INTRODUCTION
The article 191 of the Turkish Penal Code numbered 5237 regulates a probation application for drug user whether addicted or not, offering a choice of being treated without being legally punished (1-3). In accordance with this article, the narcotic and stimulant substance users are judged to treatment and probation measure. The branch offices of the Probation and Assistance Center of the chief public prosecutor’s Office of the Ministry of Justice, arrange a referral form and refer these individuals sentenced to probation to a state hospital staffed by a psychiatrist and supported by laboratory facilities. After the examination on the admission and the follow-up, individuals who are decided to be addicted are required to be referred to the substance addiction treatment centers by a psychiatrist (2-4). However, individuals who are not defined or cannot be defined as an addict, and who are decided for probation measure, are referred to the nearest substance abuse treatment center from the centers lacking the support of laboratory facilities in the city and counties.
It is observed that regardless whether these people are addicted or not, people who are decided for probation from the neighboring counties and cities have been referred directly to the Samsun Mental Health Hospital (SMHH) that comprises a substance abuse treatment center and has the opportunity of supported substance screening.
This study aimed at assessing the probation application in SMHH and the compliance with treatment in patients referred from the locations out of the Samsun city center.
METHOD
In this study, the data of 2010 of the individuals referred to SMHH according to a verdict of probation were reviewed retrospectively. The consents of the chief physician and the Scientific Study Counseling Coordination Board were obtained.
Probation application in SMHH
In SMHH, the probation application is assessed by 4 successive monthly psychiatric interviews and the results of the urinalysis. The decision on whether the patient completed the treatment or was noncompliant with treatment, is made taking into consideration whether the urinalysis was found negative successively four times or whether the patient failed to attend the interviews. The branch center is informed if the individual miss the treatment session for the first time or in case of nonattendance. When these patients restart to attend the treatment sessions they are included again in a program for the completion of the treatment. The completion of the treatment or noncompliance with treatment are assessed by the medical board. Tetrahydrocannabiol (THC), methamphetamine (MET), opiates (OPI) and cocaine (COC) are detected in the urine screen of the individuals attending the probation treatment program.
The age, sex, regular admissions for treatment or noncompliance with treatment of the individuals are determined on their application. Individuals completing their treatment or noncompliant with treatment are recorded. The city or county centers from where these individuals are referred to SMHH according to the verdict of probation are determined.
It is known that individuals who are decided for probation, are referred from neighboring cities or counties situated in the northern part of Turkey to SMHH comprising a substance abuse treatment center and having the facility of substance screening. Based upon this condition, this study was aimed to determine the compliance with treatment of the patients who were referred from the centers outside the Samsun city center. The individuals referred from the Center of Probation, Branch Office Directorship of Samsun and the individuals referred from the branch offices located out of Samsun, were divided into two separate groups and they were compared to each other. The aim of this comparison was to determine the effect of an easier transportation to the substance abuse treatment center from the city center or from the other centers located in farther distances, on the compliance with the probation application. Similarly to the comparison of the applicants from the Samsun City Center and from the other centers; a comparison was performed between the two groups constituted by individuals directed from the directorships of the Probation Branch Offices of Çarşamba, Bafra, Vezirköprü, Sinop, Çorum, Amasya, Tokat, Ünye, Ordu, Trabzon, Rize, Giresun, Artvin, Gümüşhane and the individuals referred from the other cities’ and counties’ directorships of the Probation Branch Offices. The assessments of these comparisons were performed under 5 headings as follows:
Group 1) Individuals regularly attending and nonattending treatment sessions.
Group 2) Individuals who were called back for treatment, attending/nonattending.
Group 3) Overall, the individuals who completed the treatment or noncompliant with treatment.
Group 4) Among the regularly attending individuals, who completed the treatment and who did not comply with treatment.
Group 5) Among the individuals who were called back for treatment and regularly attending the treatment sessions, who completed the treatment and who did not comply with treatment.
RESULTS
In the retrospective review of the data of 2010, it was detected that 491 individuals presented to SMHH in accordance with a probation measure. A total of 1842 psychiatric assessments and urinalysis of 491 individuals were performed during one year and an average of 7.08 individuals were assessed per day. In the assessment of the patients according to sex, age and age range; it was detected that 4 individuals were female and 487 individuals were male and the mean age was found as 3.2±9.8 and they were in the age range of 17 to 20 years. Only THC positivity was detected in the individuals who had a positive urinalysis, and no other substances were detected to be positive.
Among the aforementioned 491 individuals, 381 individuals (77.6%) regularly attended at psychiatric interviews and urinalysis and 110 (22.4%) individuals were reinvited to the treatment program due to nonattendance. 349 out of 381 regularly attending individuals, were decided to have completed their treatment by the medical board according to the results of the psychiatric interviews and urinalysis. 32 (6.5%) individuals were found to be noncompliant with treatment. 110 individuals who failed to attend regularly at sessions, were called back for a treatment program and 62 of them (12.7%) were accepted as noncompliant with treatment due to the repetition of nonattendance or irregular attendance at the treatment sessions. 44 individuals were reincluded in a treatment program. Among the individuals who were reincluded in a treatment program, 27 (5.5%) individuals completed the treatment and 21 (4.7%) individuals were found noncompliant with treatment (Figure 1).
Group 1) 382 (77.6%) individuals regularly attended at treatment sessions and 110 (22.4%) individuals failed to attend at treatment sessions regularly.
Group 2) Among the individuals who were called back for treatment, 49 (44.5%) individuals regularly attended at treatment sessions and 61 (55.5%) individuals failed to attend at treatment sessions regularly.
Group 3) Overall, 376 (77.6%) individuals completed the treatment and 115 (22.4%) individuals were noncompliant with treatment.
Group 4) Among the regularly attending individuals, 349 (94%) individuals completed the treatment and 32 (6%) individuals did not comply with treatment.
Group 5) Among the individuals who were called back for treatment and regularly attending the treatment sessions, 27 (56%) individuals completed the treatment and 21 (44%) individuals did not comply with treatment.
Data concerning the city and county centers of the probation and assistance branch offices from where the individuals were referred, are shown in Table 1. These individuals were detected to be referred from 18 different city and county centers. While the number of the individuals who were referred from Samsun was the highest (122 individuals, 24.8%), the highest number of referrals apart from Samsun was from Rize (105 individuals 21.4%) (Table 1).
The individuals referred from the Probation Branch Office of Samsun city center and from the other residential area were discussed under the headings in the 5 groups. In the intergroup comparison, no statistically significant difference was found between the admissions from the Samsun City Center and from the other residential areas (Table 2). In a similar way, no difference was found among these 5 groups on the basis of being referred from the residential areas of Bafra, Ordu, Ünye, Amasya, Tokat, Zile, Giresun, Şebinkarahisar, Artvin and from the other centers (p>0.05). However, significant differences were detected among the 5 groups in terms of being referred from certain residential areas and the others (Table 3). Even though some individuals from the Çarşamba County of Samsun regularly attended treatment sessions, the number of the noncompliant individuals was found significantly higher compared to those of the other residential areas (p=0.046) (Table 3).
Both the rates of the individuals attending regularly at treatment sessions and the rates of the individuals completing the treatment were found significantly higher among the individuals referred from the Vezirköprü County of Samsun, compared to the other residential areas (p=0.029 and p=0.030).
Nonattendance at the treatment sessions, the overall rate of the noncompliant individuals with treatment and the rate of noncompliance with treatment in spite of regular attendance, were found significantly higher among the individuals referred from Trabzon City compared to the other residential areas (p<0.001, p<0.001, p<0.001).
The rates of the individuals who were called back for treatment, the rates of attendance among the individuals who were called back for treatment and the rate of noncompliance with treatment among the individuals who were called back for treatment in spite of regular attendance were found significantly higher in the individuals referred from Rize City (p=0.002 and p=0.03). Among the patients referred from Gümüşhane City, the rate of nonattendance, the overall rates of the individuals noncompliant with treatment, the rate of noncompliance with treatment in spite of regular attendance were found significantly higher compared to the other residential areas (p<0.001, p<0.001, p=0.037).
Among the individuals who were referred from Sinop City and Boyabat County, the rates of regular attendance at treatment sessions and overall rate of the completion of treatment were found significantly higher compared to the other residential areas (p=0.026 and p=0.007) (Table 3).
DISCUSSION
The substance abuse is becoming a gradually increasing social problem in our country as in around the World (5,6). In many countries, in order to take the substance addicts under control and treatment, various legal sanctions are applied (4,7,9). A similar application was started in our country by the Penal Procedure Law that entered into force (1-3). The high prevalence of the situations influencing overall society such as theft, aggression among the substance users, indicate that this issue is also a social problem (10-13). Probation application aimed at the improving and treating the substance addicts within the community instead of prison.
In a study on the relationship between the outcomes of substance abuse and residential area, conducted by Durhant (14), a significant problem in rural residential areas, was emphasized.
The probation application in Samsun Mental Hospital includes the determination of the compliance or noncompliance consequently to four successive monthly psychiatric interviews and urinalysis. The comparison of the treatment durations indicates that this period of time varies between one month and 1 year and the number of the interviews varies between 4 and 12 in the Substance Abuse Treatment Centers of Ankara, Istanbul, Izmir AMATEM and Medical School of Ege University (2). While the mean number of the cases examined in these institutions varied between 12 and 100, the mean number of the probation cases was determined as 7 in our hospital.
In case of problems experienced in compliance with the rules of treatment or reports that may be resulted in imprisonment, the physician may turn into a target of rage (4,15). The medical board report concerning compliance or noncompliance with the treatment related to the verdict of probation, seems to be one of the measures relieving the physician of being a target (2). Therefore, the decisions of compliance or noncompliance with treatment are made by the medical board of SMHH.
The probation is defined as; instead of being sent to prison after being arrested or after being convicted by a court in relation with a crime committed by the individual, completing his/her sentence in the community under observation and control. Accordingly, probation may be considered as an enforcement system (16). In this study, 376 (77.6%) out of 491 individuals referred to SMHH, within the scope of probation application, completed the treatment and 115 (22.4%) individuals did not comply with treatment. 376 (77.6%) individuals complying with treatment and completing the treatment without being put in prison, reveal that the probation application is a modality depending on reasonable grounds. On the other hand it is well known that substance users can intend to commit a crime and can form many risky behavior more easily under the influence of the substance (17-19). During the probation measure, individuals completing the treatment in the community as a natural medium without being isolated and without being under the influence of a controlled substance, may develop impulse control against committing crime. Owing to the individual’s consciousness of being under control, this situation has also importance in acquiring skills that may prevent reuse of the substance and developing behavioral changes. In individuals revealing criminal behaviors prior to substance abuse, a reduction in the criminal behaviors was detected after the treatment. While a lower rate of arrest was observed among these individuals, the length of prison sentences was also reduced (20-23).
On the other hand, the obligatory request of treatment, the administration of treatment related to a legal obligation rather than internal motivation in individuals referred for treatment within the scope of probation is one of the major obstacles in terms of compliance with treatment (24,25). However, the reasons leading to be noncompliant with treatment in 115 (22.4%) individuals who were determined to be noncompliant should be investigated and according to the results of this investigation, the new methods that may be applied to these individuals should be developed.
While individuals are referred to SMHH comprising a substance abuse treatment center and situated in the Middle Black Sea Region, the reasons of the referral were, the lack of a staffed psychiatrist in the state hospitals of various cities and counties, or the lack of toxicological analysis facilities and the impossibility of determining whether the individual is addicted or due to the direct admission related to personal referrals. This situation results in admissions to SMHH both from the city center and neighboring cities and counties. When the individuals who are referred to SMHH from Samsun city center in accordance with the measure of probation were compared to the individuals referred from the other city and county centers, similar results were observed in all groups in terms of attendance and compliance with the treatment. SMHH is located in the Samsun city center. Due to the short distances, the individuals from the city center were expected to have a higher rate of attendance and compliance. However this study revealed that no difference was found between the individuals from the Samsun City Center and the other areas in terms of attendance and compliance with treatment. In spite of the difference in distances, individuals from the city center and from outside city center revealed similar characteristics in terms of attendance and compliance with treatment.. When assessed from this respect, focusing on the orientation of the patients to treatment has priority rather than separating the individuals as referred from Samsun and referred from other centers. Besides, due to the legal dimension of the probation treatment program, minimum standard conditions should be provided in the treatment program administered to these patients (26-28).
However when the compliance with treatment of the patients on probation in the centers outside Samsun city center were compared, the results differed between certain regions. In the two residential areas located West to Samsun; Vezirkopru county of Samsun and Boyabat county of Sinop, the rates of both regular attendance and completion of the treatment were found significantly high. This situation indicates that in case of the formation of a probation treatment program in these regions, the individuals would be followed up without problem.
On the other hand, on the east of Samsun, among the individuals coming from the Çarşamba county of Samsun, the rate of noncompliant individuals was found significantly higher compared to other regions in spite of regular attendance. Among the patients referred from Gümüşhane city and Trabzon city, the rate of nonattendance, the overall rates of the individuals noncompliant with treatment, and the rate of noncompliance with treatment in spite of regular attendance were found significantly higher compared to the other residentialareas. The highest number of admission following Samsun was from Rize city. The number of the individuals called back for treatment, the rate of noncompliance with treatment among the individuals who were called back for treatment was found significantly higher in the individuals referred from Rize city in spite of a higher rate of regular attendance. In a study conducted by Denizli AMATEM, longer duration of substance abuse was found associated with significantly higher rates of noncompliance compared to the shorter duration of substance abuse (29). Early detection of substance abuse and early involvement of the individual in probation process are considered as factors that may increase the rate of compliance with treatment. The thought that “they do not get harmed due to the substance abuse and the amount of the substance that they use is insignificant” is common among the people referred to the hospitals for probation following a legal process. The obligatory attendance of the individuals who are referred for treatment within the scope of probation and the denial of having an addiction problem, are the significant problems preventing the compliance with the treatment (30,31). The management of the additional psychiatric problems (psychotic disorders, affective disorders etc.) significantly increases the success of the treatment program (32). Recognizing the personality disorder, understanding the basic defense mechanism of the individual may guide in determining the basic approach for communication and future problems (30). These assessments and results indicate that in addition to the distance between the residential areas and the treatment center, the other dynamic factors may affect different aspects of the treatment program in a negative manner. The data from the interviews with nonattending and noncompliant individuals, focused on the attendance and noncompliance, will contribute to the resolution of the problem. The concepts of probation, informing and addiction, explaining narcotics/stimulant substances and their effects, motivation, determining the vicious circle of affection, thought and behavior, preventing the reuse, administering treatment programs encouraging change for improvement, are the other important conditions in minimizing noncompliance (2,30). In addition, new treatment programs may be developed such as providing communication between the primary physician and the physician of the substance abuse treatment center for hospitalization of the individual if the noncompliance is predictable.
It was observed for some of the referrals from various city and county centers other than Samsun city center that the individuals were referred for treatment without being asked or investigated whether they were substance addicts or not. This application was emphasized to have both advantages and disadvantages in a report of the Task Group for The Standardization of Probation Applications, Scientific Study Unit of the Turkish Psychiaty Society (2). While the probation application in an experienced center is considered as a positive aspect, the formation of excessive work load in the substance abuse treatment centers is considered as a negative aspect.
Apart from SMHH, it is explicitly required to furnish the hospitals of the neighboring areas with the equipment necessary for laboratory facilities and screening tests and to promote them for the treatment and followup of these individuals. Or one may consider storing urine samples in a refrigerator in order to send them to SMHH or another accessible hospital for urinalysis, in the treatment centers lacking laboratory facilities. One should explain primarily to the administrations of the hospital and two psychiatrists who are the practitioners, that these procedures may be performed in every hospital staffed with a psychiatrist, psychologist and/or a mental health nurse practitioner and having laboratory facilities appropriate for the screening tests or the facilities for storing the samples in a refrigerator in order to send them to a neighboring center for the assessment. Besides, since every psychiatrist may be provided to work in collaboration with a neighboring substance abuse treatment center and may be supervised by these centers if required. The information about whether the individual on probation completed the treatment, may be given according to a treatment protocol including the attendance at the treatment sessions, compliance, social improvement and urinalysis. The noncompliant individuals may be referred to the substance abuse treatment centers. In a report of the Task Group for The Standardization of Probation Applications, it is emphasized that the results of the treatment are reported by a medical board as a preventive measure for probation applications (2).
CONCLUSION
The Probation Applications and the rates of compliance with treatment were discussed in this study. The confinement of probation application in certain centers results in hitches related to compliance with treatment and access to treatment. The increased number of the hospitals of the Ministery of Health, possessing the minimum conditions to perform probation treatment program will prevent the individual to travel long distances to access the relevant centers and consequently noncompliance with treatment. New centers and the provision of the right of probation in a residential area in a short distance to the residence of the individual are considered as an obligation in certain regions. The referral of the individuals to the more easily accessible treatment centers within their residential area will increase the efficacy of the aforementioned application. In this way the probation application will have significant contribution to the prevention of substance abuse.
