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.

Locura, salud mental y ciudadanía: del individualismo posesivo al neoliberalismo / Madness, mental health and citizenship: from possessive individualism to neoliberalism

Desde que apareció como rama de la medicina en la estela de la ilustración y la Revolución Francesa, la psiquiatría ha experimentado importantes transformaciones en el marco de diferentes cambios socioeconómicos y políticos ocurridos en las sociedades occidentales. En este contexto más amplio, puede observarse una tensión recurrente entre el interés del individuo y el del cuerpo social en su conjunto. Esta fricción está íntimamente relacionada con una serie de dinámicas contrapuestas que han marcado el desarrollo de la psiquiatría y la atención a la salud mental: humanización versus disciplina, emancipación versus coerción, inclusión versus exclusión y ciudadanía democrática versus sometimiento político. Este artículo aporta un análisis conceptual y una panorámica histórica de las ambivalentes relaciones entre la psiquiatría y la atención a la salud mental, por un lado, y la política, más en concreto, el desarrollo de la noción moderna de ciudadanía, por otro

Since its emergence as a branch of medicine in the wake of the Enlightenment and French Revolution, psychiatry has experienced significant transformations against the background of different socio-economic and political changes In Western societies. In this wider context we see a recurring tension between the interest of the individual and that of the social body as a whole. This friction is closely related to opposing dynamics in psychiatry and mental health care: humanisation versus disciplining, emancipation versus coercion, inclusion versus exclusion, and democratic citizenship versus political subjection. This article provides a conceptual analysis and an historical overview on the ambivalent relations between on the one hand psychiatry and mental health care and on the other politics, and, more particularly, the development of the modern understanding of citizenship

Enfermagem e o processo de desinstitucionalização no âmbito da saúde mental: revisão integrativa / La enfermería y el proceso de desinstitucionalización en el contexto de la salud mental: una revisión integradora / Nursing and the deinstitutionalization process in the mental health scope: integrative review

Objective: To synthesize the knowledge produced on the nursing performance in the deinstitutionalization process in mental health scope. Method: It is an integrative literature review conducted from search on theinternet for studies in databases like CINAHL, Scopus and LILACS. We have identified 72 papers, of which,seven were included in the review, upon reading the taking into account the adopted inclusion and exclusion criteria. Results: The nursing performance in the face of the deinstitutionalization process in mental health has prioritized interdisciplinary therapeutic activities aimed at the guided by the principles of comprehensiveness and humanization. Conclusion: It is recognized that the process of training in nursing to equip future professionals to develop skills and competencies considering the new logic of organization of mental health services in the territory.

Objetivo: Sintetizar o conhecimento produzido sobre a atuação da enfermagem no processo de desinstitucionalização no âmbito da saúde mental. Método: Trata-se de revisão integrativa da literatura realizada a partir de busca on-line de estudos nas bases de dados: CINAHL, Scopus e LILACS. Identificou-se o total de 72 artigos, dos quais sete foram incluídos na revisão mediante os critérios de inclusão e exclusão adotados. Resultados: A atuação de enfermagem perante o processo de desinstitucionalização em saúde mental tem priorizado atividades terapêuticas interdisciplinares pautadas nos preceitos da integralidade e humanização. Conclusão: Reconhece-se que o processo de formação em Enfermagem deve instrumentalizar o futuro profissional para o desenvolvimento de habilidades e competências considerando a nova lógica de organização dos serviços de saúde mental no território.

Objetivo: Sintetizar el conocimiento producido sobre la actuación de enfermería en el proceso de desinstitucionalización en el contexto de la salud mental. Método: Se trata de una revisión integrada de la literatura por medio de la búsqueda de los estudios en línea de bases de datos: CINAHL, LILACS y Scopus. Se identificaron un total de 72 artículos, de los cuales siete fueron incluidos en la revisión, mediante la lectura de los títulos, los resúmenes y teniendo en cuenta los criterios de inclusión y exclusión adoptados. Resultados: La actuación de la enfermería frente el proceso de desinstitucionalización de la salud mental ha dado prioridad a las actividades terapéuticas interdisciplinarios guiada por los principios de integralidad y la humanización. Conclusión: Se reconoce que el proceso de formación en enfermería debería equipar a los futuros profesionales para desarrollar las habilidades y competencias teniendo en cuenta la nueva lógica de la organización de los servicios de salud mental en el territorio.

Mudanças ocorridas na prática profissional na área da saúde mental frente à reforma psiquiátrica brasileira na visão da equipe de enfermagem / Cambios que ocurren en la práctica profesional en cognitiva areas de saludque enfrenta la reforma psiquiátrica brasileña en visualización equipo de enfermería / Changes in professional practice in the mental health area against brazilian psychiatric reform in the vision of the nursing team

Descriptive qualitative study conducted in 2010 in a hospital specialized in psychiatry, in Paraná. Objective:To verify the changes in professional practice resulting from the Psychiatric Reform in view of the nursing team. Methods: Participants were 15 nurses. The data were collected through semi-structured interviews and the results organized into thematic categories. Results: It was obtained that the subjects perceived changes in the organization of care and in order to assist the person with a mental problems, the importance of the multidisciplinary team in this process and the transformation of the role of nursing staff and the nurse in the face of new forms of treatment arising. Conclusion: There are advances resulting from the Reform and they directly interfere in the formation and performance of nursing teams generating the need for preparation and training of these professionals.

Pesquisa qualitativa descritiva realizada em 2010 num hospital especializado em psiquiatria do Paraná. Objetivo: Verificar as mudanças ocorridas na prática profissional decorrentes da Reforma Psiquiátrica na visão da equipe de enfermagem. Métodos: Participaram da pesquisa 15 profissionais de enfermagem. Os dados foram obtidos mediante entrevista semiestruturada e os resultados organizados em categorias temáticas. Resultados: Obteve-se que os sujeitos perceberam mudanças na organização da assistência e no modo de assistir a pessoa com transtorno mental, a importância da equipe multiprofissional nesse processo e a transformação do papel da equipe de enfermagem e do enfermeiro frente às novas formas de tratamento surgidas. Conclusão: Há avanços decorrentes da Reforma e que estes interferem diretamente na formação e atuação das equipes de enfermagem gerando a necessidade de preparo e capacitação destes profissionais.

Estudio cualitativo descriptivo realizado en 2010 en un hospital especializado en psiquiatría de Paraná. Objetivo: Verificar los cambios en la práctica profesional de la resultante de la Reforma Psiquiátrica en opinión del equipo de enfermería. Métodos: Los participantes fueron 15 enfermeros. Los datos fueron recolectados a través de entrevistas semi-estructuradas y los resultados organizados en categorías temáticas. Resultados: Se obtiene de los sujetos los cambios percibidos en la organización de la atención y con el fin de ayudar a la persona con un trastorno mental, la importancia del equipo multidisciplinario en este proceso y la transformación de la función del personal de enfermería y la enfermero de la cara de las nuevas formas de tratamiento que surjan. Conclusión: Hay avances resultantes de la Reforma y que interfieren directamente en la formación y el rendimiento de los equipos de enfermería que genera la necesidad de una preparación y formación de estos profesionales.

An analysis of the federal funding for mental health care in Brazil.

This article analyzes spending on mental health by the Brazilian Ministry of Health between 2001 and 2014. It is documental research of the Brazilian Ministry of Health's databases. It analyzes the data using descriptive statistical analysis. Total spending on mental health for the period 2001 to 2014 shows a percentage increase in resources destined for outpatient care, but this increase is a reallocation from hospital services to community-based services and total resources for the mental health program remain at an average of 2.54% of the total health budget. Within outpatient expenditure, spending on medications remains high. Professionals committed to psychiatric reform fight to guarantee that a small fraction of the surplus appropriated by the state is directed towards social policies.

Clinical Community Psychology: Reflections on the Decades Following Swampscott.

The Swampscott report was foundational, but in some ways reflected divisions within community psychology that have continued into the present. Community psychologists trained in the 1970s and, especially, the 1980s confronted a period where the original focus of community mental health began to have less influence in the mental health field due to a variety of public policies, and the growth of third party payments as a significant source of health care funding. Programs that engaged communities and provided a base for prevention interventions were greatly curtailed because of changes in federal legislation and limited opportunities for state and local funding, although prevention interventions found growing interest from research funders. Clinical and community psychologists who trained in this period increasingly looked to a variety of areas outside of mental health. Consequently, the field of community psychology has become more applied and less academic, with increased attention to advocacy, theory, and global perspectives. The sweep of these changes and their implications for the future of the field are discussed here.

Compulsory admissions: Possibly another dark side of the Greek economic crisis.

Α number of previous articles have dealt with the negative impact of the Greek Economic crisis on public health, including significant increases in major depression prevalence and suicide and homicide rates. The mentally ill seem to represent a vulnerable social group, with particular difficulties in this context. The number of compulsory assessments and involuntary admissions was recorded by reviewing patient records in the Department of Psychiatry of the University Hospital of Patras, through years 2006-2013. Compulsory assessments increased from 176 in 2006 to 262 in 2009 and 354 in 2013, representing a 48.86% and 101.13% increase in the first and the fifth year of economic crisis, respectively. The assessments resulted in 160 involuntary admissions in 2006, which escalated to 262 admissions (63.75% rise) in 2013. Even though a rise in involuntary placements could be attributed to other factors as well, it may also partly represent a not so evident side of the Greek economic crisis.

The changing purpose of mental health law: From medicalism to legalism to new legalism.

The role of law in regulating mental health detention has come to engender great contention in the legal and sociological disciplines alike. This conflict is multifaceted but is centred upon the extent to which law should control the psychiatric power of detention. In this manner the evolution of law regulating mental health detention has been seen in terms of a pendulous movement between two extremes of medicalism and legalism. Drawing on socio-legal literature, legislation, international treaties and case law this article examines the changing purpose of mental health law from an English and Council of Europe perspective by utilizing the concepts of medicalism, legalism and new legalism as descriptive devices before arguing that the UN Convention on the Rights of Persons with Disabilities goes further than all of these concepts and has the potential to influence mental health laws internationally.

O hospital psiquiátrico em diálogos atemporais / Psychiatric hospitals in timeless dialogues / El hospital psiquiátrico en diálogos atemporales

O presente texto tem por objetivo apresentar um diálogo entre dois militantes da Reforma Psiquiátrica Brasileira que conversam sobre a imersão no cotidiano de hospitais psiquiátricos, mas a partir de vivências localizadas em diferentes tempos e em diferentes hospitais: Vera Cruz, em 2012, na cidade de Sorocaba; e Juquery, na década de 1980, em São Paulo. Bruno está em 2012, vivenciando um processo de intervenção em uma realidade manicomial que Silvio esperava já ter sido superada. Respeitadas as diferenças de lugares e das experiências por eles vividas, concluem que o modelo de tratamento proposto pelo hospital psiquiátrico apaga a fronteira do tempo e torna semelhantes as realidades que mortificam sujeitos e naturalizam práticas de segregação...

This paper aims to present a dialogue between two militants of the Brazilian Psychiatric Reform who talked about immersion in the daily life of psychiatric hospitals, but from experiences that were acquired in different hospitals and at different times: Vera Cruz, in the city of Sorocaba, in 2012; and Juquery, in São Paulo, during the 1980s. In 2012, Bruno experienced an intervention process within the reality of a psychiatric ward that Silvio had expected to have been surmounted. While respecting the differences in places and in experiences that they have been through, their conclusion is that the treatment model proposed by psychiatric hospitals has erased the boundaries of time and has led to similar realities that mortify subjects and naturalize segregation practices...

El presente texto tiene el objetivo de presentar un diálogo entre dos militantes de la Reforma Psiquiátrica Brasileña que conversan sobre la inmersión en el cotidiano de hospitales psiquiátricos, pero a partir de experiencias localizadas en diferentes tiempos y en diferentes hospitales: Vera Cruz, en 2012, en la ciudad de Sorocaba y Juquery, en la década de 1980, en São Paulo. Bruno está en 2012, viviendo un proceso de intervención en una realidad de manicomio que Silvio esperaba que ya se hubiera superado. Respetadas las diferencias de lugares y de las experiencias vividas por ellos, concluyen que el modelo de tratamiento propuesto por el hospital psiquiátrico borra la frontera del tiempo y hace semejantes las realidades que mortifican a los sujetos y naturalizan prácticas de segregación...

Psychiatry and human rights: a difficult relationship, but with a growing potential.

Persons with psychosocial disabilities (mental health problems) are under the protection of the new United Nations Convention on Rights of Persons with Disabilities (CRPD). The CRPD brings a human rights-based approach to disability: it challenges paternalistic views by emphasizing the person as a rights-holder, an active subject, and not just a passive object of care. It also represents a challenge to mainstream human rights movements and mechanisms who have long paid insufficient attention to human rights of persons with (psychosocial) disabilities. It is increasingly understood that human rights of persons with psychosocial disabilities (mental health problems) should not be seen in the narrow perspective, as if the only issue was the most controversial one, that is, deprivation of liberty. In many areas, reform-minded psychiatrists have themselves initiated human rights-friendly reforms. For instance, efforts to implement article 19 of the CRPD­independent living and inclusion in the community­are increasingly becoming part of the mainstream in mental health care. There is potential for further synergy between mental health professionals and human rights activists in looking at the whole range of civil, political, economic, and social rights listed in the Universal Declaration of Human Rights­realizing that all these rights apply also to persons with psychosocial disabilities, and working together towards removing real-life obstacles to their enjoyment.The building of bridges between the two different types of expertise should be encouraged. In this regard, psychiatry would benefit from more cooperation across borders as well as with international human rights bodies, non-governmental organizations and persons with psychosocial disabilities themselves

[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.

Deinstitutionalization of American public hospitals for the mentally ill before and after the introduction of antipsychotic medications.

Deinstitutionalization following the introduction of antipsychotic medications in 1954 has received much attention as a major narrative in psychiatry. Little attention has been given, however, to deinstitutionalization before 1954. Using United States census data on discharge and readmission rates of US mental hospitals from 1935 to 1964, this article analyzes deinstitutionalization using an interrupted time-series model, with particular attention to the statistical significance of trends before and after the advent of antipsychotics. Discharge rates significantly increased in the period before antipsychotics, indicating that deinstitutionalization began before 1954, although readmissions during that same period increased at the same rate as discharges. A reasonable inference is that patients discharged in the pre-antipsychotic period were unable to live independently outside the hospital. After 1954, both discharges and readmissions increased significantly, but due to a continuing increase in admissions, no significant decrease in mental hospital populations occurred during the seven-year period after 1954. The decline began in 1961 and coincided with changes in federal policy. The fate of mental patients discharged from hospitals during this second period of deinstitutionalization is examined. The central conclusions are (1) the overall reduction in the population of mental hospitals did not coincide with the 1954 introduction of antipsychotic medications, and (2) deinstitutionalization before and after drugs has been met with inadequate community-based care.

Deinstitutionalization and the rise of violence.

The deinstitutionalization of individuals with serious mental illness was driven by 4 factors: public revelations regarding the state of public mental hospitals, the introduction of antipsychotic medications, the introduction of federal programs to fund patients who had been discharged, and civil libertarian lawyers. The result is approximately 3.2 million individuals with untreated serious mental illness living in the community. Beginning in the 1970s in the United States, there began to be reported increasing incidents of violent behavior, including homicides, committed by these untreated individuals. Such incidents became more numerous in the 1980s and 1990s, and have further increased since the turn of the century. Existing studies suggest that individuals with untreated severe mental illness are responsible for at least 10% of all homicides and approximately half of all mass killings. Studies have also shown that when these individuals are treated, the incidence of violent behavior decreases significantly. Examples of treatment mechanisms that have proven effective include assisted outpatient treatment (AOT), conditional release, and mental health courts.

A continuidade das internações psiquiátricas de crianças e adolescentes no cenário da Reforma Psiquiátrica Brasileira / La continuidad de las internaciones psiquiátricas de niños y adolescentes en el escenario de la Reforma Psiquiátrica Brasileña / The continuity of psychiatric hospitalization of children and adolescents within the Brazilian Psychiatric Reform scenario

No cenário da Reforma Psiquiátrica Brasileira, uma política de atenção em saúde mental específica para crianças e adolescentes está em construção. Porém, estudos indicam que ainda ocorre a internação dessa população em instituições de caráter asilar. Como resultado parcial de pesquisa, identificamos, durante um período de dois meses, quem são as crianças e adolescentes internados em um serviço que dispõe de leitos psiquiátricos, e os motivos dessas internações. Analisamos os prontuários de 28 sujeitos a partir da abordagem da Hermenêutica Dialética. Os resultados indicaram a continuidade das internações em um perfil similar ao de um momento anterior à Reforma Psiquiátrica, e que a principal razão para internação gira em torno da agressividade/periculosidade. Conclui-se que, apesar da Reforma Psiquiátrica, internações psiquiátricas ainda acontecem em instituições de caráter asilar...

Within the Brazilian Psychiatric Reform scenario, a new policy for mental healthcare specifically for children and adolescents is under construction. However, studies have indicated that hospitalization in psychiatric institutions still occurs among this population. As a preliminary research result over a two-month period, we identified who are these children and adolescents in a hospital with psychiatric beds were and the reasons for their hospitalization. We analyzed the medical files of 28 subjects using a hermeneutic dialectic approach. The results indicated that hospitalization of cases with a profile similar to that of the time before the reform of psychiatric care was continuing and that the main reason for hospitalization related to aggressiveness and dangerousness. It was concluded that, despite the reform, psychiatric hospitalization in institutions of asylum nature is still occurring...

En el escenario de la Reforma Psiquiátrica Brasileña está en construcción una política de salud mental específica para niños y adolescentes. No obstante, los estudios indican que todavía se realiza la internación de esa población en instituciones del tipo asilo. Como resultado parcial de una encuesta, identificamos durante un período de dos meses quiénes son los niños y adolescentes internados en un servicio que dispone de camas psiquiátricas y los motivos de tales internaciones. Analizamos las fichas de 28 sujetos a partir del abordaje de la Hermenéutica Dialéctica. Los resultados indicaron la continuidad de las internaciones en un perfil similar al de un momento anterior a la Reforma Psiquiátrica y que la principal razón para la internación gira alrededor de la agresividad/peligrosidad. Se concluye que, a pesar de la Reforma Psiquiátrica, las internaciones psiquiátricas todavía se realizan en instituciones con carácter de asilo...

The ten most important changes in psychiatry since World War II.

Writing the recent history of a subject is notoriously difficult because of the lack of perspective and impartiality. One way to gain insight and understanding into the recent past of a discipline of knowledge is to consult directly the living practitioners who actually experienced first-hand the major changing circumstances in the discipline during the period under study. This article seeks to explore the most significant changes occurring in Western, and especially American, psychiatry from the end of World War II up to the present by interrogating a representative selection of psychiatrists and psychologists about the subject. Over a three-year period, the author surveyed approximately 200 mental health experts on their perceptions of change in the world of psychiatric theory and practice during this enormously eventful 70-year period. After presenting the survey results, the article then attempts to analyse the answers that the author did (and did not) obtain from his poll-taking subjects.

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.