Foundations of Legal Regulation of Mental Health
The sphere of mental health in Georgia is governed by a special law that sets the rules for the application of restraint to a patient, involuntary inpatient psychiatric care, forced psychiatric treatment within criminal justice, forensic psychiatric examination, and the protection of medical secrecy. The essence of these rules is uniform: psychiatric care must be as least restrictive as possible, every harsh measure must be duly justified, and the patient must enjoy a real possibility of judicial control and appeal. Below we explain each institution on the basis of the provisions that govern this field.
The Application of Restraint to a Patient
For the purpose of controlling the violent behaviour of an inpatient, restraint may be applied. According to the law, restraint is an extreme, exceptional measure: it is used only when the danger of the patient harming himself, herself or others is inevitable and cannot be avoided by verbal calming or medication. Restraint is a security measure and has no therapeutic purpose; its use for punishment or intimidation by any method is prohibited. During restraint the patient must be provided with appropriate supervision and support, and the head of the institution must be regularly informed of its application. For a patient in voluntary treatment, the application of restraint requires a review of the treatment status.
The law distinguishes three methods of restraint: manual restraint, meaning control of the patient by manual means; mechanical restraint, meaning the use of restraint instruments for immobilization; and isolation, meaning the forcible solitary confinement of the patient in a specialized room. In selecting a method, preference must be given to the less restrictive mechanism, and the patient's previously expressed opinion on the preference of a particular method, together with accumulated experience, must be taken into account. The method applied must be proportionate to the danger emanating from the patient. The combined use of several methods is permissible only in order to reduce the duration of restraint or to prevent serious harm to the patient or others. Restraint must be applied for the shortest possible period, and all methods must cease as soon as the danger is eliminated. The patient, the legal representative, or, in the absence of one, a relative, has the right to appeal to court the propriety of the applied restraint method. The rules and procedures of restraint are established by an instruction approved by the appropriate order of the minister of health.
Involuntary Inpatient Psychiatric Care
A person receives involuntary inpatient psychiatric care only where, due to a mental disorder, the person lacks the capacity to make an informed decision; the provision of psychiatric care is impossible without placement in an inpatient facility; and a delay in care would endanger the life or health of the patient or others, or the patient may through his or her own actions suffer or cause to another significant material damage. In such a case the consent of the patient, the legal representative or a relative is not required. The need for involuntary care is determined by an emergency care physician or a physician holding an appropriate certificate, and law enforcement bodies are obliged, upon request, to ensure the placement of the patient in the inpatient facility.
The procedure is strictly defined. Preliminary involuntary placement is decided by the duty physician, and that moment counts as the beginning of involuntary treatment. Within 48 hours of placement, a commission of psychiatrist physicians must examine the patient's condition and decide on the propriety of the care; the decision is taken by majority vote, a tie is resolved by the clinical head of the institution, and a dissenting opinion is attached in writing. If the commission finds the care unjustified, the patient must be discharged immediately. If the commission concludes that the criteria exist, the administration applies to the court within 48 hours of placement for an order; the decision is immediately communicated to the patient, the representative or the relative, and in the case of a foreign citizen, to the diplomatic mission. The court is obliged to examine the application within 24 hours of its receipt under the Administrative Procedure Code; the participation of the patient is mandatory, the patient's interests are represented by the legal representative or a relative together with an attorney, and if the patient has no attorney, one is appointed ex officio at state expense. By court decision, involuntary care is provided until the criteria are exhausted, but the term must not exceed 6 months. The commission is obliged to review the propriety of continuation monthly. If continuation beyond 6 months is considered necessary, the administration applies to the court no later than 72 hours before the expiry of the 6 month term, and the court decides within 72 hours of the application; such extensions are permissible without limitation until the criteria are exhausted. Upon exhaustion of the criteria, the patient is discharged by decision of the commission, the court is immediately notified, and further treatment continues on a voluntary basis with the patient's consent, which is recorded in the medical documentation and confirmed by the patient's signature. The patient, the representative, the relative and the administration may appeal the judge's order or ruling on placement, refusal or extension under the Administrative Procedure Code.