General Overview and Recommendations on Organizational Aspects of Mental Healthcare in Tajikistan (Draft Legal Regulations – Acts of MoH)

1. Subject of Overview and analysis:

Subject of analysis were instructions and draft legal regulations on improvement of mental healthcare in Tajikistan, elaborated and drafted by the Ministry of Healthcare of Republic of Tajikistan. The draft legal regulations contains 17 instructions regarding organizational aspects of mental healthcare services in the Republic of Tajikistan.

Namely

1. Instruction on Mental Health Hospital (N1)

2. Instruction on activities of Forensic Psychiatry Expertise in Republic of Tajikistan (N2)

3. Instruction on using of involuntary medical and other measures of medical character in respect with Persons with Mental Disorders with anti – social behavior, committed community – dangerous acts. (N3)

4. Instruction on Forensic psychiatric department of the mental health hospital for persons being under detention (N4)

5. Instruction on Department of Involuntary Treatment with high security regime of the mental health hospital (N5)

6. Instruction on Psychiatry Department of the General Hospitals for Patients with joint mental and somatic disorders (N6)

7. Instruction on inpatient treatment without consent of the patient or/and his/her relatives (N7)

8. Instruction on “Treatment Holidays” in mental Health Hospitals (N8)

9. Instructions on Out Patient Dispensary (N9)

10. Instruction on Primary Psychiatric Assessment of Citizens (N10)

11.Instruction on Day Care Hospital Services (11)

12. Instruction on Republican Organizational – Methodology Consultative Department of Mental Healthcare (N12)

13.Instruction on Distributing the Data and information on patients with mental disorders (N13)

14. Instruction on Issuing of medical affidavits by out – patient Dispensary (14)

15.Instruction on Chief Psychiatrist of the Healthcare Agencies (N15)

16.List of Forms of Medical Documentation necessary to use in mental healthcare services (N16) 

17.Instruction on cooperation of agencies of healthcare and Ministry of Interior acting for prevention of anti – social dangerous acts committed by the patients with psychiatric disorders (N17) .

18.Draft Act – Document on Forensic Psychiatric Examination. 

2. Methodology

Methods of overview included International Standards of Medical Ethics issued by the World Medical Association (WMA) and World Psychiatric Association (WPA). As well as Recommendations of UN and CoE on Patients Right, best practice of EU and other Democratic Countries also were taken into consideration.

3. General Considerations and Analysis

All concrete evaluations/recommendations described alongside of relevant legal drafts on comments’ areas on Russian (See in Annex 1 (78 pp) – main document for Overview).

According to the analysis following main problems were revealed:

1. There is not special Legal Code on Mental Healthcare in Tajikistan.

2. No definitions existed on key aspects of organization of mental healthcare in the country: In more detail: Definitions on Voluntary Treatment, Involuntary Treatment as well as on Compulsory treatment should be clear and differences should be underlined in all aspects.

3. In most of Drafts there is the violation of requirements of confidentiality, informed consent and professional independency – that are key aspects of international medical ethics and patients’ rights.

4. There is not definition and differentiation on involuntary treatment and involuntary admission.

5. There is not clear differences in regulations and circumstances, in which the forensic psychiatry examination/expertise should be done.

6. No clear differentiations on Responsibility – Irresponsibility and Partial Responsibility, as well as on Capability and Incapability. 

7. No differentiation existed and is not clear differences of involuntary admission and treatment in cases of committed crime and in cases of just dissocial dangerous behavior.

8. No any independent Council or Court Decision required in cases of involuntary treatment that should be different then compulsory treatment.

9. No definition of different regimes of admission or treatment in patient type – hospitals existed.

10.There is violation of confidentiality in circumstances and procedures of inpatient and outpatient type forensic psychiatry expertise.

11. There is significant violation on access to the medical documentation of patients and in case of consent – their relatives as well.

12.There is unclear justification on restrictions of fundamental rights during an involuntary admission: for e.g. right on information, outdoor exercises and outdoor communication.

13.There is no definition of outpatient type involuntary or compulsory treatment and standards and requirements, in which circumstances should be used outpatient involuntary observation or/and treatment.

14.According to the draft regulations, non – medical personnel also have access to medical documentation and information that is violation of rights on confidentiality.

15.Regulation N17 is not relevant to any international standards of medical ethics.

16.There is unclear description in circumstances of treatment of prisoners and detainees in cases of mental disorders.

17.The draft regulations contain risks of corruption due to no independent monitoring existed and also unclear clarifications - differences between several regimes and who and why can make decision on transferring patients from one to another regime department.

18.Instructions on so called “Treatment Holidays” also is not clear, because in case of voluntary treatment it is not relevant at all, in cases on involuntary or compulsory treatment it should be clear definitions and clarifications in what kinds of circumstances it could be done.

19.In all regulations any torture prevention standards are missed and there is not listed any independent boards or standards for monitoring of mental healthservices, especially in connection with involuntary or compulsory treatment and admission. 

20.Medical forms and documentation does not contain requirements of description of traumatic circumstances, if any, that also should be done according to the requirements of torture prevention, namely Istanbul Protocol standards.

21.The Draft Form of Forensic psychiatry evaluation/expertise is very simple and does not contain necessary headlines and topics of psychiatric evaluation: For e.g. Details of Anamnesis Vitae, Anamnesis of Morbidity and co – morbidity, Traumatic experience and psycho – social aspects. Data of evaluation of criminal offence – documentation, mental health status semi – structured interview, standards of clinical psychological testing, aspects of physical and neurological condition, conclusions and recommendations.

22.Draft documentation requested from the forensic experts to answer only on questions addressed to the psychiatric evaluation, questioned by the investigator or prosecutor, also contains weak considerations on rights of experts to describe any other circumstances that according to expert’s decision should be described, that means, that no obligation on description of circumstances that are not asked, exists.

23.Restrictions existed on professional independence, namely, doctor psychiatrists has right to contact primary psychiatric examination, but has no right to issue medical reference or affidavit.

4. Recommendations

1. Special Law on Mental Healthcare should be elaborated, drafted and adopted as soon as possible.

2. This Law have to contain following main chapters or/and articles, but not limited:

3. Chapter I General Provisions: Objectives of the Law, Sphere of regulations, Legal basis for psychiatric care, Definitions of the terms used in this Law: for e.g. Mental Disorder, Patient, Psychiatric Care, Psychiatric Institution, Personal working in the field of psychiatry, Decision-making capacity, Legal representative of the patient, Patient’s relative, Primary examination, psychiatric commission, etc. Chapter II Patient’s Rights and Protection Guarantees, Chapter III Psychiatric Care, Chapter IV Primary Psychiatric Examination, Chapter V Forms of Psychiatric Care, Chapter VI Forensic Psychiatric Expertise, Chapter VII Confidentiality, Chapter VIII Rights and Social Guarantees of the Personnel, working in the Field of Psychiatry, Chapter IX Transitional and Final Provisions, etc.

4. Law or regulations also have to contain clear definition and differentiation of voluntary treatment, involuntary treatment and compulsory treatment.

5. As a rule, compulsory treatment has been ordered by Criminal Courts, according to CPC and CC of relevant Country

6. Involuntary treatment should be ordered by the Administrative Court or, in several European Countries, by the special mental health board and legal safeguards should be guaranteed, for e.g. right to lawyer, right to alternative opinion, etc.

7. Status of incapable person also have to be defined and should be issued according to the Court’s Decision.

8. Forensic or any kinds of assessment should be done in situation of confidentiality, only in case of doctor’s request, the visual observation without hearing possibilities should be organized.

9. Any restrictions of rights of patients that should be equal to the rights of other citizens, should be clearly defined and justified by the private doctor or by the legislative acts.

10.Key requirements of the Rights of patients and doctors should be guaranteed (See Smart Art Graphic 1 Below):

11.In any circumstances patients or examined persons have right on access to the medical documentation and information regarding his/her condition that also refers to the Forensic Reports.

12.Limitation of access to the information or/and diagnoses should be ordered by the private doctor that should be justified, that this information will be harmful to the patient’s health condition.

13.Special Sub Law acts should be in regulations regarding Physical restrictive measures with clear definition of Emergency situations and aid that also should be defined by the Law.

14.Description of several regimes also should be in the Law and then regulations, described in detail, in the sub regulations.

15. Clear definition of responsibility – irresponsibility and partial responsibility, capability should be done in Law and in relevant regulatory acts. 

16.Regulatory acts also to be contain the rights of detainees and prisoners on mental healthcare and equality of standards

17.Regulations should include clear determinations and attitude toward to the children and juvenile, elderly and gender based attitude, standards of prevention of torture, ill treatment, any forms of discrimination and sexual exploitation, rights of sexual minorities, patients with disability and other aspects of fundamental freedoms.

18.Definition of types of forensic expertise: Outpatient or inpatient, also other kinds of expertise for disability or for professional purposes or for validity for military service, etc. 

Graphic 1: 

List of main (essential) Services