Characteristics and activities of acute psychiatric in-patient facilities: national survey in Italy

Patient's Experiences of a Cognitive Behaviour Therapy Informed Crisis Intervention for Psychosis Delivered in Inpatient Settings: A Qualitative Exploration

Cognitive behaviour therapy for psychosis (CBTp) should be offered to patients receiving psychiatric inpatient care, yet very little is known about patients' perspectives on this. The aim of this study was to examine patients' experiences of a CBTp-informed intervention delivered in inpatient settings. We recruited 10 participants from the intervention arm of a randomised controlled trial examining the feasibility and acceptability of a CBTp-informed intervention for psychiatric inpatient settings. We undertook semistructured interviews examining their experiences of the intervention and analysed them using thematic analysis. The study was conducted in partnership with a coproduction group of key stakeholders (people with lived experience, family and carers, and clinicians). The intervention was found helpful by almost all participants, and all participants would recommend it to others in similar situations to themselves. The results demonstrated that participants valued the therapist's professionalism and emphasised the importance of the therapeutic relationship. Participants highlighted the importance of the therapy focusing on navigating admission and developing skills to manage the crisis experience so they could return to their normal lives. Participants described challenges to having psychological therapy in the acute crisis context including therapy interruptions and ongoing distressing experiences of psychosis. The study demonstrated the importance of prioritising the therapeutic relationship, that therapy was a valued process to navigate admission and discharge, but that some environmental and patient-level challenges were present. Further research is needed to explore inpatients' experiences of psychological interventions in this setting. TRIAL REGISTRATION: ISRCTN trial registry: ISRCTN59055607.

No-Restraint Committed General Hospital Psychiatric Units (SPDCs) in Italy-A Descriptive Organizational Study

This study describes and explores the application of no-restraint policies in General Hospital Psychiatric Units (GHPUs) in Italy, a country pioneering in deinstitutionalization and psychiatric reform. The research aims to assess the organizational characteristics and effectiveness of no-restraint practices, contributing to the global discourse on humane psychiatric care. Following a purposive sampling approach, a nationwide descriptive study was conducted involving a detailed online survey distributed to 24 GHPUs actively engaged in or aspiring toward no-restraint practices. The survey, comprising 60 items across seven sections, gathered comprehensive data on the structural, organizational, and operational dimensions of the units, along with the prevalence and management of restraint episodes. Results reveal a significant commitment to no-restraint policies, with 14 GHPUs reporting zero restraint incidents in 2022. Despite variations in infrastructure and staffing, a common thread was the implementation of systematic procedures and risk management training aimed at reducing coercive practices. The study identified a correlation between the use of exclusive garden spaces and an increased incidence of restraints, suggesting nuanced factors influencing restraint practices. The findings underscore the viability and ethical alignment of no-restraint practices within psychiatric care, highlighting the crucial role of organizational protocols and training. This research adds empirical weight to the advocacy for restraint-free environments in mental health settings, signaling a paradigm shift toward more humane and rights-respecting psychiatric care.

Per una salute mentale di comunità: la questione dei Servizi e dei modelli

La questione di quali Servizi siano necessari per una piena applicazione della riforma psichiatrica del 1978, costruendo un'alternativa istituzionale globale, viene discussa a partire dai modelli organizzativi e dai loro contesti applicativi, che definiscono l'offerta complessiva di cura. Nel realizzare la presa in carico vanno considerate non solo le evidenze scientifiche, ma anche un ancoraggio etico e valoriale che tenga conto delle esperienze e dei bisogni delle persone che usano i Servizi. Tra i princìpi-cardine sostenuti dall'Organizzazione Mondiale della Sanità spiccano la realizzazione dei diritti umani, con l'abbandono delle pratiche coercitive e dei trattamenti obbligatori routinari, l'empowerment dell'utenza e un approccio multisettoriale per una risposta ai determi-nanti sociali di salute. Dalla pratica discende una serie di indicazioni, dall'apertura sulle 24 ore alla continuità e non frammentazione delle cure. Si descrivono punti di orientamento e princìpi di fun-zionamento dei Servizi territoriali, e si delineano prospettive per un cambio di paradigma che riguardi gli esiti globali sulla vita delle persone.

Compulsory and voluntary admissions in comparison: A 9-year long observational study

BACKGROUND

Few studies, so far, have been specifically designed to highlight the features related to Compulsory Admissions (CA) and Voluntary Admissions (VA) in Italian psychiatric emergency wards.

AIMS

The main purpose of this observational study was to compare the sociodemographic and clinical characteristics of VA and CA and to explore possible predictors of re-admissions.

METHODS

During a 6-month Index Period (February, the 1st-July, the 31st 2008) all psychiatric admissions were documented and then followed-up through all available informatic systems for the next 9 years.

RESULTS

Out of 390 hospitalizations, 101 (25.9%) were compulsory (CA rate was 2.79 per 10,000 inhabitants per year, mean duration of hospitalizations of 7.33 ± 7.84 days). Diagnoses were recorded for the 325 patients who had been hospitalized during index period: schizophrenic psychoses ([p = .042], in particular schizophrenia [p = .027]), manic episode (p = .044), and delusional disorders (p = .009) were associated with CA; conversely, the diagnosis of unipolar major depression (p = .005) and personality disorders (p = .048) were significantly more frequent in VA. The 325 admitted patients were followed up for 1,801 person-years. No significant differences were found in terms of drop-outs, transferring, and discharge rates, and mortality rates due to both natural causes and suicides. Factors associated with at least one compulsory readmission were younger age and having had a previous CA (p = .011); conversely having been engaged with psychiatric services for over 1 year prior to index hospitalization was protective for a subsequent CA (p = .013).

CONCLUSIONS

After a 40-year old political reform, the current study shows that, in a context of integrated outpatient and inpatient services, engagement with outpatient care may be protective for compulsory rehospitalization.

Impact of the hospital built environment on treatment satisfaction of psychiatric in-patients

BACKGROUND

A hospital built environment can affect patients' treatment satisfaction, which is, in turn, associated with crucial clinical outcomes. However, little research has explored which elements are specifically important for psychiatric in-patients. This study aims to identify which elements of the hospital environment are associated with higher patient satisfaction with psychiatric in-patient care.

METHODS

The study was conducted in Italy and the United Kingdom. Data was collected through hospital visits and patient interviews. All hospitals were assessed for general characteristics, aspects specific to psychiatry (patient safety, mixed/single-sex wards, smoking on/off wards), and quality of hospital environment. Patients' treatment satisfaction was assessed using the Client Assessment of Treatment Scale (CAT). Multi-level modelling was used to explore the role of environment in predicting the CAT scores adjusted for age, gender, education, diagnosis, and formal status.

RESULTS

The study included 18 psychiatric hospitals (7 in Italy and 11 in the United Kingdom) and 2130 patients. Healthcare systems in these countries share key characteristics (e.g. National Health Service, care organised on a geographical basis) and differ in policy regulation and governance. Two elements were associated with higher patient treatment satisfaction: being hospitalised on a mixed-sex ward (p = 0.003) and the availability of rooms to meet family off wards (p = 0.020).

CONCLUSIONS

As hospitals are among the most expensive facilities to build, their design should be guided by research evidence. Two design features can potentially improve patient satisfaction: family rooms off wards and mixed-sex wards. This evidence should be considered when designing or renovating psychiatric facilities.

Involuntary psychiatric hospitalization in Italy: critical issues in the application of the provisions of law

Involuntary psychiatric hospitalisation in Italy raises some critical forensic issues. We analysed the sociodemographic, psychopathological, and behavioural characteristics of involuntarily hospitalised psychiatric patients, and the effectiveness of the juridical procedure of guarantee. Case files (n = 2796) related to involuntary psychiatric hospitalisation (IPH) at the Office of the Tutelary Judge of the Ordinary Court of Rome (Italy) between January 2013 and May 2016 were analysed. For each case file sociodemographic, clinical and procedural information were collected. The sample included 53.7% men, patients had a mean age of 41.8 ± 13.9. Most of the IPH proposal certificates reported more than one reason, among which the most frequent were symptoms referring to a psychotic dimension (54.8%), agitation (38.0%), and symptoms of bipolar and related disorders (26.3%) Female patients showed a higher prevalence of symptoms of the bipolar spectrum (F = 29.7%, M = 23.3%; p < 0.05), while male patients showed a higher prevalence of aggressive behaviour (F = 7.7%, M = 12.6%; p < 0.01). Over 85% of the IPH proposal certificates did not explicitly mention issues related to adherence to care, which is the second criterium requested for IH (treatment refusal) and up to 7.3% of the proposals were not properly motivated. However, only 0.8% cases were not validated by the Tutelary Judge. Possible issues in the IPH procedures emerged since a significant number of certifications showed poor concordance with law- criteria for involuntary psychiatric hospitalisation. Despite this evidence, the low rate of unvalidated procedures by the Tutelary Judge, suggests a possible limitation of this form of guarantee.

Use of psychiatric inpatient services by heavy users: Findings from a national survey in Italy

Purpose

To analyze factors associated with a patient's probability of being a Heavy User (HU) of inpatient psychiatric services and to compare the HU inpatient population with Non-Heavy Users (NHUs).

Patients and methods

The survey was conducted among inpatients enrolled in the PROGRES-Acute-project, an Italian nationwide survey of public and private inpatient facilities. Patients with three or more admissions over the last 12 months were considered HUs, and patients who had undergone one or two admissions during the same period made up the NHU group.

Results

Four hundred and thirty-five (40.5%) were HUs, and 640 (59.5%) NHUs. HUs were younger, more frequently unmarried, unemployed, receiving a disability-pension, and either homeless or living in a residential facility. HUs were more likely to have experienced conflicts with their partners or family members during the week prior to admission. A logistic regression analysis revealed that age, age at first admission, number of life-time admissions, and having been the victim of violence were the most important predictive factors for the HU phenomenon.

Conclusion

Our study suggests that specific attention should be given to patients’ family context, due to its crucial role in daily informal care and in the triggering of events leading to rehospitalization.

Mental health supported accommodation services in England and in Italy: a comparison

PURPOSE

England and Italy are considered pioneers in the development of community mental health services. Both have implemented supported accommodation services for those with more complex needs, which can be broadly categorized into three main types with similar specification. The aim of this study was to compare the characteristics of these services and their users in England and Italy.

METHODS

Data from two cross-sectional surveys of supported accommodation services undertaken across England and in Verona, Italy (England-619 service users from 87 services; Verona-167 service users from 25 services) were compared.

RESULTS

Service users in the two samples had similar socio-demographic and clinical characteristics; most were male, unmarried and unemployed, with a primary diagnosis of schizophrenia or other psychosis and over 15 years contact with mental health services. Supported accommodation occupancy was high in both samples. The actual length of stay was greater than the expected length of stay for all three service types but overall turnover was similar between countries (p = 0.070). Across services, total needs and quality of life were higher for Italian compared to English service users (p < 0.001 for both) but, unmet needs were lower amongst English service users (p < 0.001). Around 40% in both samples moved to more independent accommodation successfully within 30 months.

CONCLUSIONS

England and Italy have similar mental health supported accommodation pathways to assist those with more complex needs to gain skills for community living, but individuals tend to require longer than expected at each stage.

A Comparison of Inpatient Adult Psychiatric Services in Italy and Canada

We examine the possibility the Organisation for Economic Co-operation and Development (OECD) bed count for Italy may be an underestimation of the actual beds available. We compared bedded services for mental disorders in two regions in Italy and Canada respectively. We found out that if we consider acute psychiatric beds only, the district of Ferrara has 30 beds (8.5 per 100,000) and the Middlesex and Elgin Counties have 89 beds (16.3 beds for 100,000). However, if we include the rehabilitation beds (that are located within a hospital setting in Ontario and in a residential community setting in Ferrara), we find that the district of Ferrara has 95 beds (27.0 per 100,000) and the Middlesex and Elgin Counties have 176 beds (32.3 per 100,000). As a result, the 10/100,000 beds rate for Italy reported by the OECD is an underestimate compared to figures reported for most other countries, as the beds included are hospital beds only.

Forty years of the Law 180: the aspirations of a great reform, its successes and continuing need

AIM

Italy pioneered deinstitutionalisation over the past 60 years and enforced a famous mental health (MH) reform law in 1978. Deinstitutionalisation has been completed with the very closure of all psychiatric hospitals over two decades.

METHODS

After 40 years of implementation, this article presents the main achievements and challenges of the Italian MH reform law, including its long-term effect and impact in Italy and abroad.

RESULTS

The Legislation of 1978 was based on the discovery of rights as a key tool in mental healthcare. At the climax of crisis of psychiatric hospitals as total institutions in this country, through the new community-based system of care, it has fostered the lowest rate of involuntary care and gave back the full citizenship to people with MH disorders. This act was also part of a social movement for expanding civil and social rights, and a promise of a true paradigm shift not only in psychiatry, but also in the way of providing an adequate welfare community for all citizens. According to the WHO, the Italian city of Trieste, together with its region, is a practical example of how the Italian movement achieved deinstitutionalisation, intended as a complex process resulting in the gradual relocation of the economic and human resources and subsequent creation of 24 h services together with the development of social inclusion programmes.

CONCLUSIONS

Even if the great principles of the Italian reform law were anticipatory (e.g., the UN Convention on Rights of Persons with Disabilities - CRPD), the law application has been poorly provided with resources and did not follow those avant-garde experiences as models. Limitations are evident today especially at the organisational levels, such as services capable to take up the challenge and transforming the field, left free from the imprint of total institutions. These endemic critical aspects concerning to implementation policies, together with the financial crisis of the Italian healthcare system, must be taken into consideration for a re-launch of this historical law. The rights-based approach opened by the Law 180 should now take into consideration the new legal situation caused by the CRPD worldwide in the area of individuals' human rights, especially about the issue of legal capacity and related involuntary care.

Forty years without mental hospitals in Italy

In 1978 Italy implemented Law Number 180, the reform law that blocked all new admissions to public mental hospitals. After 40 years without mental hospitals, we aim at understanding the consequences of the Italian reform in terms of mental health care facility and staff availability. We compared the organization of the Italian mental health system with that of countries belonging to the Group of 7 (G7) major advanced economies. Italy has nearly 8 psychiatrists, 20 nurses, 2 social workers and less than 3 psychologists per 100,000 population, while for example in France there were 22 psychiatrists, in Japan 102 nurses, in the United States 18 social workers, and in Canada and France more than 45 psychologists per 100,000 population. In terms of inpatient facilities, no beds in mental hospitals were available in Italy, while in the other G7 countries mental hospital beds ranged from 8 in the United Kingdom to 204 in Japan per 100 000 population. In Italy there were fewer beds for acute care in general hospitals but more beds in community residential facilities than in the other G7 countries. Service use data showed variability in the provision of mental health care throughout the country. Soon after the implementation of the Italian reform the absolute number of compulsory admissions progressively declined, from more than 20,000 in 1978 to less than 9000 in 2015. Alongside the progressive decline of psychiatric beds imposed by Law 180, the age-adjusted suicide rate remained stable, ranging from 7·1/100,000 population in 1978 to 6·3/100,000 population in 2012. The population of psychiatric patients placed in Italian forensic psychiatric hospitals progressively declined. During the last 40 years without mental hospitals, Italy has seen a progressive consolidation of a community-based system of mental health care. We highlighted, however, reasons for concern, including a decreasing staffing level, a potential use of community residential facilities as long-stay residential services, a still too high variability in service provision across the country, and lack of national data on physical restraints. At a national level, the resources allocated to mental health care are lower in Italy than in other high-income countries.

Geographic variations in involuntary care and associations with the supply of health and social care: results from a nationwide study

Background

Involuntary psychiatric care remains controversial. Geographic disparities in its use can challenge the appropriateness of the care provided when they do not result from different health needs of the population. These disparities should be reduced through dedicated health policies. However, their association with the supply of health and social care, which could be targeted by such policies, has been insufficiently studied. Our objectives were therefore to describe geographic variations in involuntary admission rates across France and to identify the characteristics of the supply of care which were associated with these variations.

Methods

Involuntary admission rate per 100,000 adult inhabitants was calculated in French psychiatric sectors’ catchment areas using 2012 data from the national psychiatric discharge database. Its variations were first described numerically and graphically. Several factors potentially associated with these variations were then considered in a negative binomial regression with an offset term accounting for the size of catchment areas. They included characteristics of the supply of care (public and private care, health and social care, hospital and community-based care, specialised and non-specialised care) as well as adjustment factors related to epidemiological characteristics of the population of each sector’s catchment area and its level of urbanization. Such variables were extracted from complementary administrative databases. Supply characteristics associated with geographic variations were identified using a significance level of 0.05.

Results

Significant variations in involuntary admission rates were observed between psychiatric sectors’ catchment areas with a coefficient of variation close to 80%. These variations were associated with some characteristics of the supply of health and social care in the sectors’ catchment areas. Notably, an increase in the availability of community-based private psychiatrists and the capacity of housing institutions for disabled individuals was associated with a decrease in involuntary admission rates while an increase in the availability of general practitioners was associated with an increase in those rates.

Conclusions

There is evidence of considerable variations in involuntary admission rates between psychiatric sectors’ catchment areas. Our results provide lines of thoughts to reduce such variations, in particular by supporting an increase in the availability of upstream and downstream care in the community.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3064-3) contains supplementary material, which is available to authorized users.

Implementation and development of early intervention in psychosis services in Italy: a national survey promoted by the Associazione Italiana Interventi Precoci nelle Psicosi

AIM

This is the first comprehensive, nationwide survey aimed at collecting evidence about the process of implementation and development of early intervention in psychosis (EIP) services (EIPs) in Italy, following the establishment of the pilot program 'Programma 2000' in 1999 and the publishing of the Italian National Guidelines in 2007. This survey covers all the Departments of Mental Health (DMHs) operating in Italy in 2013.

METHODS

Using a purpose-designed form to assess EIP implementation, all directors of public mental health services for adults throughout Italy (n = 216) were asked to provide information about the activities of EIP-relevant local services. The initial delivery was followed by a request for a prompt response.

RESULTS

Out of 216 enquired DMHs, 103 provided computable answers to the survey (response rate = 48%). Among responders, 45 (44%) reported the implementation of EIP (one out of five DMHs operating in Italy). About a half of the active EIPs also targeted patients at ultra-high risk of psychosis (n = 27). Strict application of guidelines related to drug prescription was reported in 35% of EIPs. Conversely, 90% provided some kind of structured psychotherapy and psychoeducation. Among EIPs, a minority reported willingness to provide initial assessment/contact at the patient's home.

CONCLUSION

Albeit slowly, the implementation of EIP is spreading throughout the Italian public network of mental health. There is still a wide variability in the distribution of EIP services across the Italian territory. Further efforts are necessary to stimulate policy endorsement and resource allocation, as well as to support the poorest zones.

Architecture and functioning of child and adolescent mental health services: a 28-country survey in Europe

The WHO Child and Adolescent Mental Health Atlas, published in 2005, reported that child and adolescent mental health services (CAMHS) in Europe differed substantially in their architecture and functioning. We assessed the characteristics of national CAMHS across the European Union (EU), including legal aspects of adolescent care. Using an online mapping survey aimed at expert(s) in each country, we obtained data for all 28 countries in the EU. The characteristics and activities of CAMHS (ie, availability of services, inpatient beds, and clinicians and organisations, and delivery of specific CAMHS services and treatments) varied considerably between countries, as did funding sources and user access. Neurodevelopmental disorders were the most frequent diagnostic group (up to 81%) for people seen at CAMHS (data available from only 13 [46%] countries). 20 (70%) countries reported having an official national child and adolescent mental health policy, covering young people until their official age of transition to adulthood. The heterogeneity in resource allocation did not seem to match epidemiological burden. Substantial improvements in the planning, monitoring, and delivery of mental health services for children and adolescents are needed.

Satisfaction with psychiatric in-patient care as rated by patients at discharge from hospitals in 11 countries

PURPOSE

There is disregard in the scientific literature for the evaluation of psychiatric in-patient care as rated directly by patients. In this context, we aimed to explore satisfaction of people treated in mental health in-patient facilities. The project was a part of the Young Psychiatrist Program by the Association for the Improvement of Mental Health Programmes.

METHODS

This is an international multicentre cross-sectional study conducted in 25 hospitals across 11 countries. The research team at each study site approached a consecutive target sample of 30 discharged patients to measure their satisfaction using the five-item study-specific questionnaire. Individual and institution level correlates of 'low satisfaction' were examined by comparisons of binary and multivariate associations in multilevel regression models.

RESULTS

A final study sample consisted of 673 participants. Total satisfaction scores were highly skewed towards the upper end of the scale, with a median total score of 44 (interquartile range 38-48) out of 50. After taking clustering into account, the only independent correlates of low satisfaction were schizophrenia diagnosis and low psychiatrist to patient ratio.

CONCLUSION

Further studies on patients' satisfaction should additionally pay attention to treatment expectations formed by the previous experience of treatment, service-related knowledge, stigma and patients' disempowerment, and power imbalance.

Stories of change: the text analysis of handovers in an Italian psychiatric residential care home

WHAT IS KNOWN ON THE SUBJECT?: There is a growing emphasis on communication as a result of the move towards the more inclusive approach associated with the community-based rehabilitation model. Therefore, more importance is attached to handovers. Besides ensuring transfer of information, handovers enhance group cohesion, socialize staff members to the practices of the service and capture its organizational culture. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: While handovers are mainly used for information transfer and to manage the services' daily routine, this paper offers an insight on how handovers can be conceived as valuable instruments to document cultural and organizational change. Only a limited amount of studies has focused on handovers in mental healthcare settings, and most of them only consider the perspectives of psychiatric nurses, while embracing a broader perspective, this paper provides valuable insights into the perspectives of various service providers. The overcoming of the dichotomy deficit-based vs. recovery-oriented model is possible if professionals use handovers to reflect upon their practice and the ways in which their cultural models are affected by the environmental context. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Handovers are valuable instruments to document organizational change. It would be important for psychiatric and rehabilitation facilities to keep track of the handover records over time as they may provide insightful information about cultural change and the transformations in the core values and beliefs held by professionals.

ABSTRACT

Handovers assure a timely and correct information transfer while socializing workers to the service's culture; however, no study describes them as instruments to document organizational change and only a few have focused on psychiatric settings. Aim To investigate the change in the culture of an Italian psychiatric residential care home as perceived by its mental health workers (MHWs) over the course of two decades. Method Emotional text analysis (ETA) was used to analyse the MHWs' handovers completed from 1990 to 2011. Results The analysis generated four clusters and three main factors illustrating the change in the MHWs' representations of the residential care home and its occupants. The factors showed: (1) the shift from an individualistic, problem-focused view to an inclusive, community-based approach; (2) the presence of a descriptive as well as a specialized language; and (3) the presence of a double focus: on patients and professionals. Conclusions Handovers transcripts document the following changes: (1) a shift from a symptom-based to a recovery-oriented approach; (2) a modification of the MHWs values towards an holistic view of the patient; (3) a growing importance assigned to accountability, services integration and teamwork. The paper shows that handovers can be used diachronically to document organizational change.

Involuntary admissions in Italy: the impact of seasonality

OBJECTIVE

The aim of this study is to assess the prevalence of involuntary admissions with regard to seasonality and clinical associated features, in a sample of patients admitted to a psychiatric unit in a period of 24 months.

METHODS

All subjects consecutively admitted to the Psychiatric Inpatient Unit of the San Luigi Gonzaga Hospital, Orbassano (University of Turin, Italy) from September 2013 to August 2015 were recruited. Socio-demographic and clinical characteristics were collected.

RESULTS

Seven hundred and thirty admissions in psychiatric ward were recognized. The prevalence of involuntary admission was 15.4%. Patients with involuntary hospitalizations showed a higher education level, a higher prevalence of admission in spring/summer with a significant peak in June, a longer duration of hospitalization and a lower suicide ideation. Among involuntary admissions, physical restraint and suicide attempts were more prevalent during spring compared to the other seasons.

CONCLUSIONS

Seasonality has an important role in the psychopathology of psychiatric disorders, particularly in bipolar and related disorder, and may represent an influencing factor in hospital admissions and hospitalizations. Seasonal pattern must be considered while managing diagnosis and treatment of mental disorders, with regard to prevention and psychoeducation of patients.

Do people with bipolar disorders have access to psychosocial treatments? A survey in Italy

BACKGROUND

Several guidelines consider psychosocial treatments an essential component of clinical management of bipolar disorders in addition to drug therapy. However, to what extent such interventions are available in everyday practice to the average patient attending mental health services is not known.

AIMS

This study aims to investigate access of people with bipolar disorders to psychosocial treatments in a community-based care system.

METHOD

Information on care delivery and service utilization were retrieved from the psychiatric database of Lombardy, Italy, covering a population of 9,743,000, for all adults who had at least one contact in 2009 with psychiatric services. Rates of patients with a diagnosis of bipolar disorder who had access to individual psychotherapy, couple/family therapy, group psychotherapy and family interventions were calculated and compared to patients with schizophrenia and depression.

RESULTS

A total of 8,899 subjects with bipolar disorder had been in contact with psychiatric services, corresponding to a treated annual prevalence rate of 1.1‰. More than 80% of patients were treated in community settings. Rates of patients receiving structured psychosocial treatments ranged from 0.7% for couple/family therapy to 6.1% for individual psychotherapy. No differences with patients with schizophrenia and depression were found. Patients with schizophrenia received more interventions labeled as rehabilitation.

CONCLUSION

Few people with bipolar disorders had access to psychosocial treatments. Even in a well-developed system of community care, offer of psychosocial interventions for bipolar disorders is inadequate. This issue should be a target for future research on dissemination and implementation strategies.

Differences in the use of involuntary admission across the Veneto Region: which role for individual and contextual variables?

AIMS

The first aim of this study is to compare involuntary admissions across the Veneto Region in Italy. The second aim is to explore the relation between mental health services provision, characteristics of population, individual factors and involuntary admissions.

METHODS

For 21 Mental Health Departments (MHDs) in the Veneto Region (Italy), the average population prevalence rate of involuntary admissions between 2000 and 2007 and the percentage of involuntary admissions were calculated. Chi-square tests for equality of proportions were used to test hypotheses. Variables at the individual, contextual and organisational levels were used in multiple regressions, with the involuntary admission data as dependent variables.

RESULTS

The average prevalence rate of involuntary commitment was 12.75 ranging from 1.96 to 27.59 across MHDs . About 75% of the involuntary admissions referred to psychotic patients, and almost half of patients were aged 25-44. Significant differences among MHDs emerged; higher percentages of involuntary admissions were generally found in densely populated areas. Higher ageing indices and rates of social workers were found as predictors of the prevalence rate. In the multilevel regression, being males and psychotic significantly increased involuntary admissions, while the percentage of singles in population decreased it.

CONCLUSIONS

This study contributes to define the specific contribution of each factor predicting the use of involuntary admission, even within areas under the same legislation. It shows how the inclusion of both individual and contextual factors may lead to better predictions and provides precious data for the services improvement.

Early intervention in psychosis: a feasibility study financed by the Italian Center on Control of Maladies

AIM

In November 2005 the Italian Center on Control of Maladies, a department operating under the Ministry of Health, financed a project aimed at evaluating the feasibility of a protocol of intervention based on the early intervention in psychosis (EIP) model within the Italian public mental health-care network.

METHODS

The study was carried out between March 2007 and December 2009. It involved five centres operating under the Departments of Mental Health of Milan (Programma 2000), Rome (area D), Grosseto, Salerno (Nocera) and Catanzaro (Soverato).

RESULTS

Enrolment lasted 12 months, at the end of which 43 patients were enrolled as first-episode psychosis (FEP), and 24 subjects as ultra high-risk (UHR) patients. Both FEP and UHR samples included a preponderance of male patients. A family history of psychosis was rarely reported in both samples. The FEP incidence rate was lower than expected on the basis of international estimates of the incidence of schizophrenia but within the expected figure for the estimated Italian rates in three centres out of five.

CONCLUSIONS

Overall, the study proved that an EIP centre can be established within the public Department of Mental Health to reach a good fraction of the cases in need of treatment. Since then, several studies have been set up to assess the feasibility of EIP in the Italian public mental health sector in Lombardy and Tuscany, and in 2012 the Emilia-Romagna Regional Authority started an educational plan aimed at implementing the EIP model in all the Mental Health Departments in the region.

Violent behavior of patients living in psychiatric residential facilities: a comparison of male patients with different violence histories

People with severe mental disorders and a history of violence are often seen as a difficult-to-manage segment of the population. In addition, this group is usually characterized by a high risk of crime recidivism, and poor compliance with community and aftercare programs. To investigate a sample of male patients living in Residential Facilities (RFs) with a history of violent behavior against people and to compare their characteristics with those of never-violent residents; to analyze the associations between aggressive behaviors in the last two years and a history of previous violence; and, to assess the predictors of aggressive behaviors. This study is part of a prospective observational cohort study which involved 23 RFs in Northern Italy. A comprehensive set of sociodemographic, clinical, and treatment-related information was gathered, and standardized assessments were administered to each participant. Also a detailed assessment of aggressive behaviors in the past two years was carried out. The study involved 268 males: 81 violent and 187 never-violent. Compared to never-violent patients, violent patients were younger, with a higher proportion of personality disorders, and have displayed an increased number of aggressive behaviors in the last two years. The presence of a history of violent behavior in the past significantly increases the probability of committing aggressive acts in the future.

Mental health services use and management of eating disorders in an Italian Department of Mental Health

OBJECTIVE

To investigate the clinical characteristics of patients with eating disorders referred to Community Mental Health Centers (CMHCs) in the Department of Mental Health of Bologna, Italy, and to evaluate the number and type of interventions delivered.

METHODS

Adult patients with eating disorders who had a first contact with CMHCs between January 1, 2007 and December 31, 2012 were extracted from Bologna Local Health Authority database. Moreover, the hospital discharge records of patients were linked to the mental health information system of Bologna.

RESULTS

Among the 276 patients with eating disorders identified, 59 (21.4%) were diagnosed as anorexia nervosa, 77 (27.9%) as bulimia nervosa and 140 (50.7%) as eating disorders not otherwise specified. The mean age of the sample was 37.3 (SD = 13.4), with no significant differences among the three diagnostic groups. The number of CMHCs outpatients increased each year from 2007 to 2011 and decreased in 2012. The proportion of new patients by year comprised about 50% of the total of patients. Psychotherapy accounted for about 10% of the interventions. Day-hospital and hospital admissions concerned 6.1 and 11.6% of the sample.

CONCLUSIONS

CMHCs are part of the system of care outlined by the Regional policies for eating disorders and are responsible for providing the first level of outpatient care to adults. To date, there is the need to extend our monitoring across the whole system of care, to assess the implementation of specific and effective strategies to decrease the age of access of patients and to improve the quality of care delivered with the inclusion of evidence-based treatments in the process of care.

Sex differences in first-episode psychosis and in people at ultra-high risk

Sex-related differences in the clinical expression and outcome of schizophrenia have long been recognized; this study set out to evaluate whether they extend to those subjects who are at high risk of developing psychosis. In a sample enrolled in two early intervention programs in northern Italy, patients with first-episode psychosis (FEP; n=152) were compared to patients at ultra-high risk of psychosis (UHR; n=106) on a series of sex-related clinical characteristics of schizophrenia. In both the FEP and the UHR samples, males outnumbered females. In FEP patients, women had been referred at an older age than men and had a shorter duration of untreated illness (DUI) and of untreated psychosis. In UHR patients no sex differences were found in age of onset or DUI. There was no diagnosis by sex interaction on symptoms severity or level of functioning at presentation. The limited number of women in both samples, and the exclusion of people who were older than 30 and of those with substance dependence may have reduced the extent of sex-related differences in this study. Sex differences of precipitating factors for psychosis might be worthy of further investigation.

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.

Is psychiatric residential facility discharge possible and predictable? A multivariate analytical approach applied to a prospective study in Italy

BACKGROUND

A growing number of severely ill patients require long-term care in non-hospital residential facilities (RFs). Despite the magnitude of this development, longitudinal studies surveying fairly large resident samples and yielding important information on this population have been very few.

AIMS

The aims of the study were (1) to describe the socio-demographic, clinical, and treatment-related characteristics of RF patients during an index period in 2010; (2) to identify predictors and characteristics associated with discharge at the 1-year follow-up; (3) to evaluate clinicians' predictions about each patient's likelihood of home discharge (HD).

METHODS

A prospective observational cohort study was conducted involving all patients staying in 23 medium-long-term RFs of the St John of God Order with a primary psychiatric diagnosis. A comprehensive set of socio-demographic, clinical, and treatment-related information was gathered and standardized assessments (BPRS, HONOS, PSP, PHI, SLOF, RBANS) were administered to each participant. Logistic regression analyses were run to identify independent discharge predictors.

RESULTS

The study involved 403 patients (66.7% male), with a mean age of 49 years (SD = 10). The participants' average illness duration was 23 years; median value for length of stay in the RF was 2.2 years. The most frequent diagnosis was schizophrenia (67.5%). 104 (25.8%) were discharged: 13.6% to home, 8.2% to other RFs, 2.2% to supported housing, and 1.5% to prison. Clinicians' predictions about HD were generally erroneous.

CONCLUSIONS

Very few patients were discharged to independent accommodations after 1 year. The main variables associated with a higher HD likelihood were: illness duration of <15 years and effective social support during the previous year. Lower severity of psychopathology and higher working skill levels were also associated with a significantly greater HD likelihood.

Patterns of referral in first-episode schizophrenia and ultra high-risk individuals: results from an early intervention program in Italy

PURPOSE

This study set out to investigate the patterns of referral in a sample (n = 206) of patients having first-time access to an Italian comprehensive program that targets the early detection of and early intervention on subjects at the onset of psychosis. The primary goal of the study was to investigate the duration of untreated illness (DUI) and/or the duration of untreated psychosis (DUP) in the sample since the implementation of the program.

METHOD

Data on pathways of referrals prospectively collected over a 11-year period, from 1999 to 2010; data referred to patients from a defined catchment area, and who met ICD-10 criteria for a first episode of a psychotic disorder (FEP) or were classified to be at ultra-high risk of psychosis (UHR) according to the criteria developed by the Personal Assessment and Crisis Evaluation (PACE) Clinic in Melbourne. Changes over time in the DUI and DUP were investigated in the sample.

RESULTS

Referrals increased over time, with 20 subjects enrolled per year in the latter years of the study. A large majority of patients contacted a public or private mental health care professional along their pathway to treatment, occurring more often in FEP than in UHR patients. FEP patients who had contact with a non-psychiatric health care professional had a longer DUP. Over time, DUP and DUI did not change in FEP patients, but DUI increased, on average, in UHR patients.

CONCLUSIONS

The establishment of an EIP in a large metropolitan area led to an increase of referrals from people and agencies that are not directly involved in the mental health care system; over time, there was an increase in the number of patients with longer DUI and DUP than those who normally apply for psychiatric services.

Heterogeneity and symptom structure of schizophrenia

Previous studies failed to identify a consistent factor structure of the BPRS-24 in schizophrenia. Our aims were to examine the fit of all previously published factor models and then to explore unobserved population heterogeneity and identify salient latent classes. Two hundred thirty-nine patients with ICD-10 schizophrenia admitted to a random sample of all Italian public and private acute inpatient units during an index period were administered the BPRS-24. Confirmatory factor analysis (CFA) was used to test all factor models derived in previous studies. Then, factor mixture analysis (FMA) with heteroscedastic components was carried out to explore unobserved population heterogeneity. No previously reported factor solution showed adequate fit in CFA. FMA indicated the presence of three heterogeneous groups and yielded a 5-factor solution (Depression, Positive Symptoms, Disorganization, Negative Symptoms, Activation). Group 1 was characterized by higher Disorganization, lower Activation, lower psychosocial functioning, greater lifetime number of admissions, more frequent history of compulsory admission. Group 2 displayed lower Disorganization. Group 3 showed higher Activation and more frequent history of recent self-harming behavior. Our finding that a reliable factor structure for the BPRS-24 could be obtained only after assuming population heterogeneity suggests that the difficulty in identifying a consistent factor structure may be ascribed to the clinical heterogeneity of schizophrenia. As compared with clinical subtypes, the psychopathological dimensions displayed much greater discriminatory power between groups identified by FMA. Though preliminary, our findings corroborate that a dimensional approach to psychopathology can facilitate the assessment of the clinical heterogeneity of schizophrenia.

State of psychiatry in Italy 35 years after psychiatric reform. A critical appraisal of national and local data

Thirty-four years have elapsed since the passing of the Italian Law 180, the reform law that marked the transition from a hospital-based system of care to a model of community psychiatry that was designed to be an alternative to, rather than to complement, the old hospital-centred services. The main principle of Law 180 is that psychiatric patients have the right to be treated the same way as patients with other diseases and only voluntary treatments are allowed, with a few exceptions that are strictly regulated. The main features and consequences of the Italian reform are initially reviewed; national and local level experiences and epidemiological data are then analysed in order to highlight and disentangle the 'active ingredients' of the Italian experience. A public health attitude with the capacity to network good practice in service organization by giving voice to successful experiences and promoting health service research, apart from some local services, is still generally lacking. Furthermore, it is still difficult to provide an evidence-based reply to the question: can à l'Italienne community-care be exported elsewhere?

Integration between Primary Care and Mental Health Services in Italy: Determinants of Referral and Stepped Care

This study, carried out in the context of a collaborative care program for common mental disorders, is aimed at identifying the predictors of Primary Care Physician (PCP) referral to Community Mental Health Center (CMHC) and patterns of care. Patients with depression or anxiety disorders who had a first contact with CMHCs between January 1, 2007-December 31, 2009 were extracted from Bologna Local Health Authority database. A classification and regression tree procedure was used to determine which combination of demographic and diagnostic variables best distinguished patients referred by PCPs and to identify predictors of patterns of care (consultation, shared care, and treatment at the CMHC) for patients referred by PCPs. Of the 8570 patients, 57.4% were referred by PCPs. Those less likely to be referred by PCPs were living in the urban area, suffered from depressive disorder, and were young. As to the pattern of care, patients living in the urban area were more likely to receive shared care compared with those living in the nonurban area, while the reverse was true for consultation. Predictors of CMHC treatment were depression and young age. Prospective studies are needed to assess length, quantity, and quality of collaborative treatment for common mental disorder delivered at any step of care.

The characteristics and activities of child and adolescent mental health services in Italy: a regional survey

BACKGROUND

To date, no studies have assessed in detail the characteristics, organisation, and functioning of Child and Adolescent Mental Health Services (CAMHS). This information gap represents a major limitation for researchers and clinicians because most mental disorders have their onset in childhood or adolescence, and effective interventions can therefore represent a major factor in avoiding chronicity. Interventions and mental health care are delivered by and through services, and not by individual, private clinicians, and drawbacks or limitations of services generally translate in inappropriateness and ineffectiveness of treatments and interventions: therefore information about services is essential to improve the quality of care and ultimately the course and outcome of mental disorders in childhood and adolescence.The present paper reports the results of the first study aimed at providing detailed, updated and comprehensive data on CAMHS of a densely populated Italian region (over 4 million inhabitants) with a target population of 633,725 subjects aged 0-17 years.

METHODS

Unit Chiefs of all the CAMHS filled in a structured 'Facility Form', with activity data referring to 2008 (data for inpatient facilities referred to 2009), which were then analysed in detail.

RESULTS

Eleven CAMHS were operative, including 110 outpatient units, with a ratio of approximately 20 child psychiatrists and 23 psychologists per 100,000 inhabitants aged 0-17 years. All outpatient units were well equipped and organized and all granted free service access. In 2008, approximately 6% of the target population was in contact with outpatient CAMHS, showing substantial homogeneity across the eleven areas thereby. Most patients in contact in 2008 received a language disorder- or learning disability diagnosis (41%). First-ever contacts accounted for 30% of annual visits across all units. Hospital bed availability was 5 per 100,000 inhabitants aged 0-17 years.

CONCLUSION

The percentage of young people in contact with CAMHS for mental disorders is in line with those observed in previous epidemiological studies. The overall number of child psychiatrists per 100,000 inhabitants is one of the highest in Europe and it is comparable with the most well equipped areas in the US. This comparison should be interpreted with caution, however, because in Italy, child psychiatrists also treat neurological disorders. Critical areas requiring improvement are: the uneven utilisation of standardised assessment procedures and the limited availability of dedicated emergency services during non-office hours (e.g., nights and holidays).

Saúde mental e os planos de saúde no Brasil

O artigo analisa o regime de regulação da assistência à saúde mental implantado pela Agência Nacional de Saúde Suplementar. Descreve as condições observadas entre a provisão de serviços de saúde mental no setor de planos privados de assistência à saúde em relação à experiência internacional e ao Sistema Único de Saúde (SUS). O artigo demonstra que a assistência à saúde mental do setor apresenta as falhas associadas ao mercado de seguro saúde. As empresas de planos de saúde adotam mecanismos de copagamento, estabelecem limites de utilização para consultas ambulatoriais, enfatizam o tratamento dos casos graves por internação hospitalar de curta duração e oferecem residualmente serviços de suporte ao paciente após a alta. Existem evidências de um descompasso entre o processo de desinstitucionalização em curso no SUS e a regulação implantada pela ANS. Em fins da década de 2000, foi observada a expansão da quantidade das internações psiquiátricas que resultaram em taxas elevadas de admissão se comparadas ao setor público no Brasil.

Italian psychiatric reform 1978: milestones for Italy and Europe in 2010?

The Italian psychiatric reform of 1978 was one of the most radical attempts in history to abolish the practise of custodial psychiatry using legislation. The work of the charismatic reformer Franco Basaglia had four main objectives, which have taken more than 30 years to achieve. Although the creation of outpatient mental health centres and a reduction in involuntary commitments occurred rapidly, the expensive development of small acute psychiatric departments in general hospitals as an alternative to psychiatric hospitals was implemented very slowly. According to a national survey by the Italian Ministry of Health, in 2001, there were a total of 9,300 acute beds for all of Italy, of which as many as 4,000 were in private facilities. With 1.72 acute beds per 10,000 inhabitants, Italy has one of the lowest figures in Europe of psychiatric beds. However, Italy's apparent and often praised low bed requirement places a large burden on families. The implementation of the reform process was most delayed and occurred at its worst in South Tyrol, in North Italy. In an effort to achieve a modern and progressive community-based psychiatric service, in particular one with more specialised services, mental health providers in this region have examined German, Austrian and Swiss models of psychiatric practice.

Payments and quality of care in private for-profit and public hospitals in Greece

BACKGROUND

Empirical evidence on how ownership type affects the quality and cost of medical care is growing, and debate on these topics is ongoing. Despite the fact that the private sector is a major provider of hospital services in Greece, little comparative information on private versus public sector hospitals is available. The aim of the present study was to describe and compare the operation and performance of private for-profit (PFP) and public hospitals in Greece, focusing on differences in nurse staffing rates, average lengths of stay (ALoS), and Social Health Insurance (SHI) payments for hospital care per patient discharged.

METHODS

Five different datasets were prepared and analyzed, two of which were derived from information provided by the National Statistical Service (NSS) of Greece and the other three from data held by the three largest SHI schemes in the country. All data referred to the 3-year period from 2001 to 2003.

RESULTS

PFP hospitals in Greece are smaller than public hospitals, with lower patient occupancy, and have lower staffing rates of all types of nurses and highly qualified nurses compared with public hospitals. Calculation of ALoS using NSS data yielded mixed results, whereas calculations of ALoS and SHI payments using SHI data gave results clearly favoring the public hospital sector in terms of cost-efficiency; in all years examined, over all specialties and all SHI schemes included in our study, unweighted ALoS and SHI payments for hospital care per discharge were higher for PFP facilities.

CONCLUSIONS

In a mixed healthcare system, such as that in Greece, significant performance differences were observed between PFP and public hospitals. Close monitoring of healthcare provision by hospital ownership type will be essential to permit evidence-based decisions on the future of the public/private mix in terms of healthcare provision.

Do patients improve after short psychiatric admission?: a cohort study in Italy

BACKGROUND

Information on outcomes of acute inpatient care in routine psychiatric practice is scant. In particular, it is uncertain to what extent short hospitalization can produce clinically meaningful changes.

AIM

Our aim was to estimate the symptomatic outcome in a representative sample of patients admitted for short treatment to general hospital psychiatric units in Italy.

METHODS

Patients were assessed at admission and discharge using 24-item Brief Psychiatric Rating Scale (BPRS). Reliable change index was calculated to estimate the proportion of change attributable to measurement error and a cut-off score of 38 was adopted to identify the patients who showed clinically significant change.

RESULTS

Average length of stay was 5.7 days. Mean BPRS score dropped from 53.2 on admission to 41.5 at discharge, showing statistically significant improvement with an effect size of 0.80. However, reliable change was achieved by 24.7% of patients and clinically meaningful change by 13.6%.

CONCLUSIONS

Reliance on statistical significance and effect size overestimates treatment effects, whereas reliable and clinically significant change index provides a conservative way to assess outcome. Few patients showed relevant improvement after a brief admission.

Psychopharmacology of aggression in schizophrenia

The management of aggression in patients with schizophrenia is a complex and challenging clinical dilemma. It also is greatly influenced by prevailing societal and medicolegal considerations regarding the perceived associations between violence and mental illness. This article provides a succinct account of a complex area and offers evidence for available treatments to reduce the occurrence of violent behavior among patients with schizophrenia.

DRGs and other patient-, service- and area-level factors influencing length of stay in acute psychiatric wards: the Veneto Region experience

PURPOSE

This study aimed to identify services-related and area-based measures together with socio-demographic factors that could improve diagnosis-related groups in explaining length of stay variability in general hospital psychiatric units in Veneto Region (North East of Italy).

METHODS

Data were collected from the regional hospital discharge records database. A hierarchical multiple regression model with only diagnosis-related groups as predictors of actual and ln-transformed length of stay was compared with a second model in which patient-, service- and area-level variables were included. Local health district was used as group-level in the hierarchical multiple regression analysis.

RESULTS

The only diagnosis explains 6.4% of actual length of stay total variance (14.8% for ln-transformation). In the second model length of stay resulted related also to gender, age, severity of hospitalization, patient's local health district, number of psychiatrists, psychologists, hospital attendants/nurses, social workers and educators in the general hospital psychiatric units, number of outpatients in each local health district and percentages of divorced and single people, with almost a 2% point increase on actual length of stay in explained variance (5% point increase for ln-transformation).

CONCLUSIONS

For the first time the hospital discharge card regional survey of all public acute inpatient psychiatric facilities in Veneto Region were used. The innovative aspect of this study was the attempt to investigate the relationship between length of stay and other indexes, characterizing not only the inpatient facilities, but also the resident population structure in each area. The information about factors that influence length of stay can be useful to inform service planning and resource allocation.

Psychoactive substance use among patients admitted to an acute psychiatric ward: laboratory findings and associations with clinical characteristics

BACKGROUND

Estimates of psychoactive substance use among acutely admitted psychiatric patients vary among studies, and few have used comprehensive laboratory methods.

AIMS

This study used chromatography-based analyses of blood and urine to identify the rates of substance use among acute psychiatric admissions, and to study the associations with socio-demographic variables, clinical characteristics and patients' reports of symptoms, substance use and need for treatment.

METHODS

A cross-sectional study was conducted in 2006/2007 in Oslo, Norway. Blood and urine samples were collected from 298 acute psychiatric admissions and extensively analysed for alcohol, medicinal and illicit drugs. Psychotic symptoms were assessed with the positive subscale of the Positive and Negative Syndrome Scale. Patient self-report questionnaires included the Alcohol and Drug Use Disorder Identification Tests. Patients were also asked if they needed professional help for substance use.

RESULTS

Psychoactive substances were detected in 63% of the 298 admissions, medicinal drugs in 46%, alcohol in 12% and illicit drugs in 28%. Patients using alcohol had a high suicidal risk score at admission and the shortest length of stay (median 1 day). Use of illicit drugs was associated with psychotic symptoms and readmission. Self-report questionnaires indicated harmful use of alcohol for half of the patients and of other substances for one-third. A need for professional help for substance use was reported by one-third of patients.

CONCLUSION

Given the high rates of substance use and the important clinical associations, drug screening seems warranted in acute psychiatric settings. Interventions designed for substance-using patients should be developed and integrated.

Shortage and underutilization of psychiatric beds in southern Brazil: independent data of Brazilian mental health reform

BACKGROUND

Mental health policies throughout the world are being subjected to several changes due to increased pressure from the public and from health administrators. Mental health policies in the developing world experienced changes following advice and consultation from the World Health Organization (WHO). This was the case with Brazil, which enacted several laws and policies affecting community care and the closure of beds in psychiatric hospitals (the deinstitutionalization movement). Rio Grande do Sul, the southeast state in Brazil, adopted this policy in 1992, but still suffers from a shortage of psychiatric beds in both general hospitals (GHs) and psychiatric hospitals (PHs), despite advances in the provision of community care. As a result, Rio Grande do Sul (RS) can be studied as an example of "what actually happens" in mental health care in the developing world.

METHODS

The study analyzed online administrative data from 2000 to 2007 for three main parameters of mental health care (i.e. hospital use rate, length of stay, and hospital bed capacity). These were used to evaluate differences in psychiatric care among GHs and PHs. The number of existing and required psychiatric beds in RS was also calculated.

RESULTS

GHs had very low hospital use rates, while PHs had a very high length of stay (200% higher than GH). The number of admissions to GHs grew by 170% over the 8 year period, and psychiatric bed availability was 1.5 per 10,000 inhabitants.

CONCLUSIONS

The study provided evidence for the need of 30-50% more psychiatric beds in GHs. Also, additional staff training is needed to increase use rates in GHs and decrease the length of stay in PHs. Additional studies covering national data must be carried out to assess the extent of these problem in other Brazilian mental health care services.

Factors associated with hospitalisation of patients with schizophrenia in four European countries

PURPOSE

To analyse factors associated with hospitalisation in patients with schizophrenia from four European countries, and to investigate whether national specificities might have an impact on the profile of inpatients.

METHOD

A randomly selected sample of psychiatrists (N = 744), from Germany, Greece, Italy and Spain, collected data on the five last patients with schizophrenia they had seen in consultation (N = 3996).

RESULTS

High positive symptoms, lack of insight, not living with the family, frequent past episodes, addiction to illegal drugs, global severity, uncooperativeness and smoking were significantly associated with hospitalisation, with OR between 4.1 and 1.26. Nevertheless, only high positive symptoms from the PANSS and lack of insight were systematically detected in the four countries. Among different results, the weight of "not living with the family" had national specificities, as Germany was the only country where this factor played no role (OR = 0.94).

CONCLUSION

Although some factors such as positive symptoms are associated with hospitalisation in a very homogenous way throughout different countries, discrepancies were detected between countries, for "living with the family", "number of past acute relapses" and "uncooperativeness". Linking these specificities to national healthcare systems might be useful to promote access to care for all patients.

Outcome and length of stay in psychiatric hospitalization, the experience of the University Clinic of Turin

BACKGROUND

Given the current tendency to shorten psychiatric hospitalization and change its organization, an issue could be raised regarding its outcomes.

PURPOSE

To analyze features related to length of stay in a short-term inpatient treatment, to study outcomes and to evaluate the diagnosis-specific effects of hospitalization.

METHOD

A sample of 310 consecutive hospitalized patients, with psychotic disorder, depressive disorder and bipolar disorder (DSM IV-TR), was recruited at the University Psychiatric Clinic, Service for Cognitive Disorders, Department of Neuroscience, University of Turin. Severity of illness was rated using the brief psychiatry rating scale (BPRS). We evaluated relations between length of stay and clinical and socio-demographic features (linear regression) and possible differences confronting BPRS scores at admission and discharge in the different diagnostic subgroups (ANOVA for repeated measures).

RESULTS

All the sample of patients showed a significant improvement in symptomatology during hospitalization. Worse symptomatology in anxiety-depression domain of BPRS at admission in the whole sample was positively correlated with length of stay. A longer length of stay was also shown in patients with diagnosis of depressive disorder. Finally, a different pattern of improvement of BPRS (total score and domains) was shown between the different diagnostic groups.

CONCLUSION

Brief hospitalization in our service was shown to be highly effective. Different diagnostic groups had different response to hospitalization, showing faster improvement in characteristic symptomatology, but the anxiety-depression domain showed the highest percentage of change for all the diagnostic groups. We therefore suppose that hospitalization has two effects: a specific (due to tailored therapies) and a non-specific one (due to non-specific therapy and to a placebo-like effect).

Correlates and antecedents of hospital admission for attempted suicide: a nationwide survey in Italy

The present study examined data on symptom patterns in the week prior to admission for suicide attempt, in a nationwide representative sample of patients. Socio-demographic, clinical, and treatment data was gathered for 1,547 patients admitted over a 12-day index period during the year 2004 to 130 public and 36 private psychiatric facilities in Italy. Patients were evaluated in terms of whether they had been admitted for having attempted suicide or not. A detailed checklist was used to assess symptom pattern at admission; diagnoses were based on ICD-10 categories. Two-hundred thirty patients (14.8%) in the sample had been admitted for suicide attempt. Patients with depression or with personality disorders were more frequently observed among suicide attempters. First-contact patients were significantly more likely to have been admitted after a suicide attempt, the only exception being individuals with bipolar disorder, manic phase. No diagnosis was statistically related to admission after suicide attempt, once symptoms pattern at admission had been accounted for. Disordered eating behavior, depressive symptoms, substance abuse, and non-prescribed medication abuse were positively related to attempted suicide, as were any traumatic events in the week prior to admission; symptoms of psychosis (hallucinations/delusions) and lack of self-care were negatively associated with suicide attempt admission. Greater attention to symptoms immediately preceding or concomitant with admission after a suicide attempt can be a key factor in establishing the best treatment plan and discharge strategy, the most effective community-service referral, and targeted intervention programmes for patients hospitalized for a suicide attempt.

First-ever admitted psychiatric inpatients in Italy: clinical characteristics and reasons contributing to admission: findings from a national survey

The aim of this study was to describe the sociodemographic, clinical and treatment-related characteristics of patients admitted to any acute psychiatric inpatient facilities in Italy for the first time in their life, and to identify reasons contributing to admission. Data from the PROGRES-Acute Project, a national survey on facilities admitting acute psychiatric patients in Italy, were used. A cluster analysis was carried out in order to identify patients' groups sharing similar sociodemographic and clinical characteristics. Among patients admitted during the index period, 337 were at their first-ever admission. Median age at admission was 40, and about 46% of patients were not receiving any treatment in the month prior to admission. Social/work functioning problems, social withdrawal and conflict with family members were the most common reasons contributing to admission. Cluster analysis yielded four patient groups: two groups of younger subjects, differentiating each other for frequency of antisocial behaviors, compulsory admissions, treatment at time of admission and family support; two groups of older subjects, with high rates of affective disorders, who showed remarkable differences with regard to their living situation and family support. Our study shows that first-ever admitted patients represent a highly heterogeneous group. Early intervention research should take this sociodemographic and clinical diversity into account, in order to better allocate resources and develop special intervention programs.

'Programma2000': a multi-modal pilot programme on early intervention in psychosis underway in Italy since 1999

AIM

The aim of this study was to describe a service operating in Milan, Italy, that provides early intervention for young people aged 17-30 years at the onset and at high risk of psychosis.

METHOD

Following 2 years of preliminary study and organization, Programma2000 was launched in Milan in 1999. This programme was targeted at early detection and intervention in subjects at the onset of, at risk of, or showing 'prodromal' signs of psychosis. This paper contains data on the organization and activities of Programma2000.

RESULTS

The service has been active since its launch and has received 378 referrals as of March 2009, 342 of which were thoroughly evaluated. At entry, patients undergo a detailed evaluation of their psychopathology, personal and social role functioning, and cognitive status, with repeated testing over time in order to multidimensionally assess outcome. Treatment involves cognitive-behavioural psychotherapy, structured and unstructured psychosocial interventions, and pharmacotherapy when deemed necessary. Treatment appears effective in reducing morbidity and improving social functioning.

CONCLUSION

A team dedicated to the early identification and treatment of young people with early psychosis is a feasible and sustainable extension of the traditional methods of care for people with mental disorders in Italy.

Violent behavior in acute psychiatric inpatient facilities: a national survey in Italy

Violence committed by acute psychiatric inpatients represents an important and challenging problem in clinical practice. Sociodemographic, clinical, and treatment information were collected for 1324 patients (677 men and 647 women) admitted to Italian public and private acute psychiatric inpatient facilities during an index period in 2004, and the sample divided into 3 groups: nonhostile patients (no episodes of violent behavior during hospitalization), hostile patients (verbal aggression or violent acts against objects), and violent patients (authors of physical assault). Ten percent (N = 129) of patients showed hostile behavior during hospitalization and 3% (N = 37) physically assaulted other patients or staff members. Variables associated with violent behavior were: male gender, <24 years of age, unmarried status, receiving a disability pension, having a secondary school degree, compulsory admission, hostile attitude at admission, and a diagnosis of schizophrenia, bipolar disorder, personality disorder, mental retardation, organic brain disorder or substance/alcohol abuse. Violent behavior during hospitalization was a predictive factor for higher Brief Psychiatric Rating Scale scores and for lower Personal and Social Performance scale scores at discharge. Despite the low percentage of violent and hostile behavior observed in Italian acute inpatient units, this study shed light on a need for the careful assessment of clinical and treatment variables, and greater effort aimed at improving specific prevention and treatment programs of violent behavior.

Patterns of care in patients discharged from acute psychiatric inpatient facilities: a national survey in Italy

OBJECTIVE

To analyze the characteristics of patients scheduled for discharge from acute psychiatric inpatient facilities in Italy, and their pattern of care.

METHODS

Socio-demographic and clinical characteristics, and patterns of care of 1,330 patients discharged from public and private inpatient facilities in Italy were assessed with a standardized methodology during an index period in the year 2004.

RESULTS

About one half of the sample had schizophrenia or bipolar disorder. However, the case-mix differed between public and private facilities, where in-patients had more frequently mood and anxiety disorders. The use of two or more drugs was very common, involving more than 90% of patients and including typically benzodiazepines and antipsychotics. Structured psychosocial treatments were rarely initiated during the hospital stay. Increasing age, male gender, long stay in the facility (>60 days), personality disorder and type of facility were associated with a higher likelihood of being discharged to a community residential facility. Predictors of discharge to another psychiatric facility were increasing age, being single, schizophrenia, personality disorder and organic mental disorder. Families were not involved in decisions about patients' discharge in a significant proportion of cases. University psychiatric clinics and private facilities were less coordinated with the community system of care than General Hospital Psychiatric Units. Referral of patients with substance use disorder to drug addiction services occurred in just 30% of subjects.

CONCLUSIONS

This study provides information on the characteristics and the pattern of care of patients discharged from inpatient facilities in a country that has closed down all its mental hospitals. This information may be relevant for those countries that are affording now the downsizing of MHs, and the expansion of community-based models of care.

Long-stay in short-stay inpatient facilities: risk factors and barriers to discharge

Background

The aim of the present study was to assess the characteristics of long-stay inpatients in public and private Italian acute inpatient facilities, to identify risk factors and correlates of the long duration of hospital stay in these patients, and to identify possible barriers to alternative placements.

Methods

All patients in 130 Italian public and private psychiatric inpatient units who had been hospitalized for more than 3 months during a specific index period were assessed with standardized assessment instruments and compared to patients discharged during the same index period, but staying in hospital for less than 3 months (short-stay inpatients). Assessed domains included demographic, clinical, and treatment characteristics, as well as process of care. Logistic regression analysis was used to identify specific variables predicting inpatient long-stay status. Reasons for delaying patient discharge, as reported by treatment teams, were also analyzed.

Results

No overall differences between long-stay and short-stay patients emerged in terms of symptom severity or diagnostic status. Admission to a private inpatient facility and display of violent behavior during hospital stay were the most powerful predictors of long-stay. Lack of housing and a shortage of community support were the reasons most commonly cited by treatment teams as barriers to discharge.

Conclusion

Extra-clinical factors are important determinants of prolonged hospitalization in acute inpatient settings.

Falls in a psychiatric institution in Beijing, China

PURPOSE

This study aimed to determine the rate of falls and their relationship with sociodemographic and clinical factors in a psychiatric institution in Beijing, China.

DESIGN AND METHODS

The case notes of 7,921 inpatients were scrutinized to identify patients who fell while in the hospital.

FINDINGS

The fall rate in this study was 1.2% of all inpatients. Nearly all (89.7%) falls occurred when patients attempted to stand up, get out of bed, or walk.

PRACTICE IMPLICATIONS

Effective measures should be provided to prevent falls in psychiatric wards. A prospective study exploring predictors of falls is warranted.

Patterns of admission to acute psychiatric in-patient facilities: a national survey in Italy

BACKGROUND

A proper understanding of patterns of care represents a crucial step in improving clinical decision making and enhancing service provision. Only a few studies, however, have explored global patterns of psychiatric admissions nationwide, and none have been undertaken in Italy.

METHOD

Sociodemographic, clinical and treatment-related information was collected for 1577 patients admitted to 130 public and 36 private in-patient facilities in Italy during an index period in the year 2004. All patients were also rated using the 24-item Brief Psychiatric Rating Scale (BPRS) and the Personal and Social Performance (PSP) rating scales.

RESULTS

Non-affective psychoses (36%) were the most common diagnoses and accounted to a large extent for compulsory admissions. Private facilities were more likely to admit patients with organic mental disorders and substance abuse/dependence and less likely to admit patients with non-affective psychoses. Overall, 77.8% of patients had been receiving treatment by a mental health professional in the month prior to admission. In 54% of cases, the admission was solicited by patients' family members. The main factors preceding admission were impairment in work or social functioning, social withdrawal, and conflict with family members. Agitation, delusions and/or hallucinations, and the presence of multiple problems were associated with compulsory admissions, whereas depressive and anxiety symptoms were associated with voluntary admissions.

CONCLUSIONS

In a mixed, public-private psychiatric care system, like the Italian one, public and private facilities admit patients with widely different clinical characteristics and needs. Family support represents an important resource for most patients, and interventions specifically addressed to relieving family burden are warranted.

Programma 2000: celebrating 10 years of activity of an Italian pilot programme on early intervention in psychosis

OBJECTIVE

This paper describes the structure and the organization of the single Italian programme specifically targeted at the early detection of and interventions for subjects at onset of or at high risk of psychosis, Programma 2000.

METHODS

Programma 2000 is a comprehensive multi-modal protocol of early intervention in psychosis, set up in Milan in 1999. The service has been very active since its opening, and at the time of writing (spring (April) 2008), more than 300 young patients have been evaluated through a detailed protocol that embraces Health of the Nation Outcome Scale (HoNOS), Brief Psychiatric Rating Scale (BPRS), Cognitive Behavioural Assessment 2.0, Disability Assessment Schedule, Camberwell Family Interview, Wechsler Adult Intelligence Scale and the Early Recognition Inventory Retrospective Assessment of Symptoms. The treatment includes psychoeducation, cognitive behavioural therapy (CBT), both structured and unstructured psychosocial interventions and pharmacotherapy, when necessary.

RESULTS

The programme focuses on young people aged 17-30 years: to date, a total of 132 subjects with definite psychosis or within the high-risk category have been enrolled in treatment after assessment. Patients with first-episode psychosis were, on average and expectedly, more severe than those in the at-risk group, and were more likely to be prescribed antipsychotic drugs. A large majority of patients in both groups received tailored CBT; individual sessions of skills training were provided to two-thirds of patients. In both groups, improvement was found in both the BPRS and HoNOS, and in the level of global functioning as assessed on Global Assessment of Functioning at 6 month and 1 year follow up. Global functioning was more sensitive to change than symptom severity, reflecting the intensive and personalized efforts to improve social and role functioning in patients.

CONCLUSIONS

Programma 2000 is still in development but it has already gained the support of therapists and other relevant people involved in the life of subjects at onset, or at high risk of psychosis.