FOSTREN Country blog- Latvia

Written by Marina Loseviča

The blog was constructed in collaboration with the research project “Towards a human rights approach for mental health patients with a limited capacity: A legal, ethical and clinical perspective”, No. lzp-2020/1-0397

What is your country’s stand on coercion reduction? ​

Coercive practices permitted in Latvia

In Latvia, formal coercion in healthcare is defined based on the Medical Treatment Law (1). This law permits coercive practices for special groups of mental health patients – such as involuntary commitment and detainment in a mental hospital and the application of confining means, and quasi-coercive measures for addiction patients.

Restrictions on the rights of persons in social welfare institutions are listed in the Law on Social Services and Social Assistance (2).

1. Mental health inpatient facilities, inpatient

Civil commitment and detainment in a mental hospital (in the law – “Psychiatric assistance without the consent of a patient”) – if a person due to a mental disorder or mental disease disturbs public order, his or her detention, conveyance to and supervision at the psychiatrist shall be performed by police officers. The police officers shall submit to the psychiatrist a notice in writing of the anti-social nature of the behavior of the patient. Police officers have the duty to assist: medical treatment institutions, medical practitioners, epidemiologists of the National Health Service, and State health inspectors – in the conveyance by force for monitoring or treatment of persons suffering from alcohol, narcotic, psychotropic, or toxic substances addiction or venereal diseases, persons who are mentally ill and a danger to the society, and also conveyance and guarding in a medical institution of persons for which there are sufficient grounds to conclude that they are infected with the immunodeficiency virus (HIV) or infectious diseases the list of which is approved by the Cabinet if they are evading the appearance at a medical treatment institution. Police officers have a duty to transport to a medical treatment institution persons with unmistakable mental disorders and who, through their actions, create an obvious danger to themselves or persons nearby; transport to a medical treatment institution persons who have attempted to commit suicide and, to clarify the circumstances of the incident (3).

Criteria for psychiatric assistance without the consent of a patient are: if the patient has threatened or threatens, tried or is trying to do personal injuries to him or herself or to another person or has behaved or behaves violently to other persons and the possible consequences of mental disorder may be a personal injury to the patient him or herself or another person; and if the patient has indicated or indicates an inability to care for him or herself or for a person under his or her guardianship and the possible consequences of her mental disorder may be unavoidable and serious deterioration of the person’s health. The detainment can be initiated by a psychiatrist in the admission ward (life–saving treatment can be ordered only), then within 72h period, this decision shall be approved by a council of psychiatrists, and, subsequently, the medical hospital treatment has to be justified by the court (for the time up to two months and then if needed prolonged up to six months more). There is no requirement for the involvement of an independent medical expert (e.g., a psychiatrist not working in the respective hospital) in the compulsory admission procedure. The patient is guaranteed a right to a lawyer.

Compulsory measures of medical nature – Historically, in many countries, forced healthcare interventions have been a part of the legal enforcement instruments. Nowadays, so-called preventive or security measures (often differently called) are stipulated by the law in many countries. Usually, they comprise compulsory measures for mentally ill, addicted persons, and sexual offenders with disorders of preference. For example, in Germany, they are called “measures of betterment and prevention”. In Latvia “the other coercive measures” are compulsory measures of an educational/correctional nature and compulsory measures of medical nature.

In the Governorate of Livland of the Russian Empire (the main one amongst the Baltic or Ostsee Governorates, now the territory of Latvia and partially Estonia), the legal regulation of coercive medical interventions in the case of infectious diseases and mental disorders was authorized at least as early as in the beginning of the 19th century. Curable mentally ill offenders who were found to be not guilty for the grounds of mental incapacity during the time of the commission of the offense (manslaughter, assault, or arson), were referred to the institutions for long-term treatment and supervision; but incurable ones (e.g., the mentally retarded or those in the advanced stage of the disease) were placed under the responsible care. The appointment and termination of compulsory treatment and placement into care were regulated by the amendments to the law.

Long-term care of the mentally ill was based on asylum-like or shelter-like institutions (both state-owned, self-governing bodies-owned and private ones); outpatient care was available as care in the families of guardians and so-called patronage familial (care into peasant families).  But mental offenders from Ostsee governorates were referred to the Alexander Heights Mental Hospital – the oldest and the largest mental hospital in the Baltics, now Riga Centre of Psychiatry and Addiction Medicine (4).

During the Soviet period, the involuntary psychiatric placement and treatment (e.g., compulsory hospital treatment and long-term care) of mental health offenders (both after criminal proceedings and without it) was regulated by law and by special instructions (issued by the Ministry of Health and the Prosecutor’s Office of the Soviet Union). Compulsory treatment of the offenders in the frame of criminal proceedings traditionally was titled as compulsory measures of a medical nature (while in the vast majority of other European countries, the outpatient treatment approach for the severely mentally ill was titled as assertive community treatment). Most of the offenders were to be treated close to the place of their residence. A minority of patients (who met special criteria of dangerousness) were referred to the high-security mental hospital in the city of Chernyahovsk (previously Insterburg) in Kaliningrad oblast of the Russian Soviet Republic, that was run by the Ministry of Internal Affairs (by contrast with other healthcare facilities, normally run by Ministry of Heath).

At least since 1954 after the cancellation of the compulsory measures of medical nature (in the hospital) the person was supposed to be submitted to surveillance by the nearest psychoneurological/neuropsychiatric district dispenser. Persons who were at risk of committing violent acts due to the type/course of their disease (without being criminally persecuted) were assigned to such observation as well. A patient under observation could be visited at home by a mental health nurse; in urgent cases – compulsory hospitalized (committed). The word “observation” received a negative connotation, as it referred to political abuse of psychiatry (e.g., hospitalization of political opponents before major holidays or state celebrations).  As a result of that, worries about “being listed” refrained inhabitants from seeing a psychiatrist and increased stigma.

Preparations for the reforms had begun in the late 1980s when central control from Moscow was decreasing. 

The fundamental reforms have been performed in health care in the 1990s (in all post-Soviet countries) – they brought in democratization, the principle of informed consent, and a shift from a paternalistic to a partnership paradigm in healthcare (not only in psychiatry).

After regaining independence in 1991, Latvia failed to build community-based psychiatric care. The principles of continuous care of the severely mentally ill in the community were excluded from practice. The doctrine of autonomy and privacy was overused; the decision-making capacity of the person refusing or consenting to treatment was not evaluated. 

According to the law, both inpatient and outpatient compulsory measures of medical nature may be assigned only if the person who committed the (criminally punishable) offense in the state of mental incapacity (“insanity defense”) or diminished capacity is considered to be also “publicly dangerous mentally ill”.

• Mental health treatment, outpatient

In line with international practice, in addition to compulsory treatment in a mental hospital and the security ward, compulsory outpatient treatment (COT) – a new form of compulsory measures of medical nature – was introduced in criminal law in Latvia in 1997 (also available for incarcerated persons).

Unfortunately, during the forensic expert evaluation, the difference between a person who poses a high risk to commit or to be involved in crime due to personality traits or attitude to the law and a mentally ill at risk of violation of law due to mental health condition is not made. This brings to memory the ideas of the Italian (anthropological) school of criminology and Jean Pinatel’s (1913-1999) writings on a “dangerous state” (resp., a high risk of committing a crime) that needs to be timely addressed and prevented (5).

The performative or executive capacity of the patient assigned for the COT (ability to follow the treatment recommendations, organize the day, self-care, and independent living capacity) is not evaluated, regardless if the person resides alone or with relatives (informal caregivers).

The clear preventive and protective role of the COT is also lacking – if the person does not carry out the compulsory measure of a medical nature (most frequently – nonadherence to the treatment, e.g., the person discontinues medical treatment, skips the outpatient appointments) and/or demonstrates some signs of gradually deteriorating mental state, the prompt compulsory commitment and treatment (a recall to the hospital) is not possible, unless the criminal court reevaluates the case and issues the new order (it takes up to several weeks) or general criteria for involuntary psychiatric commitment (or civil commitment) are met.

Statistics on compulsory measures of medical nature in 2018 – 2020 (Riga and Riga district):

According to the Riga Centre of Psychiatry and Addiction Medicine data (6), there were 70, 59, and 50 court hearings in 2018, 2019, and 2020. The court rejected the need for involuntary treatment in 3, 2, and 7 cases, respectively.

Regarding compulsory measures of medical nature in the security ward – in 2018, 2019, and 2020 there were 25, 34, and 12 patients admitted to the security ward (the only one in Latvia, with 45 beds); the patient number at the end on the year – 47, 47, 40.  

Compulsory measures of medical nature in the general psychiatric inpatient settings – 22, 19, 28 (46 patients by the end of 2020).

Outpatient compulsory measures in Riga were applied to  90, 82, and 70 patients (at the end of the years 2018, 2019, and 2020).

• Means of restraining and control

Confining means can be applied in cases, when there are direct threats that a patient due to psychic disorders may commit injuries to himself or herself or other persons or a patient demonstrates violence towards other persons and attempts to discontinue threat by verbal convincing have failed. Confining means may be used for a patient by force only if the patient is hospitalized without his or her consent (also before the court decision regarding the involuntary placement), and for a patient for whom medical treatment in a psychiatric medical treatment institution has been determined as a compulsory measure of medical nature.

Confining means are:

• Mechanical restraints (mostly bed belts)
• Physical restraint (mostly used for minors)
• Chemical restraint (short-acting antipsychotics and benzodiazepines)
• placement in a monitoring ward.

A decision to apply confining means shall be taken by a doctor and implemented by a medical practitioner. Application of confining means shall be proportional to the direct threat caused by a patient and application thereof shall be immediately discontinued, if the threat caused by the patient does not exist anymore. A doctor shall indicate the application of confining means in the medical documentation of a patient, by indicating the reasons for the application of confining means, the starting and end time, and injuries caused, if any have been caused for the patient or medical practitioner. Application of the confining measures is performed according to the Cabinet Regulation (7).  For each case of confining the medical practitioner makes an entry in the patient restraint case registration log. The medical practitioner checks the patient’s state of health at least every 15 minutes; the patient can be in a continuously restrained position for no longer than two hours at one time of restraint. After this period, the patient is released and his behavior is evaluated. If the patient continues to pose a threat due to mental disorders, repeated mechanical restraint is allowed no earlier than after 10-15 minutes. The minor patient can stay in the monitoring/observation ward for no longer than four hours; re-admission of the patient to the observation ward is allowed no earlier than after 24 hours.

Minors – If confining is applied to a minor patient, the medical practitioner shall immediately inform the patient’s legal representative and makes the corresponding notice in the log. If a minor is restrained or placed in the monitoring/observation ward, the medical practitioner checks the minor patient’s state of health at least every 10 minutes. The minor patient can be continuously restrained for no longer than one hour at one time of restraint. After this period, the patient is released and his behavior is evaluated. If the patient continues to pose a threat due to mental disorders, repeated mechanical restraint is allowed no earlier than after 15-30 minutes. The minor patient can stay in the monitoring/observation ward for no longer than four hours; re-admission of the patient to the observation ward is allowed no earlier than after 24 hours.

Other means of control in mental hospitals are:

Body search – The Cabinet determines the list of those items which are prohibited to be kept in a psychiatric medical treatment institution and to receive in consignments (parcels) – e.g., explosive and flammable objects, sharpened objects, alcohol and substances of abuse, medicines (without a doctor’s prescription), electronic devices, pornographic or violent content (7). If a medical practitioner has justified doubts that items prohibited in a medical treatment institution are kept by a patient or present in his or her belongings, a doctor has the right to decide searching of the patient or his or her belongings. A doctor shall indicate the decision and substantiation thereof in the medical documentation of the patient. A medical treatment institution shall ensure that the search is carried out by a medical practitioner of the same gender.

Reduction of contact with visitors and cancellation of daily walks – if there are direct threats that a patient due to psychic disorders may commit injuries to himself or herself or other persons, or a patient demonstrates violence towards other persons, a doctor has the right to prohibit the patient’s meeting with relatives and other persons and a daily walk. The doctor shall indicate the reason and duration of the application of the prohibition in the medical documentation of the patient. A doctor, having assessed each case, may take a decision regarding a patient’s meeting with relatives and other persons at the presence of the medical practitioner, if it is necessary due to safety considerations or it is requested by a visitor or patient. A doctor shall indicate the decision taken and substantiation thereof in the medical documentation of the patient.

• Addiction medicine

Since 1992 the compulsory treatment of addicts is canceled in Latvia (8).  But so-called quasi-compulsory treatment (substitution of imprisonment by treatment with the person’s consent) is still possible both for minors and adults and is provided in narcological institutions (traditionally, addiction medicine is called “narcology” and is a separate medical specialty). In cases where as the result of the use of alcohol, narcotic, psychotropic, toxic substances, participation in gambling or computer games, a person performs activities dangerous to the public, systematically commits administrative violations, or by his or her actions endangers himself or herself, his or her closest relatives or the public, the compulsory measures of social and psychosocial rehabilitation shall be applied, but for minors – compulsory measures of an educational/correctional nature. The compulsory measures for social and psychosocial rehabilitation are: 1) registration in the police prophylactic register and a warning in writing by the police that the patient must terminate the use of alcohol, narcotic, psychotropic, toxic substances, participation in gambling or computer games and the committing of the related administrative violations thereof, as well as to start mandatory medical treatment; 2) registration in the register of addicts and development of motivation to start the voluntary medical treatment for addiction (including gambling); 3) a court adjudication regarding the requirement for the convicted person to undergo the medical treatment. In addition, in imposing a suspended sentence, a court may impose, for a convicted person who has committed a crime under the influence of alcoholism, narcotic, psychotropic addiction or toxic substance addiction, or is addicted to gambling or computer games with his or her consent, the duty to undergo treatment at a social or psychiatric rehabilitation institution (1).  The voluntariness of such consent raises doubts.

For minors, since the age of eleven, mandatory correctional training (literally ‘compulsory measures of an educational nature’) which is applied solely to juvenile offenders and entails sending them to special educational (correctional) establishments of a closed type is possible (9).  The compulsory measures of correctional/educational nature may be applied to children from 11 to 18 years of age and they comprise some medical interventions too: so, a judge or an administrative commission upon the consent of a child or child’s parents (guardian), or the consent of the Orphan’s and Custody court, if the child or his or her parents (guardian) do not provide consent, may impose an obligation on the child to undergo treatment for addiction to alcohol, narcotic, psychotropic or toxic substances or other addictions if that was the cause of committing the offense or violation. Placing the child in an educational institution for social correction, the provision of his or her treatment for alcohol addiction, narcotic, psychotropic or toxic substances or another addiction shall be mandatory. Compulsory treatment shall be performed in accordance with the procedures specified by the Cabinet (9).  According to the national data, the body of minors who received compulsory addiction treatment in hospitals has demonstrated a decline from 228 in 2016 to 173 in 2020; while the rate of outpatient treatment remained stable: 1212 in 2016 and 1259 in 2021 (10).

• Restrictions on the Rights of a Person at a Long-term Social Care and Social Rehabilitation Institution – to prevent leaving a person without supervision and to protect the health and life thereof, and also the rights and freedoms of other people, the head of a long-term social care and social rehabilitation institution or an authorized representative thereof may take the decision on necessity to restrict the right of a person to free movement for a definite time period if the necessity of such supervision, based on the state of health of a person, is determined in the individual rehabilitation or care plan. If a person with his or her actions endangers his or her health or life or the health or life of other persons, the head of the relevant institution or his or her authorised person may take a decision, making a note in the person’s file, on the isolation of the person for a period not exceeding 24 hours in a room specially arranged for such purpose, where the necessary care and continuous supervision of the person is ensured (2).

Initiatives to reduce coercion

During the period from 1 September 2014 to 30 April 2016 the Association “Resource Centre for People with Mental Disabilities ZELDA” implemented project No. 2013.EEZ/PP/1/MAC/092/067 “Pilot Project for Introduction of Supported Decision Making in Latvia” under the European Economic Area Financial Mechanism 2009-2014, program “NGO Fund” and sub-program “NGO project measure”. The conception on supported decision making was developed and proposals to change legislative acts have been prepared and discussed. First person-centered planning experts and support persons were trained, and direct support in decision-making for 28 persons with mental disabilities and advisory support to 55 relatives or friends of people with mental disabilities was provided (11).  The pilot project was successful and the supportive decision making service (including support in healthcare decisions) is available since June 2023 (provided by the Ministry of Welfare) (12).

The current “Mental health care organization improvement plan 2023-2025” does not stipulate any target activities to abolish coercion or to promote voluntary measures (13).  

What kind of research is happening in your country on this topic? ​

By the time being, the patient is requested to sing the informed consent or refusal from hospital treatment just by signing the relevant form, without questioning his or her mental capacity (medical decision-making capacity) or level of coercion (formal or informal). The form is provided in Latvian only, the interpreter service is not avaliable.

In 2021 a research project “Towards a human rights approach for mental health patients with a limited capacity: a legal, ethical and clinical perspective” was initiated by the University of Latvia. It’s clinical objective is to study the prevalence, characteristics, and needs of patients with limited capacity in Latvian medical and psychiatry institutions. The project aims to develop recommendations for improvement of legal regulations, governance, and clinical practice to safeguard the rights of patients with limited capacity; to improve the knowledge of society, the scientific community, and health care professionals in the protection of patients with limited capacity issues, to facilitate the development of a human rights approach to patients with limited capacity legally and clinically in Latvia (14).

Why are you in the network and what would you like to achieve with it? ​

From my perspective, the most challenging issue in delivering mental healthcare is to balance the patient’s human rights, right to autonomy, and need for protection; public safety, and avoidance of coercion.

FOSTREN provides an opportunity to explore the alternatives to coercive practices and their implementation issues, and to learn the current trends in developing human rights-based mental care.

Is there anything else that you want to share with us?

In Latvia, the law does not stipulate compulsory psychiatric medical treatment (e.g., daily injections of medications or use of long-lasting neuroleptics); as well as treatment without consent in any other non-life-threatening health conditions (e.g., tuberculosis).  Regarding restraining patients (psychosis due to poisoning or drug abuse, disorders of consciousness, self-harm or suicide attempt, the aggressions delays treatment of life-threatening condition), in somatic hospitals, a national recommendation is launched (it is a lot like the procedure of mechanical restrain in mental hospitals) (15).  There is no national register of the use of coercion and involuntary hospitalization rate. The only monitoring mental health quality indicator is the psychosis patient 30-day readmission rate and this rate is still high.  Regardless of the cause for the civil commitment and subsequent involuntary hospitalization and treatment (e.g., violence, child abuse, self-harm, self-neglect) no coercive follow–up or after-care, placement into social care institution is possible as the patient is discharged home. The patient’s performative capacity, need for support, and risk of violent acts in the future is not assessed at the discharge. The persons receiving compulsory measures of medical nature and the patients with a tendency to violence, substance abuse or self-harm are precluded from social services (16, 17).  Thus, social care and rehabilitation is prohibited for those who are most in need of it.

No special sex offender therapy is available or provided in Latvia (by contrast with Estonia).

The COT for incarcerated persons is delivered in the psychiatric ward of the prison hospital, which contradicts the principles of outpatient treatment.

The absence of the appropriate external facilities and corresponding legislation on compulsory social care leads to the situation, when persons with severe mental disorders and need for supervision have to stay in hospitals for decades (e.g., intellectually impaired with sexual preference disorder). In this regard, the author would like to quote the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT), that in early 1998 called such deprivation of liberty “a highly questionable state of affairs”.

The inpatient suicide rate is underreported in Latvia – there are zero cases reported from 2000 to 2020 (18),  although at least two deaths from self-harm were detected in 2019 by the audit of the Health Inspectorate (19).

On the other hand, the violence towards medical staff in mental health settings is underestimated and underreported as well (20).

I believe that changing the mindset of stakeholders – society, policymakers, lawyers, and healthcare professionals – can help to transform the field of psychiatry and reduce all forms of coercion (both formal and informal).

An increase in funding is crucial to ensure adequate ward staffing, personnel training, continuality of treatment, and, therefore, the safety of patients and the staff.

Engaging the public, patient organization representatives, and ethicists in policy-making and developing quality indicators could facilitate the path to value-based mental care.

References

1. Law of Latvia, Ārstniecības likums/Medical Treatment Law. Latvijas Vēstnesis, 167/168, 01.07.1997., https://likumi.lv/ta/id/44108
2. Law of Latvia, Law on Social Services and Social Assistance/ Sociālo pakalpojumu un sociālās palīdzības likums. Latvijas Vēstnesis, 168, 19.11.2002. https://likumi.lv/ta/id/68488
3. Law of Latvia, Likums “Par policiju”/Law On Police. Latvijas Republikas Augstākās Padomes un Valdības Ziņotājs, 31/32, 15.08.1991. https://likumi.lv/ta/id/67957
4. Bundža, O., Kudeikina, I., Loseviča, M. Piespiedu ārstēšana kā valsts pārvaldes uzdevums jeb kas ir kopīgs tifozajai Mērijai un Trakajam Ludvigam/Compulsory Treatment as Task of Public Governance or What Thyphoid Mary and Mad King Ludwig Had in Common, Socrates. 2021, 2 (20), 212 – 231. dspace.rsu.lv/jspui/bitstream/123456789/6280/1/Socrates-20-2_15-Losevicha-Bundzha-Kudeikina_212-231.pdf
5. Mucchielli, L. (2017). Sociology of Deviance and Criminology in France: History and Controversies. The American Sociologist, 48(3-4), 276–296.
6. Limited liability state company “Riga Center of Psychiatry and Addiction Medicine” 2020 annual report/VSIA „Rīgas Psihiatrijas un Narkoloģijas Centrs” 2020.gada pārskats.
7. Ministru kabineta 2016. gada 12. jūlija noteikumi Nr. 453 “Noteikumi par kārtību, kādā ierobežojami pacienti, un priekšmetiem, kurus aizliegts turēt psihiatriskajā ārstniecības iestādē”/ Cabinet regulations Nr 453 (2016, 12 July) “Regulations on the procedure for restraining patients and items that are prohibited to be kept in a psychiatric treatment facility”. Latvijas Vēstnesis, 134, 14.07.2016. https://likumi.lv/ta/id/283493
8. Krastiņš U. Kriminālsods un citi kriminālie piespiedu ietekmēšanas līdzekļi/Criminal punishment and other measures of criminal law. Article in Latvian.  Jurista Vārds, 2007,. Nr. 11 (464), 13. marts.
9. Law of Latvia, Likums “Par audzinoša rakstura piespiedu līdzekļu piemērošanu bērniem”/ Law On Application of Compulsory Measures of a Correctional Nature to Children. Latvijas Vēstnesis, 168, 19.11.2002.
10. National Health Service, Letters Nr 16-7/16513/2022, On minors’ mandatory narcological treatment/Nacionālais veselības dienests, Par obligāto narkoloģisko ārstēšanu nepilngadīgajiem,  Vēstule Nr. 16-7/16513/2022.
11. RC ZELDA has completed the Pilot Project on Implementation of the Supported Decision Making in Latvia, https://zelda.org.lv/en/news/rc-zelda-has-completed-the-pilot-project-on-implementation-of-the-supported-decision-making-in-latvia/
12. Ministru kabineta 2023. gada 10. janvāra rīkojums Nr. 8 “Par konceptuālo ziņojumu “Par atbalsta personas lēmumu pieņemšanā pakalpojuma ieviešanu””/ Order of Cabinet of Ministers “About the conceptual report “On the implementation of the service of support person in decision-making” Nr 8 (2023 10 Jan). Latvijas Vēstnesis, 9, 12.01.2023. https://likumi.lv/ta/id/338725
13. Ministru kabineta 2022. gada 13. decembra rīkojums Nr. 939 “Par Psihiskās veselības aprūpes organizēšanas uzlabošanas plānu 2023.–2025. gadam”/Order of Cabinet of Ministers “On the Plan for improving the organization of mental health care 2023-2025. Latvijas Vēstnesis, 245, 19.12.2022. https://likumi.lv/ta/id/338032, accessed 20 December 2022.
14. Research project “Towards a human rights approach for mental health patients with a limited capacity: A legal, ethical and clinical perspective”, No. lzp-2020/1-0397. https://www.lzplemtspeja.lu.lv/en/about-project/summary/
15. Metodiskie ieteikumi pacientu piespiedu ierobežošanai stacionārajās ārstniecības iestādēs, Veselības Ministrija/ Methodological recommendations for forced restraint of patients in inpatient treatment facilities, Ministry of Health, https://www.spkc.gov.lv/lv/metodiskie-ieteikumi-stacionarajas-arstniecibas-iestades/veselbas_ministrijas_ieteikumi_pacientu_piespiedu_ierobeoanai_stacionrajs_rstniecbas_iestds1.pdf
16. Ministru kabineta 2019. gada 2. aprīļa noteikumiem Nr. 138 “Noteikumi par sociālo pakalpojumu un sociālās palīdzības saņemšanu” 1. pielikums “Psihiatra atzinums par personas psihisko veselību un speciālajām (psihiatriskajām) kontrindikācijām sociālo pakalpojumu saņemšanai”/ Cabinet of Ministers regulations No 138 (April 2, 2019) “Rules on receiving social services and social assistance”, appendix 1. “Psychiatrist’s opinion on a person’s mental health and special (psychiatric) contraindications for receiving social services”. Latvijas Vēstnesis, 68, 04.04.2019.;
17. Ministru kabineta 2006. gada 6. novembra noteikumiem Nr. 914 “Kārtība, kādā no psihoaktīvām vielām atkarīgās personas saņem sociālās rehabilitācijas pakalpojumus” 2.pielikums “Kontrindikācijas sociālās rehabilitācijas pakalpojumu saņemšanai”/ Cabinet of Ministers regulations No 914  (November 6, 2006) “Procedure in which persons addicted to psychoactive substances receive social rehabilitation services”, Appendix 2 “Contraindications for receiving social rehabilitation services”. Latvijas Vēstnesis, 180, 09.11.2006.
18. OECD Health Quality Indicators: Mental health care, In-patient suicide among patient diagnosed with a mental disorder, https://stats.oecd.org/Index.aspx?QueryId=51883
19. The Health Inspectorate, Republic of Latvia, reply Nr 3.1.-2/31773/ to the inquiry on 21.12.2020/ Veselības Inspekcija, atbilde Nr 3.1 – 2/31773 uz vēstuli no 21.12.2020.
20. Vadims Rakevichs, Karina Konstantinova, Marina Losevich. Patient-to-staff violence in mental health settings in Latvia – underreported and underestimated. Abstracts of the 63rd International Scientific Conference of  Daugavpils University, Daugavpils  Universitātes akadēmiskais apgāds „SAULE”, 2021. https://www.dukonference.lv/en/Abstracts_of_Conference