Is the long-term poor prognosis of acute myocardial infarction in patients with mental illness mediated through their poor adherence with recommended healthcare?

BACKGROUND: Compared with patients without evidence of psychiatric symptoms, those with mental disorders experience reduced adherence with recommended healthcare and poorer clinical outcomes. This study aimed to evaluate whether the worse prognosis of patients with mental disorders after experiencing acute myocardial infarction could be fully or partially mediated by their reduced adherence to recommended healthcare. METHODS: In this retrospective cohort population-based study, 103 389 residents in the Italian Lombardy Region who experienced acute myocardial infarction in 2007-19 were identified. Among them, 1549 patients with severe mental illness (SMI) were matched with five cohort members without evidence of mental disorders (references). Recommended healthcare (cardiac medicaments and selected outpatient services) was evaluated in the year after the date of index hospital discharge. The first occurrences of cardiovascular (CV) hospital admissions and any-cause-death were considered as endpoints. Mediation analysis was performed to investigate whether post-discharge use of recommended healthcare may be considered a mediator of the relationship between healthcare exposure and endpoints occurrence. RESULTS: Compared with references, patients with SMI had lower adherence with recommended healthcare and adjusted risk excesses of 39% and 73% for CV hospitalizations and all-cause mortality. Mediation analysis showed that 4.1% and 11.3% of, respectively, CV hospitalizations and deaths occurred among psychiatric patients was mediated by their worse adherence to specific healthcare. CONCLUSION: The reduced use of recommended outpatient healthcare by patients with SMI had only a marginal effect on their worse prognosis. Other key factors mediating the prognostic gap between patients with and without mental disorders should be investigated.

Allocation of Users of Mental Health Services to Needs-Based Care Clusters: An Italian Pilot Study.

In Italy, despite strong community-based mental health services, needs assessment is unsatisfactory. Using the Mental Health Clustering Tool (MHCT) we adopted a multidimensional and non-diagnosis dependent approach to assign mental health services users with similar needs to groups corresponding to resources required for effective care. We tested the MHCT in nine Departments of Mental Health in four Italian regions. After a brief training, 318 professionals assessed 12,938 cases with a diagnosis of schizophrenia, depression, bipolar disorder and personality disorder through the MHCT. 53% of cases were 40-59 years, half were females, 51% had a diagnosis of schizophrenia, 48% of cases were clinically severe. Clusters included different levels of clinical severity and diagnostic groups. The largest cluster was 11 (ongoing recurrent psychosis), with 18.9% of the sample, followed by cluster 3 (non-psychotic disorders of moderate severity). The MHCT could capture a variety of problems of people with mental disorders beyond the traditional psychiatric assessment, therefore depicting service population from a different standpoint. Following a brief training, MHCT assessment proved to be feasible. The automatic allocation of cases made the attribution to clusters easy and acceptable by professionals. To what extent clustering provide a sound base for care planning will be the matter of further research.

Capturing the variety of clinical pathways in patients with schizophrenic disorders through state sequences analysis.

BACKGROUND: Care pathways are increasingly being used to enhance the quality of care and optimize the use of resources for health care. Nevertheless, recommendations regarding the sequence of care are mostly based on consensus-based decisions as there is a lack of evidence on effective treatment sequences. In a real-world setting, classical statistical tools were insufficient to consider a phenomenon with such high variability adequately and have to be integrated with novel data mining techniques suitable for identifying patterns in complex data structures. Data-driven techniques can potentially support empirically identifying effective care sequences by extracting them from data collected routinely. The purpose of this study is to perform a state sequence analysis (SSA) to identify different patterns of treatment and to asses whether sequence analysis may be a useful tool for profiling patients according to the treatment pattern. METHODS: The clinical application that motivated the study of this method concerns the mental health field. In fact, the care pathways of patients affected by severe mental disorders often do not correspond to the standards required by the guidelines in this field. In particular, we analyzed patients with schizophrenic disorders (i.e., schizophrenia, schizotypal or delusional disorders) using administrative data from 2015 to 2018 from Lombardy Region. This methodology considers the patient's therapeutic path as a conceptual unit, composed of a succession of different states, and we show how SSA can be used to describe longitudinal patient status. RESULTS: We define the states to be the weekly coverage of different treatments (psychiatric visits, psychosocial interventions, and anti-psychotic drugs), and we use the longest common subsequences (dis)similarity measure to compare and cluster the sequences. We obtained three different clusters with very different patterns of treatments. CONCLUSIONS: This kind of information, such as common patterns of care that allowed us to risk profile patients, can provide health policymakers an opportunity to plan optimum and individualized patient care by allocating appropriate resources, analyzing trends in the health status of a population, and finding the risk factors that can be leveraged to prevent the decline of mental health status at the population level.

The quality of mental health care for people with bipolar disorders in the Italian mental health system: the QUADIM project.

BACKGROUND: The assessment of the quality of care pathways delivered to people with severe mental disorders in a community-based system remains uncommon, especially using healthcare utilization databases. The aim of the study was to evaluate the quality of care provided to people with bipolar disorders taken-in-care by mental health services of four Italian areas (Lombardy, Emilia-Romagna, Lazio, province of Palermo). METHODS: Thirty-six quality indicators were implemented to assess quality of mental health care for patients with bipolar disorders, according to three dimensions (accessibility and appropriateness, continuity, and safety). Data were retrieved from healthcare utilization (HCU) databases, which contain data on mental health treatments, hospital admissions, outpatient interventions, laboratory tests and drug prescriptions. RESULTS: 29,242 prevalent and 752 incident cases taken-in-care by regional mental health services with a diagnosis of bipolar disorder in 2015 were identified. Age-standardized treated prevalence rate was 16.2 (per 10,000 adult residents) and treated incidence rate 1.3. In the year of evaluation, 97% of prevalent cases had ≥ 1 outpatient/day-care contacts and 88% had ≥ 1 psychiatric visits. The median of outpatient/day-care contacts was 9.3 interventions per-year. Psychoeducation was provided to 3.5% of patients and psychotherapy to 11.5%, with low intensity. 63% prevalent cases were treated with antipsychotics, 71.5% with mood stabilizers, 46.6% with antidepressants. Appropriate laboratory tests were conducted in less than one-third of prevalent patients with a prescription of antipsychotics; three quarters of those with a prescription of lithium. Lower proportions were observed for incident patients. In prevalent patients, the Standardized Mortality Ratio was 1.35 (95% CI: 1.26-1.44): 1.18 (1.07-1.29) in females, 1.60 (1.45-1.77) in males. Heterogeneity across areas was considerable in both cohorts. CONCLUSIONS: We found a meaningful treatment gap in bipolar disorders in Italian mental health services, suggesting that the fact they are entirely community-based does not assure sufficient coverage by itself. Continuity of contacts was sufficient, but intensity of care was low, suggesting the risk of suboptimal treatment and low effectiveness. Care pathways were monitored and evaluated using administrative healthcare databases, adding evidence that such data may contribute to assess the quality of clinical pathways in mental health.

Are we equally at risk of changing smoking behavior during a public health crisis? Impact of educational level on smoking from the TEMPO cohort.

BACKGROUND: The COVID-19 pandemic as a public health crisis has led to a significant increase in mental health difficulties. Smoking is strongly associated with mental health conditions, which is why the pandemic might have influenced the otherwise decline in smoking rates. Persons belonging to socioeconomically disadvantaged groups may be particularly affected, both because the pandemic has exacerbated existing social inequalities and because this group was more likely to smoke before the pandemic. We examined smoking prevalence in a French cohort study, focusing on differences between educational attainment. In addition, we examined the association between interpersonal changes in tobacco consumption and educational level from 2018 to 2021. METHODS: Using four assessments of smoking status available from 2009 to 2021, we estimated smoking prevalence over time, stratified by highest educational level in the TEMPO cohort and the difference was tested using chi2 test. We studied the association between interpersonal change in smoking status between 2018 and 2021 and educational attainment among 148 smokers, using multinomial logistic regression. RESULTS: Smoking prevalence was higher among those with low education. The difference between the two groups increased from 2020 to 2021 (4.8-9.4%, p < 0.001). Smokers with high educational level were more likely to decrease their tobacco consumption from 2018 to 2021 compared to low educated smokers (aOR = 2.72 [1.26;5.89]). CONCLUSION: Current findings showed a widening of the social inequality gap in relation to smoking rates, underscoring the increased vulnerability of persons with low educational level to smoking and the likely inadequate focus on social inequalities in relation to tobacco control policies during the pandemic.

Using big data and Population Health Management to assess care and costs for patients with severe mental disorders and move toward a value-based payment system.

BACKGROUND: Mental health (MH) care often exhibits uneven quality and poor coordination of physical and MH needs, especially for patients with severe mental disorders. This study tests a Population Health Management (PHM) approach to identify patients with severe mental disorders using administrative health databases in Italy and evaluate, manage and monitor care pathways and costs. A second objective explores the feasibility of changing the payment system from fee-for-service to a value-based system (e.g., increased care integration, bundled payments) to introduce performance measures and guide improvement in outcomes. METHODS: Since diagnosis alone may poorly predict condition severity and needs, we conducted a retrospective observational study on a 9,019-patient cohort assessed in 2018 (30.5% of 29,570 patients with SMDs from three Italian regions) using the Mental Health Clustering Tool (MHCT), developed in the United Kingdom, to stratify patients according to severity and needs, providing a basis for payment for episode of care. Patients were linked (blinded) with retrospective (2014-2017) physical and MH databases to map resource use, care pathways, and assess costs globally and by cluster. Two regions (3,525 patients) provided data for generalized linear model regression to explore determinants of cost variation among clusters and regions. RESULTS: Substantial heterogeneity was observed in care organization, resource use and costs across and within 3 Italian regions and 20 clusters. Annual mean costs per patient across regions was €3,925, ranging from €3,101 to €6,501 in the three regions. Some 70% of total costs were for MH services and medications, 37% incurred in dedicated mental health facilities, 33% for MH services and medications noted in physical healthcare databases, and 30% for other conditions. Regression analysis showed comorbidities, resident psychiatric services, and consumption noted in physical health databases have considerable impact on total costs. CONCLUSIONS: The current MH care system in Italy lacks evidence of coordination of physical and mental health and matching services to patient needs, with high variation between regions. Using available assessment tools and administrative data, implementation of an episodic approach to funding MH could account for differences in disease phase and physical health for patients with SMDs and introduce performance measurement to improve outcomes and provide oversight.

Does the mental health system provide effective coverage to people with schizophrenic disorder? A self-controlled case series study in Italy.

PURPOSE: To measure indicators of timeliness and continuity of treatments on patients with schizophrenic disorder in 'real-life' practice, and to validate them through their relationship with relapse occurrences. METHODS: The target population was from four Italian regions overall covering 22 million beneficiaries of the NHS (37% of the entire Italian population). The cohort included 12,054 patients newly taken into care for schizophrenic disorder between January 2015 and June 2016. The self-controlled case series (SCCS) design was used to estimate the incidence rate ratio of relapse occurrences according to mental healthcare coverage. RESULTS: Poor timeliness (82% and 33% of cohort members had not yet started treatment with psychosocial interventions and antipsychotic drug therapy within the first year after they were taken into care) and continuity (27% and 23% of patients were persistent with psychosocial interventions, and antipsychotic drug therapy within the first 2 years after starting the specific treatment) were observed. According to SCCS design, 4794 relapses occurred during 9430 PY (with incidence rate of 50.8 every 100 PY). Compared with periods not covered by mental healthcare, those covered by psychosocial intervention alone, antipsychotic drugs alone and by psychosocial intervention and antipsychotic drugs together were, respectively, associated with relapse rate reductions of 28% (95% CI 4-46%), 24% (17-30%) and 44% (32-53%). CONCLUSION: Healthcare administrative data may contribute to monitor and to assess the effectiveness of a mental health system. Persistent use of both psychosocial intervention and antipsychotic drugs reduces risk of severe relapse.

Hypothalamic-pituitary-ovarian axis perturbation in the basis of bisphenol A (BPA) reproductive toxicity in female zebrafish (Danio rerio).

Thousands of safety-related studies have been published on bisphenol A (BPA), an ubiquitous environmental pollutant with estrogenic activity and many other potential biological effects. In recent years, BPA exposure has been shown to cause anovulation and infertility through irreversible alteration of the hypothalamic-pituitary-gonadal axis in several organisms, including fish and mammals. Recently, the European Chemical Agency classified BPA as a "substance of very high concern" because of its endocrine-disrupting properties, which have serious effects on human health. Given the risk of exposure to BPA as a pollutant in the environment, food, and drinking water, the objective of our study was to assess the effects of this compound on the adeno-hypophysis by means of a histopathological and morphometric study of the gonadotroph cells. In addition, using quantitative real-time PCR (qRT-PCR) assays, we analyzed the changes in the expression of Cyp19b (an aromatase gene). Zebrafish were randomly distributed into five groups: a control group and 4 treated groups which were exposed to different BPA concentrations (1, 10, 100 and 1000 µg/L). The effects of the different doses on Cyp19b mRNA molecules followed a non-monotonic curve, with the 1 and 1000 µg/L doses causing dramatic decreases in the number of Cyp19b transcripts while the doses of 10 and 100 µg/L caused important increases. The consequences might be deregulation of gonadotropic hormones causing degeneration of gonadotropic cells, as observed in BPA treated animals. This is the first study in which the gonadotroph cells have been evaluated using histomorphological endpoints after BPA exposure in zebrafish.

How are compassion fatigue, burnout, and compassion satisfaction affected by quality of working life? Findings from a survey of mental health staff in Italy.

BACKGROUND: Quality of working life includes elements such as autonomy, trust, ergonomics, participation, job complexity, and work-life balance. The overarching aim of this study was to investigate if and how quality of working life affects Compassion Fatigue, Burnout, and Compassion Satisfaction among mental health practitioners. METHODS: Staff working in three Italian Mental Health Departments completed the Professional Quality of Life Scale, measuring Compassion Fatigue, Burnout, and Compassion Satisfaction, and the Quality of Working Life Questionnaire. The latter was used to collect socio-demographics, occupational characteristics and 13 indicators of quality of working life. Multiple regressions controlling for other variables were undertaken to predict Compassion Fatigue, Burnout, and Compassion Satisfaction. RESULTS: Four hundred questionnaires were completed. In bivariate analyses, experiencing more ergonomic problems, perceiving risks for the future, a higher impact of work on life, and lower levels of trust and of perceived quality of meetings were associated with poorer outcomes. Multivariate analysis showed that (a) ergonomic problems and impact of work on life predicted higher levels of both Compassion Fatigue and Burnout; (b) impact of life on work was associated with Compassion Fatigue and lower levels of trust and perceiving more risks for the future with Burnout only; (c) perceived quality of meetings, need of training, and perceiving no risks for the future predicted higher levels of Compassion Satisfaction. CONCLUSIONS: In order to provide adequate mental health services, service providers need to give their employees adequate ergonomic conditions, giving special attention to time pressures. Building trustful relationships with management and within the teams is also crucial. Training and meetings are other important targets for potential improvement. Additionally, insecurity about the future should be addressed as it can affect both Burnout and Compassion Satisfaction. Finally, strategies to reduce possible work-life conflicts need to be considered.

Routine quality care assessment of schizophrenic disorders using information systems.

OBJECTIVE: To assess the quality of mental healthcare provided to patients with schizophrenic disorders in the Italian region of Lombardy. DESIGN: Forty-one clinical indicators were applied to Lombardy's healthcare databases containing data on mental health treatments, hospital admissions, somatic health treatments and pharmaceutical prescriptions. SETTING: All public departments of mental health and private residential facilities in Lombardy. PARTICIPANTS: All 28 227 patients with schizophrenic disorders that were under the care of Lombardy mental health services in 2009. INTERVENTIONS: N/A. MAIN OUTCOME MEASURES: N/A. RESULTS: The care that was delivered to patients and family members was more frequent for first-episode cases than for prevalent ones. Seven out of ten patients made use of continuing care and, after hospitalization, more than half of the discharged patients received a follow-up visit by community mental health centre staff within 2 weeks of their discharge. Psychotherapeutic and psychoeducative treatments, such as employment and independent living support, were not widespread among these discharged patients. Antipsychotic drug dosage was usually within the recommended range. The adherence of first-episode patients to antipsychotic treatment was lower than that of prevalent patients, and the monitoring of metabolic side effects was not always consistent. Inappropriateness of hospital care, in terms of longer admission, readmission, compulsory admission and restraint, was limited. Mortality during the period was significant. CONCLUSIONS: Clinical indicators demonstrate the strengths and weaknesses of the mental health system in Lombardy and they can be useful tools in the routine assessment of mental healthcare quality.

Antipsychotic drug exposure and risk of pulmonary embolism: a population-based, nested case-control study.

BACKGROUND: Only three observational studies investigated whether exposure to antipsychotics is associated with an increased risk of pulmonary embolism, with conflicting results. This study was therefore carried out to establish the risk of pulmonary embolism associated with antipsychotic drugs, and to ascertain the risk associated with first- and second-generation antipsychotic drugs, and with exposure to individual drugs. METHODS: We identified 84,253 adult individuals who began antipsychotic treatment in a large Italian health care system. Cases were all cohort members who were hospitalized for non-fatal or fatal pulmonary embolism during follow-up. Up to 20 controls for each case were extracted from the study cohort using incidence density sampling and matched by age at cohort entry and gender. Each individual was classified as current, recent or past antipsychotic user. The occurrence non-fatal or fatal pulmonary embolism was the outcome of interest. RESULTS: Compared to past use, current antipsychotic use more than double the risk of pulmonary embolism (odds ratio 2.31, 95% confidence interval 1.16 to 4.59), while recent use did not increase the risk. Both conventional and atypical antipsychotic exposure was associated with an increase in risk, and the concomitant use of both classes increased the risk of four times (odds ratio 4.21, 95% confidence interval 1.53 to 11.59). CONCLUSIONS: Adding the results of this case-control study to a recent meta-analysis of three observational studies substantially changed the overall estimate, which now indicates that antipsychotic exposure significantly increases the risk of pulmonary embolism.

Ethnic differences in the utilization of mental health services in Lombardy (Italy): an epidemiological analysis.

PURPOSE: To analyze the differences in mental health service utilization by immigrant and native populations of Lombardy, an Italian region that hosts one-fourth of the immigrants living in Italy. METHOD: The data are drawn from the regional mental health information system (based on the case register model), which supplies information on the users and mental health activities of the Departments of Mental Health, Lombardy, a region of about 10 million people; 139,775 adult users were treated in mental health services in 2010. RESULTS: Mental health services are used by 11.3 immigrant users out of 1,000 immigrants (with marked differences depending on country of origin) compared with 17.0 native users. Acute mental health services are used more frequently by immigrant patients; the types of intervention provided to immigrants differ from those provided to the native population (mainly as far as psychotherapeutic interventions is concerned), while gender differences are substantial. CONCLUSIONS: The number of immigrant users using mental health services has increased notably in recent years, and in Lombardy it has been observed that the use of such services differs from service unit to service unit. This raises the problem of how to increase the cultural awareness of mental health professionals dealing with the mental health needs of the immigrant population. On the whole, immigrants use community mental health services less than the native population; however, immigrants tend to be more frequently admitted to general hospital psychiatric units during acute phases and both the utilization rates and gender differ greatly, depending on the country of origin.

Italian community psychiatry in practice: description and comparison of three regional systems.

The psychiatric reform in 1978 assigned the regions the task of implementing community mental health (MH) services; 30 years on in Italy, there are as many MH systems as there are Italian regions and all completely differentiated. Three Italian regions (Lombardy, Emilia-Romagna, and Campania) in different geographic areas are here chosen as representing three different models of community care implementation as well as certain similarities and differences at a regional level. For each region, the article focuses on MH policy, financing, the network of community health facilities, service provision, MH staff, and the information system.

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.

Endocrine-active compound evaluation: qualitative and quantitative histomorphological assessment of zebrafish gonads after bisphenol-A exposure.

There is great social concern about the risk involved from exposure to BPA as an endocrine disrupter in humans, as well as the possible repercussion of this chemical on the environment. In this study, the short-term effects of BPA at a gonadal level were assessed by means of different biomarkers in a model animal organism in vogue, the zebrafish (Danio rerio). For this purpose, 60 female zebrafish aged 16 weeks were used. These were exposed for 14 days in aquariums (following OECD Directive no.204) to BPA concentrations of 1, 10, 100 and 1000 µg/L, in addition to a control batch. After the exposure period, the zebrafish were sacrificed and samples taken for a histopathological study by light and electron microscopy and morphometric analysis. During the fourteen days of exposure, water samples were taken from the aquariums to analyze the BPA levels. The BPA concentration in the fish and the water was determined by LC-MS/MS. The gonads of the zebrafish exposed to the BPA had a normal external appearance and there were no variations in their size or body weight. An accumulation of BPA was produced in the zebrafish tissues, and this increased as the BPA concentration to which the fish were exposed did. In the histopathological and morphometric studies, multiple alterations were observed in the zebrafish ovaries, particularly highlighting the vacuolization of the follicular cytoplasm, a great degeneration of all the cell components, and an important increase in the percentage of atretic follicles as from concentrations of 100 and 1000 µg/L of BPA, verified by morphometry. These data indicate that morphological endpoints are sufficiently sensitive to individuate early effects of environmental concentration of BPA on gonads after two weeks of exposure.

Patients With First-Episode Psychosis are Not a Homogeneous Population: Implications for Treatment.

OBJECTIVE: This study aimed at defining the characteristics of a population of patients diagnosed with first-episode psychosis (FEP), and accessing for the first time a center for early intervention in psychosis in the health district of Milan and its surroundings. METHODS: Patients were included in the study from January 2007 to December 2008; criteria: first contact with any public mental health service of the catchment area for a first episode of schizophrenia or related syndromes according to the ICD-10 criteria. Cluster analysis was used to divide patients into groups based on the main socio-demographic and clinical characteristics at presentation. RESULTS: Overall, 91 FEP patients were enrolled in the study. Two clusters were identified, which differed principally by symptom profile. Patients in cluster 1 (n=36) had severe agitation, and a history of alcohol and/or substance abuse at presentation more often than those in cluster 2 (n=55), who were more likely to suffer at presentation from severe depression or apathy, anxiety, poor self-care, functional or work impairment and severe social withdrawal. After six months of treatment patients improved on almost all symptomatic dimensions on the Health of the Nation Outcome Scale and the Brief Psychiatric Rating Scale, with greater improvement in cluster 1 than in cluster 2. CONCLUSIONS: The findings of this study need replication in larger samples and on a wider severity scale. Nevertheless, the heterogeneity of patients with FEP might impact on treatment. Policymakers should recognize the importance of the diagnostic and outcome assessment in the treatment of severe mental disorders.

Improved prediction of 5-year mortality by updating the chronic related score for risk profiling in the general population: lessons from the italian region of Lombardy.

Objective: The aim of this study was to improve the performance of the Chronic Related Score (CReSc) in predicting mortality and healthcare needs in the general population. Methods: A population-based study was conducted, including all beneficiaries of the Regional Health Service of Lombardy, Italy, aged 18 years or older in January 2015. Each individual was classified as exposed or unexposed to 69 candidate predictors measured before baseline, updated to include four mental health disorders. Conditions independently associated with 5-year mortality were selected using the Cox regression model on a random sample including 5.4 million citizens. The predictive performance of the obtained CReSc-2.0 was assessed on the remaining 2.7 million citizens through discrimination and calibration. Results: A total of 35 conditions significantly contributed to the CReSc-2.0, among which Alzheimer's and Parkinson's diseases, dementia, heart failure, active neoplasm, and kidney dialysis contributed the most to the score. Approximately 36% of citizens suffered from at least one condition. CReSc-2.0 discrimination performance was remarkable, with an area under the receiver operating characteristic curve of 0.83. Trends toward increasing short-term (1-year) and long-term (5-year) rates of mortality, hospital admission, hospital stay, and healthcare costs were observed as CReSc-2.0 increased. Conclusion: CReSC-2.0 represents an improved tool for stratifying populations according to healthcare needs.

Assessment and Monitoring of the Quality of Clinical Pathways in Patients with Depressive Disorders: Results from a Multiregional Italian Investigation on Mental Health Care Quality (the QUADIM Project).

Ensuring adequate quality of care to patients with severe mental disorders remains a challenge. The implementation of clinical indicators aimed at assessing the quality of health care pathways delivered is crucial for the improvement of mental health services (MHS). This study aims to evaluate the quality of care delivered to patients who are taken-into-care with depressive disorders by MHS. Thirty-four clinical indicators concerning accessibility, appropriateness, continuity, and safety were estimated using health care utilization databases from four Italian regions (Lombardy, Emilia-Romagna, Lazio, Sicily). A total of 78,924 prevalent patients treated for depressive disorders in 2015 were identified, of whom 15,234 were newly engaged by MHS. During the year of follow-up, access to psychotherapeutic interventions was low, while the intensity was adequate; 5.1% of prevalent patients received at least one hospitalization in a psychiatric ward (GHPW), and 3.3% in the cohort of newly engaged in services. Five-out-of-10 patients had contact with community services within 14 days after GHPW discharge, but less than half of patients were persistent to antidepressant drug therapy. Furthermore, prevalent patients showed an excess of mortality compared to the general population (SMR = 1.35; IC 95%: 1.26-1.44). In conclusion, the quality of health care is not delivered in accordance with evidence-based mental health standards. Evaluation of health interventions are fundamental strategies for improving the quality and equity of health care.

Assessing the quality of the care offer for people with personality disorders in Italy: the QUADIM project. A multicentre research based on the database of use of Mental Health services.

BACKGROUND: Italy can be viewed as a laboratory to assess the quality of mental healthcare delivered in a community-oriented system, especially for severe mental disorders, such as personality disorders. Although initiatives based on clinical indicators for assessing the quality of mental healthcare have been developed by transnational-organisations, there is still no widespread practice of measuring the quality of care pathways delivered to patients with severe mental disorders in a community-oriented system, especially using administrative healthcare databases. The aim of the study is to evaluate the quality of care delivered to patients with personality disorders taken-in-care by mental health services of four Italian regions (Lombardy, Emilia-Romagna, Lazio, Sicily). METHODS: A set of thirty-three clinical indicators, concerning accessibility, appropriateness, continuity, and safety of care, was implemented using regional healthcare utilization databases, containing data on mental health treatments and diagnosis, hospital admissions, outpatient interventions and exams and drug prescriptions. RESULTS: 31,688 prevalent patients with personality disorders treated in 2015 were identified, of whom 2,331 newly taken-in-care. One-in-10 patients received a standardized assessment, the treatment discontinuity affected half of the cases. 12.7% of prevalent patients received at least one hospitalization, 10.6% in the newly taken-in-care cohort. 6-out-of-10 patients had contact with community-services within 14 days from hospital discharge. Access to psychotherapy and psychoeducational treatments was low and delivered with a low intensity. The median of psychosocial interventions per person-year was 19.1 and 9.4, respectively, in prevalent and newly taken-in-care cases. Nearly 50% of patients received pharmacological treatments. CONCLUSIONS: Healthcare utilization databases were used to systematically evaluate and assess service delivery across regional mental health systems; suggesting that in Italy the public mental health services provide to individuals with personality disorders suboptimal treatment paths.