FOCUS ON PUBLIC MENTAL CARE IN ITALY
Focus on Public Mental Care in Italy
Italy has experienced a significant change in its mental healthsector, with a radical shift from old mental institutions tonew community-based psychiatric services. The Italian experienceattracted international attention and, in some instances, ledto similar changes occurring abroad.
The first comprehensive law on mental health in Italy datesback to 1904. At that time, the mental hospital was regardedas the cornerstone of the care system. Admissionto a mental hospital could be requested by anyone ‘inthe interest of the patient or the society’ and even by the police. Admissions were compulsory, might last indefinitelyand implied the loss of civil and political rights. Each provincewas responsible for the local provision and organisation ofmental health care and set up its own mental hospital, whichwas kept apart from the general health care system.
In 1968, a new national law was passed, integratingthe former one and including:
From here, deinstitutionalisation accelerated. Cohorts of long-stay patients in mental hospitals gradually declined with an increasein voluntary admissions lasting for shorter periods.
This trend was complemented by increasingadmissions to private psychiatric clinics, nursing homes forthe elderly and neurological wards in public and private hospitals.
In 1978, a reform law was devised and approved by the Italian parliament and then incorporated into a more comprehensive legislationsetting up the National Health Service. The reform law marked a turning point in mental health careorganisation both from a local and an international perspective.Specifically:
While the number of patients staying in mental hospitals continuedto decline over time and new community-based services were set up at an acceleratingrate, only the combined effects of strict legalpressure and financial sanctions forced the definite closureof all mental hospitals nationwide, by 31 December 2000.
At present, the department of mental health is expected to promoteand coordinate mental health prevention, care and rehabilitationwithin a defined catchment area. It is based on a multi-disciplinaryteam (psychiatrists, psychologists, nurses, social workers,educators, occupational therapists, personnel with specifictraining in psychosocial rehabilitation and secretarial staff)and deals with the full array of mental health needs of the adult population. It also offers long-term comprehensive interventionsand continuity of care.
Four types of services are anticipatedwithin the department:
a. The community mental health centre is generally responsiblefor planning and coordinating interventions across differentfacilities and settings. It is open for at least 12 hours aday from Monday to Friday and half a day on Saturday. Patientshave direct access and referral from primary care doctors isnot required. Demands of care are evaluated by the multi-disciplinaryteam and patients may receive direct interventions or be referredto other mental health facilities or different types of service,where necessary. The team working at the community mental healthcentre arranges domiciliary visits and is involved in consultation—liaisoninterventions in the local area.
b. The general hospital in-patient wards are located in hospitalswhich have an accident and emergency department. They providecrisis interventions on a short-term basis and patients arethen referred back to the community mental health centre forout-patient care or other types of intervention. Most admissionstake place on a voluntary basis and only a minority are compulsory. Psychiatrists working in inpatient wards are usually involvedin consultation—liaison programmes with medical and surgicalwards located in the general hospital.
c. The day hospital allows complex diagnostic assessments and therapeutic interventions on short- and medium-term bases. It may be locatedwithin the general hospital (although separated from the inpatientward) or outside the hospital and is functionally integratedwith the community mental health centre.
The day centre is open for at least 8 hours a day for 6 daysa week and implements programmes promoting self-care and thepractical and interpersonal skills required in everyday life.
d. Residential facilities promote patients' psychosocial rehabilitationand integration and may offer different levels of staff supervisionand types of intervention in order to meet patients' specificneeds. By law, these facilities have a limited number of bedsand are placed in urban areas in order to avoid social isolationand ensure intensity of care. The relativelack of these facilities in the public sector favours privateclinics, which are contracted by the National Health Service to satisfy unmet needs.
Last, substance misuse disorders and mental disorders in childrenand adolescents are treated by specialist services which arenot part of the department of mental health and have separatefacilities and personnel.
Better integration and closer collaboration between different services is now emergingas a leading principle in the mental health sector. TerritorialPacts for Mental Health is a new strategy promotingthe functional integration of health, social, economic andvocational resources (both public and private) available ina given catchment area.
Additional Information
As health care in general, mental care is provided in Italy by the National Health Service,and each citizen must be registered with a primary care doctor.Citizens have unlimited health care coverage, although theycontribute through charges on drug prescriptions (with theexception of so-called essential drugs), laboratory tests ordiagnostic investigations. Within the National Health Service, regions are divided into local health districts, each providinghealth care to the population of a defined catchment area.Citizens are not forced to receive care locally and may contactany health facility, irrespective of its geographical location.
In 1992, local health districts and hospitals were granted financialand managerial autonomy. Each local health district has a budgetfor health care based on the size of the local population,the number of health care facilities and other health-relatedindicators.
Each district uses its budget to run its own health facilitiesor to ‘buy’ interventions from other services,such as hospitals (run by distinct trusts) or private servicesunder contract to the National Health Service.
Italy has experienced a significant change in its mental healthsector, with a radical shift from old mental institutions tonew community-based psychiatric services. The Italian experienceattracted international attention and, in some instances, ledto similar changes occurring abroad.
The first comprehensive law on mental health in Italy datesback to 1904. At that time, the mental hospital was regardedas the cornerstone of the care system. Admissionto a mental hospital could be requested by anyone ‘inthe interest of the patient or the society’ and even by the police. Admissions were compulsory, might last indefinitelyand implied the loss of civil and political rights. Each provincewas responsible for the local provision and organisation ofmental health care and set up its own mental hospital, whichwas kept apart from the general health care system.
In 1968, a new national law was passed, integratingthe former one and including:
- the reduction in size of mental hospitals;
- a ratio of at least1 to 4 between staff members and patients,with personnel alsoincluding psychologists and social workersalongside doctors and nurses;
- the creation of psychiatric wards within generalhospitals,bringing psychiatry into the realm of medicine forthe firsttime in Italy;
- the legitimacy of voluntary admissionsto mental hospitals,with patients being granted the role ofactive partners inthe care process, with the preservationof their civil andpolitical rights;
- the establishment ofcommunity-based out-patient services toprovide treatment andsupport to patients discharged from mentalhospitals.
From here, deinstitutionalisation accelerated. Cohorts of long-stay patients in mental hospitals gradually declined with an increasein voluntary admissions lasting for shorter periods.
This trend was complemented by increasingadmissions to private psychiatric clinics, nursing homes forthe elderly and neurological wards in public and private hospitals.
In 1978, a reform law was devised and approved by the Italian parliament and then incorporated into a more comprehensive legislationsetting up the National Health Service. The reform law marked a turning point in mental health careorganisation both from a local and an international perspective.Specifically:
- new admissions to existing mental hospitals were no longer allowed,no new mental hospitals or similar facilities were to be built,and a gradual closure of existing mental hospitals had to beplanned;
- prevention, care and rehabilitation in mental healthwere assignedto new community-based services, functionallyintegrated amongthemselves.
- compulsory admissions to psychiatric wards were regardedasexceptional, had to be time-limited and were allowed onlywhenout-patient interventions were ineffective or refusedby patients.
While the number of patients staying in mental hospitals continuedto decline over time and new community-based services were set up at an acceleratingrate, only the combined effects of strict legalpressure and financial sanctions forced the definite closureof all mental hospitals nationwide, by 31 December 2000.
At present, the department of mental health is expected to promoteand coordinate mental health prevention, care and rehabilitationwithin a defined catchment area. It is based on a multi-disciplinaryteam (psychiatrists, psychologists, nurses, social workers,educators, occupational therapists, personnel with specifictraining in psychosocial rehabilitation and secretarial staff)and deals with the full array of mental health needs of the adult population. It also offers long-term comprehensive interventionsand continuity of care.
Four types of services are anticipatedwithin the department:
- the community mental health centre;
- the general hospital in-patientward;
- semi-residential facilities (day hospital and day centre);
- residential facilities.
a. The community mental health centre is generally responsiblefor planning and coordinating interventions across differentfacilities and settings. It is open for at least 12 hours aday from Monday to Friday and half a day on Saturday. Patientshave direct access and referral from primary care doctors isnot required. Demands of care are evaluated by the multi-disciplinaryteam and patients may receive direct interventions or be referredto other mental health facilities or different types of service,where necessary. The team working at the community mental healthcentre arranges domiciliary visits and is involved in consultation—liaisoninterventions in the local area.
b. The general hospital in-patient wards are located in hospitalswhich have an accident and emergency department. They providecrisis interventions on a short-term basis and patients arethen referred back to the community mental health centre forout-patient care or other types of intervention. Most admissionstake place on a voluntary basis and only a minority are compulsory. Psychiatrists working in inpatient wards are usually involvedin consultation—liaison programmes with medical and surgicalwards located in the general hospital.
c. The day hospital allows complex diagnostic assessments and therapeutic interventions on short- and medium-term bases. It may be locatedwithin the general hospital (although separated from the inpatientward) or outside the hospital and is functionally integratedwith the community mental health centre.
The day centre is open for at least 8 hours a day for 6 daysa week and implements programmes promoting self-care and thepractical and interpersonal skills required in everyday life.
d. Residential facilities promote patients' psychosocial rehabilitationand integration and may offer different levels of staff supervisionand types of intervention in order to meet patients' specificneeds. By law, these facilities have a limited number of bedsand are placed in urban areas in order to avoid social isolationand ensure intensity of care. The relativelack of these facilities in the public sector favours privateclinics, which are contracted by the National Health Service to satisfy unmet needs.
Last, substance misuse disorders and mental disorders in childrenand adolescents are treated by specialist services which arenot part of the department of mental health and have separatefacilities and personnel.
Better integration and closer collaboration between different services is now emergingas a leading principle in the mental health sector. TerritorialPacts for Mental Health is a new strategy promotingthe functional integration of health, social, economic andvocational resources (both public and private) available ina given catchment area.
Additional Information
As health care in general, mental care is provided in Italy by the National Health Service,and each citizen must be registered with a primary care doctor.Citizens have unlimited health care coverage, although theycontribute through charges on drug prescriptions (with theexception of so-called essential drugs), laboratory tests ordiagnostic investigations. Within the National Health Service, regions are divided into local health districts, each providinghealth care to the population of a defined catchment area.Citizens are not forced to receive care locally and may contactany health facility, irrespective of its geographical location.
In 1992, local health districts and hospitals were granted financialand managerial autonomy. Each local health district has a budgetfor health care based on the size of the local population,the number of health care facilities and other health-relatedindicators.
Each district uses its budget to run its own health facilitiesor to ‘buy’ interventions from other services,such as hospitals (run by distinct trusts) or private servicesunder contract to the National Health Service.