Both assailants involved in the recent knife attack at Seohyeon Station in Bundang, Gyeonggi Province, last Thursday, and at a high school in Daejeon on Saturday, had a history of mental illness but refused treatment, local news reports said.

Some local psychiatrists said the nation’s Mental Health Act should be revised to make it easier to hospitalize people with mental illness in the wake of recent violent crimes. 

The Seohyeon Station assailant reportedly dropped out of high school due to agoraphobia and had been treated at a hospital from 2015 to 2020, taking psychiatric medication.

However, after being diagnosed with schizotypal personality disorder in 2020, Choi refused to take medication or seek medical attention.

The suspect who brandished a weapon at a teacher in Daejeon was also diagnosed with schizophrenia and depression and treated at a hospital near his home from 2021 to last year. The hospital later recommended hospitalization, but he was not hospitalized or treated as the patient refused to accept such recommendations.

Doctors are calling for the government to step in and support the treatment of the severely mentally ill and strengthen management so that patients can be hospitalized even if they refuse.

Coercive hospitalization difficult in Korea

The process of forced hospitalization in Korea is nearly impossible in Korea due to the 2016 revision of the Mental Health Act. 

The previous mental health law allowed forced hospitalization for six months, regardless of the patient's will, with the consent of two guardians and one specialist.

In 2016, forced hospitalization accounted for more than half (61.5 percent) of the 69,162 hospitalized mentally ill patients.

Some forced hospitalization resulted in human rights violations such as tying the limbs of patients hospitalized with mental disorders to their beds, illegally confining them, and forcibly giving medication in psychiatric hospitals. At times, some families exploited the forced hospitalization system for family disputes.

After the Constitutional Court ruled that forced hospitalization without consent was unconstitutional in 2016, the government revised the Mental Health Act, which came into effect in May 2017.

Under the new amendment, forced hospitalization became only possible when the two conditions are met -- at least two guardians should agree on the hospitalization and two specialists working at different hospitals should express the consensus opinion for the hospitalization.

A procedure was also introduced to review the appropriateness of forced hospitalization by the Hospitalization Appropriateness Review Committee.

As a result of the law revision, there have been some successes in reducing forced hospitalizations that may violate human rights as the rate of hospitalization for patients with mental illness in Korea.

According to the Korea Health Insurance Review and Assessment Service, the number of patients hospitalized for schizophrenia decreased annually from 23,131 in 2016 to 18,212 last year, a 21.3 percent decrease over six years.

However, the number of crimes committed by mentally ill people has increased.

According to the National Police Agency's crime statistics, the total number of crimes committed by mentally ill offenders, which was 6,980 in 2015 increased to 8,850 in 2021, an increase of 26.8 percent in six years.

In particular, violent crimes, such as assaults, increased by 31.5 percent from 2,218 in 2015 to 2,917 in 2021.

Government should take responsibility 

Experts say that with no infrastructure to deal with mental illness outside of hospitals, the emphasis on “de-institutionalization” of mentally ill patients has had the side effect of failing to treat such patients who need treatment.

As a result, psychiatrists emphasized the need to introduce a national accountability system.

The Korean Neuropsychiatric Association (KNA) stressed that they have been asking the government to abolish the forced hospitalization system and the introduction of a judicial hospitalization, which allows judicial institutions such as courts to decide whether to hospitalize severely mentally ill patients.

"The judicial hospitalization implemented in developed countries are designed to protect the human rights and lives of patients, secure the safety of society, and allow medical staff to focus on treatment by directly listening to patients' stories and taking responsibility for hospitalization decisions," KNA said in a statement on Sunday.

As a result, it is necessary to actively consider the abolition of forced hospitalization, which account for the majority of involuntary hospitalizations in Korea, and revise the Mental Health Act so that human rights and treatment can be guaranteed at the same time, the association added.

The association also called for the revitalization of forensic psychiatry for reactive prevention and a complete review of the therapeutic custody system.

"In many countries, some severe mental illnesses related to crime are addressed as a matter of social safety through the criminal justice system," KNA said. "However, the number of requests for therapeutic commitment by prosecutors is very low, with only 78 cases in 2021."

Some severe mental illnesses with high levels of violence need to be actively managed by the forensic psychiatry system, which is overseen by the Ministry of Justice, not the Ministry of Health and Welfare or the medical system, it added.

A Korean Society for Schizophrenia Research (KSSR) official also agreed that the judiciary system should take responsibility for forced hospitalization.

"While the KNA had pushed for the implementation of the judicial hospitalization system five or six years ago, it was never accepted," KSSR Vice Chairman An Suk-kyoon told Korea Biomedical Review. "The main point of the system is that while there is no problem if a patient is hospitalized through his own decision if the person is hospitalized involuntarily, it should be decided legally."

An stressed that the current rules make doctors entirely responsible for forced hospitalization, which should not be the case.

"If a doctor makes an initial decision on the need for hospitalization, the family court should make the final decision without having to go through the process of getting a second opinion from another doctor from a different hospital," An said. "At the end of the day, the government is the only one who can take measures to limit someone's action in Korea, so the judiciary branch should be the ultimate decision maker."

He said it is the only way to protect the patient's human rights and not miss out on a patient's treatment.

The government to look into judicial hospitalization

The Ministry of Health and Welfare and the Ministry of Justice announced on Friday that they would form a joint task force to examine ways to improve the mental health system to minimize public unrest.

The Ministry of Health and Welfare explained, "While various reasons have been raised for the recent incidents, we plan to establish a joint task force with the Ministry of Justice to review the overall hospitalization system for the mentally ill and improve the effectiveness of treatment for the mentally ill, including improving the outpatient treatment support system."

Notably, the Ministry of Justice announced that it is considering introducing the judicial hospitalization system.

The Ministry of Justice explained, "The hospitalization and isolation system for some severely mentally ill patients who are likely to cause harm to others is being considered for introduction in consultation with the Ministry of Health and Welfare so that it can be effectively operated under due process."