Clinical determination in the insanity defense

Hello everyone, I’m Dr. Bhavika Vajawat. I’m a senior resident in forensic psychiatry at the National Institute of Mental Health and Neurosciences, NIMHANS Bangalore. In today’s lecture, we will be discussing the assessment of insanity defense and drafting of the report for the same. Let us understand unsoundness of mind from a mental health expert’s perspective.

As per the Mental Health Care Act, 2017, mental illness is clearly defined as a substantial disorder of thinking, mood, perception, orientation or memory that grossly impairs judgment, behaviour, capacity to recognize reality, or the ability to meet the ordinary demands of life, mental conditions associated with abuse of alcohol and drugs and it does not include mental retardation, which is a condition of arrested or incomplete development of the mind of a person, especially characterized by sub-normality of intelligence. However, there is no particular definition for unsoundness of mind from a medical perspective. Let us look at some differentiating points between mental illness and unsoundness of mind. As discussed earlier, mental illness is clearly defined under Mental Health Care Act,2017.

However, there is no consensus on the definition of unsoundness of mind. Secondly, mental illness clearly excludes intellectual disability. However, unsoundness of mind includes intellectual disability, which is termed as idiot in the legal context. The third point is that seizure disorders are neurological illnesses, which are classified under chapter six of the ICD, while mental illnesses are classified under chapter five. However, we know that epileptic automatisms are classified under seizure disorders and come in the purview of unsoundness of mind. Finally, mental illness includes substance abuse and related behavioural disturbance. However, acts done under voluntary intoxication are not considered under Section 84, IPC. When it comes to the Indian context, there are no systematic studies to identify specific grounds for insanity defense.

However, commonly noted are psychosis or severe mental illness, delirium, and automatisms. Therefore, mere presence of any mental illness does not warrant in itself the insanity defense. The request for the insanity defense generally comes either from the patient himself or his family members, the lawyer, the court, or sometimes from the investigating officer. Now, this assessment, however, is ordered by the court and sometimes requested by the police inspector in charge of the case in order to file the charge sheet. The questions generally posed by the court or the police inspector are as follows- Is the individual having a mental illness or not?

If he is having a mental illness, did he have a mental illness at the time of the commission of the crime? What are the things necessary to state that an individual has mental illness? What is the percentage of mental instability in this individual? What is the level of or percentage of instability in general in any individual to call them mentally unstable? Is he currently able to understand his whereabouts, like his food, clothing, information about his family members? These are the commonly asked questions from the court or the police inspector. Let’s next move on to the procedure of the assessment for insanity defense. Generally, individuals are admitted in order to provide an assessment report.

On day one of admission, the NIMHANS detailed workup proforma for forensic psychiatry patients is administered. This proforma consists of the socio-demographic details of the individual. Along with that, it captures the reason for the referral, the referring authority, the circumstances around the alleged crime. We try and get as many informants as possible, along with the patient’s report itself. We also look into the FIR, charge sheet, the information volunteered by the family of the patient, the investigating officer, the lawyer and any other past medical records of the patient.

The analysis of the circumstances around the alleged crime is captured in the following way- we look at one week prior to one week after the alleged crime, before the crime, we see if the individual was under the influence of any substance and if he had any confusion. Was he able to plan complex activities? Did he plan any complex activities? During the crime, we look for aggression, if it was provoked or unprovoked, the profile of the victims, the motive and the presence of any accomplice. After the crime, we look, if there was any attempt to conceal or escape or surrender. Let’s move on to the longitudinal assessment of the in-patient stay.

During this entire in-patient stay, observations and assessments are made- to elicit consistency in reporting of symptoms and behaviour of the patient, to get collateral information and to synthesize all the information obtained, and serial mental status examinations are done to watch for any signs or symptoms of any psychotic or affective symptoms, and to report the consistency of the reported psychopathology. Serial ward observations are done by the police personnel in the ward, the nursing staff, and the CCTV footage. The serial ward observation is done by the psychiatrist in charge, the team, including the police, as well as the nursing staff.

In this serial ward observation, various factors are assessed, such as the general appearance and behaviour of the individual, his personal hygiene, behaviour and social functioning, and also the behaviour of the individual when the staff is not observing him, actively. There are several barriers in presenting the report on insanity defense, one of which is that there is a lack of collateral informants because generally these individuals are abandoned by the family members. Also there is a significant delay in the referrals. Generally, the referrals are made a couple of months or years after the alleged crime. Also, there is difficulty in corroborating the information that has been obtained from the patient and the family.

This is more so because most of the crimes that happen are within the family itself. The subjectivity in interpretation of symptoms is also an issue due to lack of diagnostic tests. So what happens when we have insufficient or inconclusive information? Repeated attempts are made to obtain collateral information in case we do not have enough information. The mental status during the inpatient care is returned to the court. For example, no signs or symptoms of mental illness were elicited or found during the inpatient care and comment about the mental status at the time of the alleged crime is not made if there is no information to do the same. Now, moving on to the finalization of the report.

Once the information assessment has been completed and a longitudinal assessment has been done, the forensic psychiatry team comprising of the consultants and the senior resident prepare the final report. The format of the certification has been provided, which captures the demographic details. We also mention on what basis the forensic opinion was provided. So a detailed psychiatric evaluation, serial mental status examinations, serial cognitive functions, serial ward observations and collateral information. We also discuss about the circumstances around the alleged crime which is obtained from the patient, the FIR, family members and any other relevant informant. I will end my presentation here.

In the next video, I will be discussing the practical aspects of insanity defense assessment in terms of their numbers, the courtroom experiences, and the challenges associated with this assessment. Thank you.