Organization of inpatient psychiatric care. A. DrozdovPsychiatry: lecture notes. Classifications of mental illnesses

The provision of resources for psychiatric care in Russia is carried out based on the size of the population. For outpatient visits, one local psychiatrist is allocated for every 25 thousand adult population; one psychiatrist to serve children and adolescents – for 15 thousand of the relevant population. If a locality allows the creation of four or more sites, they can be combined into a psychoneurological dispensary, which is a medical institution with additional rooms and appropriate personnel.

For each area (25 thousand population) a social worker (with basic secondary social education) is also allocated, and for 75 thousand population, i.e. for three sites - one specialist social work(with basic higher social education), one psychologist and one psychotherapist.

A psychoneurological dispensary may include a day (night) hospital, medical labor workshops, a hostel for mentally ill people who have lost social ties, i.e. units whose activities are aimed at the rehabilitation and integration of mentally ill people into society.

A psychoneurological dispensary may also have a psychiatric hospital. In other cases, the role of a psychoneurological dispensary with the same rights is performed by the dispensary department of a psychiatric hospital.

IN Russian Federation in 2010, there were 276 psychoneurological dispensaries, including dispensary departments of psychiatric hospitals. In rural areas, one psychiatrist is allocated per 40 thousand population, but at least one doctor per rural area. He receives patients together with a nurse in a psychiatric office, which is usually located at the central district hospital. In large areas, an office may have two or three psychiatrists.

Inpatient psychiatric care is provided by psychiatric hospitals of varying capacity, which depends on the size of the service area. In large cities, as well as in regions (regions, territories, republics), there may be one, two or more psychiatric hospitals or inpatient departments at general somatic hospitals.

In some regions in rural areas there are psychiatric departments at central district hospitals. In some large cities, multidisciplinary somatic hospitals have somatopsychiatric departments, to which, if necessary, they refer people suffering from both severe mental and severe somatic diseases.

Psychiatric hospitals have general psychiatric (zoned) and specialized departments (gerontopsychiatric, children's, adolescent, psychosomatic, and also for borderline patients, sometimes there are epileptology departments, etc.). The remaining patients living in the given service area, regardless of condition and nosology, are sent to regional departments, often having two halves, in which it is possible to ensure separate stay of acute (excited) patients and behaviorally regulated (calm) patients.

Assistance is provided on a local-territorial basis. Doctors and other specialists in each of the two departments of the hospital (women's and men's) usually treat patients coming from several specific territorial areas. Together with the doctors of these areas and other dispensary specialists, they form almost a single team.

The most optimal option for setting up an inpatient department is 50 beds; its staff includes the head of the department and two doctors (25 beds per doctor), a senior and medical nurse, medical and paramedical staff providing round-the-clock care for patients, as well as a psychologist and social worker. Hospital departments, depending on the patient population, can work in an open-door mode, in some cases practice semi-stationary mode and medical leave in order to prevent the development of hospitalism in patients and for faster social recovery.

Children's and adolescent departments are organized with 30 beds. In addition to medical staff, they provide teaching staff who provide the opportunity to continue education for patients during inpatient treatment, as well as the positions of teachers and speech therapist.

The hospital has a laboratory and diagnostic unit, a staff of consultants of various somatic profiles depending on the number of beds, and has psychologists. In addition, a hospital (like a dispensary) may have a day hospital, occupational therapy workshops, and a hostel for people who have lost social ties.

In 2010, there were 234 psychiatric hospitals in the country, with a bed capacity of about 150 thousand beds.

In addition to the psychiatric institutions listed above, depending on the region of the country, there are regional, regional or republican psychoneurological dispensaries and hospitals that provide methodological unity in the provision of psychiatric care in a specific territory, counseling and assistance to patients in more complex cases. Regional Hospital usually also provides inpatient care to patients living in its assigned rural areas.

To ensure advisory and organizational-methodological work in psychiatry, the staff of a regional, regional or republican dispensary is allocated positions of psychiatrists per 250 thousand adults, per 100 thousand adolescents and 150 thousand children of the population of a given territory, the position of a psychotherapist for patients, those under dispensary observation (per 100 thousand population), as well as the position of head of the organizational and methodological advisory office.

In addition to basic psychiatric institutions, regional psychiatric services have a number of organizational units that provide suicidological, sexopathological, and psychotherapeutic assistance to persons visiting regional clinics, as well as those suffering from various types of speech pathology.

Consultative psychological offices for suicidology services are available not only in psychoneurological dispensaries, but also in some emergency hospitals and large universities. They can be intended for children, adolescents, and adult patients.

The suicidological service, which is organized in many large cities, is also supplemented by crisis hospitals and helplines. Psychotherapeutic rooms at district clinics have received especially great development.

Psychotherapeutic assistance is provided quite widely: in a number of regions there are offices in primary health care institutions, psychotherapeutic centers, and the possibility of organizing psychotherapeutic departments in general somatic hospitals is open.

In total, 888 psychotherapy rooms and departments operated in Russia in 2010.

It turns out it's an emergency psychological help victims of emergency situations.

These links of care constitute the non-dispensary section of the psychiatric service. Its development means an increasing movement of psychiatric care into general medical practice institutions, as well as into various spheres of social functioning.

In 2010, 14,275 psychiatrists were employed in providing mental health care.

The total number of medical psychologists employed is 3,616; social work specialists – 925; social workers – 1691.

Psychoneurological dispensaries and psychiatric offices provide two types of out-of-hospital care: consultative and therapeutic (in which patients go to these institutions on a voluntary basis) and dispensary observation (the need for which is determined by a commission of doctors, it involves monitoring the patient’s condition through periodic examinations carried out by a psychiatrist ).

Dispensary observation is established for persons suffering from chronic and protracted mental disorders with severe, persistent and often exacerbating painful manifestations.

The total number of people with disabilities due to mental illness is more than 1 million people.

Over the past decades, the number of disabled people working in ordinary enterprises has been decreasing - this is 3.5% of the total number of disabled people. The number of disabled people working in specialized workshops (0.1%) and employed in occupational therapy workshops (0.3%) has decreased three times or more.

About 60% of disabled people are of working age. The increase in unemployment among the mentally ill is outpacing the increase in unemployment among the population as a whole. According to some sample studies, it is 8–9%.

The role of day hospitals in the structure of psychiatric services is increasing. The number of places in them was more than 16,600 in 2010.

Since 1990, the number of psychiatric hospitals has decreased. Their total number in 2010 was 317. The number of hospital beds has significantly decreased.

There have been significant changes in mental health care over the past 15 years. Firstly, this is due to the transition from a medical model of care to a multiprofessional team approach with the participation of psychiatrists, psychologists, psychotherapists, social work specialists and social workers; secondly, with the increasingly widespread introduction into practice of psychosocial therapy and psychosocial rehabilitation.

In the mental health service system, a special role belongs to emergency psychiatric care.

Emergency psychiatric care teams (medical teams consisting of a doctor and two paramedics or a doctor, a paramedic and a nurse, as well as paramedic teams consisting of three paramedics or two paramedics and a nurse) in most cases are under the jurisdiction of general emergency psychiatric care, much less often included in the structure of institutions psychiatric service (dispensary or hospital).

They have a specially equipped ambulance, special equipment, and upon incoming calls they provide emergency psychiatric care, if necessary, an examination by a psychiatrist of a person without his consent or the consent of the legal representative of this person, as well as involuntary hospitalization.

In addition, they (usually paramedic teams) transport persons suffering from mental disorders upon the referral of a psychiatrist. In large cities with a population of more than 1 million people, specialized emergency psychiatric care teams (child and adolescent care, somatopsychiatric or intensive care psychiatric care) may be allocated. Psychiatric teams do not respond to calls without indications that the alleged patient has mental disorders.

Typically, the reason for calling emergency psychiatric help is cases of sudden development and exacerbation of mental disorders. The psychiatric team is often called by family members of patients and relatives, as well as police officers, work employees, neighbors and other persons, or the patients themselves.

There are two types of treatment measures carried out by the emergency psychiatric care team. One of them is medical measures that do not involve hospitalization of the patient. We are talking about persons with a wide range of conditions that are not severe mental disorders (neuroses, psychogenic reactions, decompensation in personality disorders, some cases of exogenous-organic mental disorders, as well as psychopathic and neurosis-like states in chronic mental illnesses, minor affective disorders, side effects psychotropic therapy). In these cases, assistance can be provided on an outpatient basis. It is usually accompanied by a psychotherapeutic conversation, as well as a recommendation to subsequently go to a dispensary for systematic treatment.

Another type of treatment is related to the decision to hospitalize the patient. Purpose medicines primarily aims to stop or reduce the severity of psychomotor agitation, especially in cases where transporting the patient takes considerable time. If necessary, therapeutic measures related to the development of seizures, cerebral edema, hemodynamic disorders. The ambulance team has a mandatory set of medications.

When providing assistance, legal regulations must be strictly observed. This is especially important when an emergency psychiatric team is called to persons who have not previously been examined by a psychiatrist and are not under dispensary observation, as well as in the case of involuntary hospitalization.

Day (night) hospital for the mentally ill is a widespread organizational form that occupies an important place in the mental health care system. Day hospitals There are profiles: children's, gerontopsychiatric, and also for patients with borderline conditions. More often they are used during the manifestation or exacerbation of the disease as an alternative to hospitalization or for follow-up treatment as an intermediate stage after the patient is discharged from the hospital and transferred to outpatient treatment.

Staying in a day hospital without interruption from the usual social environment allows you to reduce the time of treatment compared to a stay in a psychiatric hospital, and also contributes to its speedy readaptation.

A patient’s visit to a day hospital makes it possible for a doctor to daily assess the dynamics of his condition, promptly adjust therapy, conducting treatment in less restrictive conditions and while maintaining familiar social conditions and connections. The patient spends the second half of the day at home.

The overnight hospital is used for the same indications. Treatment is carried out in the evening and at night while work activity continues. Unlike the day hospital, the night hospital has not received widespread development. Sometimes organizational forms are created that use both modes - day and night.

A day hospital regime is often introduced in the departments of psychiatric hospitals, which will create Better conditions for social readaptation of patients.

Patients are referred to day and night hospitals by local psychiatrists or transferred for follow-up treatment from a psychiatric hospital.

Day hospitals can be created at all psychoneurological dispensaries; in some cases they exist at hospitals. In the latter option, a day hospital is more often used for follow-up treatment. The patient is transferred here if he does not require a mandatory stay in the hospital, needs strengthening of social rehabilitation measures, or shows a predisposition to the negative effects of long-term hospitalization.

To refer a patient to a day hospital, specialists use appropriate indications and contraindications. In addition, when deciding whether to send a patient to a day hospital or to a hospital, it is necessary to take into account the presence of conflicting relationships in the patient’s family that contribute to, provoke an exacerbation of, or support decompensation of the condition, as well as the adverse impact revealed by the assessment of the family situation on the patient during the period of exacerbation of the disease. children available in the family. In these cases, the patient must be hospitalized in a psychiatric hospital. The presence of concomitant infectious, as well as severe somatic diseases requiring special therapy or bed rest, is the basis for referring patients to the psychosomatic department.

In a day hospital, basically the same arsenal of therapeutic agents is used as in a hospital. Only methods that require round-the-clock monitoring are excluded.

Among psychosocial interventions, it is mandatory to include patients in group psychosocial programs using psychoeducational techniques. The goals are to develop in patients the correct attitude towards the disease, to teach them to recognize the initial manifestations of an attack or exacerbation. This is important for timely consultation with a doctor if relapses occur.

It is also possible to organize group sessions with training programs for skills of confident behavior and self-presentation, and family interaction. These programs can be varied depending on the indications. It is also possible to conduct cognitive behavioral psychotherapy or psychotherapy using other techniques. One of the tasks is to create and maintain a psychotherapeutic environment in a day hospital.

It is necessary to constantly work individually or in groups with the families (relatives) of patients, to develop in them correct ideas about the disease, the system of care and observation, interaction with patients, participation in ensuring the therapeutic process, correction of conflict relationships in families, assistance in finding employment, overcoming conflict situations in production, in work collectives.

These tasks are solved by the therapeutic team of the day hospital, including a psychiatrist, psychologist, psychotherapist, social worker, nurse. Each of these specialists solves their own specialized tasks in the process of patient management, outlined together when discussing treatment tactics at different stages, taking into account the dynamics of the condition.

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Altai State Medical University

Department of Psychiatry,

medical psychology and narcology

Head of the department professor,

Doctor of Medical Sciences Sheremeteva Irina Igorevna.

Subject:

"Organization of psychiatric care in the Russian Federation. Features of a psychiatric hospital. Regime, care for the mentally ill. Examination of the mentally ill."

Teacher:

Associate Professor, Ph.D. Karacheva Yulia Olegovna

Student:

Podrezova Sofia Stanislavovna 474 gr.

Organization of psychiatric care

The provision of psychiatric care in Russia is regulated by the Law of the Russian Federation "On psychiatric care and guarantees of the rights of citizens during its provision"

The psychiatric service in the Russian Federation has a number of organizational forms of hospital and out-of-hospital care for the population.

Psychiatric hospitals

Psychiatric hospitals are designed to treat patients with mental disorders of the psychotic level. However, in modern conditions, not all patients with psychosis require mandatory hospitalization in hospital. mental asylum(PB), many of them can receive treatment on an outpatient basis. Hospitalization in a hospital is justified in the following cases:

· patient refusal of treatment at the psychiatrist. In this case, subject to the conditions described in Art. 29 of the Law on Psychiatric Care, the court may order involuntary hospitalization and treatment for:

o Article 29. Grounds for involuntary hospitalization in a psychiatric hospital if the mental disorder is severe and causes the patient to:

a) his immediate danger to himself or others, or b) his helplessness, that is, his inability to independently satisfy the basic needs of life, or c) significant harm to his health due to a deterioration in his mental state if the person is left without psychiatric help.

The patient has psychotic experiences that could potentially lead to dangerous actions for the life of the patient and the people around him (for example, depression with delusions of guilt can push the patient to commit suicide, even if he agrees to treatment, etc.)

the need for treatment that cannot be done on an outpatient basis (high doses psychotropic drugs, electroconvulsive therapy)

· appointment by the court of inpatient forensic psychiatric examination(for persons under arrest there are special “guard” departments of forensic psychiatric examination, for others there are “non-guard” departments)

court appointments compulsory treatment mentally ill people who have committed crimes. Patients who have committed particularly serious crimes may be placed by the court in specialized hospitals with enhanced surveillance.

· helplessness of the patient in the absence of relatives capable of caring for him. In this case, registration of the patient in a psychoneurological boarding school is indicated, but before receiving a place in it, patients are forced to stay in a regular psychiatric hospital.

The structure of psychiatric hospitals corresponds to that for multidisciplinary hospitals, it includes an emergency room, medical departments, a pharmacy, offices functional diagnostics etc.

Psychiatric departments often have specialization by gender, age (children, adolescents, adults, gerontological), severity of mental disorders ("acute", rehabilitation). In large hospitals, separate departments are formed for somatically weakened patients, infectious diseases, tuberculosis, and sanatorium departments.

Since patients are treated involuntarily in the treatment departments of a psychiatric hospital, patients are on compulsory treatment and patients with auto-aggressive and aggressive tendencies, all departments provide special conditions for the stay of patients: all doors of the departments are closed to patients, there are bars and nets on the windows, there are no doors in the wards, nursing stations have been organized where staff are present around the clock, supervising patients . The closed regime of the departments, however, does not violate the provisions of the law on psychiatric care, because patients who are in the hospital voluntarily can refuse treatment at any time and will be examined by a commission of doctors, which will either agree with the patient’s decision and give an opinion on his discharge or refuse to discharge the patient and send the corresponding conclusion to the court on the need to recognize the hospitalization as involuntary.

Patients who are unable to live independently, in need of constant care, in the absence of relatives capable of providing this care, are transferred for further residence and treatment to psychoneurological boarding schools (PNI) of the social security system.

In addition to ordinary psychiatric patients, there are specialized psychiatric hospitals providing treatment non-psychotic mental disorders:

· Narcological hospitals - they provide treatment and rehabilitation for patients with addictions to various psychoactive substances (PAS). The main treatment measures in these hospitals are aimed at stopping the use of psychoactive substances, relieving the withdrawal syndrome, and establishing remission (abstaining from using psychoactive substances). These hospitals do not have conditions for the treatment of psychoses, therefore, with the development of psychoses caused by the use of psychoactive substances or its withdrawal (for example, delirium tremens - “delirium tremens”), patients must be transferred to a regular psychiatric hospital

· hospitals for the treatment of borderline mental disorders (in St. Petersburg, PB No. 7 "Clinic of Neuroses")

Psychoneurological dispensaries

Psychoneurological dispensaries (PND) are organized in those cities where the population size allows for the allocation of five or more medical positions. In other cases, the functions of a psychoneurological dispensary are performed by a psychiatrist’s office, which is part of the district clinic.

The functions of a dispensary or office include:

· mental hygiene and prevention of mental disorders,

· timely identification of patients with mental disorders,

· treatment mental illness,

· medical examination of patients,

· provision of social, including legal assistance, to patients

· carrying out rehabilitation activities

Identification of mentally ill patients is carried out in accordance with the “Law on Psychiatric Care”: when a citizen himself applies for psychiatric help or when people around him, law enforcement agencies, district administrations, social security organizations apply for a psychiatric examination, as well as during preventive examinations(conscription for military service, obtaining rights, weapons licenses, when entering work in certain professions, etc.), consultations with a psychiatrist in multidisciplinary hospitals, during examinations, etc.

Advisory and dynamic accounting in HDPE

Clinical examination provides two types of patient monitoring - A ) advisory, b) dynamic.

Advisory observation is established over patients with a non-psychotic level of disorders, in which a critical attitude towards the disease is maintained. In this regard, the time of the next visit to the doctor is determined by the patient himself, just as patients in the district clinic turn to doctors when they have any complaints. Advisory observation does not imply “registration” of the patient in the PND, therefore, persons under advisory registration most often do not have any restrictions “in performing certain types of professional activities and activities associated with a source of increased danger” and can obtain a driving license , a weapons license, work in dangerous jobs, in medicine, etc., make transactions without any restrictions.

Dynamic Dispensary observation is established for patients with a psychotic level of disorders in which there is no critical attitude towards the disease. Therefore, it can be carried out regardless of the consent of the patient or his legal representative. During dynamic observation, the main initiative for the next examination comes from the local psychiatrist, who sets the date for the next meeting with the patient. If the patient does not show up for the next appointment, the doctor is obliged to find out the reasons for the non-appearance (exacerbation of psychosis, somatic illness, departure, etc.) and take measures to examine him. The local psychiatrist, who is the main figure in the psychoneurological dispensary or office, distributes all patients in his area into 5 - 7 dynamic observation groups, depending on the mental state and method of treatment chosen.

The follow-up group determines the meeting interval between the patient and the doctor from once a week to once a year. Observation is called dynamic because, depending on the patient’s mental state, he moves from one group to another. Stable remission for 5 years with a complete reduction of psychotic manifestations and social adaptation provide grounds for deregistration in a psychoneurological dispensary or office.

Patients undergoing dispensary observation are usually recognized as unfit, due to a mental disorder, to perform certain types of professional activities and activities associated with a source of increased danger. Such a decision is made by a medical commission based on an assessment of the citizen’s mental health in accordance with the list of medical psychiatric contraindications and can be appealed in court.

Institutions for out-of-hospital care for the mentally ill

IN last years in connection with the achievements of psychopharmacotherapy, all greater distribution receive out-of-hospital care for the mentally ill and rehabilitation institutions. These include, in addition to psychoneurological dispensaries, day and night hospitals, occupational therapy workshops, special sections or special workshops at industrial enterprises, and hostels for patients with mental disorders.

Day and night hospitals are usually organized at psychoneurological dispensaries and psychiatric hospitals.

Day hospitals are intended for the relief of primary mental disorders or their exacerbations, if their severity does not correspond to those designated as conditions requiring mandatory hospitalization in a psychiatric hospital. These patients are examined daily by doctors, take medications prescribed to them, and undergo necessary examination and return home in the evening.

Night hospitals pursue the same goals as daytime ones, in cases of possible evening deterioration of the condition or an unfavorable home situation.

Therapeutic and occupational workshops, included in the system of rehabilitation of patients, are intended to develop or restore labor skills for disabled people of the 2nd or 3rd group. They receive remuneration for their work, which, combined with pension provision, makes it possible to feel relatively independent in material terms. Some patients have the opportunity to go to work in special workshops or special sections organized for disabled people at industrial enterprises.

Dormitories for the mentally ill with the process already completed and prepared for discharge, they are created in cases where patients, during the course of their illness, have lost their previous social connections, including their place of residence.

psychiatric help Russia

Features of the organization of psychiatric care in the Russian Federation

Thus, the organization of psychiatric care in the Russian Federation is characterized by the following features:

· variety of organizational forms,

· the opportunity to choose for the patient the organizational form of psychiatric care that best suits his condition,

· continuity in treatment, provided with operational information about the condition of the patient and the treatment being carried out during his transition to the supervision of a psychiatrist at another institution in the system of organizing mental health care,

· rehabilitation orientation of organizational structures.

Coordination in the work of psychiatric institutions, continuity in their work, and methodological guidance are carried out by the organizational and methodological office for psychiatry, headed by the chief psychiatrist of a particular territory.

Bibliography

Methodological manual for the course "Introduction to the specialty" (1st year, all faculties):

Methodical manuals for the course of general and medical psychology (1st year dental faculty, 2nd year medical faculty)

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Psychiatric care: history and current state
V.S. Yastrebov, T.A. Solokhin

Brief historical background

In 1792, a significant event occurred - the French doctor Philippe Pinel (1745 - 1826) removed the chains from the mentally ill. This fact demonstrated not only the possibility, but also the necessity of treating people with mental disorders with the same humane treatment as those suffering from other diseases. Russian psychiatrist N.N. Bazhenov commented on this event: “Pinel’s reform elevated the madman to the rank of the sick.”

Reform to eliminate measures of physical restraint for mentally ill people has also begun in other European countries. However, only in the first third of the 19th century were psychiatric hospitals opened here, which differed from the gloomy asylums of the past and the first institutions for isolating the mentally ill - “madhouses”.

The early period of development of psychiatric care in Russia (the first half of the 18th century) had a number of features compared to Western European countries. Charity for the mentally ill (supervision) was carried out mainly in monasteries. Russian psychiatrist Yu.V. Kannabikh, analyzing this period, noted that, in contrast to the states of Western Europe, “...in Russia, melancholics, schizophrenics, and paranoids could, with impunity, attribute to themselves intercourse with the devil, almost at the risk of being burned at the stake.”

Already in 1775 in Russia, provincial administrations began to open the first psychiatric departments in hospitals and build special houses for the mentally ill, called “yellow houses.”

The next period to focus on is Zemstvo (60s years XIX- beginning of the twentieth century), who made a huge contribution to the development of psychiatric care in Russia. It was then that the construction of psychiatric hospitals began, similar to suburban psychiatric colonies; At the same time, preference was given to pavilion construction rather than barracks, the premises were differentiated depending on the category of patients, attempts were made to organize the work of patients as a therapeutic measure, and the principle of “non-constraint” was applied as the basis of the hospital regime.

Radical changes in the entire hospital business in the field of psychiatry were carried out much easier in Russia than in the West. Representatives of zemstvo medicine, which included S.S. Korsakov, V.I. Yakovenko, V.P. Serbsky, N.N. Bazhenov, P.P. Kashchenko and many other progressive psychiatrists laid the foundations for the organization of psychiatric care, which were developed in the works of their followers.

Psychiatric clinic at Faculty of Medicine Moscow University, headed by S.S. Korsakov, became an exemplary medical institution in which progressive methods of patient management were used.

Another type of assistance at this time was the family patronage system: the patient was left with his family or placed in another and was provided not only with the necessary treatment, but also with financial benefits from the hospital. S.S. Korsakov considered this one of the first forms of out-of-hospital care. The main thing is that family patronage contributed to the preservation of the working capacity of patients and their feasible participation in the life of society. It is also important to note that from such families the correct views on mental illness, the mentally ill, and the activities of psychiatric hospitals and psychiatrists came into life.

However, despite all the advantages of psychiatric care in Russia at the beginning of the twentieth century, neither the number of psychiatric institutions nor the provision of their medical personnel satisfied the needs for it: one psychiatrist served 332 thousand people and there were only 0.25 psychiatric beds per 1 thousand. population. For comparison, here are the current indicators for Russia: one psychiatrist serves approximately 8.5 thousand people and there are 1.2 psychiatric beds per 1 thousand.

The 20s of the twentieth century marked a new stage in the development of domestic psychiatric care. P.B. made a great contribution to its improvement and development of psychiatry. Gannushkin, P.P. Kashchenko, L.A. Prozorov, I.I. Zakharov.

Let us outline important historical milestones in the development of a network of scientific and practical psychiatric institutions.

1918 - The Council of Medical Colleges decided to organize a Central Psychiatric Commission, which would provide leadership to all psychiatric institutions in the country. In the same year, the Leningrad Psychiatric Institute of Crippled Warriors was created, and a department of child psychiatry was opened in Moscow;
1919 - a psychiatrist was assigned to each district of Moscow, providing assistance to patients in many areas - from direct treatment and referral to a hospital to resolving issues such as protecting the rights of patients, providing them with social assistance, supplying food and clothing;
1921 - the Institute of Forensic Psychiatry named after. V.P. Serbian;
1924 - the first psychoneurological dispensary was opened for the purpose of carrying out therapeutic, preventive and advisory work;
1930 - the first day hospital was opened;
1936 - an emergency psychiatric service was created at the Research Institute of Emergency Medicine named after. N.V. Sklifosovsky (Moscow).

From the above brief historical overview it is clear how the foundations of the psychiatric service that exists today in our country were laid. The principle of historical continuity is important in order to identify useful but forgotten knowledge, to more fully evaluate the present, and to determine the basis for judgments about the future of this section of psychiatry.

Modern principles of organizing mental health care

Let us present the basic principles of organizing mental health care in our country.

1. Differentiation- providing it to different groups of patients: children, adolescents, people of working age and older age groups. This is ensured by a variety of forms of assistance for these groups of patients and medical personnel.

2. Continuity- functional interconnection of various psychiatric institutions for continuous provision of care. This principle is ensured by regulations on the activities of psychiatric institutions, rules for the preparation and movement of medical documents. The leading role in ensuring continuity belongs to psychiatric local service(dispensaries, offices) and its interaction with psychiatric hospitals, expert specialized commissions (medical and social, military medical, forensic psychiatric), day hospitals, medical and industrial workshops, specialized areas and workshops at industrial enterprises, as well as with social and educational institutions dealing with the problems of people with mental illness.

3. Stepping- the possibility of receiving psychiatric care depending on the patient’s condition different stages:
a) in primary health care (polyclinic);
b) in the out-of-hospital sector, the main forms of which are psychoneurological dispensaries and offices;
c) in inpatient institutions - psychiatric hospitals and psychiatric departments;
d) in the rehabilitation service, which includes medical and industrial workshops, specialized workshops, clubs for patients, mutual support groups, public organizations of consumers of psychiatric care and other institutions at the place of residence of patients where psychosocial rehabilitation is carried out.

4. Decentralization- bringing dispensary departments, psychiatric and psychotherapeutic offices, and psychiatric hospitals closer to the population. This is achieved, for example, by opening psychiatric departments for the rural population at central district hospitals, constructing small hospitals (no more than 600 beds), and disaggregating existing hospitals.

5. Integration with general somatic medicine - the organization of inpatient departments for the treatment of acute conditions in multidisciplinary hospitals, the interaction of psychiatric offices (dispensary departments) with the general out-of-hospital medical network. This contributes to the rapprochement of psychiatric institutions with general somatic ones, and makes it possible to significantly increase the volume of diagnostic, somatic and advisory care for mentally ill people, which they do not receive enough in psychiatric institutions.

The listed principles are universal and are used in other countries.

IN Lately The mental health care system in Russia has undergone a number of significant positive changes. The most important ones include:

· introduction of the legislative framework for the service’s activities and protection of patients’ rights;
· reform of the entire psychiatric service, including the transfer of basic powers from the federal to the territorial and local (institutional) levels;
· development of community-oriented mental health services (community-based services);
· the opportunity to openly discuss current problems of psychiatry in the scientific literature, the media, at meetings of members of the public with consumers of care (patients and members of their families);
· expansion of forms of specialized assistance.
· widespread introduction into practice of psychotherapeutic and sociotherapeutic assistance;
· implementation educational standards in the specialties “psychotherapy”, “ clinical psychology", "social work".

System of organization of state psychiatric care

Patients suffering from mental disorders and members of their families need information about the organization of the mental health care system in our country. They should know about institutions that provide mental health care and the types of care they can receive. Therefore, in this section we will briefly outline how mental health services generally function and present the characteristics of the main agencies. Readers who prefer to receive information “in numbers” will be able to familiarize themselves with statistical data.

You need to know that psychiatric care is provided in specialized institutions of different ministries and departments, among which the main ones are the Ministry of Health and social development and the Ministry of Education. In addition, the Scientific Center for Mental Health (SCMH RAMS), which is world famous, operates within the system of the Academy of Medical Sciences. scientific institution, within the framework of which practical assistance is provided to the population of Moscow, as well as other territories of Russia.

For the convenience of presenting the material, let’s imagine that the Ministry of Health and Social Development provides activities in two large areas - health care and social protection, each of which has specialized network institutions.

The healthcare system has created a wide network of psychiatric scientific and practical institutions. These include:

· departments of psychiatry at medical universities, where psychiatrists are trained and where persons in need of psychiatric care can receive highly qualified assistance;
· research institutes responsible for Scientific research in the field of psychiatry and the provision of highly qualified psychiatric care;
· psychiatric territorial services (there are 89 of them - according to the number of regions, autonomous republics, territories), the structure of which, as a rule, includes psychiatric hospitals, psychoneurological dispensaries, day and night hospitals.

In addition, in many areas, organizational forms that bring the provision of psychiatric care closer to the place of residence of the population (i.e., create the foundations of a community-oriented psychiatric service). These include: hospitals at home, offices (departments, centers) for helping people with crisis conditions and suicidal behavior, “helplines”, centers for socio-psychological assistance, speech therapy rooms, centers for speech pathology and neurorehabilitation, psychotherapeutic centers and offices, offices family medical and psychological counseling, “Marriage and Family” consultation, hostels for people with mental disorders who have lost social ties, institutions for psychosocial and labor rehabilitation.

The table presents some statistical information about psychiatric institutions and the staff of specialists working in them.

Table
Statistical information

Main institutions providing mental health care in the healthcare system
Psychoneurological dispensary (dispensary department, psychiatric office)- This is a non-hospital institution. They find themselves at the dispensary the following types assistance: emergency psychiatric, consultative and diagnostic, therapeutic socio-psychological, rehabilitation, all types of psychiatric examination, including determination of temporary disability, social and domestic assistance and assistance in employment, participation in the decision of guardianship, advice on legal issues, social and living arrangements for disabled people and the elderly, organizing training for people with disabilities and minors with mental disorders, providing psychiatric care during natural disasters and catastrophes.

Structure of the psychoneurological clinic:

· diagnostic and treatment rooms (for adults, children, adolescents, epileptological, psychotherapeutic, etc.);
· hospital (not always available);
· day or night hospital;
· legal aid office;
· social assistance office;
· occupational therapy workshops.

The staff of the dispensary includes local psychiatrists, psychotherapists, psychologists, social work specialists and social workers, and a legal adviser. Thus, with full staffing, it would be possible to approach a comprehensive solution to the problems of the patient and his family.

Mental hospital. A modern psychiatric hospital with its structure and staff provides wide range medical services for hospitalized patients.

The main functions of the hospital, in addition to providing emergency psychiatric care, are treatment and advisory, therapeutic, psychoprophylactic, socio-psychological and rehabilitation assistance. In addition, the psychiatric hospital carries out all types of psychiatric examinations, provides social assistance to patients and assists in their employment. She also participates in resolving issues of guardianship, consulting on legal issues, in the social and living arrangements for the disabled and the elderly, training the disabled and minors, and providing psychiatric assistance during natural disasters and catastrophes.

Structure of a psychiatric hospital:

· reception department;
· medical departments (general psychiatric, children's, adolescent, expert, forensic psychiatric, for compulsory treatment, psychotuberculosis, drug treatment, treatment and rehabilitation, resuscitation, infectious diseases, etc.);
· diagnostic and treatment department, which consists of a functional diagnostics room, a physiotherapy department with an office physical therapy, X-ray room, pathology department, clinical, biochemical, cytological, electroencephalographic, pathopsychological laboratories, offices of consultant doctors (therapist, gynecologist, ophthalmologist, otolaryngologist, etc.);
· day and night hospital;
· auxiliary departments and services (sterilization room, pharmacy, voice recording center, computer center, etc.);
· hospital management;
· administrative and utility premises (catering unit, laundry room with disinfection chamber, technical workshops, warehouses, garage);
· gardening (including greenhouses and greenhouses) and sports facilities.

The staff of medical and other personnel of psychiatric hospitals is presented in accordance with its structure and includes psychiatrists, psychotherapists, psychologists, social workers, general practitioners, ophthalmologists, otolaryngologists, laboratory assistants, paramedical personnel and many other specialists.

In our country average duration treatment in psychiatric hospitals is 75.4 days. This period does not correspond to the capabilities and requirements of modern psychiatry. To a certain extent, the long stay of patients in domestic hospitals is explained by the lack of modern diagnostic equipment in some of them, as well as the insufficient development of other forms of out-of-hospital care. In the USA, Great Britain, Italy and other countries, the duration of treatment in hospitals is much shorter - 2-3 weeks.

Day and night hospitals (semi-hospitals) is a transitional form of care between a psychiatric hospital and a dispensary. Semi-inpatient facilities are intended for the treatment of patients with exacerbations of a mental state or for follow-up treatment of those who have completed the main course of treatment in a psychiatric hospital and need gradual adaptation to life in the family and society. In terms of volume and intensity of treatment, day hospitals are close to psychiatric hospitals; they provide daily medical supervision of patients. Occupational therapy and psychosocial rehabilitation are provided (occupational therapy, cultural therapy, psychotherapy, etc.).

In the day hospital, patients receive two meals a day, and there are wards with beds for rest.
Patients with sleep disorders are mainly admitted to overnight hospitals.
The duration of treatment in a day and night hospital, as a rule, does not exceed 2-3 months.

Psychiatric ambulance and emergency medical teams and teams for transporting mentally ill patients, depending on local conditions, are part of the structure of an ambulance station, a psychiatric hospital or a psychoneurological dispensary. The tasks of psychiatric teams are to establish indications for the provision of emergency and urgent psychiatric care in all cases when the patient’s mental state requires the use of urgent medical measures, and to provide this assistance in accordance with the Law of the Russian Federation “On Psychiatric Care and Guarantees of the Rights of Citizens in its Provision.”

Hostels for people with mental disorders are created at institutions providing psychiatric care, at medical production and other state enterprises that employ the labor of people with disabilities due to mental illness. Patients who have either lost social connections, or need isolation from an unfavorable environment, or have difficulties in social adaptation are sent to the hostel. It is assumed that these patients, with minimal medical supervision, can fully care for themselves and work in ordinary or specialized enterprises. The costs of maintenance, free food, and psychiatric care for temporarily unemployed patients are provided for in the budget of the institution or enterprise where such a hostel is organized.

Three meals a day are provided for residents of the dormitory. If they wish, in agreement with the administration, they can purchase food and cook their own food. Persons who have started a family can live in a hostel in a separate room or apartment.

A public council is created in the hostel from those living in it to cooperate with the administration.

The hostel staff includes administrative and technical staff.

Institutions for persons with mental disorders in the social protection system

The main institutions intended for persons with mental disorders in this system are a psychoneurological boarding school for adults, an orphanage for children with mental retardation, and a rehabilitation center for persons with mental retardation.

Psychoneurological boarding school for adults is a place of permanent residence for elderly and disabled people suffering from chronic mental disorders and in need of care, household and medical services. Its tasks include providing material and living conditions and creating conditions close to home for patients, caring for them and providing medical assistance, carrying out cultural work and social and labor rehabilitation.

The administration of the boarding school, if necessary, performs the duties of a guardian or trustee in relation to the persons living there. Persons suffering from mental disorders can be accepted for temporary residence in a boarding school for 2 to 6 months.

Boarding school structure.

There can be several types of departments in a boarding school:

· intensive care - for patients with severe somatic and neurological disorders, profound dementia, incapable of self-care and independent movement, and other serious disabilities,
· medical and pedagogical correction - for patients whose intellectual defect is combined with severe emotional-volitional disorders, disorganization of activity and behavior,
· social rehabilitation - for those whose intellectual defect does not prevent them from learning simple professions or systematically engaging in work,
· dormitory.

For patients in the departments of medical and pedagogical correction, social rehabilitation and those living in the dormitory, there are conditions for free movement both within the boarding school and outside it.

In addition to the listed departments, the structure of the boarding school includes a reception and quarantine department, an isolation ward, offices for doctors and paramedical personnel (procedural, physiotherapeutic, dental, otolaryngological, massage, etc.), a laboratory, and a pharmacy.

Rehabilitation center for people with mental retardation is a new type of social protection institution. It can also be an independent institution, a rehabilitation unit within the structure of a psychoneurological boarding school. Its task is social adaptation, vocational and labor training of disabled people aged 16 to 45 years, incapable of independent life in society due to intellectual disability. In addition, its functions include organizing cultural, recreational and sports activities with patients. The center is engaged in the employment of trained patients at their place of permanent residence through the departments of social protection of the population.

The rehabilitation center has permanent, five-day and day departments. For vocational and labor training, it has classrooms, classrooms, and training workshops.

Analysis of the living conditions of patients in boarding homes general type and in psychoneurological boarding schools showed that in the latter there are more opportunities for social and labor rehabilitation, 1.5 times fewer patients on bed rest, lower mortality, up to 78% of patients take part in labor processes.

Institutions for persons with mental disorders in the system of the Ministry of Education

Educational and educational institutions of the education system for children with mental disorders include:

· preschool institutions - kindergartens and orphanages for children with mental retardation;

· school institutions- auxiliary boarding schools and general education boarding schools for children with delays mental development;

· special educational institutions- comprehensive schools, vocational schools, correctional secondary schools and vocational schools for children and adolescents with mental retardation and light forms mental retardation who have committed socially dangerous acts.

Thus, even from the short information provided about the system of providing psychiatric care, it is clear that currently in our country there are quite wide opportunities for almost all groups of the population to receive this help. The issues of improving the quality of services provided in all psychiatric institutions and developing new forms of assistance to most fully meet the needs of all those in need remain relevant.

The provision of psychiatric care in Russia is regulated by the Law of the Russian Federation “On Psychiatric Care and Guarantees of the Rights of Citizens in its Provision.” The psychiatric service in the Russian Federation has a number of organizational forms of hospital and out-of-hospital care for the population.

Psychiatric hospitals. Psychiatric hospitals are designed to treat patients with mental disorders of the psychotic level. However, in modern conditions, not all patients with psychosis require mandatory hospitalization in a psychiatric hospital (PH); many of them can receive treatment on an outpatient basis. Hospitalization in a hospital is justified in the following cases:

• - refusal of the patient to receive treatment from a psychiatrist. In this case, subject to the conditions described in Art. 29 of the Law on Psychiatric Care, the court may order involuntary hospitalization and treatment. Grounds for involuntary hospitalization in a psychiatric hospital if the mental disorder is severe and causes the patient to:
  • a) his immediate danger to himself or others, or
  • b) his helplessness, that is, his inability to independently satisfy the basic needs of life, or
  • c) significant harm to his health due to a deterioration in his mental state if the person is left without psychiatric help;
• - the patient has psychotic experiences that could potentially lead to life-threatening actions for the patient and the people around him (for example, depression with delusions of guilt can push the patient to commit suicide, even if he agrees to treatment, etc.);
• - the need for treatment that cannot be provided on an outpatient basis (high doses of psychotropic drugs, electroconvulsive therapy);
• - appointment by the court of a stationary forensic psychiatric examination (for persons under arrest there are special “guard” departments of forensic psychiatric examination, for others - “non-guard”);
• - court orders of compulsory treatment for mentally ill people who have committed crimes. Patients who have committed particularly serious crimes may be placed by the court in specialized hospitals with enhanced surveillance;
• - helplessness of the patient in the absence of relatives capable of caring for him. In this case, registration of the patient in a psychoneurological boarding school is indicated, but before receiving a place in it, patients are forced to stay in a regular psychiatric hospital. Forensic psychiatry: A textbook for universities / Ed. B.V. Shostokovich. - M.: Mirror, 1997.

The structure of psychiatric hospitals corresponds to that of multidisciplinary hospitals; it includes an emergency room, medical departments, a pharmacy, functional diagnostic rooms, etc.

Since in the treatment departments of a psychiatric hospital patients are treated involuntarily, there are patients on compulsory treatment and patients with auto-aggressive and aggressive tendencies, all departments provide special conditions for the stay of patients: all department doors are closed to patients, there are bars and nets on the windows, There are no doors in the wards; there are nursing stations where staff are present around the clock to supervise the patients. The closed regime of the departments, however, does not violate the provisions of the law on psychiatric care, because patients who are in the hospital voluntarily can refuse treatment at any time and will be examined by a commission of doctors, which will either agree with the patient’s decision and give an opinion on his discharge or refuse to discharge the patient and send the corresponding conclusion to the court on the need to recognize the hospitalization as involuntary.

Patients who are unable to live independently, in need of constant care, in the absence of relatives capable of providing this care, are transferred for further residence and treatment to psychoneurological boarding schools (PNI) of the social security system.

In addition to ordinary psychiatric patients, there are specialized psychiatric hospitals that provide treatment for non-psychotic mental disorders:

• · Narcological hospitals - they provide treatment and rehabilitation for patients with addictions to various psychoactive substances (PAS). The main treatment measures in these hospitals are aimed at stopping the use of psychoactive substances, relieving the withdrawal syndrome, and establishing remission (abstaining from using psychoactive substances). These hospitals do not have conditions for the treatment of psychoses, therefore, with the development of psychoses caused by the use of psychoactive substances or its withdrawal (for example, delirium tremens - “delirium tremens”), patients must be transferred to a regular psychiatric hospital
• · hospitals for the treatment of borderline mental disorders.

Psychoneurological dispensaries. Psychoneurological dispensaries (PND) are organized in those cities where the population size allows for the allocation of five or more medical positions. In other cases, the functions of a psychoneurological dispensary are performed by a psychiatrist’s office, which is part of the district clinic.

The functions of a dispensary or office include:

• · mental hygiene and prevention of mental disorders,
• · timely identification of patients with mental disorders,
• · treatment of mental illnesses,
• · medical examination of patients,
• · provision of social, including legal assistance, to patients,
• · Carrying out rehabilitation activities.

Identification of mentally ill patients is carried out in accordance with the “Law on Psychiatric Care”: when a citizen himself applies for psychiatric help or when people around him, law enforcement agencies, district administrations, social security organizations apply for a psychiatric examination, as well as during preventive examinations (call for military service, obtaining rights, weapons licenses, when entering work in certain professions, etc.), consultations with a psychiatrist in multidisciplinary hospitals, during examinations, etc. Forensic psychiatry: A textbook for universities / Ed. B.V. Shostokovich. - M.: Mirror, 1997.

Advisory and dynamic accounting in HDPE. Clinical examination provides for two types of monitoring of patients: a) advisory, b) dynamic.

Advisory observation is established over patients with a non-psychotic level of disorders, in which a critical attitude towards the disease is maintained. In this regard, the time of the next visit to the doctor is determined by the patient himself, just as patients in the district clinic turn to doctors when they have any complaints. Advisory observation does not imply “registration” of the patient in the PND, therefore, persons under advisory registration most often do not have any restrictions “in performing certain types of professional activities and activities associated with a source of increased danger” and can obtain a driving license , a weapons license, work in dangerous jobs, in medicine, etc., make transactions without any restrictions.

Dynamic Dispensary observation is established for patients with a psychotic level of disorders in which there is no critical attitude towards the disease. Therefore, it can be carried out regardless of the consent of the patient or his legal representative.

During dynamic observation, the main initiative for the next examination comes from the local psychiatrist, who sets the date for the next meeting with the patient. If the patient does not show up for the next appointment, the doctor is obliged to find out the reasons for the non-appearance (exacerbation of psychosis, somatic illness, departure, etc.) and take measures to examine him.

The follow-up group determines the meeting interval between the patient and the doctor from once a week to once a year. Observation is called dynamic because, depending on the patient’s mental state, he moves from one group to another. Stable remission for 5 years with a complete reduction of psychotic manifestations and social adaptation provide grounds for deregistration in a psychoneurological dispensary or office.

Patients undergoing dispensary observation are usually recognized as unfit, due to a mental disorder, to perform certain types of professional activities and activities associated with a source of increased danger. Such a decision is made by a medical commission based on an assessment of the citizen’s mental health in accordance with the list of medical psychiatric contraindications and can be appealed in court.

Institutions for out-of-hospital care for the mentally ill. In recent years, in connection with the achievements of psychopharmacotherapy, out-of-hospital care and rehabilitation institutions for the mentally ill have become increasingly widespread. These include, in addition to psychoneurological dispensaries, day and night hospitals, occupational therapy workshops, special sections or special workshops at industrial enterprises, and hostels for patients with mental disorders. http://yurist-online.com/uslugi/yuristam/literatura/stati/psihiatriya/010.php.

Day and night hospitals are usually organized at psychoneurological dispensaries and psychiatric hospitals. Day hospitals are intended to relieve primary mental disorders or their exacerbations, if their severity does not correspond to those designated as conditions requiring mandatory hospitalization in a psychiatric hospital. These patients are examined daily by doctors, take medications prescribed to them, undergo the necessary examinations, and return home in the evening. Night hospitals pursue the same goals as day hospitals, in cases of possible evening deterioration of the condition or an unfavorable home situation.

Therapeutic labor workshops, which are part of the patient rehabilitation system, are designed to develop or restore labor skills for disabled people of the 2nd or 3rd group. They receive remuneration for their work, which, combined with pension provision, makes it possible to feel relatively independent in material terms.

Features of the organization of psychiatric care in the Russian Federation. Thus, the organization of psychiatric care in the Russian Federation is characterized by the following features:

• · variety of organizational forms, the ability to choose for the patient the organizational form of psychiatric care that best suits his condition,
• · continuity in treatment, provided with operational information about the condition of the patient and the treatment being carried out during his transition to the supervision of a psychiatrist at another institution in the system of organizing mental health care,
• · rehabilitation orientation of organizational structures.

Coordination in the work of psychiatric institutions, continuity in their work, and methodological guidance are carried out by the organizational and methodological office for psychiatry, headed by the chief psychiatrist of a particular territory. Forensic psychiatry: A textbook for universities / Ed. B.V. Shostokovich. - M.: Mirror, 1997.

A correct solution to the issue of the further procedure for the proceedings in the case and the need to apply compulsory medical measures to a person if there are doubts about the mental state of the accused is impossible without ordering and conducting a forensic psychiatric examination (clause 2 of Article 79 of the Code of Criminal Procedure).

Forensic psychiatric examination- this is a special study conducted by one or a group of forensic psychiatric experts in order to provide an opinion on the mental state of the subject in criminal and civil proceedings.

The main tasks of forensic psychiatric examinations are:

definition of sanity - insanity;

determination of legal capacity - incapacity;

determination of procedural capacity in criminal proceedings;

determination of procedural capacity in civil proceedings;

Most forensic psychiatric examinations in Russia are carried out in state forensic psychiatric expert institutions. In forensic psychiatry, the functions of an expert institution are performed by forensic psychiatric expert commissions (FPEC) and forensic psychiatric expert departments organized at general psychiatric institutions - psychiatric hospitals and psychoneurological dispensaries. Main performance indicators of the forensic psychiatric expert service of the Russian Federation in 2009: Analytical review. M.: FSI "SSC SSP named after V.P. Serbsky" Ministry of Health and Social Development of Russia. 2010. Issue. 18. 188 p. Expert commissions and expert departments conduct forensic psychiatric examinations on a regular basis according to the rules for conducting forensic examinations in an expert institution. The leading in the system of state forensic psychiatric expert institutions is the State Scientific Center for Social and Forensic Psychiatry named after. V.P. Serbsky (GNTsS and JV named after V.P. Serbsky). The procedure for organizing forensic psychiatric expert institutions is determined by departmental regulations of the Ministry of Health of Russia, which are agreed upon in necessary cases with federal law enforcement agencies and legal departments - the Supreme Court of the Russian Federation, the Prosecutor General's Office of the Russian Federation, the Ministry of Internal Affairs of Russia, the Ministry of Justice of Russia (for example, Order of the Ministry of Health of Russia dated August 12, 2003 N 401 and Federal Law dated May 31, 2001 N 73-FZ "On State Judicial -expert activities in the Russian Federation"). According to these regulatory documents Forensic psychiatric expert commissions are divided into outpatient and inpatient. Some of them are authorized to conduct both outpatient and inpatient examinations (mixed commissions).

To carry out inpatient examinations, specialized forensic psychiatric inpatient departments are opened at psychiatric institutions that have inpatient forensic psychiatric expert commissions. One part of them is intended for persons in custody ("guard departments"), the other - for other subjects ("guardless departments") Forensic psychiatry: A textbook for universities / Ed. B.V. Shostokovich. - M.: Mirror, 1997..

The activities of forensic psychiatric expert institutions are organized according to the zonal (zonal-territorial) principle, i.e. An expert institution serves preliminary investigation bodies or courts located in a certain territory. Forensic psychiatry: A textbook for university students / E.B. Tsargyasova; Z.O. Georgadze, - M.: Law and Law, UNITY-DANA, 2003. - p. 55.

Based on the results of the forensic psychiatric examination (FPE), a conclusion in writing signed by all the experts who conducted it and sealed with the seal of the institution in which it was carried out. The term for drawing up an expert opinion is no more than 10 days after the completion of expert research and the formulation of expert conclusions. Federal Law of May 31, 2001 N 73-FZ “On State Forensic Expert Activities in the Russian Federation” (adopted by the State Duma of the Federal Assembly of the Russian Federation on April 5, 2001).

The conclusion consists of three parts: introductory, research (including an anamnestic section, a description of the somatic, neurological and mental state, with a comprehensive examination - the psychological, sexological state of the subject), conclusions. The conclusion of a forensic psychiatric examination is not mandatory for the court and is assessed by the court according to the rules established in Article 67 of this Code. The court's disagreement with the conclusion must be motivated in the court's decision or ruling. Civil Procedure Code of the Russian Federation" dated November 14, 2002 N 138-FZ (adopted by the State Duma of the Federal Assembly of the Russian Federation on October 23, 2002) Art. 86.

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Legal regulation of the provision of psychiatric care in the Russian Federation

Introduction

3.2 Contents of the contract for the provision of psychiatric care

3.3 Grounds and features of civil liability under a contract for the provision of psychiatric care

Conclusion

List of used literature

Introduction

In Rus', people with mental illness were treated differently. Those who did not pose a danger to society and were distinguished by unusual behavior and obscure statements experienced hallucinations, “visions,” etc. often revered. Dangerous mentally ill people, especially those who committed offenses of a religious and anti-state nature, were kept in special premises in Solovetsky and other monasteries and did not receive any treatment.

Currently, about 500 million people on the planet suffer from diseases and mental disorders. According to the World Health Organization, about 52 million people are susceptible serious illnesses nervous system, such as schizophrenia, 155 million are affected by neuroses, about 120 million suffer from mental retardation, 100 million from various disorders depressive type, 16 million - from dementia. Totally crazy // Echo of the Planet. 1993. No. 42. . Mental imbalance is one of the main causes of disability, decreased productivity, and family breakdown.

The rights of citizens to life and health are considered to be the most significant, influencing directly or indirectly the relationship between citizens and the state as a whole, as well as their financial situation. Until recently, there was a dispute between lawyers about the civil law method of regulating relations that arise between citizens and medical institutions regarding the provision of medical care.

Intervention in the sphere of human life and health can be expressed in various types And different ways. These differences in the types and methods of intervention will determine the individual types of contracts for the provision of particular medical care.

The subject of our research will be a civil contract for the provision of psychiatric care.

The new Civil Code of the Russian Federation has resolved the dispute that life and health are considered personal non-property benefits and inextricably belong to citizens and no one else. However, the contract for the provision of psychiatric care as such is not reflected in the Civil Code, and the legal relations that develop during the operation of this contract are quite complex and varied.

In the process of providing psychiatric care to citizens, legal relations arise that require legislative regulation. The decisive factor in these relations is the fact that mental disorders disrupt the social functioning of the individual, and often completely deprive him of the ability to make informed decisions and purposeful behavior, as a result of which it can even become dangerous. Because of this, psychiatric care in its different types has long been associated with the possible restriction of the patient’s personal freedom and the use of various involuntary measures. At the same time, mental illness, which limits the full functioning of the individual in society, requires a certain social protection of persons suffering from mental disorders, providing them with privileges and benefits. Commentary on the Legislation of the Russian Federation in the field of psychiatry / Coll. authors. Under general ed. T. B. Dmitrieva. - M.: Publishing House "Spark", 1997. P.4. .

Employees of psychiatric institutions involved in the provision of mental health care also need to be given certain rights to use specific types of mental health care, as well as protection measures related to particularly difficult and dangerous conditions activities, creating certain privileges compared to other medical professionals.

Given the severity of the problem and the seriousness of the consequences, its solution is given top priority.

In Russia in 1992, a special Law of the Russian Federation of July 2, 1992 No. 3185-1 “On psychiatric care and guarantees of the rights of citizens in its provision” was adopted by the Supreme Council of People's Commissars and the Armed Forces of the Russian Federation. 1992. No. 33. Article 1913. .

All of the above determines the relevance of this study.

The work examines the problems that arise when providing mental health care to citizens, in particular:

Problems of the legal status of persons suffering from mental disorders; protection of their rights and legitimate interests;

The problem of a civil contract for the provision of psychiatric care.

The contract for the provision of psychiatric care has not found any serious discussion among lawyers. In general terms, this problem was analyzed in the works of M. N. Maleina.

A civil contract for the provision of medical care, legal relations arising regarding the provision of medical services, the right of citizens to life and health were considered by some authors in a purely legal aspect. These include A.F. Koni, N.S. Malein, M.A. Maleina, A. N. Savitskaya. Serious research on the protection of citizens' rights to life and health is contained in scientific articles and monographs by M.N. Maleina, which are distinguished by the depth of the problem under consideration and their scientific approach. Medical confidentiality as an indispensable condition of a contract for the provision of medical care is seriously considered in N. Elshtein’s work “Glasnost and Medical Secrecy.”

Certain aspects of professional risk and liability for causing harm to health are contained in the monographs of Dontsov S.E., Glyantsev V.V. “Compensation for harm under Soviet legislation.”

When preparing and writing the final qualifying work, textbooks and teaching aids in the course “Medical Law”, scientific articles from journals, legal acts.

Chapter 1. Legislation of the Russian Federation on psychiatric care

1.1 History of the development of legislation of the Russian Federation on psychiatric care

Until recently, we did not have a law regulating the activities of psychiatric services and the legal status of persons suffering from mental disorders. It is known that attempts to develop such a law were made in pre-revolutionary Russia, but due to the outbreak of the First World War, the law was not adopted. Commentary on the Legislation of the Russian Federation in the field of psychiatry / Coll. authors. Under general ed. T. B. Dmitrieva. - M.: Publishing House "Spark", 1997. P.4. .

In Soviet times, the activities of psychiatric institutions were regulated by departmental orders and instructions of the USSR Ministry of Health, which were not published in the press and were not known to the public and significantly infringed on the constitutional rights of citizens. Too general and insufficiently defined wording of departmental by-laws, combined with a lack of non-departmental control the activities of psychiatrists and the lack of the right to judicial appeal in the provision of psychiatric care created the ground for voluntary or involuntary abuses. Superimposed on the above stereotypes of public consciousness, they led to the spread of anti-psychiatric sentiments in society, a decline in the prestige of the psychiatrist profession, and most importantly, to the infringement of the rights of persons suffering from mental disorders. Efforts aimed at establishing a legal democratic state required the resolution of numerous problems in Russian psychiatry and the creation of an adequate legal framework for this.

The lack of legislative regulation and the closed nature of psychiatric institutions created conditions for legal arbitrariness in the provision of psychiatric care and the use of psychiatry for non-medical, including political, purposes. Related to this are accusations of abuse by domestic psychiatrists; in our opinion, however, they are not always justified. Commentary on the Legislation of the Russian Federation in the field of psychiatry / Coll. authors. Under general ed. T. B. Dmitrieva. - M.: Publishing House "Spark", 1997. P.4. .

In 1987, an interdepartmental commission was created to develop a draft legislative act on the provision of psychiatric care to the population. It included representatives of the Ministry of Health, law enforcement agencies, the Institute of State and Law, the All-Russian Research Institute of Forensic Psychiatry named after. V.P. Serbian. The commission prepared a Regulation on the conditions and procedure for providing psychiatric care, approved by the Decree of the Presidium of the Supreme Soviet of the USSR of January 5, 1988, Vedomosti USSR. 1988. No. 2. Art.19. . and put into effect on March 1, 1988. Although this document did not cover a wide enough range of issues related to the activities of the psychiatric service, it still made it possible to test in practice a number of innovations aimed at expanding and protecting the rights and legitimate interests of persons suffering from mental disorders, obtain data on the need to revise some of the provisions and procedures contained in it. Work experience has shown the validity and feasibility of the basic requirements of the Regulations, as well as the sufficient preparedness of employees of psychiatric and psychoneurological institutions for their adequate application in practice. At the same time, as noted in critical statements in the press, the rights of persons suffering from mental disorders were not sufficiently protected, and some contradictions and commonplaces were allowed; Some fundamentally correct provisions, for example, on the assistance of a lawyer, on judicial appeal, were declarative in nature, since they did not have appropriate material and procedural support. Commentary on the Legislation of the Russian Federation in the field of psychiatry / Coll. authors. Under general ed. T. B. Dmitrieva. - M.: Publishing House "Spark", 1997. P.5. .

In connection with the noted shortcomings, it was decided to prepare a new normative act- the law regulating the legal problems of psychiatry. It was based on a project developed at the Institute of State and Law by Professor S.V. Borodin and Candidate of Legal Sciences S.V. Polubinskaya, which was published Law and Psychiatry: Collection. - M., 1991. P.369-282. . The authors paid special attention to further strengthening the legal guarantees of persons receiving mental health care and clarifying the criteria for the use of involuntary types of such assistance. Work on the project was initially carried out on the basis of the Institute. V.P. Serbian by a team of specialists created by the USSR Ministry of Health. Then it is transferred to the working group of the Supreme Soviet of the USSR under the leadership of deputy A.E. Sebentsova. After the collapse of the USSR, the preparatory work on the bill was completed by the working group of the Supreme Soviet of the RSFSR, headed by deputy L.I. Kogan. The group included specialists (lawyers and psychiatrists), including representatives of the Independent Psychiatric Association, who took an active part in the work at all stages of the preparation of the bill.

It should be added that at various stages of readiness the bill was discussed at public forums, mainly psychiatric - a meeting of chief psychiatrists, a plenum of the Board of the All-Union Society of Psychiatrists, a plenum of the Board of the Russian Society of Psychiatrists, published in the Medical Gazette (twice), the Journal of Neuropathology and Psychiatry named after. S.S. Korsakov." The results of these discussions and responses to publications were taken into account and used in preparing the draft Law.

On July 2, 1992, the Law of the Russian Federation “On psychiatric care and guarantees of the rights of citizens during its provision” (hereinafter referred to as the Law) was adopted by the Supreme Council and then signed by the President of the Russian Federation.

Since that time, this Law has been the main regulatory legal act, the only source that regulates the provision of psychiatric care to citizens in the Russian Federation.

1.2 Sources legal regulation agreements for the provision of psychiatric care

The sources of legal regulation of the contract for the provision of psychiatric care are understood as the system of legal acts adopted by the authorized bodies of the representative (legislative) and executive authorities of the Russian Federation and the constituent entities of the Russian Federation on the provision of psychiatric care.

The most important legal act in this system is this federal law, which sets out the fundamental norms and principles for all legal regulation of the provision of mental health care and the protection of the rights of citizens in this area. The basic nature of this Law in the sphere of relations regulated by it is confirmed by direct references to it contained in other federal laws where the provision of mental health care is concerned. Thus, the Fundamentals of the legislation of the Russian Federation on the protection of the health of citizens establish that examination and hospitalization of persons suffering from severe mental disorders is carried out without their consent in the manner established by the Law of the Russian Federation “On psychiatric care and guarantees of the rights of citizens in its provision” Law of the Russian Federation “On the protection of health of citizens." Adopted by the Supreme Council of the Russian Federation on July 22, 1993 // Gazette of the Armed Forces of the Russian Federation. 1993. No. 33. Art. 318. .

The main reasons for the adoption of the Law are indicated in the preamble:

"Recognizing high value for every person's health in general and mental health in particular;

Considering that a mental disorder can change a person's attitude towards life, himself and society, as well as society's attitude towards the person;

Noting that the lack of proper legislative regulation of psychiatric care may be one of the reasons for its use for non-medical purposes, causing damage to health, human dignity and the rights of citizens, as well as the international prestige of the state;

Taking into account the need to implement in the legislation of the Russian Federation the rights and freedoms of man and citizen recognized by the international community and the Constitution of the Russian Federation, the Supreme Council of the Russian Federation adopts this Law "Law of the Russian Federation of July 2, 1992 No. 3185-1 "On psychiatric care and guarantees of rights citizens when it is provided” // VSND and the Armed Forces of the Russian Federation. 1992. No. 33. Article 1913. .

They are equivalent and, in a generalized form, determine the need for the adoption of this Law, arising from the living conditions of Russian society and the state.

There have been cases of use in the former Soviet Union

psychiatry for non-medical, including political purposes - to suppress dissent or get rid of people disliked by some officials. The denial of these facts, the refusal to investigate them and publicly discuss them led to the fact that for several years domestic psychiatry was deprived of the opportunity to participate in the activities of the international professional community - the World Psychiatric Association. Some damage was also caused to the state's prestige in the international arena.

In the Russian Federation it is recognized that placement for compulsory treatment in psychiatric medical institutions applied by the state for political reasons, i.e. was political repression. The Russian Federation has recognized the use of psychiatry for political purposes and the responsibility of the state to the victims of “political psychiatry,” although such cases occurred during the existence of the Soviet Union.

Among the many reasons for the abuse of psychiatry, and, above all, for political purposes, was the lack of proper legislative regulation of the provision of mental health care.

In accordance with Art. 1 of the Constitution, the Russian Federation is a democratic federal state governed by the rule of law. The main values ​​of a democratic state are human life, his rights and freedoms. This provision is fixed in Art. 2 of the Constitution of the Russian Federation, which also establishes that the recognition, observance and protection of human and civil rights and freedoms is the duty of the state. Constitution of the Russian Federation. Adopted by popular vote on December 12, 1993. - M., 1995. P. 4. . These norms of the supreme law of our country are closely interrelated: a state cannot be called legal and democratic if a person, his rights and freedoms do not have priority over other social values. Ultimately, ensuring the rights and freedoms of man and citizen is the main goal of the activities of a democratic state governed by the rule of law.

Let us emphasize that these values ​​are extremely important for every individual citizen, especially when there is a threat of their loss. A mental disorder is precisely that “increased risk” factor, which often leads to the infringement of the rights and freedoms of the person suffering from such a disorder. A widespread stereotype in societies with different socio-cultural and economic conditions, which perceives and interprets mental disorders as something shameful, and people suffering from them as dangerous to society, leads to unreasonable legal restrictions imposed on these people. Moreover, the idea of ​​the social danger of mentally ill people led in the past to excessively harsh and inhumane methods of treating them, which have not been completely eliminated in modern times. modern states. Meanwhile, persons suffering from mental disorders are the same members of society as other citizens, endowed with the same set of fundamental rights and freedoms, which today are called human rights and freedoms. These rights and freedoms are a fundamental category, and their possession does not depend on additional factors, which may include the mental disorder of the subject. Therefore, the task of the state in the area under consideration is to give these rights and freedoms legal registration and establish procedures that protect their bearer from any unlawful attacks on them.

The main meaning of the Law is the desire to make psychiatric care as humane and democratic as possible, to bring it closer together and even legally equalize it with other types of medical care. At the same time, the Law proceeds from the fact that the specific nature of mental disorders makes it necessary and justified in some cases to use measures of psychiatric care independently and even contrary to the patient’s currently expressed wishes. Indications for the use of such measures should be clearly defined, the range of patients should be narrowed as much as possible, and the measures themselves should be strictly regulated.

The law is aimed at solving four main tasks:

1) protection of the rights and legitimate interests of citizens in the provision of psychiatric care from unjustified interference in their lives;

2) protection of persons suffering from mental disorders from unjustified discrimination in society on the basis of a psychiatric diagnosis, as well as the facts of seeking psychiatric help;

3) protecting society from possible dangerous actions of persons suffering from mental disorders;

4) protecting doctors, medical personnel and other specialists involved in the provision of mental health care, providing them with benefits as workers operating in particularly dangerous, difficult working conditions, as well as ensuring the independence of a psychiatrist when making decisions related to the provision of mental health care, from possible influence of third parties, including representatives of the administration and management bodies.

To solve these problems, the Law establishes a number of special norms and procedures. Among them, special mention should be made of the judicial procedure for resolving issues of psychiatric examination (in a certain part of cases) and hospitalization in a psychiatric hospital without the consent of the person or his legal representative; creation of a special independent service for protecting the rights of patients in psychiatric hospitals; guarantees of the right to social insurance and social security for persons with mental disorders who have committed socially dangerous acts and are subject to compulsory treatment by court decision; introduction of compulsory state insurance of specialists involved in the provision of mental health care in case of harm to their health, etc.

Giving a general description of the Law, we note that it consists of a short preamble and six sections, including 50 articles.

The law creates a legal basis for bringing Russian legislation concerning the legal status of persons suffering from mental disorders and the practice of domestic psychiatry into conformity with international human rights standards. International legal norms relating to human rights and freedoms, which, in accordance with Art. 15 of the Constitution of the Russian FederationConstitution of the Russian Federation. Adopted by popular vote on December 12, 1993. - M., 1995. P. 15. are part of the legal system of the Russian Federation and at the same time have priority in relation to the norms of internal laws that contradict them, and have become the starting point for a detailed regulation of the rights of persons with mental disorders. These same norms served as the basis for establishing in the Law procedures and mechanisms for the implementation of such rights and their protection, as well as the protection of the rights of Russian citizens from their infringement with the help of psychiatry. Neither government bodies, nor public associations, nor officials at any level, and finally, nor psychiatrists themselves can take any actions within the framework of providing mental health care without strictly following established legal procedures. Thus, the Law contains guarantees against possible use psychiatry for non-medical purposes. The law is ultimately aimed at improving the situation of people suffering from mental disorders and at humanizing the practice of domestic psychiatry.

On the basis of the above Law, in 1993, a List of medical psychiatric contraindications was developed for the implementation of certain types of professional activities and activities associated with a source of increased danger, and the Regulations on the procedure for issuing licenses for activities to provide psychiatric care for state, non-state psychiatric, psychoneurological institutions, private practitioners psychiatristsSAPP. 1993. No. 18. Article 1602. .

Subjects of the Russian Federation may adopt their own laws on the provision of psychiatric care, which should not contradict the Law in question.

In addition to legal acts of federal executive authorities and executive authorities of constituent entities of the Russian Federation, among the sources, it is also necessary to name decrees and orders (acts) of the President of the Russian Federation.

Acts of the Government of the Russian Federation constitute an important link in the entire legal system of the country. In the field of providing psychiatric care and in pursuance of this Federal Law, the Government issued the following resolutions: dated April 28, 1993 No. 377 “On the implementation of the Law of the Russian Federation “On psychiatric care and guarantees of the rights of citizens during its provision” (SAPP. 1993. No. 18 1602) and dated May 25, 1994 No. 522 “On measures to provide psychiatric care and social protection persons suffering from mental disorders" (SZ RF. 1994. No. 6. Art. 606).

In federal executive authorities - ministries and departments - On the basis of the Constitution of the Russian Federation, federal laws, regulatory decrees of the President of the Russian Federation and legal acts of the Government of the Russian Federation, departmental legal acts (orders, instructions, etc.) are issued.

From the legal acts of the Ministry of Health of the Russian Federation, one can indicate the order dated January 11, 1993. No. 6 “On some issues of the activities of the psychiatric service,” which contains a list of regulatory legal acts of the USSR Ministry of Health that have lost force due to the adoption of the commented Law (BNA. 1993. No. 7); order dated October 30, 1995 No. 294 “On psychiatric and psychotherapeutic care”, which is important for the comprehensive provision of medical and social care, in particular, for the full participation of medical psychologists and social workers in this activity (Health. 1996. No. 2); order No. 270 of July 2, 1996, which approved the Temporary List of types of medical activities, medical care and certain methods of its provision, subject to licensing in the Russian Federation (Health. 1996. No. 8).

In the field of psychiatric care, departmental legal acts can be issued, in addition to the Ministry of Health of the Russian Federation, also by the Ministry of Labor and Social Development of the Russian Federation, the Ministry of Defense of the Russian Federation, and other federal executive authorities on specific issues within their competence. On some issues, for example, on the interaction of health authorities and internal affairs authorities when carrying out involuntary hospitalization Joint legal acts, in particular orders or instructions, may be issued.

Regulatory legal acts issued by federal executive authorities within the limits of their powers are more or less general in nature and are designed for repeated use - in contrast to legal acts of individual significance. Such acts may be of a general nature in relation to the relevant branch of executive power or interdepartmental, i.e. regulate relations within several industries.

Among the sources, it is also necessary to note generally accepted principles and norms international law, which in accordance with Art. 15 of the Constitution of the Russian Federation are an integral part of the legal system of the Russian Federation and have priority over domestic legislation.

The priority of the rules of an international treaty over the domestic legislation of Russia means that in the event of a contradiction between the treaty and the law, one should be guided not by the rules of the law, but by the norms of the treaty. Moreover, this applies to laws at any level - federal, subject of the Federation.

One more thing should be noted general position, relating to legislation on mental health care. The adoption of the relevant law at the federal level does not exclude the constituent entities of the Russian Federation from making their own laws in this area, since the regulation and protection of human and civil rights and freedoms falls under the jurisdiction of the Russian Federation and at the same time is the subject of joint jurisdiction of the Federation and its constituent entities. However, when a constituent entity of the Federation issues its own law on psychiatric care, all constitutional requirements regarding the relationship between federal and other legislation issued in the Russian Federation must be observed. In addition, the norms of the Federal Law are quite specific and, in our opinion, can in most cases be applied directly, without issuing by-laws. Commentary on the Legislation of the Russian Federation in the field of psychiatry / Coll. authors. Under general ed. T. B. Dmitrieva. - M.: Publishing House "Spark", 1997. P.35.. .

Thus, to summarize what is stated in this chapter, it should be noted that the only source that regulates the provision of psychiatric care to citizens in the Russian Federation is the Law of the Russian Federation “On psychiatric care and guarantees of the rights of citizens during its provision.”

Chapter 2. general characteristics psychiatric care

2.1 The concept and essence of psychiatric care

Due to the insufficient definition of the concepts of “mental illness” and “mentally ill”, these terms and their derivatives are not used in the Law. As a generic collective concept covering all people in need of psychiatric competence, the Law uses the formula: “persons suffering from mental disorders”, since it includes the mentally ill themselves, and persons with borderline neuropsychiatric disorders, and patients with so-called psychosomatic diseases or symptomatic mental disorders in general somatic diseases. Differentiation of this vast contingent in order to determine indications for certain types of psychiatric care, including those provided on an involuntary basis, is carried out using additional criteria that take into account the degree and depth of disorders, level of social adaptation, etc., which makes it possible to adopt individual decisionsCommentary to the Legislation of the Russian Federation in the field of psychiatry / Coll. authors. Under general ed. T. B. Dmitrieva. - M.: Publishing House "Spark", 1997. P.7. .

Psychiatric care includes: consultative and diagnostic, therapeutic, psychoprophylactic, rehabilitation care in out-of-hospital and inpatient settings; all types of psychiatric examination; social and domestic assistance in employment of persons suffering from mental disorders, as well as care for them; training of disabled people and minors suffering from mental disorders Maleina M. N. Man and medicine in modern law. Educational and practical guide. - M.: BEK Publishing House, 1995. P.104. .

Psychiatric care is guaranteed by the state and is provided on the basis of the principles of legality, humanity and respect for human and civil rights.

The diagnosis of a mental disorder is made in accordance with generally accepted international standards and cannot be based solely on a citizen’s disagreement with moral, cultural, political or religious values ​​accepted in society, or on other reasons directly related to the state of his mental health. Law of the Russian Federation of July 2, 1992 No. 3185-1 “On psychiatric care and guarantees of the rights of citizens during its provision” // VSND and the Armed Forces of the Russian Federation. 1992. No. 33. Article 1913. .

Psychiatric care is provided by authorized state, non-state psychiatric and psychoneurological institutions and private practicing psychiatrists. Activities providing psychiatric care without a state license are prohibited.

To obtain a license from the licensing commission under the authority government controlled submit an application indicating the types of medical activities for the provision of psychiatric care and the established documents (charter, constituent agreement, documents confirming the qualifications of employees, conclusion on the technical condition of the building, etc.). The licensing commission reviews the application within two months. If a license is refused, the commission informs the applicant in writing of the reason for the refusal, which can be appealed in court.

Institutions and private practicing psychiatrists who have received a license are included in the corresponding unified state register. The license shall indicate the full name of the institution or the surname, name and patronymic of the privately practicing psychiatrist, their legal address and types of medical activities for the provision of mental health care, the implementation of which is given permission. Suspension and revocation of a license is carried out by court decision.

A psychiatrist who has received a higher education degree has the right to practice as a physician in the provision of psychiatric care. medical education and has confirmed his qualifications in the manner prescribed by law. Other specialists and medical personnel involved in the provision of mental health care must undergo special training and confirm their qualifications to be allowed to work with persons suffering from mental disorders.

When providing psychiatric care, a psychiatrist is independent in his decisions and is guided only by medical indicators, medical duty and the law. A psychiatrist whose opinion does not coincide with the decision of the medical commission has the right to give his opinion, which is attached to the medical documentation Maleina M. N. Man and medicine in modern law. Educational and practical guide. - M.: BEK Publishing House, 1995. P.105. .

2.2 Characteristics of types of mental health care

Psychiatric assistance is provided on a voluntary and involuntary (compulsory) basis.

When voluntarily seeking psychiatric help, the relationship between the citizen-patient and the institution (private practitioner) is formed on the basis of an agreement for the provision of medical care. Treatment of a person suffering from a mental disorder is carried out only after obtaining his written consent. A minor under the age of 15, as well as a person recognized as legally incompetent in accordance with the established procedure, is provided with psychiatric assistance at the request or with the consent of their legal representatives.

Psychiatric assistance can be provided without the consent of a person suffering from a mental disorder or without the consent of his legal representative only:

1) when applying compulsory measures of a medical nature on the grounds provided for by the Criminal Code and the Code of Criminal Procedure;

2) during involuntary psychiatric examination, clinical observation, hospitalization on the grounds provided for by the Law “On Psychiatric Care and Guarantees of the Rights of Citizens in its Provision” Maleina M. N. Man and Medicine in Modern Law. Educational and practical guide. - M.: BEK Publishing House, 1995. P.106. .

Compulsory medical measures are applied by court decision in relation to persons suffering from mental disorders who have committed socially dangerous acts, on the grounds and in the manner established by the Criminal Code and the Code of Criminal Procedure.

Compulsory medical measures are carried out in psychiatric institutions of health authorities.

Persons placed in psychiatric hospitals by a court decision to apply compulsory medical measures enjoy the rights of patients in psychiatric hospitals. They are recognized as incapacitated for work for the entire period of stay in a psychiatric hospital and have the right to state social security benefits, insurance or a pension on a general basis.

Discharge of a patient to whom compulsory medical measures have been applied by court decision is carried out only by court decision.

An involuntary psychiatric examination of a person without his consent may be carried out in the following cases: when, according to available data, the subject is under dispensary observation or performs actions that give reason to assume that he has a severe psychiatric disorder, which causes:

a) his immediate danger to himself or others,

b) his helplessness, that is, his inability to independently satisfy the basic needs of life, or

c) significant harm to his health due to deterioration of his mental state if the person is left without psychiatric helpArt. 23 of the Law of the Russian Federation of July 2, 1992 No. 3185-1 “On psychiatric care and guarantees of the rights of citizens during its provision” // VSND and the Armed Forces of the Russian Federation. 1992. No. 33. Article 1913. .

In these cases, the decision is made by the psychiatrist independently or with the sanction of the judge.

If a person poses an immediate danger to himself or others, then an application for an involuntary psychiatric examination can be submitted orally by relatives, a doctor of any medical specialty, officials and other citizens, and the decision is made immediately by a psychiatrist and recorded in the medical documentation.

In the absence of an immediate danger of a person to himself and others, an application for an involuntary mental examination must be in writing, contain detailed information justifying the need for such an examination, and an indication of the refusal of the person or his legal representative to consult a psychiatrist.

Having established the validity of an application for a psychiatric examination of a person without his consent, the psychiatrist sends his written reasoned conclusion on the need for such an examination and other available materials to the court at the place of residence of the person. The judge decides whether to issue a sanction within three days from the receipt of all materials. The judge's actions can be appealed to the court.

Dispensary observation involves monitoring the state of mental health of a person through regular examinations by a psychiatrist and providing him with the necessary medical and social assistance and is established regardless of consent in relation to a person suffering from a chronic and protracted mental disorder with severe persistent or partially exacerbating painful manifestations Maleina M. N. Man and medicine in modern law. Educational and practical guide. - M.: BEK Publishing House, 1995. P.107-108. .

The decision on the need to establish dispensary observation and its termination is made by a commission of psychiatrists appointed by the administration of a psychiatric institution providing outpatient psychiatric care. The reasoned decision of the commission of psychiatrists is documented in the medical documentation.

A person suffering from a mental disorder may be hospitalized in a psychiatric hospital without his consent or without the consent of his legal representative until a judge’s decision by decision of a psychiatrist, if his examination or treatment is possible only in an inpatient setting, and the mental disorder is severe and causes:

a) his immediate danger to himself or others, or b) his helplessness, that is, his inability to independently satisfy the basic needs of life, or

c) significant harm to his health due to deterioration of his mental state without psychiatric helpArt. 29 of the Law of the Russian Federation of July 2, 1992 No. 3185-1 “On psychiatric care and guarantees of the rights of citizens during its provision” // VSND and the Armed Forces of the Russian Federation. 1992. No. 33. Article 1913. .

A person placed in a psychiatric hospital for these reasons is subject to mandatory examination within 48 hours. a commission of psychiatrists of a psychiatric institution, which makes a decision on the validity of hospitalization. In cases where hospitalization is considered unfounded and the hospitalized person does not express a desire to remain in a psychiatric hospital, he is subject to immediate discharge.

If hospitalization is considered justified, then the conclusion of a commission of psychiatrists within 24 hours. sent to the court at the location of the psychiatric institution by its representative to resolve the issue of the person’s further stay there.

When accepting applications for hospitalization of a person in a psychiatric hospital and a reasoned conclusion of a commission of psychiatrists, the judge simultaneously gives permission for the person to remain in a psychiatric hospital for the period necessary to consider the application in court. The application is considered by the judge within 5 days from the date of its acceptance.

The person must be given the right to personally participate in the judicial consideration of the issue of his hospitalization. If, according to information received from a representative of a psychiatric institution, the mental state of a person does not allow him to personally participate in the consideration of the issue of his hospitalization in the courthouse, then the application for hospitalization is considered by a judge in a psychiatric institution. Participation in the consideration of the application of the prosecutor, a representative of a psychiatric institution applying for hospitalization, and a representative of the person in respect of whom the issue of hospitalization is being decided is mandatory.

Having considered the application on its merits, the judge grants or rejects it. The judge's decision to satisfy the application is the basis for hospitalization and further detention of the person in a psychiatric hospital.

The judge's decision may be appealed within ten days from the date of issuance by a person placed in a psychiatric hospital, his representative, the head of a psychiatric institution, as well as an organization that is granted protection of the rights of citizens by law or its charter, or by a prosecutor.

Discharge of a patient hospitalized in a psychiatric hospital on an involuntary basis is carried out according to the conclusion of a commission of doctors and psychiatrists or a judge’s decision to refuse to extend such hospitalization in cases of recovery or improvement of his mental state, in which no further inpatient treatment is required, as well as the completion of an examination or examination , which were the grounds for placement in a hospital Maleina M. N. Man and medicine in modern law. Educational and practical guide. - M.: BEK Publishing House, 1995. P.109. .

Thus, to summarize the above, we note that psychiatric care includes an examination of the mental health of citizens on the grounds and in the manner established by the Law and other laws of the Russian Federation, and, if necessary, the diagnosis of mental disorders, treatment, care and medical and social rehabilitation of persons suffering from mental disorders.

Chapter 3. Legal nature of the contract for the provision of psychiatric care

3.1 Concept and essence of the contract for the provision of mental health care

The debate about the nature of relationships in the provision of medical care among lawyers and doctors has been going on in the press for a long time. For the first time, A. N. Savitskaya tried to prove that there is a special subjective civil right to life and health, which belongs to the category of absolute rights. Savitskaya A. N. Compensation for damage caused by improper healing. Lvov, 1982. P.19. . But now, when new legislative acts have appeared and the legal regulation of relationships relating to health protection and the provision of certain types of medical care, in particular psychiatric care, has been improved, it would be unethical to cite the statements of K. B. Yaroshenko, who categorically denied the existence of a contractual relationship between a citizen and a hospital ( clinic) providing free medical care Yaroshenko K. B. Review of the book by Savitskaya A. N. “Compensation for damage caused by improper medical treatment” // Jurisprudence. 1989. No. 6. P.91. , or the statement of V. I. Novoselov that relations regarding medical care of citizens are of an administrative and legal nature, since, in this way, the state function of health protection is implemented, and patients are obliged to comply with the regime of medical institutions established by an administrative act Novoselov V. I. Legal position of citizens in branches of public administration. Saratov, 1977. P.58. . Therefore, leaving aside disputes about the presence or absence of a contractual relationship between a citizen and a medical institution regarding the provision of psychiatric care, we will try to prove that these relationships are of a legal nature and are regulated by civil law.

The civil legislation of the Russian Federation regulates property and related non-property relations based on equality, autonomy of will and property independence of their participants. Personal non-property relations are for a citizen a benefit that inextricably belongs only to him and no one else. Such goods naturally include name, honor, dignity, life, health and personal integrity.

Personal non-property relations are usually divided into those related to and not related to property. Relationships that develop regarding health can be classified in the first group, along with the author’s. Moreover, the state of health is often a factor determining the ability to work, the choice of profession and type of activity, and, consequently, the property status of a citizen. But if relations regarding health are related to property, then in this case they can be the subject of civil law regulation even without special instructions in the law Ardasheva N. A. Problems of civil law ensuring individual rights in a contract for the provision of medical care. - Tyumen: “SoftDesign”, 1996. P. 13. .

The services provided to citizens by the consumer services sector are clearly classified by civil law as subject to regulation by civil law. However, some types of services can be rather conditionally classified as consumer services, since their provision requires compliance with the rules of hygiene and sanitation, and their implementation requires certain medical knowledge - services of hairdressing salons, beauty salons, etc. Sometimes it is even impossible to draw a clear line between where there is a contract for personal services, and where there is a contract for the provision of medical care - for example, hairdressers provide services such as pedicures, and here they can remove part of the ingrown nail that was causing painful sensations. When a citizen applies to a paid self-supporting medical institution, the civil legal nature of the legal relationship is clearly determined. However, the absence or presence of remuneration for the services provided by a medical institution does not and should not affect its legal nature.

The civil law method of regulation is characterized by such features as legal equality and independence of the parties, making certain decisions independently, without any pressure. These signs are enshrined in the Fundamentals of Legislation on the Protection of the Health of Citizens of the Russian Federation, Gazette of the Supreme Council of the Russian Federation. 1993. No. 33. Article 318. , which establishes that citizens have the right to seek medical care of their choice (Article 30), and also have the right to refuse medical intervention (Article 33). These same features also express such a feature inherent in a civil contract as disposition, expressed in the use of one or more methods of treatment and diagnosis, in various ways concluding an agreement (written or oral), choosing a place to provide assistance.

The administrative-legal method of regulating relationships in the provision of medical care to citizens is applied only in cases specified in Article 34 of the Fundamentals of Legislation on Health Protection, which states that the provision of medical care (medical examination, hospitalization and isolation) without the consent of citizens or their legal representatives is permitted in in relation to persons suffering from diseases that pose a danger to others, persons suffering from severe mental disorders, or persons who have committed socially dangerous acts. Law of the Russian Federation “On the Protection of Citizens’ Health”. Adopted by the Supreme Council of the Russian Federation on July 22, 1993 // Gazette of the Armed Forces of the Russian Federation. 1993. No. 33. Art. 318. . In these cases, the decision to conduct medical examination is made by a council of doctors, and the decision to hospitalize a citizen is made by the court. The provision of medical care to persons suffering from diseases that pose a danger to others is regulated by sanitary legislation.

Thus, from the above it follows that a citizen makes a proposal to conclude an agreement - an offer - it is he who is the initiator of the conclusion of the agreement, with the exception of specified cases, and it (the offer) can be addressed either to a specific person in a medical institution, or to an indefinite circle of persons in in cases where a citizen, contacting the ambulance service by phone, does not yet know who exactly will provide him with psychiatric care: it can be provided directly by an ambulance team that arrives on call, or he will be taken to a specialized clinic. In accordance with Art. 435 of the Civil Code of the Russian Federation, the offer must clearly express the intention of the person who made the proposal to conclude the contract. The offer must contain the essential terms of the contractCivil Code of the Russian Federation. Part one. Adopted by the State Duma of the Russian Federation on October 21, 1994 // SZ RF. 1994. No. 31. Article 3302. . At this stage of concluding a contract, the nature of the required assistance, the place of delivery (inpatient or outpatient), the need for additional diagnostics or treatment methods are clarified, and the specific performer - a medical worker - is determined. These same signs also express discretion in the activities of the medical institution.

Agreement with the patient’s offer is recognized as acceptance by the medical institution, and this consent is unconditional and entails legal consequences, moreover, acceptance must be complete and unconditional (Article 438 of the Civil Code of the Russian Federation) Civil Code of the Russian Federation. Part one. Adopted by the State Duma of the Russian Federation on October 21, 1994 // SZ RF. 1994. No. 31. Article 3302. . A citizen has the right to seek medical care of his choice at a medical institution, and also has the right to choose a doctor, taking into account his consent.

It is precisely when voluntarily seeking psychiatric help that the relationship between the citizen-patient and the institution (private practitioner) develops on the basis of an agreement for the provision of medical care. Maleina M. N. Man and medicine in modern law. Educational and practical guide. - M.: BEK Publishing House, 1995. P.106. .

Before we begin to consider the subjective rights and obligations of the parties to an agreement for the provision of psychiatric care, which together constitute its content, it is necessary to find out who may be the subject of such an agreement.

One party - the citizen, as mentioned above, acquires the right to life and health from the moment of birth and from that moment has legal capacity (Article 17 of the Civil Code of the Russian Federation) Civil Code of the Russian Federation. Part one. Adopted by the State Duma of the Russian Federation on October 21, 1994 // SZ RF. 1994. No. 31. Article 3302. . The state provides citizens with health protection regardless of gender, race, nationality, language, social origin, official position, place of residence, attitude to religion, beliefs, membership in public associations, as well as other circumstances. The Law of the Russian Federation “On the Protection of Citizens’ Health”. Adopted by the Supreme Council of the Russian Federation on July 22, 1993 // Gazette of the Armed Forces of the Russian Federation. 1993. No. 33. Art. 318. .

Consent to medical intervention in relation to persons under 15 years of age and citizens recognized as legally incompetent in accordance with the established procedure is given by their legal representatives. In the absence of legal representatives, the decision on medical intervention accepts the consultation, and if it is impossible to assemble a consultation, the attending (duty) doctor directly. Law of the Russian Federation “On the Protection of the Health of Citizens”. Adopted by the Supreme Council of the Russian Federation on July 22, 1993 // Gazette of the Armed Forces of the Russian Federation. 1993. No. 33. Art. 318. .

Using medical terminology, a citizen as a party to a contract for the provision of psychiatric care, depending on the service provided to him, will be referred to as: when diagnostic study- patient, during treatment in a hospital (hospital, clinic) - sick.

The other party to the agreement for the provision of psychiatric care are medical institutions, which are represented in the form of hospitals, specialized clinics, local points, clinics, ambulance stations, etc., as well as individual medical workers.

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Legal subjects of the Russian Federation, features of their legal status. The system of regulatory legal acts of the constituent entities of the Russian Federation. Municipal legal act. Current problems of legal regulation regarding the adoption and registration of charters.