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.

The Deinstitutionalization of Psychiatric Hospitals in Ghana: An Application of Bronfenbrenner's Social-Ecological Model.

Institutionalization of people living with mental illness has evolved over the years, especially in the 19th and early 20th century. This has created over crowdedness in various psychiatric institutions, specifically in low and-middle-income countries, including Ghana. The objective of this study is to use Bronfenbrenner's Social-Ecological Model (1979) to propose a process for deinstitutionalizing psychiatric services in Ghana while supporting a transition to community-based mental health care. Using the concept of Bronfenbrenner's Social-Ecological Model, this article explores some benefits and difficulties with the concept of deinstitutionalization with regards to mental health care services in Ghana. Individuals living with mental illness will be more comfortable in various communities in Ghana where education on stigmatization and discrimination is heightened to subsequently prevent it. Education and intervention policies are required to intensify the campaign to win the support of all people in the community. Residents of Ghana should learn to say no to stigma and discrimination among people living with mental illness.

The Life Esidimeni tragedy: Moral pathology and an ethical crisis.

The Life Esidimeni tragedy highlights several ethical transgressions. Health professionals' ethics are put to the test when their own interests are balanced against competing claims. Core values of compassion, competence and autonomy, together with respect for fundamental human rights, serve as the foundation of ethical practice in healthcare. These values are increasingly being challenged by governments and other third parties. The duties conferred on healthcare practitioners require them to act responsibly and be accountable for their actions. Codes in healthcare serve as a source of moral authority. The Gauteng health authorities exerted tremendous power and created a culture of fear and disempowerment among healthcare practitioners. When health professionals choose to support state interests instead of those of patients, problematic dual-loyalty conflicts arise.

Management of psychiatric patients before deinstitutionalization: an inquiry into the years 1907-1913 in Pisa

Aim: Asylums comprises the main focus of historical research on early 20th century psychiatry. To assess the characteristic of asylum transfers in a clinical population, we analyzed newly found clinical records from University of Pisa Clinic for Mental and Nervous Illness. We focused on the early years of this structure's activities considering all admissions from 24th April 1907 to 31st January 1913. Methods: We collected demographic and clinical data from 1,068 patients performing Chi-Square Tests to study correlation between asylum transfer and diagnosis and gender difference; independent sample Student's t-tests were also performed to compare mean Age, mean number of Days of Hospitalization and mean number of Subsequent Admissions to the Clinic observed in patients transferred to an asylum versus those who had been discharged. Multiple logistic regression model was employed to identify the best predictors of asylum transfers. Results: Most patient were discharged, and only a third of the hospitalization led to asylum confinement. Our data outlines a peculiar discharge rationale, suggesting that the Clinic acted like a "sieve-institution" to prevent asylum overcrowding from treatable, non-chronic conditions. Discussion: These data suggest that our historical view of psychiatric care is probably not complete, and that a different approach to source materials could provide new research paradigms.

Internados en casa: del manicomio a la «institución doméstica total» / Caged at home: from the asylum to the «total domestic institution»

A partir de una etnografía realizada en Barcelona y Tarragona entre 2013 y 2014 se problematizan las interacciones y relaciones de personas diagnosticadas con trastorno mental grave y sus familiares en el espacio doméstico. A través de una comparación de las dinámicas y lógicas del hospital mental extraídas de las etnografías del custodialismo y las del espacio doméstico, se pone de relieve la proyección y reproducción de dinámicas manicomiales en el ámbito familiar. Desde una lectura cultural del espacio doméstico, los ejemplos etnográficos sirven para argumentar que el modelo de externalización actual perpetúa la cronificación y la hospitalización doméstica de los pacientes (AU)

Based on an ethnography carried out in Barcelona and Tarragona between 2013 and 2014, this article problematizes the interactions and relationships of people diagnosed with severe mental disorder and their relatives at home. Through a comparison of the dynamics and logics of the mental hospital as described in classic ethnographies of mental asylums and those of domestic spaces, the projection and reproduction of asylum features at home are highlighted. From a cultural perspective of the domestic space, these ethnographic examples suggest that the current externalized model of psychiatric care causes domestic hospitalization and tends to perpetuate the patient’s chronification (AU)

La rehabilitación psicosocial entre la desinstitucionalización y la recuperación / Psychosocial rehabilitation between deinstitutionalization and recovery

En este artículo se propone una revisión de los aspectos conceptuales y de las prácticas que han venido caracterizando la rehabilitación psicosocial (RPS) en los últimos 60 años, esto es, desde los inicios de la desinstitucionalización psiquiátrica hasta la actualidad, en que los nuevos valores y prácticas de la recuperación (con una mayor participación y protagonismo de los usuarios) están adquiriendo cada vez más relevancia. Se abordan las dos dimensiones nucleares de la RPS: las técnicas de intervención y los contextos biográficos, sociales y asistenciales, teniendo en cuenta los aspectos más relevantes de la experiencia internacional y prestando una atención especial a la evolución y la situación actual de la cuestión en España (AU)

This article offers a review of both the conceptual aspects and the practices of psychosocial rehabilitation in the last 60 years, that is, from the beginning of psychiatric deinstitutionalization to the present, which is growingly influenced by the new principles and practices of recovery and a stronger involvement and participation of users of mental health services. Two core dimensions of psychosocial rehabilitation will be assessed: intervention strategies and biographical, social and care contexts. The most relevant aspects of the international experience are considered, focusing specially on the evolution and present situation of the field in Spain (AU)

[Community residential devices associated with Psychiatric Hospital "Dr. Manuel A. Montes De Oca" in the Province of Buenos Aires, Argentina]. / Dispositivos residenciales comunitarios asociados a la Colonia Nacional "Dr. Manuel A. Montes de Oca" de la provincia de Buenos Aires, Argentina.

The psychiatric hospital "Dr. Manuel A. Montes de Oca" has developed a Program for the Reform of the Model of Attention and Integral Rehabilitation that includes the implantation of community residential devices in the area of influence of the Institution. This program, which aims at the progressive replacement of asylum beds, has been the subject of an evaluative investigation that has included almost all the devices through a transversal and descriptive design, with instruments of survey created by the equipment and in agreement with the References of the Institution. The present article proposes to initiate a set of evaluative works in different dimensions concerning the institutional reform process, describing the antecedents, the objectives and the methodology and development of the study to achieve the general characterization of the devices. The main results of the study are summarized below on a set of aspects that we consider most signifcant for the characterization of the devices: a) Type of users served; B) Coverage of Care; C) Method of approach; D) Use of social and health services; E) Expenses and returns to the Institution; E) Main barriers encountered in the implementation of such devices. The work concludes with a series of proposals that are based on the survey carried out tending to promote the greatest possible sustainability in the implementation of the selected community devices.

[Deinstitutionalization in Italian psychiatry - the course and consequences Part I. The course of deinstitutionalization - the activity of Basaglia's group]. / Deinstytucjonalizacja psychiatrii wloskiej - przebieg i skutki Czesc I. Przebieg deinstytucjonalizacji - dzialalnosc grupy Basaglii.

Psychiatric reform in Italy consisted of the implementation of legislative changes derived from anti-institutional experiments conducted by Franco Basaglia and his group in the 60's and 70's of the 20th century. The activity of Basaglia's group was an integral part of the European reform movement of that time, which profited from the economic, cultural and political prosperity for changes in psychiatry. Italian antipsychiatry has led to the most radical experiment in deinstitutionalization in history. It involved the whole public sector of psychiatry and across a quarter-century resulted in a grand social debate on the situation of the mentally ill and the need for systemic change of their treatment and care. Inspired mainly by phenomenological analysis, Basaglia opted for close emphatic contact with the mentally ill. While the British, French and American anti-psychiatrists contested the psychiatric care system as such, the Italian radicals made an approach to disassemble it from the inside and successfully gained social support for the process of deinstitutionalization. Basaglia promoted his ideas across Europe, including the World Health Organization (WHO) forum.

[Deinstitutionalization in Italian psychiatry - the course and consequences Part II. The consequences of deinstitutionalization]. / Deinstytucjonalizacja psychiatrii wloskiej - przebieg i skutki Czesc II. Skutki deinstytucjonalizacji.

The Italian mental health care is based on Law 180 (it. Legge 180), also called Legge Basaglia, from the name of the author of the reform, Franco Basaglia. It was adopted on May 13th 1978. The new legislation resulted from the actions of a strong anti-psychiatric movement and it brought about a major change in the organization of psychiatric care. The reform and its consequences were widely studied by the researchers, especially in the United Kingdom and the United States of America. The authors point out many successes of the reform, especially in its beginning. They seek the sources of its failure in a faulty and incomplete implementation. Legge Basaglia completely changed the structure of mental health care in Italy, finally bringing psychiatry back to medicine and the general hospitals, as well as promoting community-based psychiatry. Deinstitutionalization in Italy was not related to an increase in compulsory psychiatric hospitalizations, suicide attempts by the mentally ill, nor did it raise the number of crimes committed by them. It also did not cause common trans-institutionalization, with the transfer of patients to the private sector, as predicted by its opponents.

Postgraduate education in psychiatric nursing in Israel: closing the gap.

Deinstitutionalization policies are being gradually implemented in Israel. Most recently, an insurance reform has been approved, in which mental health services will be included in the HMO's service package. As most Israeli mental health nurses are currently employed in institutional settings, the Ministry of Health's Nursing Division seeks to estimate their scope of employment in preparation for the anticipated changes. The aim of this study is to describe present-day professional practice characteristics of qualified psychiatric nurses and identify practice areas for which advanced training may be required. The research design is cross-sectional on a national level, including all state psychiatric hospitalization services. A countrywide sample of nurses with post-basic training in state psychiatric hospitals identified areas of practice in which further training may be required: psychotherapy intervention (60% of respondents); consultation for the elderly (60%); care prescriptions (64%); community drug treatment management (69%); and referral to professionals and community resources (56%). Nurses reported gaps in continued care and community rehabilitation activities. These findings have training implications in an era of increased focus on chronic mental illness in the community.

[The upper-limits of deinstitutionalization not yet reached]. / De grens van extramuralisering is nog niet bereikt.

The government aims at decreasing the number of elderly with disabilities in institutional care, and supplying them with homecare instead. This article provides starting points to identify the elderly for whom homecare is a realistic alternative to institutionalized care. Data from two Dutch surveys are used: the Amenities and Services Utilization Survey (AVO'07) and Elderly in Institutions (OII'08). We use a regression model that explains the use of care from several characteristics, and predict the probability to use a certain type of care for each individual. One ninth to a fifth of the elderly receiving institutional care have similar characteristics to homecare users. They are generally younger than other users of institutional care, attained higher educational levels, have higher incomes and have fewer disabilities. The prevalence of dementia is noticeably lower in this group. Domestic help, often in combination with personal care and nursing, is the most likely alternative for institutional care. Personal assistance may also prove to be an alternative, but could not be included in this research. However, there will always be a group of elderly that are more suitably and more efficiently cared for in an institutional setting. It is important that institutionalized care remains an option for this group.

Everyone's talking about it, but does it work? Nursing home diversion and transition.

In response to increasing Medicaid expenditures and consumer preferences, states are reforming their long-term care systems to provide more community-based services. One popular reform is renewed efforts to prevent unnecessary long-term nursing home placement (diversion) and to provide nursing home residents an opportunity to return to the community (transition). Nearly 3,800 individuals, 60 years old and older, participated in Ohio's statewide nursing home diversion and transition initiative between March 2010 and May 2011. This research tracked outcomes for consumers and evaluated the implementation of the new program. Nearly 80% of diversion and transition participants who were still living at the time of their 6-month follow-up were residing in the community. An agency-level process analysis revealed innovative intervention strategies, promising practices, and barriers. Process results found that Area Agencies on Aging (AAAs) have become more proactive in working with high-risk individuals, with agencies identifying new at-risk consumers through hospital and nursing home interventions.

Mental health care delivery system reform in Belgium: the challenge of achieving deinstitutionalisation whilst addressing fragmentation of care at the same time.

Most mental health care delivery systems in welfare states currently face two major issues: deinstitutionalisation and fragmentation of care. Belgium is in the process of reforming its mental health care delivery system with the aim of simultaneously strengthening community care and improving integration of care. The new policy model attempts to strike a balance between hospitals and community services, and is based on networks of services. We carried out a content analysis of the policy blueprint for the reform and performed an ex-ante evaluation of its plan of operation, based on the current knowledge of mental health service networks. When we examined the policy's multiple aims, intermediate goals, suggested tools, and their articulation, we found that it was unclear how the new policy could achieve its goals. Indeed, deinstitutionalisation and integration of care require different network structures, and different modes of governance. Furthermore, most of the mechanisms contained within the new policy were not sufficiently detailed. Consequently, three major threats to the effectiveness of the reform were identified. These were: issues concerning the relationship between network structure and purpose, the continued influence of hospitals despite the goal of deinstitutionalisation, and the heterogeneity in the actual implementation of the new policy.

Mental health nursing in Australia: resilience as a means of sustaining the specialty.

As a concept, resilience is continuing to attract considerable attention and its importance across various life domains is increasingly recognised. Few studies, however, have defined or considered the notion of the group or collective resilience of a profession, including the capacity of that profession to withstand adversity and continue to develop positively in the face of change. This article considers the notion of resilience from the perspective of the specialty of mental health nursing, including the ways the specialty has adapted--and continues to develop--to changes experienced since deinstitutionalisation. Insights are drawn from a national Delphi study undertaken in Australia to develop a Scope of Practice for Mental Health Nurses, with responses used as a springboard to consider the impact of the perceived loss of professional identity on the collective resilience of the profession. Recommendations for a way forward for the profession are considered, including the ways in which a collective professional resilience could be developed to sustain and strengthen the professional identity of mental health nursing in Australia and across the globe.

[Opening up psychiatric care]. / Vers une ouverture des soins en psychiatrie.

The post-war phase of the deinstitutionalisation of psychiatry, which led to the legal recognition of the sector, has been followed by the years of economic crisis. As in the past, such times favour the exclusion of the weakest. As resources dwindle, only the clinical meaning, the dynamism and creativity of the nursing teams can ensure the emergence of new solutions for complex care situations.