Boris Mendelevich: “Timely consultation with a psychiatrist will help prevent a tragedy”

When a mother kills her children

If we talk about the specific terrible case, we do not yet have any data that a woman who killed one of her children and maimed another has been declared insane. We can't say that she is mentally ill yet — we need to wait for the examination.

I agree that if a mother kills her child, the cause may be some kind of mental disorder. For example, in my practice, there was a story of a woman who, in a state of insanity, killed her little daughter. She was a prima ballerina of one of the regional theaters and at one time became interested in a religious sect.

In psychiatry, there is such a concept — induced delirium, when one sick person “infects others” with their delusional ideas. And that's what happened there. One of the leaders of the sect was a mentally ill man who induced people who came to him with his delusions. At some point in this state of induction, in a state of general psychosis, they decided that they needed to perform a rite of sacrifice. The woman brought her little daughter, and the members of the sect sacrificed her. It was really committed in a state of insanity.

But there are also cases when sane parents killed their children. And then it is no longer a question of psychiatry, but the area of moral qualities of a particular person.

But again, in this case, we can only talk about insanity after a comprehensive examination of the woman.

Insanity at the time of committing a crime is determined in the course of a psychiatric or complex forensic psychological and psychiatric examination

What is insanity and how difficult it is to define it

Insanity at the time of committing a crime is determined in the course of a psychiatric or complex forensic psychological and psychiatric examination. These examinations can be carried out both inpatient (a person is 30 days in the hospital) and outpatient. In the second case, doctors first examine outpatient records, medical history (if any), interview relatives and neighbours, and then talk to the patient. On the basis of all these data, the forensic psychiatric examination makes a medical conclusion about whether the person was in a state of insanity at the time of the crime or not.

Separately, I note that even the presence of a previously diagnosed mental illness does not mean that a person will necessarily be recognized as insane at a particular time of committing a crime. For example, schizophrenia is a wave-like disease that occurs with remissions and exacerbations. The task of doctors is to determine whether the person was really in an exacerbation at this moment and whether the painful production of his brain really affected the commission of the crime. Again, the state of insanity is determined at the time of the commission of the crime.

There are different cases: for example, a person with schizophrenia was in remission but committed a domestic crime while intoxicated. In this case, he was not insane at the time of the crime!

Sometimes mental illness develops after the commission of a crime — for example, when the perpetrator suffers a psychotrauma. I have seen such medical reports: when at the time of the examination, the person is already mentally ill, but at the time of the crime, he was mentally healthy — and therefore, was sane.

Sometimes mental illness develops after the commission of a crime — for example, when the perpetrator suffers a psychotrauma

Compulsory treatment and doctors' responsibility

If the court on the basis of the expert opinion finds a person insane, then he is completely released from criminal liability, but he is sent to compulsory treatment. It can be carried out both in the most strict conditions (in a specialized psychiatric hospital with intensive supervision) and in a normal psychiatric hospital. It depends on the condition of the person. Treatment lasts as long as it is necessary to bring the person out of this condition and for doctors to recognize that he is no longer a danger to society after discharge. To do this, every six months, commissions are held, at which doctors determine whether all manifestations of mental disorders have passed and whether the patient can be discharged. If the commission decides that it is possible, then this decision is considered by the court, and even then the person from such a hospital is not discharged home. He is transferred to the hospital at his place of residence, then — to outpatient compulsory treatment, and then — under the supervision of a district psychiatrist.

In Astrakhan, there has ben a high profile criminal case not so long ago: a psychiatrist was convicted there. He worked in in a specialized psychiatric hospital with intensive supervision and gave the conclusion on the basis of which the patient was discharged. A year later, this patient again committed a terrible crime — he killed a child. The investigative committee accused the doctor of negligence and improper performance of duties. There was a trial, the doctor was jailed. However, now the case has been returned for further investigation. I wrote appeals in defense of this doctor, because he alone could not discharge a patient from compulsory treatment, such a decision is always made by the entire commission. Besides, the patient is discharged not just to nowhere, but under the supervision of a district psychiatrist. So it was a surprise to me that he was the only one to be blamed.

If psychosis occurs suddenly

Not all cases of insanity are associated with long-standing diagnoses. A crime can also be committed in a state of sudden psychosis. Dangerous psychoses can be different: for example, alcohol, chemical (under the influence of certain drugs). There may be a reactive psychosis — a reaction to an event, psychotrauma.

Psychosis can also be the debut of a mental illness — for example, the same schizophrenia. This has often happened in my practice: when a disorder, very abruptly and suddenly, like a bolt from the blue, developed in a person when the crime was committed.

Not all cases of insanity are associated with long-standing diagnoses. A crime can also be committed in a state of sudden psychosis

Alcoholism and mental disorders

Another negative factor that can lead to tragedy is alcoholism, especially when it is superimposed on an existing mental disorder. This is a very dangerous cocktail that often leads to aggressive actions. In my practice, more than 60% of mentally ill people who committed crimes had clearly expressed alcoholism. Therefore, if a person with a psychiatric diagnosis lives next to you and suddenly begins to drink alcohol, this is a reason to think about the prevention of their socially dangerous acts. All these issues should be resolved with your doctor — he will tell you what to do.

It also happens the opposite, when an alcoholic has psychosis, and this is also not uncommon. We treated patients who committed crimes in a state of alcoholic psychosis. This is a temporary state: such a person does not have a mental disorder when he is not drinking. In other words, alcoholic psychosis is a reactive state that lasts for a certain limited amount of time.

How to distinguish the development of mental illness

Separately, I want to talk about those cases when a mental illness develops in a person gradually. The role of relatives and close people of the patient is very important here: you need to pay attention in time to the fact that something is wrong with the person. Symptoms of the growing disease can be:

• inadequate behaviour;
• instability;
• illogical thinking (after all, delusional ideas are primarily a violation of thinking and cognitive chains);
• aggression.

I want to talk about aggression separately: if it manifests itself and is not motivated by anything, then you need to contact either psychiatrists, or (if the situation gets out of control) law enforcement agencies. According to the law, if a patient begins to pose a danger to themselves and their environment, they can be involuntarily hospitalized and examined without their consent. In this case, doctors will determine whether he has a mental illness and whether he needs treatment.

You shouldn't wait for physical aggression: verbal aggression should alert you, first of all, when nothing irreparable has happened yet

Therefore, I urge: if you notice unusual and inexplicable changes in the behavior of your loved ones, then contact a district psychiatrist. You shouldn't wait for physical aggression: verbal aggression should alert you, first of all, when nothing irreparable has happened yet

Be more attentive to your loved ones because indifference can lead to tragic consequences. Yes, I admit that our society is still wary of psychiatrists, this area of medicine is stigmatized. But the price of this stigma can be a human life. Therefore, a timely consultation with a psychiatrist will help prevent a tragedy and take timely measures.