Twenty years have elapsed since a new mental health law, called “Law 180,”was approved by the Italian Parliament. This law, aimed to change radicallythe architecture of psychiatric care in Italy, had a broad international impact,as shown by the large number of papers and monographs published in interna-tional journals on this issue: in a 1989 comprehensive review of the interna-tional literature focusing on the Italian psychiatric reform, one of the authorsof the present article (G.d.G.) was able locate as many as 161 papers publishedin foreign (mostly English-language) journals (de Girolamo, 1989).
Through the reform law, and the experiences of change realized prior to thereform, “the Italian psychiatry expanded its size, influence, and prestige dra-matically” (Mollica, 1985, p. 22). The aim of this article is to carry out an analy-sis of the state of application of the law and of its overall effects, to examine towhat extent the claims made either by the advocates or by the opponents of thereform have been supported by reliable evidence and to extract a number ofgeneral lessons from the Italian experience of mental health reform.
Methods
Tansella and Thornicroft (1998) consider two dimensions necessary to de-scribe and analyze complex mental health services data: the geographical di-mension, which refers to three levels (country, local, and individual-patient
*Coordinator, National Institute of Health, National Mental Health Project, Rome, Italy.
†Researcher, Italian Institute of Social Medicine, Rome and Department of Mental Health, RMC,Rome, Italy.
Thanks are due to Giorgio Bignami, Ian Falloon, Michele Tansella, and Richard Warner for theirthoughtful comments and suggestions.
Address correspondence and reprint requests to Giovanni de Girolamo, M.D., National Institute ofHealth, National Mental Health Project, Viale Regina Elena 299, 00161 Rome, Italy; E-mail: [email protected]
198 G. DE GIROLAMO and M. COZZA
level), and the temporal dimension, with three phases (inputs, processes, andoutcomes).
To perform the structure (input) analysis (service provision, number of per-sonnel, etc.) we have relied on official data recently published by the Ministryof Health (Ministero della Sanità, 1998), and based on a national survey car-ried out through the Regions and the Local Health Units, yielding a responserate of 100%. We have also utilized information gathered in three nationalsurveys on mental health services carried out in 1984, 1994, and 1996 by theItalian Institute of Social Medicine (IISM), a nonprofit research institutefunded mainly by the Italian Ministries of Labour and of Health (Cozza & Na-politano, 1996; Frisanco, 1989; Italian Institute of Social Medicine, 1997); thethird survey, made with the same methodology as adopted for the second one,has been carried out in order to update the 1994 data, at the request of theItalian Ministry of Health.
Finally, with regard to nonhospital residential facilities, we have used datarecently gathered in the framework of a national project (the PROGRESproject), directly coordinated by the National Institute of Health and aimed tocarry out an extensive and indepth evaluation of such facilities in the all coun-try (Progetto Nazionale PROGRES, in press).
Additional process and outcome data for our analysis have been obtainedfrom other studies (some currently ongoing) carried out in different areas ofthe country. With the exception of the Ministry of Health and the IISM data,almost all the studies considered here have been published in English-lan-guage journals since 1989, the year of the previous review.
The Background of Law 180
Italy is a country with some 57 million inhabitants, according to the last na-tional demographic census (in 1996); 67% of the population is classified as ur-ban. Health care is provided to all the population by the National Health Ser-vice, which is built like the British National Health Service (NHS). All thepopulation has unlimited health care coverage, which is provided by “LocalHealth Units” (LHU), each responsible for a geographically defined catch-ment area. As of March 31, 1998 there were 226 LHUs in the country. EachLHU has a defined budget for health care, which is assigned by the RegionalHealth Ministry, based on the number of inhabitants, number of health facili-ties located in the catchment area, and other health-related indicators. De-pending on specific regional regulations (which may vary across regions), mosttertiary hospitals, providing highly specialist, technologically intensive care,have been separated from LHUs, are run by autonomous agencies or trusts,and provide services at fees in part specified by the Ministry of Health, in partby the Regions.
Access to health services is generally free of charge. However, in recentyears, in order to reduce health expenditures and stimulate a less “consumer-oriented” attitude of citizens toward health care (especially in terms of drugprescriptions and laboratory examinations), a system of partial contribution tohealth expenses has been introduced; citizens are required to pay a so-called“ticket” for each drug prescription (with the exception of a limited number of
THE ITALIAN PSYCHIATRIC REFORM 199
“essential” drugs), lab tests, or radiological examination they receive. Eachcitizen is registered with a general practitioner (GP).
Italy has the highest number of physicians per capita among all Westerncountries, with 1 doctor for every 211 inhabitants; however, a large number ofdoctors are unemployed or, mainly, underemployed (The Economist, 1999).In 1997, public national health expenditures were 5.6% of the GNP (Ministerodella Sanità, 1999). This percentage is one of the lowest among all industrial-ized countries; on the other hand, private health expenses have increased inrecent years, although no reliable data are available about this phenomenon.Health expenditure for mental health care is approximately 5% of the entirehealth budget. It should be noted that the sector of drug and alcohol abuse,both in terms of prevention and care, is managed outside the mental healthsector: therefore, the data presented in this article do not include data on pa-tients with substance abuse problems.
The Law and its Developments
The 1978 psychiatric reform law established four principal components: (1) agradual phasing out of mental hospitals (MHs), with the cessation of all new ad-missions; (2) the establishment of general hospital psychiatric wards (GHPW)for acute admissions, each having a maximum of 15 beds; (3) the restriction ofcompulsory admissions; and (4) the setting up of community mental health cen-ters (CMHC) providing psychiatric care to geographically defined areas.
Because the law was drafted and approved over a very short time, mainlywith the aim of preventing a national referendum to ban mental hospitals,which was being promoted by a small political party, it did not set specificstandards in terms of service provision, nor did it allocate a specific budget tomental health care and to the newly established services, nor did it establishtraining procedures for the large number of mental health workers who wereto be diverted from MHs to the new community services. The law was basi-cally a “guideline” law (
legge quadro
), and regions were entrusted with thespecific tasks of drafting and implementing detailed norms, methods, andtimetables for the organizational translation of the law general principles.Over time, these conditions has led to an uneven national situation, with re-gions adopting different standards in terms of service provision and organiza-tion, and sometimes approving different statutes for the formal organizationof mental health services.
In order to overcome this national lack of homogeneity, the Ministry ofHealth has launched two multi-year “National Target Plans for MentalHealth.” They have spelled out, for the first time ever, a set of (mainly struc-tural) standards to be achieved. However, for a variety of reasons (e.g., lack ofsanctions against noncompliant regions and health managers; lack of a moni-toring system; unsatisfactory specificity of the plan), the first “National TargetPlan 1994–1996” has had a negligible impact on the restructuring and planningof mental health services, and it has been applied minimally. A new “NationalTarget Plan for Mental Health 1998–2000,” born out of the general NationalHealth Plan, has just been approved by the Government, after a long and wideconsultation which has involved professional organizations, consumers and ex-
200 G. DE GIROLAMO and M. COZZA
perts, etc. It is likely that the fate of psychiatric care in Italy in the forthcomingyears will depend largely on the application of this new plan.
Structure (Input) Data
The questions discussed in this section focus on the current structure of psy-chiatric care in Italy: (a) whether or not the reorganization and construction ofservices has actually taken place, and to what degree, and (b) what is the cur-rent level of provision of mental health services.
Table 1 shows all the most important data, gathered in the framework of theMinistry survey, concerning the provision of mental health services as ofMarch 31, 1998; additional data, as indicated in Table 1, refer to the IIMS 1996survey and to the PROGRES project. Table 1 also shows the rate per 1,000 in-habitants of service provision, the number of services per 150,000 inhabitantsand the national standards for selected facilities as put forward by the “Na-tional Target Plan for Mental Health 1998–2000.” These data will be discussedseparately by type of facility.
To What Extent Have Mental Hospitals Been Closed?
The number of residents in 76 Italian MHs, at that time operational, peaked in1963 (91,868 residents, 1.61 per 1,000 population); in 1978, when the reform lawwas approved, there were 78,538 MH residents (ISTAT, 1983). This number hasdeclined at an accelerating rate, so that in Italy on 03.31.98 there were 7,704 resi-dents (0.13 per 1,000 population) in 50 MHs (39 public and 11 private). In addi-tion, 6,459 former residents in public MHs and 587 former residents in privateMHs are hosted in a variety of residential facilities, in some cases built in the samepremises of the former MHs. Overall, the number of MH residents dropped by53% in the 10 years after the approval of the law (1978–1987) (Tansella, DeSalvia, & Williams, 1987). In the 2 years from 1996 to 1998, because of strict legaland financial pressures aimed at accelerating the closing down of MHs, 26 MHshave “officially” been closed, and the number of “official” MH residents hasdropped from 17,068 (recorded in the IISM survey as of 12.31.1996) to 7,704.
Disappointingly, almost no data have been gathered in a standardized fash-ion about the large number of patients discharged from MHs over these twodecades, their clinical and extra-clinical features, their social networks, theirplace of discharge; nor have any reliable data been available until recentlyabout the population currently living in MHs.
The “QUALYOP” study is the first survey aimed at monitoring and com-paring closure policies of 22 MHs located in three Northern regions (plusRome), and to evaluate a representative cohort of 4,493 patients residents inthose hospitals in the years from 1994 to 1996 (D’Avanzo, Frattura, Barbui,Civenti, & Saraceno, 1999; Frattura & D’Avanzo, 1997, 1998). Twenty percentof this cohort were below the age of 50, whereas 25% were 70 or older. Halfhad a diagnosis of schizophrenia, and one quarter a diagnosis of mental retar-dation; 49% of these patients had been in hospital for at least 30 years. Sur-prisingly, more than two thirds of the cohort was judged by the treating staff asnot showing any significant behavioral problem, while aggressive behaviors
THE ITALIAN PSYCHIATRIC REFORM 201
TABLE 1Mental Health Services in Italy According to the Ministry of Health Survey, to the Italian Institute of
Social Medicine Survey, and to the PROGRES project
Facility
N
Rateper 1,000
inhabitants
n
/150,000inhabitants
Nationalstandard
Community mental health centers 695 – 1.81 1/150,000Outpatient facilities 1,132 – 2.95 –General hospital psychiatric wards (GHPW) 320 0.83
Number of GHPW beds 4,084 0.07 0.1/1,000Average number of beds per GHPW 12.8Average number of rooms per GHPW 11.3
a
University psychiatric department wards 19
a
– – –Overall number of beds 404
a
Average number of beds 21.3
a
Private psychiatric inpatient facilities 65
a
0.17
a
–Overall number of beds 5,595
a
0.09
a
–Average number of beds 86,1
a
Overall number of acute beds 10,083 0.17% GHPWs 40.5% University psychiatry departments 4.0% of private inpatient psychiatric facilities 55.5
Day-hospitals 257 0.67Day-hospital beds 942 0.01 0.1/1,000Average number of beds 3.6
Day centres 481 1.26 1/150,000Nonhospital residential facilities 1,377
b
3.43Number of beds 17,343
b
0.30 0.1–0.2/1,000Average number of beds 12.4
Former mental hospitals (MH)Public MHs 39 – – –
Inpatients in public MHs 4,769Former patients hosted in various
residential facilities 6,459Private MHs 11
Inpatients in public MHs 2,935Former patients hosted in various
Based on data from the Third National Survey of Mental Health Services by the Italian Institute of SocialMedicine (1997).
b
Based on the PROGRES project data (Progetto Nazionale progres, in press).
c
Rate per 1,500 inhabitants, as the standard for personnel is based on this rate.
202 G. DE GIROLAMO and M. COZZA
were regarded as a problem for only 19% of the sample. Independence indaily living activities was full for 41% of the sample, and almost complete foran additional 24% (as judged by the treating staff).
To What Extent Have Alternatives to Mental Hospitals Been Provided?
Three types of facilities alternative to mental hospitals have been set up for themanagement of psychiatric illness. These are: (a) GHPWs, (b) residential, non-hospital facilities (with full- or part-time staff care), and (c) nonresidential, outpa-tient facilities, which include day hospitals, day centers, and outpatient clinics.
In 1998 there were in Italy 320 GHPWs, comprising a total of 4,084 beds(0.07 per 1,000 population). The average number of beds in each GHPW was12.8. With regard to private psychiatric inpatient facilities, the third IIMS sur-vey found 65 private psychiatric inpatient facilities with 5,595 beds (0.09 per1,000 population). The average number of beds in each of these facilities is 86and patients admitted here are fully reimbursed by the NHS.
Overall, taking also into account the 19 university psychiatry departmentsthat have an inpatient ward, for a total of 404 beds, there are in the country10,083 psychiatric beds available for acute, short-term admissions (0.17 per1,000); the majority (55.5%) are located in private psychiatric inpatient facili-ties, while the remaining are in GHPWs (40.5%) or in university psychiatrydepartments (4.0%).
In March 1998, 695 CMHCs were operating—an average of 1.81 of theseservices per 150,000 population. CMHCs deliver the bulk of outpatient andnonresidential care: they provide individual consultations and visits, they orga-nize a variety of daytime, home, and domiciliary care activities for the most se-verely and disabled patients, they establish and keep contacts with otherhealth and social agencies and provide emergency interventions when they areneeded. They generally operate 12 hours a day for 5 or 6 days a week, andhave a multidisciplinary staff, including psychiatrists, psychologists, socialworkers, nurses, and educators. In the same year, there were 1,132 outpatientclinics—an average of 2.95 such services per 150,000 population.
Of the “intermediate structures,” the Ministry survey found that in March1998 there were 257 day hospitals (0.67 per 150,000 population) and 481 daycenters (1.26 per 150,000 population).
In terms of residential facilities, 1,316 facilities have been recorded by thePROGRES project (3.43 per 150,000 inhabitants). The large majority of thesebeds (
n
5
16,330) have a direct staff supervision for more than 12 hours a day;the average number of beds is 10.6. Private (but reimbursed) intermediate fa-cilities have an average number of beds that is higher as compared to public fa-cilities. Mostly of these facilities are located in the community; some, however,are located in the premises of former MHs.
The third IIMS survey found 433 “social enterprises” for the social reintegra-tion and for vocational rehabilitation of the most severely mentally ill: they in-volve 3,942 patients, with an average number of 9.1 patients for each enterprise.
Few data are available about the quality (in terms of structure) of residen-tial and nonresidential facilities. Based on the available data (and on the directknowledge of the authors), it can be stated that many GHPWs are hosted in
THE ITALIAN PSYCHIATRIC REFORM 203
very small, often inadequate wards; indeed, for an average number of 12.7beds the average number of rooms (including rooms for the staff, common ar-eas, etc.) in GHPWs is only 11.3.
The Personnel
In March 1998, 30,978 mental health workers were officially employed inNHS mental health facilities (with a rate of 0.81 mental health worker per1,000 inhabitants). An additional number of some 7,000 mental health workersare still working in former MHs. Psychiatrists are 5,094, psychologists 1,785,and nurses 15,482 (with different degrees of qualification).
Process Data
Another possible way to look at the changes that have occurred in the archi-tecture of the system of care is to investigate process data, available eitherfrom studies that have evaluated service functioning or the quantity and qual-ity of specific modes of treatment; additional data come from areas equippedwith a psychiatric case register (PCR).
National Data
At a national level, in the first 10 years after the reform, hospital admissionsdropped sharply: De Salvia and Barbato (1993) compared the rate of psychiat-ric hospitalizations to any facility before and after the implementation of thelaw, and found that the admission rate in the public sector dropped from 4.78per 1,000 population over 15 years of age in 1975, to 2.78 in 1987, to 2.22 in1994; the decrease in the private sector was much more limited (from 1.55 per1,000 in 1975 to 1.40 in 1994).
Even the percentage of compulsory admissions, on the total of psychiatric ad-missions, has steadily declined from about 50% in 1975, three years before theintroduction of the law, to about 20% in 1984; ten years later, in 1994, this per-centage has further dropped to 11.8% of the total of admissions (ISTAT, 1997).
Available data support the assumption that GHPWs have become a se-lected facility for the inpatient treatment of patients with severe psychotic dis-orders, who tend to be repeatedly admitted in place of one, long-term admis-sion, which was the case with the MH model of care. The “revolving-door”phenomenon seems to be particularly evident in those areas in which well-organized, effective, community-based services are not in place. The presenceof a selected, very disabled population in contact with public mental health fa-cilities is confirmed by a 1-week survey carried out in 1992 in 47 CMHCs inSouthern Italy, among 3,845 patients (Marino et al., 1996). These facilitieswere caring for a socially deprived and severely ill population; moreover, lessthan one third of the entire sample of services (13 out of 47 CMHCs) had acomprehensive range of facilities. Similar results about the specific casemix ofGHPW patients have been obtained in a regional study carried out in centralItaly on 1,379 psychiatric inpatients (Mattioni et al., 1999).
204 G. DE GIROLAMO and M. COZZA
Regional Data
A few in-depth regional analyses have been performed: the most illustrativehas focused on the Emilia-Romagna Region, which is located in the northernpart of the country and has some 4 million inhabitants (Fioritti, Lo Russo, &Melega, 1997). All psychiatric facilities were monitored from 1978 to 1994 todetermine the number and rate of admissions, average duration of stay, aver-age intake, and percent of beds occupied at inpatient facilities, as well as thenumber of patients residing in former mental hospitals and the number andrate of first contacts with mental health community centers. The results of thisregional analysis point to a substantial change which has occurred in the archi-tecture of psychiatric care in Italy in the last 20 years.
Psychiatric Case Register Data
The large majority of PCR studies have been conducted in South Verona,the most active and productive Italian research site in the area of clinical ser-vices research and one of the very few University departments fully operatingwithin the NHS (Tansella, 1993; Tansella, Amaddeo, Burti, Garzotto, & Rug-geri, 1998; Tansella, Balestrieri, Meneghelli, & Micciolo, 1991; Tansella, Micci-olo, Biggeri, Bisoffi, & Balestrieri, 1995; Thornicroft, Bisoffi, De Salvia, &Tansella, 1993). Service comparisons have been made between South Veronaand Groningen (Sytema, Balestrieri, Giel, Ten Horn, & Tansella, 1989;Sytema, Micciolo, & Tansella, 1996, 1997) and South-Verona and Manchester(Gater, Amaddeo, Tansella, Jackson, & Goldberg, 1995), and they haveshown that the Italian service, strongly community-oriented, relies much lesson inpatient care as compared to the Dutch and the British services.
Studying the pattern of care over a 15-year period in South Verona, Tansellaand Ruggeri (1996) and Ruggeri and Tansella (1996) have found that, since1979, the number of long-stay patients (those who stay in hospital for as long as1 year at least) has been consistently decreasing, whereas the numbers of long-term patients (those not long-stay who are continuously in contact with any psy-chiatric service, with a gap between two contacts never longer than 90 days) andthe number of outpatients are steadily increasing. Their analysis shows thatcommunity care needs substantial time to be implemented, and that even after15 years the number of contacts in the community is still increasing.
Comparing data from different psychiatric case registers, the 1-year preva-lence of long-term users was consistent in Northern Italy, including South Ve-rona (1.5 per 1,000 inhabitants), higher in Central Italy (e.g., Arezzo: 4.4 per1,000) and lower in Southern Italy (e.g., Caltagirone: 0.8 per 1,000) (Veltro,Magliano, Lobrace, & Morosini, 1993). Whether the reasons for these differ-ences are entirely service-related, or whether they point to different preva-lence rates of severe patients with high needs, has to be clarified. The inci-dence rate of long-term users in all these areas was consistently in the area of0.04 per 1,000.
While case register data are invaluable in order to provide in-depth infor-mation about the functioning of a service over time and the pattern of care,contacts with the service, etc., it has to be ascertained to which degree data
THE ITALIAN PSYCHIATRIC REFORM 205
from a good clinical practice, university-based site, such as South Verona, canbe generalized to most areas of the country, which do not have at all the re-search capabilities (and resources) available in South Verona.
Quality of Care Studies
In 1998, the IISM has selected 48 departments of mental health, located indifferent parts of the country and equipped with a full range of in- and outpa-tient facilities; in these departments, a more in-depth evaluation has beenperformed through the direct visit of a researcher and the administration of along, semi-structured interview, in order to go beyond structure data and ana-lyze the daily functioning of these departments (process data) (Frisanco,1997). In almost half of these departments, there was no written list of assess-ment, treatment or administrative procedures, while the proportion of unitsadopting specific treatment guidelines was even smaller; in 80% of the de-partments assessed there was no evaluation of results, whereas a regular re-port of the activities of the department was provided in 56% of cases; in over80% of the departments there was no quality assurance program, nor anyprogram aimed to monitor users’ satisfaction in parallel with outcome evalua-tion. In 50% of the departments there were no regular contacts with child orpsychogeriatric services, whereas in 80% of them there was some sort of co-operation with social services, with social enterprises running vocational re-habilitation programs and with family and voluntary organizations. Overallthe results of this survey were judged by the authors as disappointing, espe-cially bearing in mind that the survey was carried out in several of the bestequipped services.
With regard to process data concerning the quality of care provided, prob-ably the most illustrative piece of research is a large drug utilization studycarried out in 3,823 patients in treatment in virtually all in- and outpatientpsychiatric facilities of the Piedmont region (Munizza et al., 1995; Tibaldi etal., 1997). The results of this study, and of similar, recent surveys (Barbui,D’Avanzo, Frattura, & Saraceno, in press; Fassone et al., 1999) are discourag-ing. Twenty years after the introduction of Law 180 and after the publicationof the first large-scale drug-utilization study of 2,000 MH inpatients (Bellan-tuono, Colombo, Righetti, & Tognoni, 1978), which demonstrated a severelyinadequate and often harmful picture of drug treatment provided to psychiat-ric inpatients, the recent surveys show that the situation has not improved,and that psychiatric patients, even in the context of the new services, are un-likely to receive state-of-the-art, rational, and cautious pharmacotherapy.
The availability of psychosocial modes of treatment that are evidence-basedis also unevenly distributed across mental health services. While the influenceof psychodynamic treatments has been decreasing in the last 15 years, specific,empirically supported psychosocial treatments (e.g., cognitive-behavioraltechniques, psychoeducational interventions, interpersonal psychotherapy, so-cial skills training, etc.) have not achieved a wide diffusion and are not easilyavailable to meet the clinical needs of different types of service users (Mor-lino, Martucci, Amendola, & Muscettola, 1993). For instance, a recent surveycarried out in the framework of a national wave of mental health research
206 G. DE GIROLAMO and M. COZZA
projects, funded by the Ministry of Health and coordinated by the National In-stitute of Health, has found that, in a sample of 750 relatives of patients with adiagnosis of schizophrenia cared for in 30 departments of mental health acrossthe country, only a tiny minority of the families (8%) was receiving some formof psychoeducational intervention, although this treatment is widely regardedas an essential component of the care to be provided to a patient sufferingfrom schizophrenia (Magliano et al., in press).
Outcome Data
Disappointingly very few outcome studies have been carried out in Italysince the approval of the law. Therefore, it is difficult to evaluate the overall re-sults of the radical change in mental health care in a standardized, evidence-based fashion, avoiding impressionistic or opinion-biased statements, and tounderstand how the system change has been reflected in parallel changes in theclinical condition of different typologies of patients in contact with the services.
Outcome of Mental Hospital Residents
Reliable data concerning the fate of some 80,000 patients discharged overthe last 20 years from 76 MHs in operation in 1978 are particularly scanty: asnoted in an official report on the closing of MHs published by the “Social Af-fairs Committee” of the Italian Parliament after a large number of hearingsand site visits, “
almost no data are available about the patients discharged fromMHs over the years”
(Commissione XII Affari Sociali, 1997). Similarly, verylimited information is available about the patients still residents in MHs, un-der different administrative terms (
inpatients
,
residents
,
guests
, etc.): whilethese terms may differ, the reality behind them is often the same.
In one of the subprojects of the QUALYOP study (see above), aimed toidentify predictors of discharge in a cohort of 4,493 patients, residents in 22MHs in the years from 1994 to 1996, discharge was scheduled within 12months for only 11% of the sample (D’Avanzo et al., 1999; Frattura &D’Avanzo, 1998). No change in the residential condition was foreseen for 89%of the patients in the year subsequent to the survey.
The only longitudinal, methodologically sound study aimed to evaluate mor-tality rates in long-stay MH patients was carried out among 533 residents in aMH located in central Italy, followed up during the period 1979–1993 (Valentiet al., 1997). This study has found a very high Standardized Mortality Rate(SMR) for patients still residents of MHs, with exceptionally high rates foryounger patients (20–29 years of age: SMR
5
43.6 in males and 97.5 in females).
Outcome of Patients Treated in New Services
With regard to the outcome of severely ill patients treated in the new services, alarge, multicenter, prospective follow-up study is investigating the 5-year multidi-mensional outcome of patients with a diagnosis of functional psychosis or se-vere personality disorder in five areas (clinical condition, personal autonomy,
THE ITALIAN PSYCHIATRIC REFORM 207
work, family, and social relationships) (Terzian et al., 1997). The study is beingcarried out by 76 outpatient psychiatric services throughout the country, cov-ering approximately one tenth of the Italian population. The preliminary re-sults of the study point to a substantial proportion of patients showing a favor-able psychosocial outcome (Tognoni, personal communication).
In a shorter (6-month) follow-up study of 559 patients discharged from 21GHPWs located in different areas, a fairly high readmission rate (43%) wasfound combined with indicators of good community functioning (Barbato,Terzian, Saraceno, De Luca, & Tognoni, 1992; Barbato, Terzian, Saraceno,Montero Barquero, & Tognoni, 1992). The use of private inpatient facilitiesused to admit patients after discharge from the GHPWs varied considerably.Interestingly, only half of the patients originally recruited for the 6-month fol-low-up could be traced, indicating a widespread loss of contacts after dis-charge. On the whole, this study found a high degree of variability of outcomesamong discharged patients, coupled with a high degree of variability of thecare provided (and, consequently, of the quality of the care).
A few additional outcome studies of severely ill patients treated in the newservices have been carried out (Mezzina & Vidoni, 1995; Mezzina et al., 1992;Savio & Righetti, 1993; Veltro et al., 1993). The main limitations of these stud-ies are represented by the small sample size, which prevents meaningful gener-alizations, and the use of insufficiently validated assessment instruments andof short follow-up periods.
Only one study, carried out in South-Verona, has followed-up a full cohort(
N
5
60) of patients who received a diagnosis of functional psychosis in 1979,immediately after the approval of the law (Faccincani, Mignolli, & Platt, 1990;Lesage, Mignolli, Faccincani, & Tansella, 1991; Mignolli, Faccincani, & Platt,1991). This study has shown the difficulty of achieving a satisfactory remissionwith the most severe psychotic patients even in the context of community-ori-ented, well-equipped services.
Outcome Studies and Nonclinical Variables
The importance of nonclinical factors for the overall outcome of severe pa-tients has been shown in a study that has compared the psychopathology andthe quality of life (QOL) in patients suffering from schizophrenia in Boulder,Colorado, and in Bologna (Warner et al., 1998). Patients in Bologna reportedseveral significant QOL advantages over Boulder patients; patients in Bolo-gna also scored lower on some dimensions of psychopathology. However, theQOL advantages, rather than being the result of more effective, or better or-ganized mental health services, appear to reflect the sociocultural differencesbetween the two countries, especially in terms of family structure. As many as74% of Bologna patients were living with their families, as compared to a tinypercentage (17%) of Boulder patients: not surprisingly, most advantages forBologna patients were strictly dependent on their family ties and situation.This study clearly shows that outcome data can be misleading for service eval-uation if considered in isolation and without proper consideration of sociocul-tural and extraclinical variables.
208 G. DE GIROLAMO and M. COZZA
Trends in Suicide Rates
Suicide rates have been regarded as an indicator of the quality of services.There have been conflicting results among the analyses completed so far. Al-though several observers have found an increasing suicide rate in Italy overthe last 20 years, this phenomenon is probably not just the result of changes inthe system of psychiatric care, but is due to a variety of ecological factors (DeLeo, Conforti, & Carollo, 1997; Platt, Micciolo, & Tansella, 1992; Williams, DeSalvia, & Tansella, 1986, 1987). Overall, it is difficult to draw any general con-clusions about trends in suicide rates over time, or to make meaningful corre-lations with the reform law.
Discussion
This article is published exactly 50 years after the appearance in the
Ameri-can Journal of Psychiatry
of the first survey of Italian psychiatry jointly per-formed by an American (P. V. Lemkau) and an Italian psychiatrist (C. DeSanctis) (Lemkau & De Sanctis, 1950). A glance at that article, and a compari-son with the current scenario of psychiatric care in Italy can easily give an ideaof the impressive changes that have occurred in mental health care over half acentury. However, the changes that have taken place in Italy in the mentalhealth sector have largely accompanied, and sometimes preceded, parallelchanges that have occurred internationally, with a clear trend toward thedownsizing of MHs and the increase of community-based models of care. Inthis perspective, the peculiarity of the Italian situation has perhaps been over-emphasized, relying more on personal judgement than on “objective” evalua-tions: this was the case with several articles discussed in the previous literaturereview (de Girolamo, 1989), as well as with more recent contributions (Roma-nucci-Ross, 1996; Samele, 1999).
In other countries the gradual phasing-out of mental hospitals has been accom-panied by substantial phenomena of “transinstitutionalization” (Kiesler & Sim-pkins, 1993). The extent of such phenomena in Italy is hard to assess, due to thelack of reliable, national data; while some authors (Barbato, 1998) have found avery limited number of former MH residents hosted in institutions for the elderly,others (Bollini & Mollica, 1989) have found substantially higher rates.
With regard to the new services, in many parts of the country the implemen-tation of community-oriented models of mental health care has been successfuland has made mental health care accessible to many people with mental healthneeds who would have refrained in the past from any contact with the old-fash-ioned system based on asylums. The quality of care delivered is, however, stillquestionable in several areas of the country, and there is room for improvement;below we will discuss in more detail some of the most important points relatedto the Italian mental health reform and the current scenario of psychiatry.
Reliability of Official Data
A major problem in assessing the deinstitutionalization process has beenthe unreliability of most official data, especially after the recent approval
THE ITALIAN PSYCHIATRIC REFORM 209
(1996–1998) of laws aimed to force regions and LHUs to accelerate the dis-mantling of MHs and the patients’ discharge. Several MHs have been officially“closed” just to avoid the financial sanctions foreseen by these recent laws.However, this closure has largely been an “administrative” closure, resultingin a “relabeling policy” (Frattura & D’Avanzo, 1997). In this way, several hos-pital wards, from one day to another, have been renamed “staffed residentialfacility,” or “supervised community,” and their residents reclassified as“guests.” Similar problems of data reliability emerge with regard to other psy-chiatric facilities (e.g., private facilities).
Public Versus Private Facilities
A remarkable and unforeseen outcome of the change in the overall architec-ture of the system is represented by the higher percentage of acute, short-termbeds located in private facilities (55%) as compared to GHPW (and universitydepartment) beds (45%). For comparison purposes, the overall proportion ofprivate medical and surgical hospital beds in Italy is 16.2% (
n
5
51,836) out of atotal of 319,988 hospital beds (Ministero della Sanità, 1999): therefore, the pro-portion of private psychiatric beds is three times as much as compared to non-psychiatric private hospital beds. Unfortunately, no reliable, systematic dataabout the type and the quality of care provided by these private facilities arecurrently available. It should also be noted that in Italy no real accreditationsystem is in operation to guarantee the quality of these facilities. In parallel withthe large number of private beds, the rate of GHPW beds (0.07 per 1,000 in-habitants) is still substantially lower as compared to the national standard(0.1 per 1,000).
This overall situation points to the existence (as it was the case in the past)of a substantial difference between psychiatry and the rest of health care, withthe former relying extensively on private facilities for the treatment of acuteepisodes. It is noticeable that this point has very rarely been raised in the largeItalian- and English-language literature on the Italian psychiatric reform. Anin-depth evaluation of what really happens to the thousands of patients admittedto private facilities, of their distinctive sociodemographic and clinical charac-teristics, and of the type of aftercare that they receive is perhaps the highestpriority in the area of clinical services research in Italy today.
General Hospital Psychiatric Wards and Other Residential Facilities
All the studies that have monitored the fate of patients admitted to GHPWshave found high readmission rates, and this finding, in the collaborative studycarried out in 21 GHPWs, was independent of the aftercare received after dis-charge (Barbato, Terzian, Saraceno, Montero Barquero & Tognoni, 1992). Thisfinding indicates that the mean length of stay in these facilities (about 12 days) istoo short and inadequate for the most severe patients, who would probably re-quire longer stays in hospital settings structurally and functionally more ade-quate (more space available, less noisy environments, better organization ofdaytime, better structured psychosocial interventions, etc.) and a more effectivecare after discharge; indeed a recent comparison between length of stay in ad-
210 G. DE GIROLAMO and M. COZZA
mitted patients in Italy and in the United Kingdom has found a shorter stayamong Italian patients (McCrone & Lorusso, 1999). The provision of nonhospi-tal residential facilities seems satisfactory according to the standard set out bythe National Mental Health Target Plan 1998–2000. However, nobody knowswhich types of patients are resident in these facilities, and the quality of the caredelivered is not being assessed in any reliable fashion; a close look at these facil-ities represents another important research priority, and the PROGRES projectwill provide these answers (Progetto Nazionale PROGRES, in press).
Variability of the Reform Implementation
In the first years after the approval of the law, several experts noted a highvariability in service provision between different areas of the country, in par-ticular between the more wealthy areas of Northern and Central Italy and thepoorer regions of the South and the islands (e.g., Sicily and Sardinia) (Bollini,Muscettola, Piazza, Puca, & Tognoni, 1986; de Girolamo, 1989). This variabil-ity has diminished: overall the number of mental health services of any kind(in- and outpatient services) has increased by 55% between the first and thesecond IIMS surveys (1984–1994) (Cozza & Napolitano, 1996) and by 12% inthe 2 years between the second and the third IIMS survey (1994–1996) (ItalianInstitute of Social Medicine, 1997). On the whole, there has been a move froma variability across macro-areas (or regions) of the country to a variabilityacross different services, even those serving neighboring areas (Barbato, Ter-zian, Saraceno, De Luca & Tognoni, 1992; Barbato, Terzian, Saraceno,Montero Barquero et al., 1992; de Girolamo et al., 1988).
While the number of services has shown a consistent increase over theyears, there has not been a parallel increase in the number of personnel work-ing outside the former MHs, and the official standard of 1 mental healthworker per 1,500 inhabitants is still far from being achieved.
Quality of Care and Variables Affecting Outcome
A more difficult issue to be tackled is the quality of the care delivered in theexisting mental health services. Both the IIMS survey carried out in 48 depart-ments of mental health, the drug utilization studies and a variety of other datapoint to an unsatisfactory situation. More indepth evaluations are needed andwill soon become available.
With regard to the state of mental health research in Italy, carried out bothin the university departments of psychiatry and psychology and in the NHS,the situation is poor as compared to most industrialized countries (Fava &Montanari, 1996, 1997). In addition, most university departments of psychiatryhave not been (and are not) involved in the implementation of the reform law,nor are they affiliated with the NHS. The scarcity of clinical services researchcarried out in most university departments, and the lack of regular links be-tween services and university can be one of the reasons of the relatively poorquality care delivered somewhere. On the other hand, as shown by the datamentioned earlier, in 20 years mental health care in Italy has grown and im-proved in terms of coverage of the population, number of available facilities,
THE ITALIAN PSYCHIATRIC REFORM 211
filling of the gap between more rich and less advanced areas. An important in-dicator of the changes occurred in psychiatric care is represented by the sharpdecline in the rate of compulsory admissions mentioned above; this declinepoints to a type of service in which efforts are made to achieve a real therapeu-tic alliance with the patient, rather than making only a policy of social control.
Very few studies have addressed the issue of the stress on families associ-ated with the massive change in the locus of care, with the subsequent stay infamily of many patients who would have been previously institutionalized atlength (eventually lifelong). The scanty data seem to show that family burdenis high, that families have taken up much of the informal care for the ill rela-tive, which was previously a responsibility of the MH, and that at least some ofthe advantages of the new situation are more due to the everyday family sup-port granted to patients by their families rather than to the services.
Additional information will also be necessary to understand to which extentthe relatively more favorable outcome of severely ill patients (as compared tothe past), shown by the few outcome studies carried out so far, can be attributedto more effective forms of treatment or to the elimination of an iatrogenic envi-ronment (e.g., the MH), or to nonclinical factors (e.g., changes in the socioeco-nomic environment, or wider availability of family support, as shown, for in-stance, by the results of the Bologna-Boulder comparison) (Warner et al., 1998).
Conclusions: a Few Lessons
What are the main lessons, if any, that can be drawn from the Italian experi-ence? The points put forward more than 10 years ago by Tansella and Wil-liams (1987) in a landmark account of the Italian reform still hold true.
The first point is that the transition from a predominantly hospital-basedservice to a predominantly community-based service cannot be accomplishedsimply by closing the mental hospitals. Appropriate alternative structuresmust be provided and this requires adequate time for planning and implemen-tation. Moreover, this move must involve a real change in the philosophy andquality of treatment and in the work-style: otherwise, as stated by Goldman,Morrissey, and Bachrach (1983), “only the locus of care changes, not themethod of treatment or the resources available to support a system of care.”
The second point is that political and administrative commitment is neces-sary. Community care is not, and will never be, a cheap solution (althoughMHs with minimally acceptable standards of care are expensive). Indeed, ifcommunity care is to be effective, investments have to be made in buildings,staff, their training, and the provision of backup facilities.
The third point is that “monitoring and evaluation are important aspects ofchange: planning and evaluation should go hand in hand and evaluation should,wherever possible, have an epidemiological basis” (Tansella & Williams, 1987).
Finally, the fourth point is that a reform law should not only be a guidelinelaw (as for the Italian law) but should be a prescriptive law, and “minimalstandards in terms of care, reliable systems of monitoring, compulsory timeta-bles for implementing the foreseen facilities and central mechanisms of verifi-cation, control and comparison of the quality of services need to be deter-mined” (de Girolamo, 1989).
212 G. DE GIROLAMO and M. COZZA
All these tasks are still to be accomplished in Italy. We hope that in a re-evaluation of the state of Italian psychiatry in 10 years’ time, these targets willbe shown finally to have been achieved.
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