Is freedom (still) therapy? The 40th anniversary of the Italian mental health care reform.

On 13 May 1978, the Italian Parliament approved Law 180, universally known as 'Basaglia Law' after the name of the leader of the anti-institutional movement which promoted this radical community mental health care reform. Forty years later, Italian psychiatry still runs a community care system, albeit with degrees of solidity and quality very varied along the peninsula. Mental health care is still an integral part of the National Health System, with liberal regulations on coercion and a lowest number of general hospital and residential facilities beds. Recently, Italy has also closed the special forensic psychiatric institutions and brought the care of the mentally ill offenders within the responsibilities of local Mental Health Departments. Over time, psychiatric deinstitutionalisation inspired policies in other sectors of Italian society, such as those regarding physical and intellectual disabilities, education of children with special needs, drug addictions and management of deviant minors. Furthermore, debate about Law 180 has reached and maintained an international dimension, becoming a term of reference for international agencies such as the World Health Organization and the European Commission, for good and for evil. The overall balance sheet of the Reform process would seem mostly positive, though the last decade has seen many threats challenging the system. Mental health care services have been asked to do much more, in terms of care to a larger population with very diversified needs, but with much less resources, due to the financial consequences of the economic crisis. Although there is no evidence of a trend towards re-institutionalisation, intensity and quality of care may have fallen below acceptable standards in some parts of Italy.

Influence of childhood trauma on diagnosis and substance use in first-episode psychosis.

BackgroundChildhood trauma has been significantly associated with first-episode psychosis, affective dysfunction and substance use.AimsTo test whether people with first-episode psychosis who had experienced childhood trauma, when compared with those who had not, showed a higher rate of affective psychosis and an increased lifetime rate of substance use.MethodThe sample comprised 345 participants with first-episode psychosis (58% male, mean age 29.8 years, s.d. = 9.7).ResultsSevere sexual abuse was significantly associated with a diagnosis of affective psychosis (χ2 = 4.9, P = 0.04) and with higher rates of lifetime use of cannabis (68% v 41%; P = 0.02) and heroin (20% v 5%; P = 0.02). Severe physical abuse was associated with increased lifetime use of heroin (15% v 5%; P = 0.03) and cocaine (32% v 17%; P = 0.05).ConclusionsPatients with first-episode psychosis exposed to childhood trauma appear to constitute a distinctive subgroup in terms of diagnosis and lifetime substance use.

Disparities in mental health care provision to immigrants with severe mental illness in Italy.

AIM: To determine whether disparities exist in mental health care provision to immigrants and Italian citizens with severe mental illness in Bologna, Italy. METHODS: Records of prevalent cases on 31/12/2010 with severe mental illness and ≥1 contact with Community Mental Health Centers in 2011 were extracted from the mental health information system. Logistic and Poisson regressions were carried out to estimate the probability of receiving rehabilitation, residential or inpatient care, the intensity of outpatient treatments and the duration of hospitalisations and residential care for immigrant patients compared to Italians, adjusting for demographic and clinical covariates. RESULTS: The study population included 8602 Italian and 388 immigrant patients. Immigrants were significantly younger, more likely to be married and living with people other than their original family and had a shorter duration of contact with mental health services. The percentages of patients receiving psychosocial rehabilitation, admitted to hospital wards or to residential facilities were similar between Italians and immigrants. The number of interventions was higher for Italians. Admissions to acute wards or residential facilities were significantly longer for Italians. Moreover, immigrants received significantly more group rehabilitation interventions, while more social support individual interventions were provided to Italians. CONCLUSIONS: The probability of receiving any mental health intervention is similar between immigrants and Italians, but the number of interventions and the duration of admissions are lower for immigrants. Data from mental health information system should be integrated with qualitative data on unmet needs from the immigrants' perspective to inform mental health care programmes and policies.

Residential care in Italy. National survey of non-hospital facilities.

BACKGROUND: In Italy, where all mental hospitals have been gradually phased out since 1978, psychiatric patients requiring long-term care are being treated in non-hospital residential facilities (NHRFs). However, detailed data on these facilities are sparse. AIMS: The Progetto Residenze (PROGRES) residential care project is a three-phase study, the first phase of which aims to survey the main characteristics of all Italian NHRFs. METHOD: Structured interviews were conducted with the manager of each NHRF. RESULTS: On 31 May 2000 there were 1370 NHRFs with 17 138 beds; an average of 12.5 beds each and a rate of 2.98 beds per 10 000 inhabitants. Residential provision varied ten-fold between regions and discharge rates were very low. Most had 24-hour staffing with 1.42 patients per full-time worker. CONCLUSIONS: There is marked variability in the provision of residential places between different regions; discharge rates are generally low.

[Predicting length of stay in Italian Psychiatric Forensic Hospitals: a survival analysis]. / I fattori predittivi della durata di degenza in Ospedale Psichiatrico Giudiziario: un'analisi di sopravvivenza.

UNLABELLED: Admission to an Italian Forensic Hospital (OPG) results in formal exit from psychiatric care provided by NHS community based psychiatric services. The length of stay in such facilities is often perceived as a factor negatively affecting the opportunity for reintegration in the community. METHOD: Factors predicting length of stay in OPG were investigated by means of a survival analysis carried out on a cohort of 118 inmates of three OPGs (Castiglione delle Stiviere, Reggio Emilia and Montelupo Fiorentino), who represent the whole forensic population from 3 different geographical areas at 30.06.97; all discharges occurred in the following 18 months were examined. RESULTS: In survival analyses conducted on individual predictors, five variables predicted a longer stay: type of offenses (homicide: 706.6 weeks vs. 307.1 for minor offenses and 194.7 for grievous bodily harm, log-rank = 31.8, p < 0.001), type of admission (RR = 0.98, CI 95% 0.97-0.99, p < 0.001), the diagnosis of schizophrenia (621.9 weeks vs. 398.9 weeks or less for other diagnoses; log rank = 9.08, df = 3, p = 0.028), BPRS thought disturbance score (RR = 0.89, CI 98% 0.81-0.98, p < 0.01), hospital of stay (314.6 weeks in Montelupo Fiorentino vs. 706.6 for Reggio Emilia and 621.9 for Castiglione delle Stiviere; log-rank = 9.64, df = 2, p < 0.001). In a Cox linear regression model three significant factors were selected: type of offenses stype of admission, diagnosis of schizophrenia. CONCLUSIONS: Judicial factors are relevant in determining the length of stay in OPG. The diagnosis of schizophrenia seems to play an independent role in predicting a longer stay.

Case management and assertive community treatment in Europe.

OBJECTIVE: Case management studies from Europe and the United States continue to yield conflicting results. At a symposium at the World Psychiatric Conference in Hamburg in 1999, researchers from four European countries explored the possible reasons for differences in outcome. They also examined reasons for the differing foci of case management studies across the different cultures. The authors summarize the symposium's findings. METHODS: Individual case presentations were given of studies and services from the United Kingdom (three studies), Sweden (two studies), Germany, and Italy (one each). Outcomes, methodologies, and national service context were examined. RESULTS AND CONCLUSIONS: A significant influence of national culture is evident both in the acceptability of case management and in approaches to researching it. Case management is perceived as an "Anglophone import" in Italy but is now national policy for persons with severe mental illness in the other three countries. Studies from the United Kingdom emphasized methodological rigor, with little attention to treatment content, whereas those from Sweden accepted a less disruptive research approach but with a more prescriptive stipulation of treatment content. Studies from Italy and Germany emphasized the importance of differing descriptive methodologies. Marked differences in the range of social care provision were noted across Europe. Overall, European researchers are less concerned than U.S. researchers with studying the impact of case management on hospital use.

[Electroshock (ESK) and electroconvulsive therapy (ECT)]. / Elettroshock (ESK) e terapia elettroconvulsivante (ECT).

OBJECTIVE: To discuss the ethical and legal basis of ECT use in Italy, one year after the regulation set up by the Minister of Health. METHOD: Literature review and presentation of authors' personal opinions. RESULTS: Despite being the oldest somatic therapy still practised in psychiatry, ECT effectiveness has been systematically evaluated only during the last 20 years, and its clinical indications have become progressively restricted. Yet there are wide variations between countries and within each individual country about the extension, the modalities and the indications for its use. ECT seems to be practised mainly in large scale public psychiatric hospitals and in private clinics, but its use in systems following a community approach is very limited. Wide variations exist also with reference to the severity of regulations imposed by governments or suggested by professional associations. The extent of education and auditing by university centres varies considerably, but is generally considered unsatisfactory. There are still some reports about possible political and repressive use of ECT in some countries, especially developing ones. CONCLUSIONS: The authors consider that every national system of care should have a clear policy and clear regulations about ECT. The provisions set up by the Italian Minister of Health seem to be consistent with Italian health policies and psychiatric community care.

The quality of life of people with schizophrenia in Boulder, Colorado, and Bologna, Italy.

The aim of the study was to compare the quality of life (QOL) and needs of people with schizophrenia in comprehensive treatment systems in two countries. One hundred people with schizophrenia and schizoaffective disorder were randomly selected from the caseload of a community mental health center in Boulder, Colorado, and 70 were similarly selected from public psychiatric treatment services in and around Bologna, Italy. Subjects were interviewed with QOL and needs assessment instruments and rated with the Brief Psychiatric Rating Scale. Objective QOL measures favored Bologna subjects over Boulder subjects, particularly with respect to employment, accommodation, and family life. In a factor analysis, objective QOL variables sorted separately from subjective satisfaction ratings, suggesting that they measure different underlying constructs. Patient needs in both Boulder and Bologna samples were primarily psychological and social rather than basic survival issues. Boulder subjects were more likely to report accommodation needs. Many apparent QOL advantages for Bologna subjects could be attributed to the greater frequency with which the Italian patients lived with family of origin. Living with family also appeared to confer practical benefits in meeting needs. Objective QOL measures discriminated between patient populations better than subjective ratings of satisfaction and well-being.

Substance use among the mentally ill: a comparison of Italian and American samples.

Thirty-six patients with long-standing psychotic illness randomly selected among attenders at two community centers of Bologna were interviewed as were their therapists, in order to determine prevalence and patterns of substance use, reasons for use and effects on illness. Protocols were the same as used in previous research carried out in Boulder, Colorado. For all substances, except stimulants and over-the-counter products, prevalence rates were lower in the Bologna sample than in Boulder. Overall lifetime rates of substance use were significantly lower in the Bologna sample. Nevertheless 47.2% of the Bologna sample had a lifetime moderate to severe drug use and nearly two-thirds of the sample had a current drug use of some severity. Reasons for use equally reflected attempts to alleviate unpleasant emotional states and recreational purposes. Patients with high degrees of psychopathology had significantly lower scores on severity of drug use.

Choking incidents among psychiatric patients: retrospective analysis of thirty-one cases from the west Bologna psychiatric wards.

OBJECTIVE: To determine the rate of choking incidents among the psychiatric population of 4 inpatient facilities, classifying the incidents according to their probable etiology. METHOD: All incidents recorded over 18 months were retrospectively analyzed for demographic variables, psychiatric and medical diagnoses, and drug therapy at the time of incident. Where possible, patients underwent psychiatric, neurological, and medical examination. RESULTS: Thirty-one incidents were recorded involving 18 patients at a rate of one incident every 56.32 months' hospitalization per person. One case proved fatal, one patient died several weeks after the incident from aspiration pneumonia, and 5 patients needed reanimation or the Heimlich manoeuvre. Etiological classification showed that incidents due to bradykinetic dysphagia and "fast eating" were the most numerous, even among the fatal or grave cases. CONCLUSIONS: Various simple, effective preventive measures emerge from the study.

Reform said or done? The case of Emilia-Romagna within the Italian psychiatric context.

OBJECTIVE: The authors sought to evaluate how the services required by the Italian Psychiatric Reform of 1978 were implemented in Emilia-Romagna, a region of 4 million inhabitants in Northern Italy. METHOD: All psychiatric facilities were monitored from 1978 to 1994 to determine the number and rates of admissions, average duration of stay, average intake, and percent of beds occupied at inpatient facilities as well as the number of patients residing in former mental hospitals and the number and rates of first contacts with mental health community centers. RESULTS: Three mental hospitals out of nine were closed during the period, and the number of patients who resided in mental hospitals declined from 4,798 to 655. By 1994, there were 145 community centers, 48 day treatment centers, 12 general hospital psychiatric wards, three university psychiatric clinics, seven private psychiatric clinics, 24 psychiatric residences, and 123 supervised apartments that were operating as alternatives to asylums. The overall rate of inpatient admissions remained stable, but compulsory admissions gradually decreased by 35% throughout the period. First contacts at outpatient centers increased by 17.9% from 1984 to 1991. CONCLUSIONS: The shift from a hospital-based to a community-based psychiatric system of care, as foreseen by the Italian psychiatric reform, seems feasible. Some general political, administrative, and social backup conditions appear crucial to ensure the good outcome of this process.

[HPLC method for measuring (Na(+)-K(+)) ATPase and (Ca(++)-Mg(++)) ATPase in erythrocytes from different species of mammals]. / Metodo HPLC per il dosaggio della (Na(+)-K(+) ATPase e della (Ca(++)-Mg(++)) ATPase in eritrociti di diverse specie di mammiferi.

(Na(+)-K+)ATPase and (Ca(++)-Mg++)ATPase are enzymes located in erythrocyte plasma membranes, driving back ions against the electrochemical gradient; (Na(+)-K+)ATPase transports 3 Na+ ions out of the cell, and 2 K+ ions into it for each hydrolyzed ATP molecule, whereas the Ca(2+)-pump transports Ca2+ ions out of the cells, by utilizing still the ATP hydrolysis. The method used to test the activity of the above mentioned enzymes is based on the measuring of the ADP quantity released during the reaction by HPLC, that is High Performance Liquid Chromatography; the chromatographic type is a Ion-Pair Reversed-Phase. This method presents the following important advantages for the assay of the enzymes we analysed: 1) It is reproducible through time; 2) It is perfectly linear; 3) It is extremely sensitive. This method allowed us to carry out a comparative study of (Na(+)-K+)ATPase and (Ca(++)-Mg++)ATPase in erythrocyte plasma membranes of several species of mammalia: man, horse, rabbit, lamb, rat. We recovered different values in ATPase activity; (Ca(++)-Mg++)ATPase shows a higher activity than Na(+)-K+)ATPase; moreover, some differences exist in the various Mammalia considered, with relation to each pump: the lamb shows the lowest activity for both pumps, whereas the rabbit shows the highest one. At present, the different values obtained are being interpreted and analysed. This method is also very versatile, since it allowed us to assess the Km value for Ca++ of the (Ca(++)-Mg++)ATPase in erythrocyte plasma membranes of rabbit. The value resulted to be 100 microMs, thus 10 times higher than the human Km value for the Ca++.