The Basaglia Law. Returning dignity to psychiatric patients: the historical, political and social factors that led to the closure of psychiatric hospitals in Italy in 1978.

Law no. 180 of 1978, which led to the closure of psychiatric hospitals in Italy, has often been erroneously associated with one man, Franco Basaglia, but the reality is much more complex. Not only were countless people involved in the movement that led to the approval of this law, but we should also take into account the historical, social, and political factors that came into play. The 1970s in Italy were a time of change and political ferment which made this psychiatric revolution possible there and nowhere else in the world.

Impact of closure of the in-house psychiatric care unit on prehospital and emergency ward length of stay and disposition locations in patients who attempted suicide: A retrospective before-and-after cohort study at a community hospital in Japan.

ABSTRACT: Suicide is an increasingly serious public health care concern worldwide. The impact of decreased in-house psychiatric resources on emergency care for suicidal patients has not been thoroughly examined. We evaluated the effects of closing an in-hospital psychiatric ward on the prehospital and emergency ward length of stay (LOS) and disposition location in patients who attempted suicide.This was a retrospective before-and-after study at a community emergency department (ED) in Japan. On March 31, 2014, the hospital closed its 50 psychiatric ward beds and outpatient consultation days were decreased from 5 to 2 days per week. Electronic health record data of suicidal patients who were brought to the ED were collected for 5 years before the decrease in in-hospital psychiatric services (April 1, 2009-March 31, 2014) and 5 years after the decrease (April 1, 2014-March 31, 2019). One-to-one propensity score matching was performed to compare prehospital and emergency ward LOS, and discharge location between the 2 groups.Of the 1083 eligible patients, 449 (41.5%) were brought to the ED after the closure of the psychiatric ward. Patients with older age, burns, and higher comorbidity index values, and those requiring endotracheal intubation, surgery, and emergency ward admission, were more likely to receive ED care after the psychiatric ward closure. In the propensity matched analysis with 418 pairs, the after-closure group showed a significant increase in median prehospital LOS (44.0 minutes vs 51.0 minutes, P < .001) and emergency ward LOS (3.0 days vs 4.0 days, P = .014) compared with the before-closure group. The rate of direct home return was significantly lower in the after-closure group compared with the before-closure group (87.1% vs 81.6%, odds ratio: 0.66; 95% confidence interval: 0.45-0.96).The prehospital and emergency ward LOS for patients who attempted suicide in the study site increased significantly after a decrease in hospital-based mental health services. Conversely, there was significant reduction in direct home discharge after the decrease in in-house psychiatric care. These results have important implications for future policy to address the increasing care needs of patients who attempt suicide.

Tracking rural hospital closures.

(1) Over 50 percent of primary care health professional shortage areas (HPSAs) were in rural areas in November 2016, according to the Health Resources and Services Administration. (2) Rural areas face a higher uninsured rate than metropolitan areas. (3) Rural hospitals tend to have low patient volume, a high portion of patients on Medicare and Medicaid, and a high number of uninsured patients.

[Closing forensic psychiatric hospitals in Italy: a new deal for mental health care?]. / Il superamento degli Ospedali Psichiatrici Giudiziari: a new deal per la salute mentale?

The date of March 31, 2015, following the Law 81/2014, has marked a historical transition with the final closure of the six forensic psychiatric hospitals in Italy. This law identifies a new pathway of care that involves small-scale high therapeutic profile facilities (Residenze per la Esecuzione della Misura di Sicurezza, REMS) instead of the old forensic psychiatric hospitals. The Law promotes a new recovery-oriented rehabilitation approach for the persons with mental disorders who committed a criminal offence, but lack criminal responsibility and deemed as socially dangerous. After a brief description of what happens abroad, this article highlights the positive aspects of the law that, as a whole, has to be considered innovative and unavoidable. The main debated problems are also reviewed, including the lack of changes to the Criminal Code; the improper equation between insanity and mental illness and social dangerousness; the evaluation of "socially dangerousness", based solely on "subjective qualities" of the person, assessed out of his/her context, without paying attention to family and social conditions suitable for discharge; the expensive implementation of the REMS, mainly based on security policies and less on care and rehabilitation, the delay in their construction, and the search for residential alternatives structures; the uncertain boundaries of professional responsibility. Finally, several actions are suggested that can support the implementation of the law: information programs addressed to the general population; training activities for mental health professionals; systematic monitoring and evaluation of the outcomes of the care provided to the forensic psychiatric population; implementation of Agreement Protocols and a better cooperation with the judiciary. Scientific societies dealing with psychosocial rehabilitation need to be involved in such issues relating to the identification of the best care and rehabilitation pathways, which should be implemented following closure of forensic psychiatric hospitals.

[How do we treat the broad spectrum of patients with serious mental illness who have committed crimes? The Law 81/2014: limits and problems]. / Come cureremo l'ampio spettro di pazienti con gravi malattie mentali autori di reato? La Legge n. 81/2014: limiti e problematiche.

In Italy an ongoing process of deinstitutionalization unprecedented in the world is been enacted. The Judicial Psychiatric Hospitals, that were never reformed in the past 80 years, are now on the edge of their closure. This process is being implemented through a layering of rules that had no purpose other than the rapid closure of these structures. The Mental Health Departments have now the responsibility of a multiplicity of new and highly specialized tasks, and an extension of their power to control. There is no previous organization for these tasks in the Mental Health System. Some of the recently enacted laws, such as the Law 81 of 2014, are intented to solve some problems, althought issues of deinstitutionalization are getting worse. In our opinion several management aspects of this population of severe psychiatric patients are unfit with the present organization of the Mental Health Services. There is need for legislative action coordinated and based on a long-term perspective.

Records access and management on closure of a medical practice.

Despite uneven regulation, health practitioners registered with the Australian Health Practitioner Regulation Agency have immediate and continuing obligations to patients when contemplating practice closure. Recent enforcement actions by regulators highlight the importance of knowledge and compliance with requirements relating to record management.

Closing forensic psychiatric hospitals in Italy: a new revolution begins?

On 30 May 2014 the Italian Parliament approved a new law regarding forensic psychiatric hospitals. Forensic psychiatric hospitals are facilities that admit individuals who have committed a criminal offence but lack criminal responsibility because of a mental disorder and are deemed as dangerous to public safety. Here we report the key aspects of the new legislation together with some critical considerations.

[The closure of forensic hospitals and the implications for nursing care]. / La chiusura degli ospedali psichiatrici e le implicazioni per l'assistenza.

SUMMARY: The closure of forensic hospitals and the implications for nursing care. The closure of forensic hospitals led to the opening of new wards to admit psychiatric patients who committed a crime and by Italian law, cannot be imprisoned. Over 826 residents of forensic hospitals, around 350 cannot be discharged because considered dangerous for the society. The new wards where these patients will be admitted raise some legal and ethical problems as health professionals (doctors and nurses) will be responsible not only of the patients health but also of their legal custody. The professional and ethical implications need a debate among professionals.

Some perspectives on criminalization.

In recently published articles, there has been an underemphasis on the role serious mental illness (SMI) plays in causing persons to be in the criminal justice system. Increasing attention has been paid to other factors, including criminogenic needs. While these needs may be present and contribute to criminal behavior, persons with SMI who are at greatest risk of criminalization are those who are not receiving adequate treatment, structure, social control, and, when necessary, 24-hour care in the mental health system. Cognitive behavioral therapy (CBT) has been used to reduce recidivism for prisoners, including those with SMI, but persons impaired by their untreated psychotic symptoms may not be able to profit from it. The importance of psychiatric treatment must not be underestimated. Moreover, given their current constraints, correctional systems may not be able to continue accepting large numbers of persons with SMI. Many offenders with serious mental illness pose difficult and expensive problems in treatment and management, such as nonadherence to medication, potential for violence, and substance abuse. The mental health system needs to be given more funding and to take more responsibility for these challenging individuals.