[Closing forensic psychiatric hospitals in Italy: a new deal for mental health care?]

Difference between forensic patients with schizophrenia spectrum disorders in Italy and other European countries: Results of the EU-VIORMED project

BACKGROUND

There has been a substantial change in the law on the provision of secure health services for offender-patients in Italy, a country currently with the lowest general psychiatry bed availability per head of the population in Europe, raising questions about possible differences in offender-patient admissions between European countries.

AIMS

In this multicentre case-control study, our aim was to compare the socio-demographic, clinical and criminological characteristics of a sample of Italian forensic in-patients with schizophrenia or similar psychosis with patients in a similar diagnostic range in specialist in-patient services elsewhere in Europe.

METHODS

Secure hospital unit in-patients with psychosis were recruited across five European countries (Italy, Austria, Germany, Poland and England). Consenting patients were interviewed by researchers and assessed using a multidimensional standardised process. Within country similarities between Austria, Germany, Poland and England were confirmed.

RESULTS

Overall, 39 Italian participants had had fewer years of education than the 182 patients in the other countries and were less likely to have ever had skilled or professional employment. The Italian patients had been older at first contact with any mental health services than the other Europeans. Diagnosed comorbidity rates were similar, but the Italian group reported higher levels of disability. Although the other European forensic patients were more likely to be undergoing treatment at the time of their index offence, they were also more likely to have been poorly compliant with treatment. The rate of suicide-related behaviours was significantly lower among the Italian patients than among the others.

CONCLUSIONS

Notwithstanding similar diagnoses, important differences emerged between patients in Italian forensic mental health resident services and those in four other European countries, some possibly reflecting less access to earlier relevant services in Italy. Others, including lower disability ratings among the Italian patients and a lower rate of suicide-related behaviours, may indicate that the Italian reforms carry benefits. This is worthy of further evaluation.

Protection of Prisoners with Mental Health Disorders in Italy: Lights and Shadows after the Abolition of Judicial Psychiatric Hospitals

In Italy, a person suffering from a mental disorder who commits a crime will be given a custodial security order and serve the period of admission at a Residenza per la esecuzione delle misure di sicurezza (REMS) (Residence for the Execution of Security Measures, hereinafter "REMS"). These institutions have been established recently and though equipped with the necessary safety measures, the focus is on psychiatric therapy. Despite being present on a national scale, access is very limited in terms of capacity. Immediate remedial measures are needed, so much so that the European Court of Human Rights recently condemned Italy for this very reason. This article, through a review of the constitutive principles of these institutions, shows how they have very positive aspects such as the attention to necessary psychotherapy in order to protect the right to health and the real taking charge of the fragility of the subjects; however, it is seen how there are many negative aspects linked above all to the scarce availability of places in these structures. The article provides suggestions on a more comprehensive strategy for facilities for detainees with mental disorders.

The Prevalence of PTSD in a Forensic Psychiatric Setting: The Impact of Traumatic Lifetime Experiences

Background

Several studies have identified traumatic history among forensic patients and its association with criminal behaviors and psychiatric diagnoses. Post-traumatic stress disorder (PTSD) is highly prevalent in forensic settings causing a serious deterioration of the primary psychiatric disorder.

Aims

Our study aims to evaluate the prevalence of PTSD and the role of traumatic experiences and abuse in the development of severe psychiatric disorders in a sample of psychiatric offenders.

Methods

Fifty-three patients admitted in Italian high intensity therapeutic facilities-the Residenze per l'Esecuzione delle Misure di Sicurezza (REMS)-were evaluated with the Trauma Experience Checklist (TEC) and the Millon Clinical Multiaxal Inventory (MCMI-III) to study lifetime traumatic memories and general psychopathology, respectively.

Results

Preliminary findings show that about 41% (N = 22) of psychiatric offenders were affected by PTSD, often not due to a single episode but to multiple lifetime traumas. Therefore, lifetime traumatic experiences and specifically sexual abuse are significant risk factors for the development of a personality disorder, which is present in the 38% (N = 20) of the sample.

Conclusions

The high PTSD prevalence and the strong association found between trauma and abuse with the development of a personality disorder emphasizes the importance of an early evaluation and intervention on traumatic experiences in this difficult population of psychiatric patients; in fact, the treatment of psychiatric offenders is actually vague and devoid of scientific evidence. Our results open up the perspective on the use of known and specific interventions for trauma, such as EMDR and Mindfulness.

European violence risk and mental disorders (EU-VIORMED): a multi-centre prospective cohort study protocol

BACKGROUND

The link between schizophrenia spectrum disorders (SSD) and violence is a core issue for most forensic psychiatric services. However, the drivers of violence in this population remain unclear, and, to date tools to predict violence risk have a range of limitations. Perhaps because of this uncertainty about the nature of violence risk, treatment programmes and care pathways for mentally disordered offenders vary substantially across the European Union, and differences in legal and policy frameworks are highly relevant.

METHODS

The three-year EU-VIORMED project (Grant Number PP-2-3-2016, November 2017-October 2020) involves forensic centres in Italy, Austria, Germany, Poland, and the U.K. It aims to: (a) identify and compare violence risk factors, clinical needs, and decision making capacity in violent (N = 200, "cases") and nonviolent patients with SSD (N = 200; "controls") using a case-control design; (b) test the predictive validity of the HCR-20v3, OxMIS and FoVOx among cases alone (N = 200), using a prospective cohort study; and (c) compare forensic-psychiatric care pathways across the EU, in a continent wide service mapping study.

DISCUSSION

Data collection started in September 2018 and continues. By September 2019, 333 participants have been enrolled (201 cases and 132 controls were recruited). Experts from 23 countries provided data for the service mapping exercise.

TRIAL REGISTRATION

Retrospectively registered on January 2, 2019 as researchregistry4604 January 2, 2019.

Italian Investigation on Mental Health Workers' Attitudes Regarding Personal Recovery From Mental Illness

This study aimed to investigate attitudes toward personal recovery in a sample of 436 healthcare professionals and students of psychiatric rehabilitation techniques through the Italian version of the recovery knowledge inventory (RKI). The sample in our study showed a good global orientation toward recovery. Statistically significant differences were found among mental health professionals based on gender difference, professional role, and level of experience. Women seemed more inclined to accept users' decision-making processes, including therapeutic risk-taking. Nurses seemed more cautious in considering the users able to "live beyond their illness". Professionals with fewer than 15 years of experience had more favorable attitudes and expectations than the more experienced respondents. Students had more optimistic expectations regarding recovery than nurses and social workers. Academic curriculum development for students and training courses for mental health professionals could further improve the homogeneity in attitudes and skills in the support of users' "unique" recovery processes.