of the inpatient examination are documented in a report signed by the commission and approved by the healthcare authority. Forensic psychiatric examinations conducted in court, before an investigator, in absentia, or posthumously are documented in a similar manner.

In the concluding part of the report, experts must provide a clear answer to the questions posed by the court or investigation, specifically:

1. Regarding the assessment of the accused person's mental state both at the time of the offense and at the present time, as well as regarding their sanity.

2. Regarding convicted persons, concluding whether they are able to serve their sentence in places of deprivation of liberty.

3. Regarding witnesses and victims, answering whether they are capable of giving testimony.

4. Regarding plaintiffs and defendants, the examination must conclude regarding their legal capacity.

Other questions of interest to judicial and investigative bodies may also be submitted for expert review.

In resolving the issue of sanity, one must be guided by the relevant article of the Criminal Code of Ukraine, which states that "a person who, at the time of committing a socially dangerous act, was in a state of insanity is not subject to liability (and therefore to sanity)." That is, they were incapable of critically evaluating their own actions and "controlling them As a result of mental illness, temporary mental disorder, dementia, or another pathological state."

Thus, METABOLISM/2.html">THE CONCEPT OF "sanity" includes two criteria:

✵ the legal criterion (an individual's inability to be accountable for their actions and control their deeds);

✵ medical (presence of mental illness, temporary mental disorder, dementia, or other pathology).

Given this, a person is recognized as insane only if, due to mental disorders, they are unable to answer for their actions and control them. In all other cases, a person is deemed sane and is subject to criminal liability. However, if a mentally ill person is found insane, the court applies medical measures to them, i.e., compulsory Treatment until recovery or improvement of mental health, with the subsequent resolution by the court on the termination of compulsory treatment.

When determining a person's legal capacity, the relevant article of the Civil Code of Ukraine is also applied, according to which a person is deemed legally incompetent due to mental disorders (illness) or dementia (including mental retardation). Thus, individuals are declared legally incompetent when both the medical criterion (presence of mental disorders) and the legal criterion (the patient does not understand the meaning of their actions and cannot control them) coincide. The issue of a person's legal capacity is decided exclusively by the court. By court decision, or upon the petition of public organizations, relatives, or interested parties, local executive authorities through the guardianship council establish guardianship over the incompetent person and appoint a guardian, who becomes the legal representative of this person and protects their property interests.

For the forensic psychiatric examination of so-called other morbid states, which mainly include pathological affect, intoxication, and twilight state, experts and investigative authorities must meticulously study the circumstances during the commission of the offense by the person.

The need to order an in-absentia and posthumous forensic psychiatric examination arises when there is suspicion (or information) that unlawful actions were committed by a person in a morbid state and this led to certain consequences, i.e., when the person was in a state of impaired mental activity.

Review Questions

1. Organization of Medical and social expertise.

2. Main tasks of medical and social expertise.

3. Concepts of temporary disability, partial loss of working capacity, complete permanent loss of professional working capacity, and complete permanent loss of working capacity requiring constant care and Supervision of the patient.

4. Purpose and organization of forensic psychiatric examinations.

5. Criteria for insanity.

6. Compulsory treatment.

7. Concept of legal incompetence and its establishment. Guardianship and the Procedure for its appointment.

8. Purpose and organization of military medical expertise.