Thirty-five years of community psychiatry in Italy.

The Italian Psychiatric Reform of 1978 is reviewed here in terms of national/regional mental health (MH) policies and with the help of epidemiological data. The reform law was essentially a framework one, and Italy's 21 regions were called to draft detailed organizational norms and to implement their systems. This explains a relevant interregional variability, despite several national MH plans. In a recent survey, compliance with national standards found homogeneous implementation on structural parameters but quite a variable one on functional parameters (continuity, coordination, accessibility, specialization). Epidemiological data show the impact of regional variability on the quality of treatment provided. Because of discrepancies among regional information systems, we analyze data from six Italian regions, where regional case registers have long been implemented, focusing on adult population prevalence and incidence rates and outpatient-inpatient care. Indicators of service use and some national MH documents are discussed in relation to the system's future prospects.

Evaluation of an integrated system for classification, assessment and comparison of services for long-term care in Europe: the eDESDE-LTC study.

BACKGROUND: The harmonization of European health systems brings with it a need for tools to allow the standardized collection of information about medical care. A common coding system and standards for the description of services are needed to allow local data to be incorporated into evidence-informed policy, and to permit equity and mobility to be assessed. The aim of this project has been to design such a classification and a related tool for the coding of services for Long Term Care (DESDE-LTC), based on the European Service Mapping Schedule (ESMS). METHODS: The development of DESDE-LTC followed an iterative process using nominal groups in 6 European countries. 54 researchers and stakeholders in health and social services contributed to this process. In order to classify services, we use the minimal organization unit or "Basic Stable Input of Care" (BSIC), coded by its principal function or "Main Type of Care" (MTC). The evaluation of the tool included an analysis of feasibility, consistency, ontology, inter-rater reliability, Boolean Factor Analysis, and a preliminary impact analysis (screening, scoping and appraisal). RESULTS: DESDE-LTC includes an alpha-numerical coding system, a glossary and an assessment instrument for mapping and counting LTC. It shows high feasibility, consistency, inter-rater reliability and face, content and construct validity. DESDE-LTC is ontologically consistent. It is regarded by experts as useful and relevant for evidence-informed decision making. CONCLUSION: DESDE-LTC contributes to establishing a common terminology, taxonomy and coding of LTC services in a European context, and a standard procedure for data collection and international comparison.

Public beliefs and attitudes towards depression in Italy: a national survey.

BACKGROUND: Previous studies have shown that attitudes towards depression may be influenced by country-specific social and cultural factors. A survey was carried out to collect beliefs on and attitudes toward depression in Italy, which has an established community-based mental health system. METHODS: A telephone survey was carried out in a probabilistic sample aged ≥15 years. A 20-item questionnaire was administered to explore knowledge of depression, stigma, causal beliefs, treatment preference, and help-seeking attitudes. RESULTS: Of the 1001 participants, 98% were aware of depression, and 62% had experienced it, either directly or indirectly. A widespread belief (75%) was that people suffering from depression should avoid talking about their problem. A minority of the sample viewed depression as a condition that should be managed without recourse to external help or a "socially dangerous" illness. Among perceived causes of depression, most respondents mentioned life stressors or physical strains. Psychologists were often indicated as an adequate source of professional help. Half of the sample believed that depression should be pharmacologically treated, but drugs were often seen as addictive. Referring to a primary care physician (PCP) was considered embarrassing; furthermore, many people thought that PCPs are too busy to treat patients suffering from depression. CONCLUSIONS: Our findings indicate that depression is seen as a reaction to significant life events that should be overcome with the support of significant others or the help of health professionals (mainly psychologists). However, there are still barriers to the disclosure of depressive symptoms to PCPs, and concerns about the addictive effect of antidepressants. In the presence of a gap between people's beliefs and what health professionals consider appropriate for the treatment of depression, a "shared decision making" approach to treatment selection should be adopted taking into account the patients' preference for psychological interventions to ensure active compliance with effective treatments.

Process of implementation and development of early psychosis clinical services in Italy: a survey.

AIM: To carry out an in-depth survey into the method of providing early intervention in schizophrenia in Italy and to evaluate the process of development of early psychosis clinical services following the pilot programme 'Programma 2000' and the publishing of Italian National Guidelines. METHODS: Topic-specific national and international clinical and research programmes, alongside national guidelines, were taken into consideration in order to create an ad hoc questionnaire. A telephone survey using this questionnaire was carried out. A randomized sample of 152 mental health centres (MHCs) were involved, equal to 21.5% of all Italian MHCs. RESULTS: The process of nationwide diffusion of early psychosis clinical services in Italy is frustratingly slow. Italian MHCs, including a specialized service for early interventions in schizophrenia, are estimated at being between 20% and 30%. Most services adopt a generalist approach and more frequently follow guidelines drawn up within the centres than Italian National Guidelines, involve few patients and provide a high variability of treatment options. The distribution of these services in Italy is not homogenous and influenced by demographic factors. CONCLUSION: Our data are consistent with worldwide literature showing a slow and variable implementation of early psychosis services in all nations. The main efforts to make these services diffused should be addressed to favour the process of localized adaptation to the guidelines, to demand possible and realistic implementation of the standard method, to stimulate policy endorsement and resources' allocation, and to particularly support the rural and the poorer zones.

CMHC adherence to National Mental Health Plan standards in Italy: a survey 30 years after national reform law.

OBJECTIVE: The PROG-CSM (Progetto Centri di Salute Mentale) survey was conducted in all Italian community mental health centers (CMHCs) with the aim of evaluating the extent to which these services adhered to the standards defined by the Italian National Mental Health Plan 1998-2000. METHODS: The policy recommendations of the Italian National Mental Health Plan were translated by a multidisciplinary group of experts into key indicators, including continuity of care, coordination with other community-based services, accessibility, implementation of specific programs, and provision of care. RESULTS: There was high adherence to the standards of the National Mental Health Plan in continuity of care and coordination with other services, but there were lower levels of accessibility and implementation of specific projects. CONCLUSIONS: CMHCs were sufficiently developed throughout Italy, and continuity of care and service coordination levels were satisfactory; however, adherence to the standards was unrelated to the duration of activity of the CMHCs.

From treatment adherence to advanced shared decision making: new professional strategies and attitudes in mental health care.

Treatment adherence is related to "self-regulation" of prescribed drugs. Patients organise their drug intake around their own priorities, which may be very different from prescribers' priorities, since most of the patients value their personal concerns and/or their social roles more than the benefits of a prescribed treatment. A gap exists between patients' and professionals' views. This gap is mainly related to patients' health beliefs and physicians' attitudes. A number of strategies can help professionals overcome gaps between their treatment options for depression and schizophrenia and the "real world" alternatives shared by the lay public, patients, their relatives, and political stakeholders. These strategies include integrated care and recovery, family engagement, and the development of a mutualistic patient/physician relationship with the adoption of advance directives and appropriate guidelines that incorporate the patient's choices. The effective implementation of these combined strategies within the person-centred care model empowers patients to collaborate with mental health professionals and their families in making complex health care choices. Barriers to this process include factors affecting the control, contact and communication facets of the patient/physician relationship.

The utility of the Necessity--Concerns Framework in explaining treatment non-adherence in four chronic illness groups in Italy.

OBJECTIVE: To translate the Beliefs about Medicines Questionnaire (BMQ) into Italian and explore the utility of the Necessity-Concerns Framework in explaining treatment non-adherence in four chronic illness groups in Italy. METHODS: 449 patients with chronic illness (depression, asthma, diabetes and cardiac disease) were approached at outpatient clinics in Turin and asked to complete Italian translations of the BMQ and the Medication Adherence Report Scale. RESULTS: 427 patients consented to participate in the study. The BMQ demonstrated good internal consistency, with Cronbach's alphas of 0.78 (Necessity subscale) and 0.72 (Concerns subscale). Participants were divided into four attitudinal groups based on their responses to the BMQ: 59% Accepting (high Necessity, low Concerns), 29% ambivalent (high Necessity, high Concerns), 8% Indifferent (low Necessity, low Concerns) and 4% Skeptical (low Necessity, high Concerns). Those in the Accepting group reported the highest adherence to medication and those in the Skeptical group the lowest (p50.01). DISCUSSION: The BMQ has been successfully translated and validated in Italian. This study provides support for the Necessity-Concerns Framework in explaining medication non-adherence in chronic illness. Interventions that address low perceived need for treatment and concerns about potential adverse effects of treatment are likely to facilitate optimal use of medicines.

Structural and organizational determinants of quality of care in patients with schizophrenia in Italy.

Several reports have described the poor quality of care delivered to psychotic patients. However, the context in which care was delivered, including the structure, organization, and performance of the health care system, as a possible determinant of quality of care has received less attention. In this study we explored the relationship between conformance with guidelines and structural and organizational characteristics in 2 departments of Mental Health in Italy. Dosing of antipsychotic drugs in the maintenance phase was investigated in 125 patients. Higher than recommended doses could be explained by the high patient caseload per psychiatrist, leading to insufficient contacts with patients and their families and to excessive reliance upon drug treatment. The analysis of structural and organizational determinants of care at the local level may help to explain insufficient quality and to plan suitable interventions.

Indicators of conformance with guidelines of schizophrenia treatment in mental health services.

OBJECTIVE: The aim of this study was to develop indicators of conformance in clinical practice with guidelines for care in schizophrenia. Recommended guidelines rarely apply to all patients and need to allow for social ability, family context, and phase of the disorder. These indicators were therefore devised for tailoring to patient characteristics and allowing for factors that may justify the lack of adherence to clinical guidelines. METHODS: A team of senior clinicians and methodologists reviewed three clinical guidelines (from the Schizophrenia Patient Outcomes Research Team, McEvoy and colleagues, and the National Institute for Health and Clinical Excellence) and defined criteria for their operationalization into clinical indicators. For each indicator, the team defined criteria for eligibility (requirements to be met to qualify for evaluation), conformance (criteria to be satisfied to comply with each recommendation), and moderators (factors that could justify the lack of application of a given recommendation). These indicators were tested with a random sample of 807 patients with schizophrenia or schizoaffective disorders in outpatient facilities, long-term residential facilities, and hospital units for acute care in the Piedmont region of Italy. RESULTS: A set of 15 indicators was derived, nine concerning pharmacological treatment and six for general care and psychosocial rehabilitation. Moderators such as patient or family refusal of antipsychotic treatment and the patient's level of disability helped to justify a considerable proportion of nonconformant care. CONCLUSIONS: The indicators developed are a simple and useful tool to monitor the conformance of care with recommended practices and to identify areas needing improvement.

[Social deprivation and mental health. Replicability and applicability in the Italian context of the resource allocation methods developed in the United Kingdom]. / Deprivazione sociale e salute mentale. Le esperienze di ricerca e di allocazione delle risorse sanitarie nel Regno Unito e la loro possibilità di "traduzione" nel contesto italiano.

AIMS: Most of the available evidence on the relationship between socioeconomic indicators of social deprivation and patterns of use of mental health services has been produced in the United Kingdom, where the Ministry of Health has developed a resource allocation formula based upon the results of those studies. The main aim of the paper is to evaluate the replicability in the Italian context of such research, and of the resulting allocation strategies. METHODS: Detailed description of the resource allocation method currently adopted in the United Kingdom, whose main purpose consists in reaching the best balance between available funding and patterns of need. Detailed description of resource allocation processes in Italy; discussion of the main methodological and statistical limitations restraining the replicability of the British formula in the Italian context. CONCLUSIONS: There is a growing interest in Italy towards the introduction of evidence-based methods in health decision making, in order to correct the overwhelming influence of political issues. What is needed is a better understanding of the relationship between higher levels of equity in health services access, and their effects in terms of better outcomes.

Indicators predicting use of mental health services in Piedmont, Italy.

BACKGROUND: Since the 1978 Italian reform, an integrated network of community mental health services has been introduced. With few exceptions, research on determinants of mental health service use at the district level has focused on inpatient activities and social deprivation indicators. The European Psychiatric Care Assessment Team (EPCAT) standardized methodology allows for an evidence-based comparison of mental health systems between geographical areas. AIMS: To compare service provision and utilization between local catchment areas; to explore quantitative relationships between residential and community service use and socio-demographic indicators at the ecological level. METHODS: The European Socio-demographic Schedule (ESDS) was used to describe area characteristics, and the European Service Mapping Schedule (ESMS) to measure service provision and utilization in 18 catchment areas in Piedmont. RESULTS: Substantial variation in service use emerged. Acute hospital bed occupancy rates were lower in areas with more intensive community continuing care service users and with a smaller percentage of the population living alone. The non-acute hospital bed occupancy rate was directly related to the percentage of the population living alone or in overcrowded conditions, and to the level of mobile continuing care service users. Community continuing care service use was highest in areas with a larger percentage of the population living alone. DISCUSSION: Multiple regression models explained between 48 and 55% of the variation in inpatient and community service use between areas. Relationships based on ecological characteristics do not necessarily apply to the individual. This level of assessment, however, is necessary in evaluating mental health policy and service systems, and in allocating resources. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: The distribution of mental health care resources should be weighted in terms of indicators of social deprivation shown to be important predictors of both inpatient and community service use, as these are likely to be related. IMPLICATIONS FOR HEALTH POLICIES: To ensure horizontal equity in access to mental health care, particularly for people with severe mental illness, evaluation of mental health policy should be based on a concurrent evidence-based assessment of the organization and use of both residential and community services, in relation to area level indicators of social deprivation. IMPLICATIONS FOR FURTHER RESEARCH: Cross-national research using an internationally standardized methodology should consider the influence of the social network independently of other socio-economic indicators, to verify the relative importance of this in predicting service use in southern and in northern European countries.

Patterns of mental health service utilisation in Italy and Spain--an investigation using the European Service Mapping Schedule.

BACKGROUND: Methods for comparing local mental health service systems are needed to allow identification of different patterns of service provision and of inequities within and between countries. AIM: The aim of this study was to describe and compare mental health service systems in 13 catchment areas in Spain and Italy. Within each country, a range of area characteristics was represented. METHOD: The European Service Mapping Schedule (ESMS) and European Socio-Demographic Schedule (ESDS) were used to describe: (i) socio-demographic and geographical area characteristics; (ii) services provided; and (iii) service utilisation in each area. RESULTS: Great differences emerged in patterns of service provision and use between and within countries. In contrast to Northern Europe, high unemployment rates were not associated with high service utilisation rates, but areas with large numbers of single-person households tended to have high service use. Most service utilisation rates were substantially below those reported from Northern European studies. Spanish centres tended to have low rates of hospital service utilisation despite limited development of community-based services. Trieste, where there has been a strong emphasis on developing innovative community services, showed a distinctive pattern with low hospital bed use and high rates of day service use and of contacts in the community. CONCLUSION: This methodology yielded useful data, which raise significant questions regarding equity and the implementation of mental health policy. The very large variations indicate that underlying local patterns of service provision must be investigated and taken into account in the interpretation of research evaluations of interventions.

Combined pharmacotherapy and psychological treatment for depression: a systematic review.

BACKGROUND: Adherence to antidepressant medication use is a problem in clinical practice. Some authors have posited that combined psychological treatment facilitates adherence to pharmacotherapy. OBJECTIVES: To study the relationship between adherence to use of and efficacy of antidepressant drugs plus psychological treatment vs drug treatment alone in depressive disorders. DATA SOURCES: MEDLINE, Current Contents, PsychInfo, Cochrane Library, and reference lists were searched, from January 1980 to November 2002. STUDY SELECTION: Randomized clinical trials comparing antidepressant treatment alone with antidepressant treatment in combination with a psychological intervention in depressive disorders were considered. The decision to include studies in the meta-analysis was performed by 2 reviewers. DATA EXTRACTION: Three independent reviewers extracted the data, using a precoded form. Methodological quality of the studies was evaluated in terms of allocation concealment and independence of evaluators. DATA SYNTHESIS: Sixteen trials met the inclusion criteria, with 932 patients randomized to pharmacotherapy alone and 910 to combined treatment. Overall, patients receiving combined treatment improved significantly compared with those receiving drug treatment alone (odds ratio [OR], 1.86; 95% confidence interval [CI], 1.38-2.52), but dropouts and nonresponders did not differ in distribution between the 2 treatment modalities (OR, 0.86; 95% CI, 0.60-1.24). Studies longer than 12 weeks showed a significant advantage of combined treatment over drug treatment alone (OR, 2.21; 95% CI, 1.22-4.03), with a significant reduction in dropouts compared with nonresponders (OR, 0.59; 95% CI, 0.39-0.88). These estimates were not affected by study quality. CONCLUSIONS: Psychological treatment combined with antidepressant therapy is associated with a higher improvement rate than drug treatment alone. In longer therapies, the addition of psychotherapy helps to keep patients in treatment. Further studies are needed to investigate whether the improvement in response attributable to the combination of drug treatment and psychotherapy can be achieved by a combination of pharmacotherapy and a compliance-enhancing intervention.