European Mental Health Laws,Social Inclusion

and Fundamental Rights

Hans Joachim Salize

Central Institute of Mental Health

Central Institute of Mental Health Mannheim, Germany

• Civil Detention: Involuntary Placement and Treatment of Mentally Ill –Legislation and Practice in European Union MemberStates (1999-2002)

• Forensic Care: Placement and Treatment of Mentally Ill Offenders –Legislation and Practice in European Union MemberStates (2002-2004)

• Mental Health in Prison: Treatment of Mentally Ill or Disordered Persons in European Prison Systems - EUPRIS

(2005-2007)

Studies on Law and Coercion in European Psychiatryfunded by DG Sanco

Regulation forCivil Detention

0

25.000

50.000

75.000

100.000

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

Austria BelgiumDenmark Finland Ireland LuxembourgPortugal EnglandSweden France Germany Italy

n

GERMANY

FRANCE

Involuntary placement of mentally ill – annual frequencies

ENGLAND

AUSTRIAFINLAND

ITALY

0

10

20

30

40

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

Austria Belgium Denmark

Finland Ireland Luxembourg

The Netherlands Portugal England

Germany Italy

* The Netherlands: admissions to psychiatric hospitals onlyLuxembourg: percentage refers to the country‘s only hospital treating involuntary patients

%

LUX

ITAGER

ENGIRE

BEL DENPORT

FIN

AUS

NETH

percentage of involuntary placements on all inpatient episodes in psychiatric facilities

• involuntary placements correlate with the overall trend in general mental health care in Europe (more frequent episodes due to decreasing lengths of stay)

• no overall indication for an increasing coercion during the 1990s, although rates vary considerably between Member States

• But the variety of legal regulations contributing to this rates needs to be analysed closer, in how far they safeguard of violate fundamental rights

plus Threat/Danger

Main Criteria for Involuntary Placementin European Mental Health Laws

Austria Belgium FranceGermany LuxembourgNetherlands

Mental Disorder

plus Threat/Danger or

Need for Treatment

plus Need for Treatment

Denmark Finland GreeceIreland Portugal England & Wales

Italy Spain Sweden

50,950

68,562,7

61,469

52,152,2

68,8

0 50 100

Belgium 1997

Denmark 2000

Finland 1999

France 1998

Ireland 1999

Luxembourg 2000

The Netherlands 1997

Sweden 1997

United Kingdom 1999

Percentages of Males among Involuntary Placed Persons

%

specified by law

DenmarkGermanyIrelandEngland & Wales

Criteria – Mental Disorders

not specified by law

AustriaBelgium FinlandFranceGreece Italy LuxembourgNetherlandsPortugalSpainSweden

distinct modalities

AustriaDenmark Germany LuxembourgNetherlandsSwedenEngland & Wales

Legal Distinction between Involuntary Placement and Treatment

not separated

BelgiumFinlandFranceGreeceIrelandItalyPortugalSpain

Independent Counsel / Patient Advocate

mandatory 40%(Austria, Belgium, Denmark, Ireland, Netherlands, Portugal)

not mandatory 60%

trained psychiatrist

AustriaGreece IrelandLuxembourgNetherlands*PortugalSpainSweden*United Kingdom*

Assessment of Mental State by

any physician

BelgiumDenmarkFinland*France*Germany*Italy

• Finland: preliminary assessment: any physician, hospital assessment: psychiatrist • France: HO-procedure: any physician• Germany: physician in some federal states, psychiatris or “physician experienced in psychiatry” in others • The Netherlands: physician only in case of emergency • Luxembourg: two required, one can be a physician, other must be a psychiatrist• Sweden,: two required, one can be a physician, other must be a psychiatrist• United Kingdom: two required, one can be a physician, other must be a psychiatrist

311

211

2

23

2

102

0 2 4 6 8 10 12

AUSTRIA

BELGIUM

DENMARK

FINLAND

FRANCE

GERMANY

GREECE

IRELAND

ITALY

LUXEMBOURG

NETHERLANDS

PORTUGAL

SPAIN

SWEDEN

ENGLAND & WALES

Emergency Procedures: Max. Length of Short-Term Detention

no emergency procedure

days

no emergency procedure

no emergency procedure

61

12

0,250,75

612

9

243

0 5 10 15 20 25

AUSTRIA

BELGIUM

DENMARK

FINLAND

FRANCE

GERMANY

GREECE

IRELAND

ITALY

LUXEMBOURG

NETHERLANDS

PORTUGAL

SPAIN

SWEDEN

ENGLAND & WALES

Maximum Length of Initial (Regular) Placement

not legally defined, reassment monthly

months

not legally defined, reassessment monthly

not legally defined, reassessment after 6 monthnot legally defined, reassessment after 2 month

Powpoint/Vorträge-2002/Bukarest-2002 (Compulsory).ppt

Option: Compulsory Outpatient Treatment

mentioned in law26,7%(Belgium, Luxembourg, Portugal, Sweden)

not mentioned in law73,3%

Disorders of Involuntary Placed Patients

0%

25%

50%

75%

100%

Belgium 1998

Denmark 2000

Finland 1999

France 1998

Ireland 1999

The Netherlands 1997

others

dementia +organic p.

affectivedisorder

substanceabuse

psychosis

Powpoint/Vorträge-2002/Bukarest-2002 (Compulsory).ppt

• Mental health laws and practices regarding involuntary placement and treatment of mentally ill vary remarkably across Europe

• Laws are often not in line with current standards of mental health care and do hardly provide clear guidelines for decision making

• Fundamental right protection may be increased in various aspects

- clear definition of criteria

- usage of professional diagnostic terminology

- definition and training of experts for assessment and decision making

- time frames for emergency and re-assessment procedures

- inclusion of patient counsel

- appropriate service provision

- health reporting standards

Conclusion - Civil Detention

Mentally Disordered Offenders

- Forensic Legislation and Care

4,7

10,3

6,66,1

6,9

0,8

8,6

2,4 2,2 2,1

8,1

1,81,4

8

0

4

8

12

Austri

a Belg

iumDen

mark

Englan

d & W

...Finlan

dFran

ce

German

yGre

ece

Italy

Irelan

dNeth

erlan

dsPor

tugalSpa

inSwed

en

Specified Beds in Forensic Care (per 100.000 population, 1998-2002)

Number of specified Beds in Forensic Care (1998-2003)

no. of additional capacity prison placementbeds in general psychiatry due to shortage

Austria 384 yes (incl.) noBelgium 1,061 yes (not incl.) yesDenmark 250 yes (not incl.) unknownEngland & Wales 3,200 yes (not incl.) noFinland 360 yes (incl.) unknownFrance 486 yes (not incl.) yesGermany 7,123 yes (not incl.) yesGreece 250 – 330 yes (incl.) yesItaly 1,282 no noIreland 80 yes (not incl.) unknownThe Netherlands 1,304 yes (not incl.) yesPortugal 189 no noSpain 593 yes (not incl.) noSweden 713 yes (incl.) unknown

Availability of Forensic Outpatient Facilities

available in

AustriaBelgium GermanyThe Netherlands

not availablein 11 Member States

12 months

12 months

6 months

106 days

28 days

0 2 4 6 8 10 12 14

IRELAND

NETHERLANDS

GREECE

GERMANY

PORTUGAL

month

Maximum Time Frames for Pre-trial Placement

Not specified

AustriaBelgiumDenmarkEngland & WalesFinlandFranceItalyLuxembourgSpainSweden

• Forensic service provision is extremely varying (in quality or quantity), although hard to evaluate and compare

• under-provision with specialized services is common

• Major fundamental right concerns include

- a “forensification” of difficult to treat (non-offendering) mentally ill

- to avoid trans-institutionalization of forensic patients into prisons or jails due to lacking capacities in the specialized forensic sector

Conclusions

This paper was produced for a meeting organized by Health & Consumer Protection DG and represents the views of its author on the subject. These views have not been adopted or in any way approved by the Commission and should not be relied upon as a statement of the Commission's or Health & Consumer Protection DG's views. The European Commission does not guarantee the accuracy of the data included in this paper, nor does it accept responsibility for any use made thereof.