1
|
Integration of Care in Complex and Fragmented Service Systems: Experiences of Staff in Flexible Assertive Community Treatment Teams. Int J Integr Care 2022; 22:17. [PMID: 35651735 PMCID: PMC9139156 DOI: 10.5334/ijic.6011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 05/16/2022] [Indexed: 11/28/2022] Open
Abstract
Introduction: To provide more integrated care, several countries have implemented the Flexible Assertive Community Treatment (FACT) model. However, this model does not guarantee full integration, especially in complex and fragmented service systems like in Norway. Hence, we investigated which barriers that might reduce the potential for integrated care in the Norwegian system, as described by staff in FACT teams, and how they adjust their way of working to increase the opportunities for integration. Methods: Online focus group interviews involving 35 staff members of five Norwegian FACT teams were conducted using a semi-structured interview guide. The material was analysed using thematic text analysis. Results: Six themes described the barriers to integrated care in the service system: fragmentation, different legislation and digital systems, challenges in collaboration, bureaucracy and limited opening hours. Three themes described adjustments in the teams’ way of working to enhance integration: working as the responsible co-ordinator, being a collaborator, and the only entry channel into the service system. Conclusion: The FACT team staff described several barriers to integration within the system. However, they made some adjustments in their way of working that might provide opportunities for integrated care within complex and fragmented service systems.
Collapse
|
2
|
Stupak R, Dobroczyński B. From Mental Health Industry to Humane Care. Suggestions for an Alternative Systemic Approach to Distress. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:6625. [PMID: 34202995 PMCID: PMC8296326 DOI: 10.3390/ijerph18126625] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 06/16/2021] [Accepted: 06/17/2021] [Indexed: 01/17/2023]
Abstract
The article proposes a rough outline of an alternative systemic approach to mental health issues and of a more humane mental health care system. It suggests focusing on understanding mental distress as stemming from problems in living, using medications as agents facilitating psychotherapy, or as a last resort and short-term help, according to the principles of harm reduction. It argues that understanding drugs as psychoactive substances and studying the subjective effects they produce could lead to better utilization of medications and improvements in terms of conceptualizing and assessing treatment effects. Qualitative research could be particularly useful in that regard. It also advocates a radical departure from current diagnostic systems and proposes a synthesis of already existing alternatives to be used for both research and clinical purposes. Accordingly, a general idea for an alternative mental health care system, based on a combination of Open Dialogue Approach, Soteria houses, individual and group psychotherapy, cautious prescribing, services helping with drug discontinuation, peer-led services and social support is presented. The proposition could be seen as a first step towards developing a systemic alternative that could replace the currently dominating approach instead of focusing on implementing partial solutions that can be co-opted by the current one.
Collapse
Affiliation(s)
- Radosław Stupak
- Institute of Philosophy, Faculty of Philosophy, Jagiellonian University, 52 Grodzka St., PL 31044 Kraków, Poland
| | - Bartłomiej Dobroczyński
- Institute of Psychology, Faculty of Philosophy, Jagiellonian University, 6 Ingardena St., PL 30060 Kraków, Poland;
| |
Collapse
|
3
|
Thornicroft G, Ahuja S, Barber S, Chisholm D, Collins PY, Docrat S, Fairall L, Lempp H, Niaz U, Ngo V, Patel V, Petersen I, Prince M, Semrau M, Unützer J, Yueqin H, Zhang S. Integrated care for people with long-term mental and physical health conditions in low-income and middle-income countries. Lancet Psychiatry 2019; 6:174-186. [PMID: 30449711 DOI: 10.1016/s2215-0366(18)30298-0] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 07/24/2018] [Accepted: 07/27/2018] [Indexed: 11/19/2022]
Abstract
Integrated care is defined as health services that are managed and delivered such that people receive a continuum of health promotion, disease prevention, diagnosis, treatment, disease management, rehabilitation, and palliative care services, coordinated across the different levels and sites of care within and beyond the health sector and, according to their needs, throughout the life course. In this Review, we describe the most relevant concepts and models of integrated care for people with chronic (or recurring) mental illness and comorbid physical health conditions, provide a conceptual overview and a narrative review of the strength of the evidence base for these models in high-income countries and in low-income and middle-income countries, and identify opportunities to test the feasibility and effects of such integrated care models. We discuss the rationale for integrating care for people with mental disorders into chronic care; the models of integrated care; the evidence of the effects of integrating care in high-income countries and in low-income and middle-income countries; the key organisational challenges to implementing integrated chronic care in low-income and middle-income countries; and the practical steps to realising a vision of integrated care in the future.
Collapse
Affiliation(s)
- Graham Thornicroft
- Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
| | - Shalini Ahuja
- Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; Public Health Foundation of India, New Delhi, India
| | - Sarah Barber
- Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Daniel Chisholm
- Division for Non-Communicable Diseases and Promoting Health through the Life-Course, WHO Regional Office for Europe, Copenhagen, Denmark
| | - Pamela Y Collins
- Department of Psychiatry and Behavioral Sciences, and Department of Global Health, University of Washington, Seattle, WA, USA
| | - Sumaiyah Docrat
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Lara Fairall
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa; Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Heidi Lempp
- School of Immunology & Microbial Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Unaiza Niaz
- University of Health Sciences, Lahore, Pakistan; Dow University of Health Sciences, Karachi, Pakistan
| | - Vicky Ngo
- RAND Corporation, Santa Monica, CA, USA
| | - Vikram Patel
- Department of Global Health and Social Medicine, Harvard Medical School, Cambridge, MA, USA; London School of Hygiene & Tropical Medicine, London, UK; Sangath, Porvorim, Goa, India; Centre for Chronic Conditions and Injuries, Public Health Foundation of India, New Delhi, India
| | - Inge Petersen
- Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa
| | - Martin Prince
- Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Maya Semrau
- Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; Global Health and Infection Department, Brighton and Sussex Medical School, Brighton, UK
| | - Jürgen Unützer
- Department of Psychiatry and Behavioral Sciences, and Department of Global Health, University of Washington, Seattle, WA, USA
| | - Huang Yueqin
- Peking University Sixth Hospital, Key Laboratory of Mental Health, Ministry of Health (Peking University), National Clinical Research Centre for Mental Disorders, Beijing, China
| | - Shuo Zhang
- Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| |
Collapse
|
4
|
Almeda N, García-Alonso CR, Salinas-Pérez JA, Gutiérrez-Colosía MR, Salvador-Carulla L. Causal Modelling for Supporting Planning and Management of Mental Health Services and Systems: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16030332. [PMID: 30691052 PMCID: PMC6388254 DOI: 10.3390/ijerph16030332] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 01/19/2019] [Accepted: 01/19/2019] [Indexed: 12/17/2022]
Abstract
Mental health services and systems (MHSS) are characterized by their complexity. Causal modelling is a tool for decision-making based on identifying critical variables and their causal relationships. In the last two decades, great efforts have been made to provide integrated and balanced mental health care, but there is no a clear systematization of causal links among MHSS variables. This study aims to review the empirical background of causal modelling applications (Bayesian networks and structural equation modelling) for MHSS management. The study followed the PRISMA guidelines (PROSPERO: CRD42018102518). The quality of the studies was assessed by using a new checklist based on MHSS structure, target population, resources, outcomes, and methodology. Seven out of 1847 studies fulfilled the inclusion criteria. After the review, the selected papers showed very different objectives and subjects of study. This finding seems to indicate that causal modelling has potential to be relevant for decision-making. The main findings provided information about the complexity of the analyzed systems, distinguishing whether they analyzed a single MHSS or a group of MHSSs. The discriminative power of the checklist for quality assessment was evaluated, with positive results. This review identified relevant strategies for policy-making. Causal modelling can be used for better understanding the MHSS behavior, identifying service performance factors, and improving evidence-informed policy-making.
Collapse
Affiliation(s)
- Nerea Almeda
- Universidad Loyola Andalucía, Department of Psychology, C/ Energía Solar 1, 41014 Seville, Spain.
| | - Carlos R García-Alonso
- Universidad Loyola Andalucía, Department of Quantitative Methods, C/ Energía Solar 1, 41014 Seville, Spain.
| | - José A Salinas-Pérez
- Universidad Loyola Andalucía, Department of Quantitative Methods, C/ Energía Solar 1, 41014 Seville, Spain.
| | | | - Luis Salvador-Carulla
- Centre for Mental Health Research, Research School of Population Health, Australian National University, 63 Eggleston Rd, Acton ACT 2601, Australia.
| |
Collapse
|
5
|
Bouras N, Ikkos G, Craig T. From Community to Meta-Community Mental Health Care. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:E806. [PMID: 29677100 PMCID: PMC5923848 DOI: 10.3390/ijerph15040806] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 04/17/2018] [Accepted: 04/17/2018] [Indexed: 11/24/2022]
Abstract
Since the 1960s, we have witnessed the development and growth of community mental health care that continues to dominate mental health policy and practice. Several high-income countries have implemented community mental health care programmes but for many others, including mostly low- and middle-income countries, it remains an aspiration. Although community mental health care has been positive for many service users, it has also had severe shortcomings. Expectations that it would lead to fuller social integration have not been fulfilled and many service users remain secluded in sheltered or custodial environments with limited social contacts and no prospect of work. Others receive little or no service at all. In today’s complex landscape of increasingly specialised services for people with mental health problems, the number of possible interfaces between services is increasing. Together with existing uneven financing systems and a context of constant change, these interfaces are challenging us to develop effective care pathways adjusted to the needs of service users and their carers. This discussion paper reviews the developments in community mental health care over the recent years and puts forward the concept of “Meta-Community Mental Health Care”. “Meta-Community Mental Health Care” embraces pluralism in understanding and treating psychiatric disorders, acknowledges the complexities of community provision, and reflects the realities and needs of the current era of care.
Collapse
Affiliation(s)
- Nick Bouras
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, De Crespigny Park, P.O. Box 27, London SE5 8AF, UK.
| | - George Ikkos
- Royal National Orthopaedic Hospital NHS Trust, Brockley Hill, Stanmore, Middlesex HA4 7LP, UK.
| | - Thomas Craig
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, De Crespigny Park, P.O. Box 27, London SE5 8AF, UK.
| |
Collapse
|
6
|
Developing capacity-building activities for mental health system strengthening in low- and middle-income countries for service users and caregivers, service planners, and researchers. Epidemiol Psychiatr Sci 2018; 27:11-21. [PMID: 28965528 PMCID: PMC6998877 DOI: 10.1017/s2045796017000452] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
There is increasing international recognition of the need to build capacity to strengthen mental health systems. This is a fundamental goal of the 'Emerging mental health systems in low- and middle-income countries' (Emerald) programme, which is being implemented in six low- and middle-income countries (LMICs) (Ethiopia, India, Nepal, Nigeria, South Africa, Uganda). This paper discusses Emerald's capacity-building approaches and outputs for three target groups in mental health system strengthening: (1) mental health service users and caregivers, (2) service planners and policy-makers, and (3) mental health researchers. When planning the capacity-building activities, the approach taken included a capabilities/skills matrix, needs assessments, a situational analysis, systematic reviews, qualitative interviews and stakeholder meetings, as well as the application of previous theory, evidence and experience. Each of the Emerald LMIC partners was found to have strengths in aspects of mental health system strengthening, which were complementary across the consortium. Furthermore, despite similarities across the countries, capacity-building interventions needed to be tailored to suit the specific needs of individual countries. The capacity-building outputs include three publicly and freely available short courses/workshops in mental health system strengthening for each of the target groups, 27 Masters-level modules (also open access), nine Emerald-linked PhD students, two MSc studentships, mentoring of post-doctoral/mid-level researchers, and ongoing collaboration and dialogue with the three groups. The approach taken by Emerald can provide a potential model for the development of capacity-building activities across the three target groups in LMICs.
Collapse
|
7
|
Fleury MJ, Grenier G, Bamvita JM. Associated and mediating variables related to quality of life among service users with mental disorders. Qual Life Res 2017; 27:491-502. [DOI: 10.1007/s11136-017-1717-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2017] [Indexed: 11/24/2022]
|
8
|
Fleury MJ, Grenier G, Bamvita JM, Chiocchio F. Variables associated with work performance in multidisciplinary mental health teams. SAGE Open Med 2017; 5:2050312117719093. [PMID: 28839935 PMCID: PMC5548312 DOI: 10.1177/2050312117719093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 06/06/2017] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES This study investigates work performance among 79 mental health teams in Quebec (Canada). We hypothesized that work performance was positively associated with the use of standardized clinical tools and clinical approaches, integration strategies, "clan culture," and mental health funding per capita. METHODS Work performance was measured using an adapted version of the Work Role Questionnaire. Variables were organized into four key areas: (1) team attributes, (2) organizational culture, (3) inter-organizational interactions, and (4) external environment. RESULTS Work performance was associated with two types of organizational culture (clan and hierarchy) and with two team attributes (use of standardized clinical tools and approaches). DISCUSSION AND CONCLUSION This study was innovative in identifying associations between work performance and best practices, justifying their implementation. Recommendations are provided to develop organizational cultures promoting a greater focus on the external environment and integration strategies that strengthen external focus, service effectiveness, and innovation.
Collapse
Affiliation(s)
- Marie-Josée Fleury
- Department of Psychiatry, McGill University, Montreal, QC, Canada.,Douglas Mental Health University Institute Research Centre, Montreal, QC, Canada
| | - Guy Grenier
- Douglas Mental Health University Institute Research Centre, Montreal, QC, Canada
| | - Jean-Marie Bamvita
- Douglas Mental Health University Institute Research Centre, Montreal, QC, Canada
| | | |
Collapse
|
9
|
Bouras N, Ikkos G, Craig T. Meta-community mental health care: towards a new concept. Lancet Psychiatry 2017; 4:581-582. [PMID: 28748791 DOI: 10.1016/s2215-0366(17)30108-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 02/28/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Nick Bouras
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London SE5 8AF, UK.
| | - George Ikkos
- Royal National Orthopaedic Hospital NHS Trust, Middlesex, UK
| | - Tom Craig
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London SE5 8AF, UK
| |
Collapse
|
10
|
Thornicroft G. An architect for mental health: an appreciation of Michele Tansella. Br J Psychiatry 2017; 210:379-380. [PMID: 28572429 DOI: 10.1192/bjp.bp.116.197343] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 03/08/2017] [Accepted: 03/14/2017] [Indexed: 11/23/2022]
Abstract
Michele Tansella, Professor of Psychiatry at the University of Verona, died in 2015. This editorial pays tribute to his contributions to scholarship in the field of psychiatric epidemiology and health service research, and to his highly effective efforts to improve mental healthcare, locally, nationally and internationally.
Collapse
Affiliation(s)
- Graham Thornicroft
- Graham Thornicroft, PhD, Centre for Global Mental Health & Center for Implementation Science, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London SE5 8AF, UK.
| |
Collapse
|
11
|
Sanatinia R, Cowan V, Barnicot K, Zalewska K, Shiers D, Cooper SJ, Crawford MJ. Loss of relational continuity of care in schizophrenia: associations with patient satisfaction and quality of care. BJPsych Open 2016; 2:318-322. [PMID: 27713834 PMCID: PMC5052512 DOI: 10.1192/bjpo.bp.116.003186] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 06/30/2016] [Accepted: 09/08/2016] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Users of mental health service are concerned about changes in clinicians providing their care, but little is known about their impact. AIMS To examine associations between changes in staff, and patient satisfaction and quality of care. METHOD A national cross-sectional survey of 3379 people aged 18 or over treated in secondary care for schizophrenia or schizoaffective disorder. RESULTS Nearly 41.9% reported at least one change in their key worker during the previous 12 months and 10.5% reported multiple changes. Those reporting multiple changes were less satisfied with their treatment and less likely to report having a care plan, knowing how to obtain help when in a crisis or to have had recommended physical health assessments. CONCLUSIONS Frequent changes in staff providing care for people with psychosis are associated with poorer quality of care. Greater efforts need to be made to protect relational continuity of care for such patients. DECLARATION OF INTEREST M.J.C. was co-chair of the expert advisory group on the NICE quality standard on Service User Experience in Adult Mental Health. S.J.C. has previously been a member of the Health and Social Care Board Northern Ireland Formulary Committee. D.S. received a speaker's fee from Janssen Cilag in 2011. He is a topic expert on NICE guideline for psychosis and schizophrenia in children and young people and a board member of National Collaborating Centre for Mental Health. COPYRIGHT AND USAGE © The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.
Collapse
Affiliation(s)
- Rahil Sanatinia
- MD, Centre for Mental Health, Imperial College London, London, UK
| | - Violet Cowan
- , BSc, Centre for Mental Health, Imperial College London, London, UK
| | - Kirsten Barnicot
- , PhD, Centre for Mental Health, Imperial College London, London, UK
| | - Krysia Zalewska
- , BSc, College Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - David Shiers
- , MBChB MRCGP, College Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - Stephen J Cooper
- , MD, College Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - Mike J Crawford
- , MD, College Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| |
Collapse
|
12
|
Corrao G, Soranna D, Merlino L, Monzani E, Viganò C, Lora A. Do patterns of mental healthcare predict treatment failure in young people with schizophrenia? Evidence from an Italian population-based cohort study. BMJ Open 2015; 5:e007140. [PMID: 26041489 PMCID: PMC4458586 DOI: 10.1136/bmjopen-2014-007140] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE Little is known about the practice of predicting community-based care effectiveness of patients affected by schizophrenic disorders. We assessed predictors of treatment failure in a large sample of young people affected by schizophrenia. METHODS A cohort of 556 patients aged 18-35 years who were originally diagnosed with schizophrenia during 2005-2009 in a Mental Health Service (MHS) of the Italian Lombardy Region was identified. Intensity of mental healthcare received during the first year after index visit (exposure) was measured by patients' regularity in MHS attendance and the length of time covered with antipsychotic drug therapy. Patients were followed from index visit until 2012 for identifying hospital admission for mental disorder (outcome). A proportional hazards model was fitted to estimate the HR and 95% CIs for the exposure-outcome association, after adjusting for several covariates. A set of sensitivity analyses were performed in order to account for sources of systematic uncertainty. RESULTS During follow-up, 144 cohort members experienced the outcome. Compared with patients on low coverage with antipsychotic drugs (≤ 4 months), those on intermediate (5-8 months) and high (≥ 9 months) coverage, had HRs (95% CI) of 0.94 (0.64 to 1.40) and 0.69 (0.48 to 0.98), respectively. There was no evidence that regular attendance at the MHS affected the outcome. CONCLUSIONS Patients in the early phase of schizophrenia and their families should be cautioned about the possible consequences of poor antipsychotic adherence. Physicians and decision makers should increase their contribution towards improving mental healthcare.
Collapse
Affiliation(s)
- Giovanni Corrao
- Department of Statistics and Quantitative Methods, Laboratory of Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy
| | - Davide Soranna
- Department of Statistics and Quantitative Methods, Laboratory of Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy
| | - Luca Merlino
- Operative Unit of Territorial Health Services, Region Lombardia, Milan, Italy
| | - Emiliano Monzani
- Department of Mental Health, Cà Granda Niguarda Hospital, Milan, Italy
| | - Caterina Viganò
- Department of Biomedical and Clinical Sciences Luigi Sacco, University of Milano, Milan, Italy
| | - Antonio Lora
- Department of Mental Health, Lecco Hospital, Lecco, Italy
| |
Collapse
|