The Italian psychiatric reform: some quantitative evidence

Summary The Italian experience of providing psychiatric care with comprehensive and integrated community services while blocking admissions to mental hospitals needs evaluation on the basis of quantitative evidence as well as opinion. In this paper, national statistics and local case-register data pertaining to this issue are reported. Questions referring to the structure of the services (whether or not the prescribed reorganisation has actually taken place) as well as to function (the way in which the reorganised services, were they have been provided, actually operate) are examined. The available data show that there is a marked regional variation in service provision, as well as a globally inadequate provision of alternative structures. However, the evidence suggests that where adequate community psychiatric services have been provided, they function successfully without the availability of backup from the mental hospitals. The results suggest that a national coordination of regional and local policy is urgently necessary, together with an increase of the resources devoted to psychiatric care and a shift of expenditure from the declining mental hospitals to the progressively more overburdened community services.     

The Italian mental health reform nine years on

It is 9 years since the mental health reform was passed by the Italian Parliament. The author presents a data-based evaluation of the effects of the Italian mental health reform. There are still many problems to be resolved: More than 30,000 inpatients are still in psychiatric hospitals and little is known of the fate of those discharged in recent years. District mental health services are still lacking, especially in the south of the country; Psychiatric units in the general hospital function much the same way as the "old" psychiatric hospitals. The pattern of mental health services consumers have changed: They are younger with less severe psychiatric diagnosis and come from a higher social background.     

Measuring the treatment environment of a psychiatric ward and a community mental health center after the Italian reform

In 1978 a major psychiatric reform drastically changed the Italian psychiatric system by the closing of admissions to mental hospitals and the development of psychiatric units in general hospitals and of alternative services in the community.The paper presents the results of a study in which two treatment environments set up according to the reform, i.e a psychiatric unit in a general hospital and a community mental health center run by the same staff, were examined using the Ward Atmosphere Scale (WAS) and the Community Oriented Programs Environemt Scale (COPES). In addition, validity studies of the Italian versions of the WAS and COPES are presented. Both instruments were found to be feasible and useful, easily understood, easy to administer and relatively well accepted by the psychiatric staff. The quality of the two scales has been confirmed by psychometric analysis, with the exception of the independence of scales. No major differences between the two environments emerged, both showing characteristics consistent with the new treatment philosophy.This study was supported by the Consiglio Nazionale delle Ricerche (CNR, Roma) through a grant to Professor M. Tansella (No 122.04, Prot. 51359, 1981).     

Suicide and the Italian psychiatric reform: An appraisal of two data collection systems

Summary The reliability of Italian suicide data derived from returns made by the Police and Carabinieri was examined by comparing regional suicide data from that source with those based on medically certified cause of death for the years 1973–1980. Rates of medically certified suicide were found to be higher than those derived from the Police/Carabinieri returns, a difference which increased steadily over the years of study. The between-region within-year correlations (between the suicide rates derived from the two sources) were very high, but tended to decrease with time. The between-year within-region correlations were +0.700 or above for 12 of the 19 Italian regions and between +0.500 and +0.700 for a further 3. The correlation between the rates of suicide derived from the two sources was poor for the remaining 4 regions. A previous analysis of the influence on suicide of the Italian psychiatric reform used Police/Carabinieri data (Williams et al. 1986): this was repeated excluding data from these 4 regions, and the previous results were confirmed. Indeed, the negative correlation between suicide and the provision of general hospital psychiatric beds was stronger than that previously reported.     

The psychiatric services in cremona: A case study of the Italian reform law

Italy's mental health law of 1978 provided for the gradual phasing out of psychiatric hospitals (PH) and the creation of comprehensive community-based systems. However, these changes have taken place at different times and in different forms. There are now three different organizational and care models operating in Italy: in the first, common in Southern Italy, the former PH and the new general hospital general wards (GHPW) coexist; in the second, outpatient departments complement the above facilities, but the hospital activity remains central; in the third model, a community model has been given priority-the so-called community priority. While many reports have been published describing the activity of some of the services adhering to the third model, no report has been published specifically describing the activity of services which work according to the second model, such as Cremona. In this paper, the activity of the Cremona psychiatric services is described, and the consequences of the reform law and the problems related to an hospital-based activity are emphasized.     

Status and development of psychiatric care in Italy. 22 years after Franco Basaglia's reform regulation no. 180

Since reforms were introduced in 1978, the treatment of mental illness in Italy is less uniform than ever before. The essential and core aspects of these reforms were not implemented in many southern provinces, but there are flourishing private clinics in Rome and other metropolitan areas, and in the highly developed regions of northern and central Italy there are institutions meeting very high standards of complementary care. However, reforms in these areas had begun as early as in 1968 in accordance with Act 431 passed that year, and in these regions the newer reforms functioned only as a catalyst. The extremely high goals set by the "Italian experiment" were not realized, but the achievements of several Italian provinces in the areas of ambulant and supporting psychiatric care can certainly be viewed as exemplary. A general trend toward increased critical examination of ways of dealing with the mentally ill from the medicinal, humanitarian, and social points of view is emerging.     

Improving treatment for the severely mentally ill: implications of the decade-long Italian psychiatric reform

Recent reviews of the results of the important Italian Psychiatric Reform have been unusual in that they have ranged from very enthusiastic to very negative. No recent report has focused on extrapolating from the Italian experience the pluses and minuses that might be applicable to the U.S. system of delivery of mental health services so as to improve the care of the seriously mentally ill. In this paper I will summarize my observations and clinical research during 6 months in Italy, emphasizing what has not been reported by others; I will analyze the impact of the Italian changes on Italian practice and try to identify in a balanced way any inferences that can be drawn from the Italian experience that add to ideas now current in the United States about treatment of the severely mentally ill.     

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

Abstract 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?     

司法精神病鉴定责任能力评定20年变迁

目的　探讨２０ 年来司法精神病鉴定中责任能力评定的现状。方法　以１９８９ 年《精神疾病司法鉴定暂行规定》颁布为界,对前后１０ 年责任能力评定结果进行比较分析。结果　规定后较规定前责任能力评定总体呈趋严的趋势（ Ｐ＜ ０－０１） ;对精神分裂症、精神发育迟滞、癫痫性精神病障碍患者责任能力评定趋严（ Ｐ＜０－０１、Ｐ＜ ０－０１ 和Ｐ＜０－０１） ;对盗窃、强奸和流氓危害行为责任能力评定趋严（Ｐ＜ ０－０５） 。结论　规定后１０ 年较规定前１０ 年责任能力评定呈趋严倾向,动机论对责任能力评定的影响较深远,但尚有待进一步研究完善。     

The status of Italian psychiatric reform: the example of Lombardy in comparison with Switzerland]

In Italy, the worldwide reduction in numbers of psychiatric beds since the fifties had led already by 1971 to a much lower per capita rate of beds than in most European countries. In Northern Italy the psychiatric reform of 1979 speeded up the ongoing reduction of beds, ameliorated conditions for hospitalized patients and built up ambulatory care. A comparison with three Swiss cantons shows that, in Lombardy, the largest and economically most developed Italian Region, the rate of patient contacts with outpatient services has probably reached or surpassed the level found in Switzerland. Contacts by home visits are much more frequent than in Switzerland. The number of psychiatric beds per 1,000 inhabitants is 0.7 in Lombardy and thus has been reduced to one third the Swiss bed-ratio. Comparisons of Italian with Dutch and Danish psychiatric register data show that the Italian psychiatric service as a whole reaches a considerably smaller segment of the severely disordered patients. The Region of Lombardy has recently been trying to increase the psychiatric bed-ratio by agreements with private hospitals. The shortage of beds is not compensated by the ambulatory services and is leading to increasing stress for the families of the severely disordered.     

Outcome of discharged psychiatric patients after short inpatient treatment: an Italian collaborative study

Summary This paper presents the results of an Italian multicentre study on the 6-month outcome of psychiatric patients discharged after short-term in-patient treatment from 21 general hospital psychiatric units. Two outcome measures were used: relapses (defined as readmissions for psychiatric treatment or suicide) and community tenure. The data showed, on average, a fairly high relapse rate (43% in 6 months) combined with a good community tenure. The findings are discussed in the light of the heterogeneity in patterns of care provision observed in Italian psychiatric services after the changes introduced by the 1978 Mental Health Act, reported in a previous paper.