Changes in the ability to correctly identify schizophrenia and depression: results from general population surveys in Germany over 30 years.

PURPOSE: This study aims to examine time trends in the ability to correctly identify schizophrenia and major depression within the German general population from 1990 to 2020, as an indicator of changing mental health literacy (MHL). Additionally, we investigated shifts in the use of stigmatizing language. METHODS: Our analysis is based on four waves of representative population surveys in Germany in 1990/1993 (West Germany: N = 2044, East Germany: N = 1563), 2001 (N = 5025), 2011 (N = 2455), and 2020 (N = 3042) using identical methodology. Respondents were presented with an unlabelled case vignette describing a person who exhibited symptoms of either schizophrenia or major depression. Participants were then asked to name the problem described in the vignette using an open-ended question. RESULTS: From 1990/1993 to 2020, correct identification of schizophrenia increased from 18% to 34% and from 27% to 46% for major depression. However, derogatory labels remained constant throughout all survey waves, particularly for schizophrenia (19% in 1990/1993 and 18% in 2020). For depression, more trivializing and potentially devaluing statements were recorded. CONCLUSION: Despite the increasing use of psychiatric terminology among the general population, the persistence of derogatory labels suggests that improved MHL, reflected in higher recognition rates, may not automatically translate into a reduction in stigmatizing language. With depression, a normalization and trivialization of a severe illness could pose new challenges to people with major depression. Dedicated efforts to combat the stigma of severe mental illness are still needed.

Stigma and public attitudes toward euthanasia or assisted suicide for psychiatric conditions: results from a general population survey in Germany.

BACKGROUND: With growing numbers of countries legalizing euthanasia or assisted suicide (EAS), there is a debate as to whether EAS should also be available to people with severe, treatment-resistant mental illness. Excluding mental illness as a legitimate reason to receive EAS has been framed as discriminating against people with mental illness. AIMS: We examine whether approval or opposition to psychiatric EAS are related to stigma toward people with mental illness. METHOD: We asked a representative sample of the general population in Germany (N = 1515) whether they would approve of EAS for someone with severe, treatment-resistant mental illness. Stigma was assessed with the Value-Based Stigma Inventory (VASI), addressing rejection of people with mental illness in relation to different personal values. RESULTS: A total of 19% of the German population approved of psychiatric EAS. Higher stigma scores were associated with greater approval of EAS (Spearman rank correlation coefficient, 0.28; P < 0.001). This association held true when controlling for sociodemographic variables. It was strongest for stigma related to perceived threats to one's security, reputation and meritocratic values. CONCLUSIONS: Our results highlight that, although opposing psychiatric EAS is sometimes framed as discriminatory, approval of psychiatric EAS might also carry hidden, stigmatising motives. To avoid any unintended negative consequences for people with severe, treatment-resistant mental illness, any legislation on psychiatric EAS needs to be crafted with particular caution.

Public attitudes towards protecting the human rights of people with mental illness: a scoping review and data from a population trend study in Germany.

The human rights of people with mental illness are constantly threatened. We conduct a scoping review showing how public attitudes towards protecting human rights have so far been examined and providing an overview of our present knowledge of these attitudes, and present novel findings from a trend study in Germany over nine years, reporting attitudes elicited in 2020 and examining whether these attitudes have changed since 2011. Few studies address attitudes towards human rights explicitly, but several studies contain single items on either first generation human rights, mainly concerning involuntary admission, or civil liberties like the right to vote, or second generation human rights, mainly with regard to funding for healthcare, but also for example regarding career choice. Recent data from Germany showed little improvement in attitudes towards protecting human rights over the last decade and particularly high support for restricting job opportunities for people with mental illness. Although generally, most restrictions were supported by a minority of respondents only, both our data and our scoping review indicate substantial support for several restrictions in several countries, showing that public attitudes pose a challenge to the human rights of persons with mental illness. We discuss possible lines of future research.

Changes in continuum beliefs for depression and schizophrenia in the general population 2011-2020: a widening gap.

PURPOSE: The public discourse about mental health and mental illness seems to have become more open over the last decade, giving rise to the hope that symptoms of mental illness have become more relatable. We examine whether continuum beliefs regarding schizophrenia and depression have increased on a population level over a period of 9 years, and whether notions of unfamiliarity and incomprehensibility have decreased. METHODS: In 2011 (n = 2455) and 2020 (n = 3042), two methodologically identical cross-sectional population surveys were conducted in Germany. After the presentation of an unlabeled case vignette depicting someone with schizophrenia or depression, we asked about continuum beliefs, perceived unfamiliarity and perceived incomprehensibility of the person described. RESULTS: Multinomial logit models holding sociodemographic variables fixed at their means for both surveys showed that agreement with continuum beliefs increased in depression from 43 to 46% [change 4%; 95% confidence interval (CI) 0; 8], but decreased in schizophrenia from 26 to 20% (change - 6%, 95% CI - 9; - 3). Unfamiliarity (change - 4%; 95% CI - 7; 0) and incomprehensibility (change - 7%, 95% CI - 10; - 4) decreased for depression, while remaining largely unchanged for schizophrenia. CONCLUSION: An already pronounced gap in the perception of both disorders with regard to continuity of symptom experiences and perceived otherness further widened over the last decade. While the public's increasing familiarity with symptoms of depression might be further aided by using continuum beliefs as part of anti-stigma messages and awareness campaigns, promulgating continuity models for schizophrenia seems more challenging.

Changes in mental illness stigma over 30 years - Improvement, persistence, or deterioration?

BACKGROUND: Large efforts have been made to erase the stigma of mental illness, but it is unclear whether they have succeeded on a population level. We examine how attitudes toward people with depression or schizophrenia have evolved in Germany since 1990, and whether there are different developments for both disorders. METHODS: Using data from the three decades, four wave repeated cross-sectional representative population study in the "old" (western) states in Germany with surveys in 1990 (n = 2,044), 2001 (n = 4,005), 2011 (n = 1,984), and 2020 (n = 2,449), we calculate time-trends for social distance and emotional reactions toward someone with major depression or acute schizophrenia. RESULTS: Social distance worsened in six out of seven situations for schizophrenia, whereas improving in two out of seven situations for depression. Emotions related to fear and uneasiness increased for schizophrenia, whereas tending to decrease for depression. Pro-social reactions like the desire to help increased for depression, but decreased for schizophrenia. Initially observed differences, favoring depression over schizophrenia, widened over the 30-year study period. For schizophrenia, the biggest negative changes occurred between 1990 and 2001, whereas some improvements with regard to depression occurred more recently. CONCLUSION: Contrary to expectations, stigma has become more severe regarding acute schizophrenia in Germany over the last 30 years, whereas only slightly improving for depression. The apparent normalization of mental health problems seems not to directly translate into improving attitudes toward people with severe mental illness. Re-focusing of anti-stigma efforts on people with severe mental illness seems necessary.

Frequency and gender differences in the use of professional home care in late life. Findings from three German old-age cohorts.

Aim: The aim of this study was to investigate the frequency of and the gender differences in the use of professional home care in Germany. Methods: We used harmonized data from three large cohort studies from Germany ("Healthy Aging: Gender-specific trajectories into the latest life"; AgeDifferent.de Platform). Data were available for 5,393 older individuals (75 years and older). Mean age was 80.2 years (SD: 4.1 years), 66.6% were female. Professional homecare outcome variables were use of outpatient nursing care, paid household assistance, and meals on wheels' services. Logistic regression models were used, adjusting for important sociodemographic variables. Results: Altogether 5.2% of older individuals used outpatient nursing care (6.2% women and 3.2% men; p < 0.001), 24.2% used paid household assistance (26.1% women and 20.5% men; p < 0.001) and 4.4% used meals on wheels' services (4.5% women and 4.0% men; p = 0.49). Regression analysis revealed that women had higher odds of using paid household assistance than men (OR = 1.48, 95% CI: [1.24-1.76]; p < 0.001), whereas they had lower odds of using meals on wheels' services (OR = 0.64, 95% CI: [0.42-0.97]; p < 0.05). No statistically significant differences in using outpatient nursing care between women and men were found (OR = 1.26, 95% CI: [0.87-1.81]; p = 0.225). Further, the use of home care was mainly associated with health-related variables (e.g., stroke, Parkinson's disease) and walking impairments. Conclusions: Our study showed that gender differences exist in using paid household assistance and in culinary dependency. For example, meals on wheels' services are of great importance (e.g., for individuals living alone or for individuals with low social support). Gender differences were not identified regarding outpatient nursing care. Use of professional home care services may contribute to maintaining autonomy and independence in old age.

Why Was the Perception of Human Rights Respect and Care Satisfaction So High in Users of Italian Mental Health Services during the COVID-19 Pandemic?

The aim of this study was to compare users' and mental health workers' (MHW) perception of respect of human rights and job/care satisfaction in mental health services in Italy during the COVID-19 pandemic. A sample of users and MHW of Sardinia, Italy, fulfilled the "Well-Being at work and respect for human rights questionnaire" (WWRR). The study included 240 MHW and 200 users. Users showed a higher level of satisfaction of care than MHW of work, and a higher perception of the satisfaction of users and human rights respected for health workers. Both user and MHW responses were about 85% of the maximum score, except for satisfaction with resources. Responses were higher for users, but users and MHW both showed high levels of satisfaction. In previous surveys, MHW of Sardinia showed higher scores in all items of WWRR, except for satisfaction with resources, compared with workers from other health sectors of the same region, and with MHW from other countries. The low score for satisfaction with resources (in users and staff) is consistent with a progressive impoverishment of resources for mental health care in Italy. The study, although confirming the validity of the Italian model, fully oriented towards community, sets off an alarm bell on the risks resulting from the decrease in resources.

[Psychometric Evaluation of a Long and Short German Version of the Prejudice Towards People with Mental Illness Scale (PPMI-D)]. / Psychometrische Evaluation einer deutschen Version der Lang- und Kurzform der Prejudice towards People with Mental Illness Scale (PPMI-D).

OBJECTIVE: We present a German version of the Prejudice towards People with Mental Illness Scale in long (PPMI-DL) and short form (PPMI-DK) and provide a psychometric evaluation in a German population sample. METHODS: After German translation (including back-translation), an online survey (N = 1004) was conducted. RESULTS: Item difficulty and selectivity are in the desirable medium range. Internal consistencies are high to excellent (PPMI-DL: α = 0.919; PPMI-DK: α = 0.872) in the overall scale. Confirmatory factor analyses confirm the 4 subscales of the original scale. Medium correlations are found with authoritarian attitudes (KSA-3) and low negative correlations with social desirability (KSE-G). Norm values for the PPMI subscales are reported. CONCLUSION: The PPMI-D can be used in German-speaking countries to survey prejudice towards people with mental illness.

Development and validity of the Value-based Stigma Inventory (VASI): a value-sensitive questionnaire for the assessment of mental health stigma.

BACKGROUND: It has been hypothesized that mental illness stigma differs according to what matters most to people, and that this results in value-based differences in stigma within societies. However, there is a lack of stigma measures that account for a broad range of values, including modern and liberal values. METHODS: For the development of the Value-based Stigma Inventory (VASI) a preliminary item-pool of 68 VASI-items was assembled by mental health and stigma experts. For psychometric evaluation, we tested the VASI in an online sample of the general population (n = 4983). RESULTS: Based on item-characteristics as well as explorative and confirmatory factor analyses, a final version of the VASI was developed, comprising 15 items and 5 subscales. The VASI shows good psychometric properties (item difficulty = 0.34 to 0.67; mean inter-item correlation r = 0.326; Cronbach's α = 0.879). Medium to high correlations with established stigma scales (SDS, SSMI), medium associations with instruments assessing personal values (PVQ, KSA-3) and small to no associations with a social desirability scale (KSE-G) attest to good convergent and discriminatory validity of the new instrument. Normative values for the VASI subscales are presented. CONCLUSIONS: The developed VASI can be used to assess public stigma of mental illness including personal stigma-relevant value orientations.

Are informal family caregivers stigmatized differently based on their gender or employment status?: a German study on public stigma towards informal long-term caregivers of older individuals.

BACKGROUND: Stigma and informal caregiving are determinants for health and wellbeing, but few studies have examined stigma towards informal caregiving. Public stigma may be expressed differently towards caregivers depending on their gender and employment status due to societal norms. Therefore, this study analyzes if there is a difference in public stigma shown by the general population toward informal caregivers of care recipients aged 65 years or older based on the observed caregiver's gender or working status. METHODS: A cross-sectional study was conducted in Germany. Data from 1038 adult participants from the general population in Germany were assessed with an Online-Survey. They were recruited with a quota-system based on the German micro census. Participants were randomly assigned to one of 16 vignettes describing a caregiving situation, which varied in the caregiver's gender and working status, and care recipient's gender and type of impairment. After reading the vignette, they were asked to provide sociodemographic information and complete three questionnaires on public stigma assessing their emotional (Emotional Reactions), behavioral (Social Distance) and cognitive reaction (Statements on informal caregivers) to the caregiver described in the vignette. Regression analyses, adjusted for sociodemographic data of the participants, were conducted. RESULTS: Findings indicated an association between reading about male caregivers and increased social distance, compared with reading about female caregivers. Reading about working caregivers was associated with decreased social distance and increased appreciative statements, compared to reading about non-working caregivers. Analyses after stratifying by gender of the caregiver in the vignette indicated an association between reading about female working caregivers and increased appreciative statements, compared to reading about female non-working caregivers. When stratifying by working status, an association was found between reading about male working caregivers and increased social distance, when compared to reading about female working caregivers. CONCLUSIONS: This study's findings indicate that gender and working status of the perceived informal caregivers are of relevance to the public stigma directed towards these caregivers. Male and non-working informal caregivers were shown more public stigma than female and working informal caregivers. Thus, interventions to reduce public stigma, in particular towards male and non-working caregivers, are recommended.

Association of Alcohol and Tobacco Consumption with Depression Severity in the Oldest Old. Results from the Age Different Old Age Cohort Platform.

This study aimed to examine the association of alcohol and tobacco use with severity of depression in older age. Analyses were performed on a pooled data set (n = 3724) from two German old-age cohort studies (LEILA 75+, 6 follow-ups and AgeCoDe/AgeQualiDe, 9 follow-ups). Depressive symptoms were assessed via two screening scales for depression (CES-D and GDS-15) which were harmonized for pooled analysis. A mixed-effects linear regression model for the total sample and additional stratified models for men and women were used. Smoking at baseline was significantly associated with a higher level of depression severity (ß = 0.142, 95% CI: 0.051-0.233, p = 0.002), whereas drinking was significantly associated with a decreased level of depression (ß = -0.069, 95% CI: -0.119--0.021, p = 0.005). Concurrent substance use at baseline increased longitudinal depression severity (ß = 0.193, 95% CI: 0.011-0.375, p = 0.037). Analyses stratified by gender showed a significant inverse association between drinking and depressive symptoms in men (ß = -0.138, 95% CI: -0.231--0.045, p = 0.004), but not in women (ß = -0.060, 95% CI: -0.120-0.001, p = 0.052). Given the burden of major depression, it is important that health care providers, especially primary care physicians, assess and monitor lifestyle factors, even at older ages.

Do self-reported hearing and visual impairments predict longitudinal dementia in older adults?

BACKGROUND: Sensory impairments have been associated with dementia in older adults. However, the contribution of different impairments and how they interact in the development of dementia is not clear. We examined the independent and interaction effects of hearing impairment (HI) and visual impairment (VI) on incident dementia. DESIGN: Multi-centric population-based prospective cohort study. SETTING: Data were taken from the AgeDifferent.de platform, pooling participants aged 75 and older from the German LEILA75+ and AgeCoDe/AgeQualiDe cohorts. PARTICIPANTS: Older adults (N = 3497) with mean age 79.8 years, 67.2% female. MEASUREMENTS: Standardized interviews and questionnaires were used to assess self-reported HI and VI at baseline and all-cause dementia in 9 follow-ups, spanning over 20 years. METHODS: Competing risk regression models were conducted to test the main and interaction effects of HI and VI on dementia incidence, adjusting for established risk factors of dementia and accumulated mortality. RESULTS: HI and VI at baseline were reported by 30.3% and 16.6% of individuals, respectively. Adjusting for baseline information on sociodemographics, substance use, cognitive functioning and morbidity, and controlling for accumulated mortality risk, HI (sHR 1.16, 95% CI 1.04-1.30, p = 0.011) but not VI (sHR 1.07, 95% CI 0.90-1.28, p = 0.462) was significantly associated with incident dementia. There was no interaction between HI and VI (sHR 1.09, 95% CI 0.81-1.46, p = 0.567). CONCLUSIONS: Hearing impairment is associated with an increased incidence of all-cause dementia in older adults. There is no excess risk or risk compensation through the additional presence or absence of visual impairment. Early prevention measures for hearing impairment might help to reduce the long-term risk of dementia.

Disorientation in Time and Place in Old Age: Longitudinal Evidence from Three Old Age Cohorts in Germany (AgeDifferent.de Platform).

BACKGROUND: Only little evidence is available on disorientation, one of the most challenging symptoms of Alzheimer's disease and related dementias. OBJECTIVES: The aim of this study was to investigate the prevalence of disorientation in older age in association with the level of cognitive status, personal characteristics, and life events. METHODS: Three longitudinal population-based cohort studies on cognitive health of elderly adults were harmonized (LEILA 75 + , AgeCoDe/AgeQualiDe, AgeMooDe). Participants who completed a baseline and at least one follow-up assessment of cognitive functioning and who did not have stroke, Parkinson's disease, atherosclerosis, kidney disease, and/or alcoholism were included in the analysis (n = 2135, 72.6% female, mean age 80.2 years). Data was collected in standardized interviews and questionnaires with the participant, a proxy informant, and the participant's general practitioner. RESULTS: Making three errors in the MMSE other than in the questions on orientation (MMSEwo) came with a probability of 7.8% for disorientation, making ten errors with a probability of 88.9%. A lower MMSEwo score (HR 0.75, CI 95 0.71-0.79, p < 0.001), older age (HR 1.11, CI 95 1.08-1.14, p < 0.001), and living in a nursing home (HR 1.64, CI 95 1.02-2.64, p = 0.042) were associated with incident disorientation. Impairments in walking (OR 2.41, CI 95 1.16-4.99, p = 0.018) were associated with a greater probability for prevalent disorientation. None of the life events were significant. CONCLUSION: Our findings suggest that disorientation is primarily associated with cognitive status. Regular walking activities might possibly reduce the risk for disorientation but further research is necessary.

Attention Deficit Hyperactivity Disorder in Children and Adults: A Population Survey on Public Beliefs.

Objective: To investigate beliefs and attitudes of the public toward attention deficit hyperactivity disorder (ADHD) in children and adults. Method: In a representative population survey in Germany (N = 1,008) using computer-assisted telephone interviews, we asked participants about causal beliefs, illness recognition, treatment recommendations, and beliefs about ADHD, presenting an unlabelled vignette of a child or an adult with ADHD. Results: The most frequently endorsed causal beliefs for the depicted child with ADHD were "TV or Internet," "lack of parental affection," and "broken home." In comparison with the child vignette, biological causal beliefs were endorsed more often after the adult vignette. In the child vignette, 66% advised against a treatment with stimulant medication. About 90% of respondents had heard of ADHD. Of those, 20% said they believed ADHD to be not a real disease. Conclusion: Beliefs of the German public partly contradict evidence and should be considered in therapeutical and public contexts.

The importance of familiarity with caregiving for public caregiver stigma: Evidence from a cross-sectional study in Germany.

OBJECTIVES: This study aimed to investigate the association between familiarity with caregiving and public stigma towards informal caregivers of older individuals. MATERIAL AND METHODS: The sample for this Online-Survey was identified using a quota-system based on German micro census data (N=1037; aged 18 years and older, living in Germany). Familiarity with caregiving was assessed by asking whether the participant has experience in or has friends or relatives with experience in informal or professional caregiving for individuals aged 65 years or older. Public caregiver stigma was assessed by analyzing the emotional, behavioral and cognitive reactions towards caregivers as described in a vignette. RESULTS: Adjusted regressions analyses indicated that experience in providing informal care was associated with increased appreciative feelings and statements, and decreased social distance. Experience in providing professional care was associated with increased devaluing statements. Having friends or relatives who have experience in informal caregiving was associated with decreased social distance. Having friends or relatives who have experience in professional caregiving was associated with decreased devaluing feelings, increased appreciative feelings and decreased social distance. CONCLUSIONS: Results indicate that familiarity with caregiving, through one's own informal care experience or through contact with informal or professional caregivers, reduced public stigma towards informal caregivers. Moreover, experience with informal care or contact with professional caregivers increased appreciation of informal caregivers. However, increased negative stigmatizing statements were indicated among participants with experience in professional caregiving. Fostering contact and cooperation between informal caregivers and non-caregivers, as well as with professional caregivers may help reduce stigmatizing reactions.

Evolution of public beliefs about schizophrenia and attitudes towards those afflicted in Austria over two decades.

PURPOSE: In the recent years, it was possible to observe two trends: First, there has been a trend to greater mental health literacy, in particular towards a biological model of schizophrenia. Secondly, an increase in public acceptance of professional help and psychiatric treatment has been observed in western countries. This indicates that the societal idea about mental illness and how it can be treated has changed. However, no changes or even changes to the worse occurred regarding the attitudes towards those suffering from the illness, particularly concerning schizophrenia. Thus, the question arises as to whether similar trends can also be found in Austria. METHODS: We use data from two representative population surveys in Austria, conducted 1998 (n = 1042) and 2018 (n = 1010) using face-to-face interviews, the same sampling procedure, interview mode, and interview schedule. RESULTS: The data show that today Austrians tend to opt less frequently for genetic factors and chronic stress as causes of schizophrenia than 20 years ago. There were only slight changes regarding intended first help-seeking actions except for a stronger endorsement of lay help. The believe in an effective treatment of schizophrenia has increased significantly and there was a marked trend towards preference of medication over psychotherapy. Social acceptance of people with schizophrenia has increased, but also the ascription of violence. CONCLUSION: In summary, the evolution of attitudes and beliefs concerning schizophrenia in Austria shows a rather inconsistent pattern and differs to some extent from what has been observed in other western countries. This is important to know when planning awareness-raising or stigma-reducing initiatives.

Cultural Variations in Public Beliefs about Mental Disorders: A Comparison between Tunisia and Germany.

BACKGROUND: In recent years there is a growing interest in public beliefs about mental disorders. Numerous representative population-based studies have been conducted around the globe, also in European countries bordering on the Mediterranean Sea. However, relatively little is known about public beliefs in countries in Northern Africa. OBJECTIVE: To fill this gap by comparing public beliefs about mental disorders in Tunisia and Germany, focusing on causal beliefs, help-seeking recommendations and treatment preferences. METHODS: Representative national population-based surveys have been conducted in Tunisia in 2012 (N = 811) and in Germany in 2011 (N = 1852), using the same interview mode and the same fully structured interview starting with a vignette depicting a person suffering from either schizophrenia or depression. RESULTS: In Tunisia, the public was more likely to adopt psychosocial and to reject biogenetic explanations than in Germany. Correspondingly, psychological treatments were more frequently recommended and biological ones more frequently advised against. There was also a strong inclination to share religious beliefs and to recommend seeking religious advice. Tunisians tended much more than Germans to hold moralistic views and to blame the afflicted person for his or her illness. In Tunisia, the public tended less to differentiate between schizophrenia and depression than in Germany. CONCLUSION: Marked differences between Tunisia and Germany exist in public beliefs about the causes of mental disorders and their treatment, which correspond to differences in cultural orientations prevailing in these countries. Mental health professionals need to be sensitive to the particular cultural context in which they operate, in order to be able to reach those they intend to care for.

Impact and differences of illness course perception on the desire for social distance towards people with symptoms of depression or schizophrenia in Hanoi, Vietnam.

OBJECTIVES: Public stigma against psychiatric disorders leads to delayed treatment utilization and worsens treatment outcome. This study analyses the impact of expectations regarding the course of illness and attribution as medical illness on the desire for social distance towards schizophrenia and depression in Vietnam. METHODS: In 2013, a survey (n = 771) using unlabelled vignettes either depicting a person with symptoms typical for schizophrenia or major depression was carried out in Hanoi. All respondents had to indicate whether the person was suffering from a medical illness or not. As an indicator of public stigma, the desire for social distance was measured. A possible correlation between expectations towards the course of illness and social distance was evaluated using a linear regression model. RESULTS: 85 % of respondents endorsed that the person depicted in the schizophrenia vignette had a mental illness, compared to only 60 %, who were confronted with the depression vignette. This attribution of mental illness was correlated with higher levels of desire for social distance only in the schizophrenia vignette. While in the case of schizophrenia negative prognostic perceptions were associated with more desire for social distance, in the event of depression, it was only the expectation of lifelong dependency. Moreover, only for depression, positive expectations towards the course of illness correlated with less desire for social distance. CONCLUSION: These results indicate an impact of prognostic expectations on the desire for social distance and support strategies that aim at maintaining social integration and strengthening autonomy.

Mental health care in Italy: Basaglia's ashes in the wind of the crisis of the last decade.

BACKGROUND AND AIMS: The purpose is to highlight the legal and ethical principles that inspired the reform of mental health care in Italy, the only country to have closed its psychiatric hospitals. The article will also try to verify some macro-indicators of the quality of care and discuss the crisis that the mental health care system in Italy is experiencing. METHODS: Narrative review. RESULTS: The principal changes in the legislation on mental health care in Italy assumed an important role in the evolution of morals and common sense of the civil society of that country. We describe three critical points: first, the differences in implementation in the different Italian regions; second, the progressive lack of resources that cannot be totally attributed to the economic crisis and which has compromised application of the law; and finally, the scarce attention given to measurement of change with scientific methods. CONCLUSION: Italy created a revolutionary approach to mental health care in a historical framework in which it produced impressive cultural expressions in many fields. At that time, people were accustomed to 'believing and doing' rather than questioning results and producing research, and this led to underestimating the importance of a scientific approach. With its economic and cultural crisis, Italy has lost creativity as well as interest in mental health, which has been guiltily neglected. Any future humanitarian approach to mental health must take the Italian experience into account, but must not forget that verification is the basis for any transformation in health care culture.