Dissertation committee:
Χαράλαμπος Παπαγεωργίου, Καθηγητής Ψυχιατρικής, Ιατρική, ΕΚΠΑ
Γρηγόριος Βασλαματζής, Καθηγητής Ψυχιατρικής, Ιατρική, ΕΚΠΑ
Παύλος Σακκάς, Καθηγητής Ψυχιατρικής, Ιατρική, ΕΚΠΑ
Αθανάσιος Δουζένης, Αν. Καθηγητής Ψυχιατρικής, Ιατρική, ΕΚΠΑ
Ελευθερία Φωτεινή Πουλάκου Ρεμπελάκου, Αν. Καθηγήτρια Ψυχιατρικής, Ιατρική, ΕΚΠΑ
Χρήστος Χριστοδούλου, Αν. Καθηγητής Ψυχιατρικής, Ιατρική, ΕΚΠΑ
Ρουσέτος Γουρνέλης, Αν. Καθηγητής Ψυχιατρικής, Ιατρική, ΕΚΠΑ
Summary:
Summary
Introduction
The Psychiatric Forensic Medicine is a scientific sector located in the borderline area between Psychiatry and the Science of Law. The scientific faculties that converge to this interscientific junction are not limited of course only to Psychiatry and Law Science, but include also other sciences, like Sociology, Philosophy and History.
A historical review of the relationship between mental disease and law is considerably interesting, since it reflects the dynamic equilibrium and the mentality of every different, in time and place, human society in relation to its mentally ill members. In ancient Greece the first conception of mental illness is to be found in the theocratical view of soul and human emotions, a view that characterizes all antique societies. However, later, through the development of Medicine, but also due to the foundation of Psychology, mental illness is detached from the sphere of superstition and enters into the scientific field. Although, the Roman Empire promoted and diffused the scientific achievements of ancient Greece, in medieval Europe, with the pretext of the newly introduced Christian religion, fanatism and obscurantist theocracy are being imposed. A similar, but less strict and extreme, situation is observed in the Byzantine Empire. Gradually and through the work of enlightened people the obscurantist fundamentalism is replaced by scientific thought, signaling the Age of Enlightenment and establishing the scientific approach of different phenomena.
Methodology
Material
The research sources in Psychiatric Forensic Medicine, which lies in the borderline area between Law and Medicine, are principally either legal or psychiatric.
The current research was based on a study of legal sources and specifically, of case files. These were tracked down through an extended review of the legal jurisprudential bibliography, either electronically (legal data base LAW), or using published journals [“Poinika Chronika” (“Penal Chronicles”), Armenopoulos]. The case files (n=100) that were examined considered cases in which an appeal to the articles 34 and 36 of the Penal Code had taken place. The articles 34 and 36 regulate the attribution of responsibility in cases of consciousness disorders or mental function disorders. The legal concept of consciousness disorder in articles 34 and 36 of the Penal Code can be determined as a blurring or a partial disruption of self-consciousness or of consciousness of the external world or of the relationship between the two, while the term “mental function” covers the whole range of mental functions (emotion, will) and not only the superior cognitive functions (judgment, memory, perception).
The current study, as far as the researchers know, is the first of this kind in Greece and can be added to a relatively small number of similar studies worldwide. The difficulties of the research in this field also explain the relatively limited bibliography. A collective data base of courts’ decisions does not exist in Greece. As a result the detection, but also the follow-up of the course of a case file mentioned in a certain court’s decision, is extremely difficult. Also it is not possible to extract comparative results, since there are no collective results either for all the cases, or for specific cases of a special thematic category. The extraction of comparative results is difficult not only nationwide, but also between different countries, even between the E.U. countries. The difficulty lies in the fact that great variations can be observed between different countries, at the level of the applied law on one hand and on the other hand in the procedures followed to administer justice.
Statistical Analysis
In order to describe the demographic, psychiatric and legal – criminal data of the study sample were used tables with absolute and relative % frequencies. The concordance rate between different psychiatrists – experts concerning their decisions was summarized using cross tabulation tables and was evaluated using Cohen’s kappa coefficient. Similar methods were used to evaluate the concordance between the decision of the court and of the psychiatrists.
Correlations between factors such as the presence of a psychiatrist, court’s decision, diagnosis at the onset of disease, compliance to pharmaceutical treatment, seriousness of the crime, type of crime and contact time with a psychiatrist (before / after the crime), were initially examined using cross tabulation tables that included absolute and relative % frequencies and the related bar charts of relative frequencies. The statistical significance of these correlations was evaluated using the method of exact tests for nominal data.
Results
The sample consisted of 100 persons (90 men and 10 women). The age at first degree trial was 30-49 years in the majority of cases (48/100). The age group 18-29 years followed (33/100) and last was the age group over 50 years of age (19/100). The majority were Greeks, while 12 persons were foreigners. The foreigners were mainly coming from the Balkans (7/12) and the majority of them (9/12) were staying legally in the country. Most of the accused were unmarried (43/100), while 3 of them had a relationship. Forty seven persons out of 100 had at least one child. Sixty nine per cent (69%) of the sample were graduates of primary education and 22% of secondary education. Seventy persons out of 100 had a job during the time they committed the crime (most of them were working manually). A significant percentage (38/100) stayed with their families, 30/100 were living alone and 25/100 were living in a parental family, while two persons were homeless. From the 79 Greek men 61 had done their military service, 17 were released and one was a deserter. Out of the 17 men that were released from military service, 2 were for pathological reasons, 14 for psychological and one for other reasons.
In a great percentage of the accused persons (38/100) the mental illness was presented before the age of 20 years. In 28/100 the age at the onset of the disease was between 21 and 30 years old, while in lower percentages (18/100 and 6/100) the age at the onset was between 31-40 years and over 41 years, respectively. The majority (78/100) had been in contact with a psychiatrist before the commitment of the crime. The most common diagnoses at the onset of the disease were drug dependence (16/100), schizophrenia – psychosis (12/100), followed by depression type mood disorders and alcohol dependence in equal percentages (8/100). In lower percentages the diagnoses of mixed personality disorder (antisocial – borderline) and of antisocial personality disorder were recorded (6/100 and 5/100, respectively). In lower percentages (below 5/100) the accused were diagnosed with bipolar disorder, schizophrenia – substance dependence, antisocial personality disorder – substance dependence, adjustment disorders, mental retardation, etc. In 18/100 the initial diagnosis was unknown (6 out the 18 had not seen a psychiatrist before the commitment of the crime). The diagnoses at the time of the commitment of the crime were in great percentage the same (83/100) as those at the onset of the disease. There were four cases in which the initial diagnosis was unknown, but the diagnosis at the time the crime was committed was known (3 cases of alcohol dependence and one case for each of the following diagnoses: schizophrenia – psychosis, anxiety – mood disorders, antisocial personality disorder, drug dependence - antisocial personality disorder and adjustment disorders).
In 97 cases the crime was considered as a separate crime. The vast majority of the crimes committed (84/100) was against life or against life and physical integrity (6/100). In the rest crime cases (against physical integrity, property, sexual freedom, etc.) the relative percentages were below 3%. In great and similar percentages the medium used to commit the crime was a knife or another sharp object (42%), or a gun (40%). Persecutor and victim were strangers in 25 of 100 cases, just acquaintances in 14 cases, while in 7 cases they had a professional relationship. There were also cases where the relationship was conjugal (15/100), or partners (13/100) or relatives (7/100). Twenty out of the 100 accused had been previously convicted, but only in two cases out of the 20 the conviction’s crime had been against life. The rest of the previously committed crimes were mainly against property (6/20) or related to substances (4/20).
According to first degree court’s decision one case was classified in article 34 of Penal Code, in 29 cases in article 36, while in the rest cases the accused were regarded as fully capable of charge. The decisions of the Court of Appeal or of the Supreme Court of Appeal were 2 (article 34), 36 (article 36) and 62 (fully capable of charge), respectively. The decisions were unanimous in 78 out of the 100 cases.
Concordance in great extent was observed (k=0.696) regarding the opinions of the psychiatrist of the defense and the attendant doctor (marginally non – statistically significant result, p =0.053). Specifically, in 7 cases there were expert opinions of the defense and of the attendant doctor for the same case. The opinions were in great extent (85.7%) totally concordant with the exemption of one case, in which the expert of the defense suggested classification in article 34, while the attendant doctor in article 36.
Concordance in a significant extent (k=0,780) was observed between court’s decision and the opinion of the psychiatrist that was appointed by the court (statistically very significant result, p<0.001) in 35 cases, in which there was an opinion by an expert appointed by the court. In more details, the first degree court’s decision was in total concordance with the proposal of the expert in 31 out of 35 cases (88.6%), in which the accused was regarded as fully capable of charge (11 cases), was classified in article 36 (19 cases) or in article 34 (1 case). In two cases the expert suggested classification in article 36, but the court judged that the accused was fully capable of charge. Similar was the court’s judgment also in one case in which the expert suggested classification in article 34. On the contrary, in one case the expert judged that the accused was fully capable of charge, but the court decided classification in article 36.
Finally, concordance in great extent (k=0.805) was observed between decisions of the Court of Appeal or of the Supreme Court of Appeal and first degree court’s decisions (statistically very significant result, p<0.001). In 91% (91/100) of the cases the decisions remained unchanged. In the rest 9 cases, 8 were regarded as classified in article 36 by the Court of Appeal or the Supreme Court of Appeal, while the first degree court had judged the accused as fully capable of charge. Finally, in one case the initial decision for classification in article 36 was changed into classification in article 34.
The percentages of classification in articles 34/36 were higher when the initial diagnosis at the onset of the disease was a mental disorder (47.5%). In contrast, they were lower in cases of personality disorder (22.2%) and even lower in cases of substances abuse (16.7%). These differentiations were statistically significant (p=0.023).
In persons with schizophrenic type psychosis the victims were either relatives or a spouse in 41.2%. In contrast, in other diagnoses the respective percentage was almost half (21.5%). This difference was statistically significant (p=0.044).
In persons that were previously hospitalized the percentage of classification in articles 34/36 was above 50% (55.6%). In contrast, in persons without prior hospitalization this percentage was much lower (24.4%). The difference was statistically significant (p=0.020).
The percentage of persons under psychiatric pharmaceutical treatment during the time of the crime commitment was almost double in those cases that the person has recently dealt with stressful events (35.7% vs. 18.2%), but this difference was marginally non – statistically significant (p=0.073).
Conclusions
Proper appeal to the articles about legal responsibility (articles 34 and 36 of the Penal Code) in our sample (n=100) was noted in 30% of the cases. This finding is close enough to the numerical results demonstrated in studies conducted in other countries, as for example, in the U.S.A., where the respective percentage was 25%. Of course, as we have stressed elsewhere in the current study, the generalization and the comparison between this kind of studies requires caution and it should be taken into account the fact that different procedures are followed by the national judicial system of different countries.
In the Greek judicial system the total lack of data computerization and digitization does not allow us to reach safe conclusions in many critical research areas, as is, for example, the percentage of cases in which an appeal to the examined articles has taken place out of the total number of cases with a relative objective. Thus, the engraved in the collective thought illusion of a massive and proper appeal to incapability to charge is sustained, as is, subsequently, the circumspection and the distrust of a right and proper application of the articles about legal responsibility.
Another factor that enhances the distrust mentioned above is that it has been observed that the appeal of incapability to charge is undocumented and fragmentary by the counsels of the defendant. The study of the case files demonstrated the unsuccessful effort that was made by the counsels of the defendants to obtain a decision for diminished responsibility for their clients, but without the special weight of a thorough and scientifically documented opinion. As was demonstrated by the current study the presence of a psychiatrist was the catalytic factor for a successful appeal to the studied articles. If we combine this finding with the very important ascertainment that a consensus in great extent is observed in the decisions of different degree courts, we can conclude that the presence of a psychiatrist already at the first degree court, is a necessary prerequisite for a successful appeal to the articles 34 and 36 of the Penal Code in court. Finally, a significant finding related to the qualitative consideration of the psychiatric opinions by the courts is the finding of a statistically significant correlation between court’s decision and the opinion of the psychiatry – expert assigned by the court itself.
The qualitative characteristics related to psychopathology and also to criminal activity that were studied, also resulted in significant findings. These findings are in concordance with respective findings mentioned in foreign bibliography. The most common diagnoses before the crime commitment were those of substance abuse and schizophrenia. We should stress at this point that although the strong correlation between delinquency - criminality and substance abuse has been proved in studies, the penal treatment of the users – criminals, and also of the abuse itself, shows significant variations between different countries depending on the anti-criminal policy followed. Schizophrenia though is the most common mental disorder correlated with cases of offenders incapable of charge in all international studies. A constantly observed qualitative characteristic of criminal activity, which is correlated with mental disorder and was also demonstrated in the current study, is that the victims of psychotic crimes are people that belong to the closest surroundings of the offender, while the most common crime is homicide. Two other facts that can and should raise further speculation in relation to the efficiency and the effectiveness of the psychiatric – psychiatric forensic practice and method, not only in our country, but worldwide, is the fact that a great percentage of the offenders (a percentage varied according to the study) had a previous contact with psychiatric services and psychiatric hospitalizations. A history of psychiatric hospitalization is a very strong predictive factor of obtaining a court’s decision for diminished responsibility.
The above mentioned findings of the current study, but also the review of the international bibliography, demonstrate the vast need for a further and more thorough research in order to improve the provided psychiatric services, to develop effective strategies to prevent criminality in psychiatric patients and to reintegrate socially and destigmatize them.
