Seppänen et al. Int J Ment Health Syst (2020) 14:29 https://doi.org/10.1186/s13033-020-00362-x International Journal of Mental Health Systems REVIEW Open Access Forensic psychiatry in Finland: an overview of past, present and future Allan Seppänen1,2*, Petteri Joelsson3, Aulikki Ahlgren‑Rimpiläinen3 and Eila Repo‑Tiihonen4 Abstract Despite a recent contrary trend, Finland has been for decades one of the most violent countries in Western Europe. Also, Finland has had one of the highest number of psychiatric beds per capita in Europe, although this, too, has seen a sharp decline. Against this background, among other national idiosyncrasies, Finland has developed its forensic psychiatric services. Here, we describe the legal, organizational and clinical structure of these services, and outline the historical and current issues that have shaped them. Finally, we consider future challenges facing the Finnish forensic service system, as part of wider European and global trends. Keywords: Forensic psychiatry, Finland, Forensic assessments Introduction: violence in Finland in 1918, a year after Finland gained independence, the Finland (ind. 1917) is a Northern-European urbanized recorded homicide rate was > 60/100,000 as the country parliamentary democracy and a member of both the was recovering from civil war. Te rate remained similar OECD and the EU, with a total population of approxi- well into the 1930s, after which it began to decline, only mately 5.4 million, and which usually scores high in indi- to peak again after World War II [2]. cators such as peacefulness, stability and quality of life In addition to violence-inducing historical and cultural [1]. Similarly to other Nordic countries, Finnish health factors, such as the widespread civil unrest and prohibi- services are publicly funded and the general access to tion laws of the early twentieth century, the latter argu- these services is considered good. On these grounds, it ably contributing to a culture of binge- drinking still may come as a surprise that Finland is, in fact, one of the prevalent today [5, 6], demographic features specifc to most violent countries in Western Europe [2]. Indeed, Finland need to be taken into account. Immigration to according to an unbroken series of statistics from the Finland has remained low compared to other West Euro- mid-1750s onwards [3], in Finland homicide rates have pean countries. Also, migration within the country has been considerably higher and more volatile than in the historically been low and distinct genetic diferences have other Western European and Nordic Countries. In Fin- developed between the populations living in the western land, the period of industrialization was accompanied by and eastern parts of the country [7]. Finland is sparsely a more or less permanent increase in violent crime, whilst populated and the population lives more rurally than that elsewhere in Western Europe homicide rates decreased in Western Europe despite gradual urbanization. Accord- [4]. Yet, in recent years, homicides have become less ingly, unique genetic features of the Finnish founder frequent in Finland too: in 2017 the lowest rate/capita population have contributed to violent crime in Finland. ever—1.11/100 000—was recorded [3]. In comparison, For instance, there are genotypes enriched to the Finn- ish population which predispose to severe impulsivity (a stop codon in HTR2B) [8] or committing severe recidi- *Correspondence: [email protected] vistic impulsive violent crimes when exposed to heavy 1 Psychoses and Forensic Psychiatry, Helsinki University Hospital, Helsinki, Finland drinking and childhood physical abuse (MAO-H allele) Full list of author information is available at the end of the article [9]. Indeed, the majority of Finnish homicides occur in © The Author(s) 2020. This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creat iveco mmons .org/licen ses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/publi cdoma in/ zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Seppänen et al. Int J Ment Health Syst (2020) 14:29 Page 2 of 8 the context of drinking quarrels between unemployed, in the 1930s, and their current status as specialist state middle-aged male alcoholics, i.e. a so-called “ryyppy- forensic hospitals operating under the Ministry of Social riitatappo” (homicide during a drunken quarrel). For Afairs and Health was cemented by the reforms in men- instance, during the period 2010–2015, in 67% of all tal health legislation of 1952 [16–18]. Te current unit of homicides all persons involved were intoxicated and in Enhanced Rehabilitation and Forensic Psychiatry within 82% of the crimes at least one of the persons involved was Helsinki University Hospital, on the other hand, was intoxicated [4]. established as late as 2015 by incorporating and refor- matting units located at the site of the century-old Kel- Historical developments lokoski Hospital north of Helsinki. A psychiatric hospital General psychiatric services specifcally for prisoners has also been operating within Between the years 1809 and 1917 Finland was a Grand the prison system since 1911 in Turku [14] and later also Duchy of Russia with its own parliament and civil admin- in Vantaa. istration. According to the law passed in 1840, psychi- atric hospitals were separated from other hospitals and thus the frst specifc psychiatric hospital—Lapinlahti Academic contributions hospital—was founded in Helsinki in 1841. Since the Te frst book published in Finland dealing with forensic beginning of the twentieth century and particularly psychiatric issues was by Dr. Teodor Löfström (1857– after independence, local administration began increas- 1907) in 1901 [19]. Later, in 1910s and 1920s, Dr. Akseli ing the number of hospital beds. Te amount of hospital Nikula (1884–1956) continued to diversify the foren- beds peaked in the 1970s, reaching over 4 beds for 1000 sic literature in Finland by publishing on topics such as inhabitants, which was one of the highest in Europe [10]. fratricide, mass criminality and psychiatric presentations Deinstitutionalization began in the 1980s as the focus of associated with criminal behavior [20]. Professor Martti treatment transferred from hospitals to outpatient care. Kaila (1900–1978) continued to develop Finnish forensic Te development of antipsychotic medications and the psychiatry with his seminal work on adolescent ofenders need for treating also non-psychotic disorders contrib- [21, 22]. Furthermore, Dr. Panu Hakola (1932-), who was uted signifcantly to this trend. In the 1990s psychiatric later to become the frst professor of forensic psychiatry organizations started yet again to integrate with general in Finland (see below), completed his thesis on polycys- hospitals [11]. Te current general psychiatric bed provi- tic lipomembranotic osteodysplasia with sclerosing leu- sion is ca. 0.6/1000 [12]. koencephalopathy, also known as Nasu-Hakola disease, in 1972 [23]. As several cases of Nasu-Hakola disease had Forensic psychiatric examinations committed violent and sexual ofences due to the disease Te frst forensic examinations in Finland were con- afecting the frontal lobes, the thesis contributed to our ducted by prison doctors in the 1830s and the frst hos- understanding of the neurophysiological basis of behav- pital to conduct forensic examinations was Lapinlahti ior regulation. hospital in 1841. However, despite this emerging prac- More recently, there has been an increasingly wide tice of forensic examinations, the concept of decreased array of contributions by Finnish forensic psychiatrists to criminal responsibility due to mental illness was prop- the scientifc literature, ranging from biological psychia- erly embedded into law only after 1889 [13]. Yet in the try [24–29] and pharmacological interventions [30–32] beginning of the twentieth century still only a few exami- to the psychiatric epidemiology of violence [33, 34] and nations were conducted annually. After independence, forensic nursing and rehabilitation [35–39], to mention the amount of annual examinations began increasing but a few. together with the number of hospital beds nationwide. Te frst chair of forensic psychiatry in Finland was Also, the frst vacancy for a forensic psychiatrist was established in 1983 at Kuopio University [16] (later reor- founded in Lapinlahti 1918. After WW2, the number of ganized and -named as the University of Eastern Fin- annual examinations rose to approximately 200, peaking land), in afliation with Niuvanniemi Hospital. Panu at ca. 300 in the late 80s [14, 15]. Hakola, MD, PhD, was appointed as the frst professor and chairman, and he continued for 12 years in that posi- Forensic hospitals tion, whilst continuing as medical director for Niuvan- Niuvanniemi Hospital has been operating since 1885 and niemi Hospital. He continued to consolidate the strive Vanha Vaasa Hospital since 1768, the latter as a general for clinical, academic and organizational excellence in hospital until 1931. Teir role as forensic psychiatric Finnish forensic psychiatry [16], which continues today. hospitals developed by degrees; the number of forensic Now, forensic psychiatry is in Finland an established, patients in these hospitals was increased dramatically independent medical specialty with a six-year training Seppänen et al. Int J Ment Health Syst (2020) 14:29 Page 3 of 8 program.