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[The current status of psychiatric care in Italy].

Psychiatric reforms in Italy have been the subject of many publications since 1978, when these reforms became law. One such publication is the article by Hinterhuber et al. entitled "Status and Development of Psychiatric Care in Italy" appearing in this edition of Der Nervenarzt [17]. In it, a number of unsolved issues are pointed out, concentrating on some of the main problems encountered by any country going through a process of major institutional change. Some additional points are helpful to a discussion of Italian psychiatric methods and their implications for reorganizing psychiatric practice elsewhere in Europe. Making use of certain "key concepts," we review these questions [2].

Community Mental Health Centers↗

Do long-term hospitalised patients benefit from discharge into the community?

OBJECTIVE: The study investigated whether long-stay patients would benefit from discharge into the community in Berlin, Germany. METHOD: In a prospective controlled study, all long-term hospitalised psychiatric patients from a defined catchment area were assessed using established standardised instruments. Quality of life, treatment satisfaction, needs and psychopathology were re-assessed in 63 non-discharged patients 1.5 years later, and in 65 resettled patients 1 year after discharge. RESULTS: Discharged patients were younger and had spent less time in psychiatric hospitalisation. Whilst patients who remained in hospital care did not show significant changes over time, discharged patients did. Changes in subjective quality of life and total number of needs - but not in psychopathology, unmet needs, and treatment satisfaction - were significantly more favourable in resettled patients as compared to the control group. CONCLUSION: The findings are in line with other studies and suggest that long-stay patients can benefit from discharge into the community, particularly with respect to their quality of life. Positive changes in the process of deinstitutionalisation seem not dependent on the specific national context, and also apply to younger patients who have not yet spent 10 or more years in psychiatric hospitals.

Adult↗

Met and unmet needs of severely mentally ill persons--the Psychiatric Care Reform in Sweden.

BACKGROUND: There has been a process of deinstitutionalisation and mental health care reforms in most countries in Europe. The objective of this study was to discuss the effects of the Psychiatric Care Reform in Sweden in 1995 on the development of needs of severely mentally ill persons and to analyse whether the efforts made by social services and psychiatric care have been more adequate since the reform. METHOD: Two hundred and eighteen persons who were considered to be severely mentally ill both in 1995/96 and 2000/2001, using the same criteria of definition, were interviewed using the same form of interview and their needs were assessed according to Camberwell Assessment of Need on both occasions. RESULTS: The results were in the expected direction. The total sum of unmet needs and unmet needs in important need-domains had decreased on the occasion of the second interview. The degree of effort by psychiatric care and social services had increased. CONCLUSIONS: The target group had made some progress. Due to methodological difficulties, it was not possible to ascribe these results to the reform, but the often negative picture of the reform deserves to be more nuanced.

Deinstitutionalization↗

Impact of a rehabilitation legislation on the survival in the community of long-term patients discharged from psychiatric hospitals in Israel.

BACKGROUND: The aim of the present study was to examine the impact of the Rehabilitation Law 2000 in Israel (which provides a basket of rehabilitation services for every mentally disabled patient) on the survival in the community of a population of long-stay psychiatric patients released from psychiatric hospitals. METHODS: A naturalistic follow-up study was performed on long-stay patients discharged ("key discharge") from two Israel psychiatric hospitals closed before (in 1997) and after (in 2000) introduction of the Rehabilitation Law 2000. The data source was the National Psychiatric Hospitalization Registry. RESULTS: The study population consisted of 611 patients. The percentage of patients who, at closure of hospital, were discharged directly into the community was eightfold higher following the Rehabilitation Law 2000 than before. There was also a trend for a lower readmission rate for those patients who were discharged into the community in the post-law period, both for those whose key discharge was directly to the community and for those who were later discharged after being transferred to another hospital at key discharge. Concerning the mean duration of inpatient stay, there was no difference between the two cohorts, whether hospitalizations followed transfer to another hospital from key discharge or rehospitalization from the community. Interestingly, the Rehabilitation Law did not have a significant effect on patients' mortality after key discharge. CONCLUSION: The Rehabilitation Law 2000 has a beneficial effect on the opportunities of long-stay psychiatric patients to resettle in the community without increasing risk of death.

Adult↗

The quality of life of people with schizophrenia living in community in Rio de Janeiro, Brazil.

INTRODUCTION: The influence of sociodemographics and clinical factors on the quality of life (qol) of an individual with schizophrenia is being widely studied, particularly in developed countries. The de-institutionalization process that is taking course in Brazil, to a less symptoms-focused approach, makes necessary the assessment of the qol of these patients living in the community. OBJECTIVES: To evaluate factors related to the qol in patients diagnosed with schizophrenia or schizo-affective disorder, and who are users of one of the two municipal community mental health services of a Rio de Janeiro district, Brazil. MATERIAL AND METHODS: A cross-sectional study was carried out. Selected patients were interviewed with Brazilian versions of Lancashire Quality of Life Profile, Brief Psychiatric Rating Scale and Calgary Depression Scale for Schizophrenia. RESULTS: A total of 136 patients participated in the study. Most of them were single and lived with their relatives, had low educational level, were unemployed and had low income. A great number of the interviewed did not have any social contact outside the family and leisure activity, except watching television and/or listening to the radio. Finances and work situation had the lowest satisfaction level. Educational level, presence of positive and depressive symptoms, hospital admissions were negatively associated with qol. For those receiving state benefit, perceived qol increased with age. These predictors explained more than 42% of the total subjective qol score variance.

Adolescent↗

Service use and costs of supporting the most socially disabled patients in a hospital reprovision programme. A two-hospital comparison.

BACKGROUND: The UK, in common with other Western countries, has seen a marked reduction in the number of long-stay hospital beds over the past few decades and most asylums have been closed. Whilst hospital closure and discharge programmes differ, a common characteristic is likely to be that those patients who are "difficult-to-place" in the community are amongst the last to be discharged. This paper compares service use and costs of difficult-to-place patients from two UK hospitals (Friern and Warley) and identifies predictors of cost. One of these hospitals (Warley) provided a more intensive programme of rehabilitation. METHOD: The study included 84 patients (Friern 63, Warley 21). Patient characteristics prior to discharge were recorded. Service use was measured and costs calculated for the year following discharge. Comparisons were made between the Warley and Friern groups and cost predictors were identified using multiple regression analysis. RESULTS: Post-discharge accommodation, in-patient and outpatient costs were substantially higher for the Friern group, whilst the Warley group had higher day care costs. The total mean costs were pound 13,432 higher for the Friern group. However, non-accommodation costs were substantially higher for the Warley group. Patients with more social skills had higher non-accommodation costs. Higher total costs were associated with more self-care skills, fewer domestic skills and younger age. Longer length of stay prior to discharge was associated with higher non-accommodation and total costs. CONCLUSIONS: The costs of care following discharge differed substantially between these two groups. This is partly a supply effect given the different strategies for caring for these difficult-to-place patients. In common with other studies, patient characteristics can explain some of the differences in future costs.

Deinstitutionalization↗

The Barents project in psychiatry: a systematic comparative mental health services study between Northern Norway and Archangelsk County.

BACKGROUND: There is virtually no readily accessible systematically recorded evidence on how the organization of mental health services in Europe's largest country, Russia, may differ from other national systems. This study systematically compares the mental health services in Archangelsk County and Northern Norway using instruments developed for trans-cultural use. METHODS: The European Service Mapping Schedule (ESMS) and The International Classification of Mental Health Care (ICMHC) were used to describe: (i) resources, organisation and utilisation of the services; (ii) their decentralisation and differentiation; (iii) some interventions delivered by the mental health service units (n = 132) in both regions. RESULTS: The Norwegian services are more decentralised and differentiated, while the Russian services are largely hospital-based. The GPs are of considerable importance to the Norwegian services, functioning as gatekeepers-both centrally and peripherally. In contrast, the GP model is still poorly established in Archangelsk County. There are more units for long term stay in the Russian services than in Norway. General health care and taking over daily living activities are more organised in Archangelsk County, while psychopharmacological treatment and psychosocial interventions are more developed in Norway. CONCLUSION: The study has revealed several differences in resources, organisation and utilisation of the mental health services between the two compared areas. The very large variations indicate that underlying local patterns of service delivering must be further investigated and taken into account in the planning of the services development.

Catchment Area, Health↗

Patterns of psychiatric hospital service use in Finland: a national register study of hospital discharges in the early 1990s.

We were interested in studying the possible concurrent changes in the psychiatric inpatient population during a rapid phase of deinstitutionalisation, and severe economic recession with a record level unemployment rate, and after the amendment of the mental health legislation. Although there were 4540 fewer beds in the psychiatric hospitals in 1993 compared to 1990, the rate of patient admissions remained the same. There was a significant increase in readmissions (P < 0.001) to the psychiatric hospitals, and particularly in multiple (three or more) readmissions among new inpatients (P < 0.001). The prevalence of inpatients with major depression increased by 0.2/1000 in the whole cohort and by 0.12/1000 among first-timers from 1990 to 1993 (P < 0.001). In addition, the rate of involuntary admissions decreased significantly (P < 0.001).

Adolescent↗

Predictors of social relations in persons with schizophrenia living in the community: a Nordic multicentre study.

BACKGROUND: Deinstitutionalisation has led to persons with serious mental illness spending most of their time outside psychiatric institutions. Not much is known about their social life. The paper presents the results of structured interviews with non-institutionalised persons with schizophrenia about treatment, care and social network. The network data are analysed from three perspectives: finding predictors of the number and of the quality of social contacts, and establishing the respective variables that characterise persons with high, and those with low, scores on both the quantity and quality dimensions of social integration. METHODS: Random samples of persons with schizophrenia receiving outpatient services in ten psychiatric centres in the four Nordic countries were interviewed. The following instruments were used: Interview Schedule for Social Interaction (ISSI), Camberwell Assessment of Needs, Lancashire Quality of Life Profile, General Assessment of Functioning (GAF) and Brief Psychiatric Rating Scale (BPRS), in addition to a checklist covering the utilisation of different services. The ISSI provided the main data for this paper. A restricted number of possible predictors were used in General Linear Model (GLM) factorial analysis and discriminant analysis. RESULTS: A total of 418 persons took part in the study. The overall participation rate was 55%. Social integration in terms of number of contacts was related to a high GAF score, few BPRS negative and hostility symptoms, having contact with user organisations and living in urban (in contrast to rural) areas. Availability of emotional relations was predicted by female sex, low scores on the BPRS hostility dimension, high GAF score, having contact with one's family more than once a month, and living in urban areas. Work, adequate leisure activities and GAF score discriminated between the best and worst integrated groups. CONCLUSIONS: Living in urban areas, being female, having a high GAF score and low scores on hostility predicted better integration in terms of number of contacts and emotional relations.

Adult↗

Managing severe mental illness in the community using the Mental Health Act 1983: a comparison of Supervised Discharge and Guardianship in England.

BACKGROUND: Two measures in the English Mental Health Act allow requirements to be imposed upon patients living in the community. These are Guardianship (Section 7) and Supervised Discharge (Section 25A). AIMS: The paper aims to compare patients with mental illnesses, made subject to Guardianship or Supervised Discharge. METHOD: Data on patient characteristics, impairment, needs and interventions were collected from keyworkers in a random national sample of Trusts and local authorities. Ratings were obtained on standardised measures of disability, impairment and needs. RESULTS: Patients placed on Supervised Discharge were more likely to have problems of treatment compliance and drug misuse, whilst those on Guardianship were more likely to have problems of social welfare and higher ratings of disability and impairment. Supervised Discharge has a higher proportion of African-Caribbean patients. Interventions delivered are rated as effective for both measures. CONCLUSIONS: Legal changes proposed in England include a single power for supervision in the community. This should not mean a focus on risk management to the neglect of social welfare interventions.

Adult↗

Restructuring mental health: a South American survey.

BACKGROUND: There is little information available on the changes in mental health services in South American countries following the social and political upheavals of recent decades. METHODS: A postal survey was conducted of all South American countries (health ministries, national psychiatric associations and key informants) to assess the development of mental health programs and the organization of alternative psychiatric care centers such as the psychiatric units in general hospitals (PUGH). RESULTS: Most of the mental health programs were implemented during the 1980s and 1990s, and aimed at incorporating psychiatric care into primary health care, as well as relocating provision from large hospitals to decentralized services. Most of the countries surveyed have less than 0.5 psychiatric beds per 1000 inhabitants. This change reflects a tendency to reduce the total number of psychiatric beds and increase the number of PUGH. Over the last 10 years this increase was significant in some countries (50-75%), but was not reflected in the availability of adequate human and material resources. CONCLUSIONS: A transition from a system based on large mental hospitals to alternative service provision is on the way in South American countries. Intensive efforts have to be made to collect and disseminate information, as well as to monitor the development and outcome of the mental health programs in these countries.

Deinstitutionalization↗

The future pattern of psychiatric provision in England.

The events that led to a reduction in both the size and number of mental hospitals in the United Kingdom are reviewed, and the mental hospitals remaining are shown to be mainly providing care in specialised units. Studies of mental hospital closure have shown that care in the community is generally preferred by patients, although for the "old long stay" the total costs are broadly similar. However, for patients with new illnesses care is undoubtedly much cheaper, and patients acquire fewer secondary handicaps of their psychotic illness. Hospital beds are still needed for a community mental health service; and in inner city areas, where prevalence rates for psychotic illness are higher, there are often too few beds to run an efficient service so that patients needing admission may either not be admitted at all, or be admitted to a distant hospital. The allocation of funds for mental illness to local health authorities takes some account of socio-demographic indicators of illness, but authorities are free to spend more or less than their allocation on the mental illness service. One study suggests that there is an optimal number of beds for a given location and that costs of the service increase if there are either too few or too many beds available. It is argued that for care in the community to succeed there must be adequate numbers of beds available, a range of sheltered residential accomodation in the community, as well as enough staff to provide a service for them. Future changes to the way in which the National Health Service is funded--with resource being allocated by groups of general practitioners--make it likely that there will be a shift of resources towards primary care services.

Cost-Benefit Analysis↗

Deinstitutionalisation in the Netherlands.

In the Netherlands mental hospitals and psychiatric departments in general hospitals kept the initiative in implementing community-based replacements for inpatient care. The goal of this study is to determine to what extent day treatment, sheltered residences and assertive home treatment were effective alternatives, rather than additions to inpatient care. All adult users and their use of intensive community- and hospital-based services between 1989 and 1997 were retrieved from the Groningen case register. Statistics about changes in the use of mental health care provisions were corrected for changes in the population as to size and age. The number of patients in day treatment, sheltered residences and in particular home treatment grew between 1989 and 1997 to a large degree, as did their average use of these services. In that same period inpatient care lost some, though not many patients, but the average length of their stay in the hospital was reduced by 33%. Analysis of treated incidence and prevalence showed that the implementation of alternatives to hospital-based care did not attract new patients but kept patients longer in mental health care.

Adult↗

Understanding the relationship between mental disorder and violence: the need for a criminological perspective.

This paper offers a criminologically informed framework to guide research on the relationship between mental disorder and violence. Criminological theories examined include social learning, social stress, social control, rational choice, and social disorganization. In addition, the "criminal careers" and "local life circumstance" methodologies are reviewed. It is argued that adopting a criminologically informed framework that takes into account within-person changes over time will contribute greatly to our understanding of the factors that affect violence among people with mental disorder living in the community, and enhance the capacity of research to support effective evidenced-based case management programs aimed at reducing violence.

Anomie↗

[Psychiatry as a profession].

With reference to Max Weber's timeless analysis of science and politics as a profession, the present paper describes the philosophical background and historical development of the tasks and tools, institutionalization, and socialization of psychiatry as a profession. In the mid twentieth century, psychiatrists' emergence from ideological confinement in asylums, where they were separated from urban culture and medicine in general, finally allowed them to benefit from accumulating knowledge and technological progress in the field of medicine. After its transition from a custodial to a therapeutic discipline, psychiatry has acquired a variety of new fields of action and duties that require a high degree of expertise on psychological and biological levels. At the same time, people have increasingly come to expect relief not only from disease, but also from manifold problems of everyday life. As a consequence, there has been an inflationary growth of professional psychiatric and psychotherapeutic and nonprofessional services. The professional requirements that psychiatrists should meet have also increased quantitatively and qualitatively in the wake of the historical change from a caring, paternalistic attitude towards the mentally ill to a therapeutic partnership. To a greater degree than physicians working in other medical fields, psychiatrists get personally involved with their patients. As a consequence, the mental burden of their profession is at times immense. For this reason, the ethics of a medical profession has special implications for psychiatrists. The fascinating advances in therapeutic methods, neurobiological knowledge, and the increasingly differentiated diagnostic tools, e.g., noninvasive investigation of the morphology and functioning of the brain, have turned psychiatry into one of the most interesting contemporary professions. Psychiatry is now facing an enormous challenge of meeting the standards of expertise.

Biological Psychiatry↗

Community reentry: perceptions of people with substance use problems returning home from New York City jails.

Each year about 100,000 people return to New York City communities from municipal jails. Although about four-fifths report drug or alcohol problems, few have received any formal drug treatment while in jail. Researchers and practitioners have identified a number of policies related to corrections, income, housing, and drug treatment that may be harmful to the successful reintegration of people leaving jail. In order to explore the challenges to successful community reentry, six focus groups and one in-depth interview were conducted with 37 men and women who had been released from jail or prison in the last 12 months. Participants were asked to describe their experiences prior to and immediately following release from jail. Findings suggest that many people leaving jail are not prepared for release and, upon release, face a myriad of obstacles to becoming healthy, productive members of their communities. We discuss the implications of these findings for programs and policies that promote community reintegration of individuals returning from correctional facilities.

Deinstitutionalization↗