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To identify the demographic and clinical characteristics associated with access to Emergency Departments for Suicide Attempt in a cohort of patients with Gambling disorders. We used electronic health records of inpatient and outpatient services to identify individuals who received a diagnosis of gambling disorder (ICD-9 or ICD-10 codes) in the Metropolitan area of Bologna from 2009 to 2019. In this cohort we identified accesses to Emergency Departments for suicide attempt through cross-matching with electronic records. We calculated Crude Suicide Attempt Rates; we also included the demographic-clinical variables in a multivariate Poisson regression. We identified 692 patients with a diagnosis of gambling disorder and a total of 2733 Person Years. The Crude Suicide Attempt Rate per 1000 Person Years was 9.17 (95% CI 6.20-13.58), higher for females and much higher than the general population (incidence rate ratio = 93.72). The multivariate analysis showed a higher risk of suicide attempt in the year following the first contact with a clinical service, in patients younger than 45 years, with alcohol use disorders and personality disorders. This study evidenced a high risk of access to Emergency Departments for suicide attempt in individuals with a diagnosis of gambling disorder and highlighted important demographic and clinical factors that should be considered when evaluating suicide risk in this population.

Background “Impulse Control Disorders” are behavioral conditions (e.g., gambling, hypersexuality), which are increasingly reported as reactions to dopamine agonists in Parkinson's disease. The Questionnaire for Impulsive-Compulsive Disorders in Parkinson's disease focuses only on 6 behaviors. Nonetheless, impulsivity could affect the entire range of human practices. Because of their heterogeneity and undefined boundaries, it is not clear what conditions should be considered as Impulse Control Disorders. This results in poorly standardized scientific literature and underdiagnosis. Objective We aimed to create a comprehensive list of possible manifestations of drug-induced Impulse Control Disorders in Parkinson's disease and test it on pharmacosurveillance data. Methods PubMed was used to identify reviews in English about Impulse Control Disorders in Parkinson's disease. Mentioned conditions were charted and translated to the lexicon of MedDRA, ICD-11, and DSM-5. The relevant MedDRA terms were used to test potential association with dopamine agonists on the FDA Adverse Event Reporting System. Results 50 reviews published between 2001 and 2020 were identified. 66 conditions were collected as possible Impulse Control Disorders. Pathological gambling, shopping, eating and sexuality, dopamine dysregulation syndrome, hobbyism and punding were the most frequently mentioned, together with leisure activities, body-focused compulsivity, disruptive, impulse control and conduct disorders, and substance abuse. All these conditions were disproportionately reported with dopamine agonists, except for substance abuse. Conclusions We defined a potential extended list of ICDs, which, along with its conversion to international taxonomies, can support the identification of drug-induced conditions in pharmacovigilance archives, as well as monitoring processes in clinical practice.

Purpose In this paper, the authors present insights and findings drawn from the authors’ experiences of containing a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak in a large prison in northern Italy.Within penitentiaries, close-quarter living is ripe terrain for outbreaks of disease among detainees and staff. If left unchecked, these outbreaks can easily spill over the prison walls to threaten the general public. Moreover, these risks are heightened by preexisting environmental conditions, especially overcrowding. It is thus paramount to establish effective protocols for prevention, early detection and outbreak management. The purpose of this article is to document a strategy that been at least partially successful in reducing the damage that could potentially be caused by a sustained SARS-CoV-2 outbreak within a correctional facility. Design/methodology/approach The authors conducted a retrospective analysis on patients’ and health-care workers’ medical records to obtain demographic and clinical information. Descriptive data analysis was then carried out. Findings In total, the authors tested 453 people with oropharyngeal swabs from March 15, 2020, to June 30, 2020. Of these people, 58 were positive and 395 were negative, with a prevalence of 12.8%.Of the 453 patients, 60 were health workers: 24 tested positive for SARS-CoV2 ribonucleic acid (RNA); 18 developed symptoms; and three needed hospitalization.Among patients in detention, 34 resulted positive for SARS-CoV-2 RNA. Two were hospitalized and later died. Both had severe preexisting conditions; they were aged 76 and 59 years old, respectively. Originality/value In this study, the authors describe the design and effective implementation of prevention and containment measures against SARS-CoV-2 within the walls of a correctional facility. The authors describe how they rapidly created clean confinement sections to isolate cases in an environment designed for security at the expense of virus containment and how educational efforts have played a vital role in their strategy.

Individual placement and support (IPS) is an evidence-based intervention helping people with mental illness to obtain competitive jobs. In the last decade, European mental health leaders were interested on its implementation. Aim of the study was to assess the IPS feasibility in Italian patients with moderate-to-severe mental illness. To date, no evaluation of IPS has been conducted exclusively in Italy. Participants (n = 95) were clients of community mental health centers of the Reggio Emilia Department of Mental Health. In addition to drop-out rates, we calculated job acquisition, job duration, and total hours per week worked. A crude competitive employment rate of 41.1% and a crude drop-out rate of 30.5% were found over 42-month follow-up period. Using a Kaplan-Meyer survival analysis, the cumulative employment rate increased up to 44% at 12 months and 61% both at 24 and 42 months. This study documents the feasibility of an implementation strategy for introducing the IPS model in the public mental health care system in Italy.

Background The aim of this study was to examine heroin mortality trends and changes in causes of death, across time and age, in a cohort of the heroin population of treated. Methods 5899 subjects attending twelve centers for addiction treatment (SERT) in north Italy following problems due to heroin abuse between 1975 and 2013 were recruited. Results This study documented elevated mortality among subjects with primary heroin abuse, with an elevated death risk in all the classes of age, declining until 2009 ad increasing starting from 2010. AIDS was the first cause of death, followed by overdose and liver-related diseases. In the course of time mortality for AIDS and for drug-related deaths has declined, whereas liver mortality and all tumors mortality have risen over time, becoming the most common causes of death by the end of the follow up. As compared with the general population, the excess mortality (SMR) observed for all causes in either sex was 13.2, higher in females (SMR=21.5) as compared with males (SMR=12.1). Higher SMRs were found in 25/34 age-group patients, with a progressive decrease in subjects with age >34years. Conclusions In the course of time, among heroin users, mortality and the causes of death have changed; for SERT clients special attention should be paid to the prevention and treatment of liver-related diseases.

Evidence from previous research demonstrated a gap in mortality between patients with mental disorders and the general population. However, a more exhaustive assessment is required to address this public health issue. The aim of this study was to provide comprehensive analysis of mortality examining all causes of death and all psychiatric diagnoses. We conducted a 10-year retrospective cohort study, including all in and out patients registered in the Mental Health Registry of Emilia-Romagna, Italy. Standardized mortality ratios (SMRs) were calculated. The cohort consisted of 137,351 patients 11,236 of whom died during the study period and the overall SMR was 1.99. 85.9 % of excess mortality was attributable to a broad range of natural causes. Diseases of circulatory and respiratory systems as well as neoplasms were the principal contributors to the mortality gap. All psychiatric conditions led to a higher risk of death. The greatest excess was due to neoplasms in depressed and neurotic patients and to cardiovascular diseases in patients with schizophrenia and personality disorders. Our results highlight the need for close collaboration between mental and primary health care services with the aim of reducing excess mortality as a result of medical diseases among all patients suffering from psychiatric condition.

Identifying the most vulnerable subjects is crucial for the effectiveness of health interventions aimed at limiting the adverse consequences of high temperatures. We conducted a case crossover study aimed at assessing whether suffering from mental health disorders modifies the effect of high temperatures on mortality. We included all deaths occurred in the area of Bologna Local Health Trust during the summers 2004&ndash, 2017. Subjects with mental disorders were identified by using the local Mental Health Registry. A conditional logistic model was applied, and a z-test was used to study the effect modification. Several models were estimated stratifying by subjects&rsquo, characteristics. For every 1 &deg, C above 24 &deg, C, mortality among people without mental disorders increased by 1.9% (95% CI 1.0&ndash, 2.6, p &lt, 0.0001), while among mental health service users, mortality increased by 5.5% (95% CI 2.4&ndash, 8.6, p &lt, 0.0001) (z-test equal to p = 0.0259). The effect modification varied according to gender, residency and cause of death. The highest probability of dying due to an increase in temperature was registered in patients with depression and cognitive decline. In order to reduce the effects of high temperatures on mortality, health intervention strategies should include mental health patients among the most vulnerable subjects taking account of their demographic and clinical characteristics.

Aim Current diagnostic systems, DSM-5 and ICD-10, still adopt a categorical approach to classify psychotic disorders. The present study was aimed at investigating the structure of psychotic symptomatology in both affective and non-affective psychosis from a dimensional approach. Methods Participants with a first episode psychosis (FEP) were recruited from a cluster-randomized controlled trial (GET-UP PIANO TRIAL), offered to all Community Mental Health Centres (CMHCs) located across two northern Italian regions. After clinical stabilization, patients were assessed with a comprehensive set of psychopathological measures including the Positive and Negative Syndrome Scale, the Hamilton Depression Rating Scale and the Bech-Rafaelsen Mania Rating Scale. A two-step cluster analysis was performed. Results Overall, 257 FEP patients (male, n = 171, 66.5%; mean age = 24.96 ± 4.56) were included in the study. The cluster analysis revealed a robust four-cluster solution: delusional-persecutory (n = 82; 31.9%), depressed (n = 95; 37%), excited (n = 26; 10.1%) and negative-disorganized (n = 54; 21%), thus suggesting a quadripartite structure with both affective and non-affective dimensions. Among non-affective dimensions, negative and disorganization symptoms constituted a unique construct apart from positive symptoms. Conclusions Symptom dimensions may represent a useful tool for dissecting the indistinct and non-specific psychopathology of FEP in order to better target specific interventions.

PurposeThis study aims to describe factors associated to treatment continuity and psychiatric relapses in patients treated with Long Acting Injectable antipsychotics (LAIs) in Bologna Community Mental Health Centers (CMHCs).MethodsNew LAI treatments administered between July 1, 2010 and June 30, 2015 in CMHCs were selected. The cohort was followed-up for 6 months; predictors of continuity and psychiatric admissions were investigated by using logistic regression- and Cox- analysis respectively.ResultsAmong the cohort of 1 070 patients, only 222 (21%) continued LAI treatment during the follow-up. LAI continuity was higher with first generation agents (OR: 1.71, 95%CI 1.18-2.49) and in case of previous psychiatric hospitalizations (OR 2.00, 95%CI 1.47-2.74). Incidence of psychiatric hospital admissions showed a sharp reduction in the follow-up compared with 6-month period before initiation (from 458 to 212), and was associated with previous psychiatric hospitalizations (HR 3.20, 95%CI 2.22-4.59), immigration (HR 3.13, 95%CI 1.28-7.69) and LAI discontinuation (HR 1.14, 95%Cl 1.01-1.97).ConclusionsPsychiatric hospital admission before LAI initiation was the main predictor both of LAI continuity and hospitalization during the follow-up.

In this paper the relation between psychosocial rehabilitation and job in Italy, a theme that can be traced back to two cultural roots, that of the right to work enshrined in the Italian Constitution and that of the ergotherapy in the asylum tradition, is stressed. After 1978 the efforts to assure community psychiatry patients a job opportunity has led to the emergence of cooperatives against exclusion. The story of one of them was told in an Italian movie, in which it is possible to understand the main problems of rehabilitation through labor. In recent decades, the transformation of Italian society and the evolution of services has necessitated the evolution of cooperatives to social enterprise, which respond to a different philosophy, and a broader range of opportunities, with the introduction of new models, such as IPS. The example of two regional projects of the last years is here illustrated.

The molecular underpinnings associated to first episode psychosis (FEP) remains to be elucidated, but compelling evidence supported an association of FEP with blood alterations in biomarkers related to immune system, growth factors and metabolism regulators. Many of these studies have not been already confirmed in larger samples or have not considered the FEP diagnostic subgroups. In order to identify biochemical signatures of FEP, the serum levels of the growth factors BDNF and VEGF, the immune regulators IL-1RA, IL-6, IL-10 and IL-17, RANTES/CCL5, MIP-1b/CCL4, IL-8 and the metabolic regulators C-peptide, ghrelin, GIP, GLP-1, glucagon, insulin, leptin, PAI-1, resistin and visfatin were analysed in 260 subjects collected in the GET UP project. The results indicated an increase of MIP-1b/CCL4, VEGF, IL-6 and PAI-1, while IL-17, ghrelin, glucagon and GLP-1 were decreased in the whole sample of FEP patients (p

Objective To identify descriptors of Antipsychotic (AP) prescription, focusing on second generation antipsychotics (SGAs), polypharmacy, and long-acting injections (LAIs). Methods Outpatients of the Bologna-Community-Mental-Health-Centres with at least one AP prescription were selected. Patients' characteristics, service utilization, and AP prescriptions were collected from administrative databases. Prescriptions were grouped by class (SGA vs. First Generation Antipsychotics), drug combination (polypharmacy vs. monotherapy), and preparation (LAIs vs. regular administration). Multi-variate analyses were performed to identify prescription descriptors among socio-demographic and clinical variables. Results Among 6,074 patients and 41,121 AP prescriptions, SGAs were used in 70.7% of subjects, AP polypharmacy in 25.3%, and LAIs in 17.5%. SGAs were prescribed more often for young, Italian patients, with higher education, voluntary hospital-ization, and high number of visits. Descriptors of AP polypharmacy were: high number of visits and hospitalization, length of treatment, non-urban residency, male gender, unemployment. Characteristics associated to LAI prescription were: long duration of treatment, high number of visits, compulsory admissions, non-Italian nationality, male gender, age > 34, low education, unmarried status. Conclusions Besides illness severity, this study identified different socio-demographic descriptors of AP choices, raising concerns on the equity of treatments. Efforts should be directed to investigate appropriateness of AP treatments especially in social disadvantaged populations.

ObjectivesTo evaluate the effect of cardiologist care on adherence to evidence-based secondary prevention medications, mortality and readmission within 6 months of discharge in patients with heart failure (HF).DesignRetrospective observational study based on administrative data.SettingLocal Healthcare Authority (LHA) of Bologna, one of the largest LHAs of Italy with ~870 000 inhabitants.ParticipantsAll patients residing in the LHA of Bologna discharged from hospital with a diagnosis of HF between 1 January 2015 and 31 December 2015.Primary and secondary outcome measuresMultivariable regression analysis was used to assess the association of inpatient and outpatient cardiologist care with adherence to evidence-based medications, all-cause mortality and hospital readmission (including emergency room visits) within 6 months of discharge.ResultsThe study population included 2650 patients (mean age 82.3 years). 340 (12.8%) patients were discharged from cardiology wards, while 635 (24.0%) were seen by a cardiologist during follow-up. Inpatient and outpatient cardiologist care was associated with an increased likelihood of adherence to ACE inhibitors/angiotensin receptor blockers (ACEIs/ARBs), β-blockers and aldosterone antagonists after discharge. The risk of mortality was significantly lower among patients adherent to ACEIs/ARBs and/or β-blockers (–53% and –28%, respectively); the risk of hospital readmission was significantly lower among patients adherent to ACEIs/ARBs (–28%).ConclusionsCompared with non-specialist care, cardiologist care improves patient adherence to evidence-based medications and might thus favourably affect mortality and readmission following HF.

A total of 852 participants attending 11 centers for addiction treatment in north Italy following problems due to cocaine abuse between 1989 and 2013 were recruited. Two typologies were created: cocaine users (never heroin) (CU) and heroin and cocaine users (HCU). During the 38-year follow-up period, 4.8% of the whole cohort died. Over the whole period, tumors were the main causes of death; starting in 2010, suicide deaths became the first cause of death. Among CUs, most deaths were due to road accidents and suicide; among HCUs, most of the deaths were from opiate overdose and from cardio-circulatory system diseases. The excess mortality observed for all causes in either sex was 6.24; higher in females (15.03) as compared in males (6.23), higher in HCUs (9.06) as compared in CUs (5.21). The directly age-sex standardized mortality rates were 5.31 per 100, higher for females, declining after 2009 for all patients and after 2004 for HCUs. Multivariate analysis confirms the decreasing trend in the risk of death and shows a higher mortality risk for participants in the under-25 age group. Among cocaine users, special attention should be paid to the prevention of suicide deaths.

Background: Literature has documented the role of family in the outcome of chronic schizophrenia. In the light of this, family interventions (FIs) are becoming an integral component of treatment for psychosis. The First Episode of Psychosis (FEP) is the period when most of the changes in family atmosphere are observed; unfortunately, few studies on the relatives are available. Objective: To explore burden of care and emotional distress at baseline and at 9-month follow-up and the levels of service satisfaction at follow-up in the two groups of relatives (experimental treatment EXP vs. treatment as usual TAU) recruited in the cluster-randomized controlled GET UP PIANO trial. Methods: The experimental treatment was provided by routine public Community Mental Health Centers (Italian National Health Service) and consisted of Treatment as Usual plus evidence-based additional treatment (Cognitive Behavioral Therapy for psychosis for patients, Family Intervention for psychosis, and Case Management). TAU consisted of personalized outpatient psychopharmacological treatment, combined with non-specific supportive clinical management and informal support/educational sessions for families. The outcomes on relatives were assessed by the Involvement Evaluation Questionnaire (IEQ-EU), the General Health Questionnaire (GHQ-12), and the Verona Service Satisfaction Scale (VSSS-EU). Differences within and between groups were evaluated. Results: At baseline, 75 TAU and 185 EXP caregivers were assessed. In the experimental group 92% of relatives participated in at least 1 family session. At follow-up both groups experienced improvement in all IEQ and GHQ items, but caregivers belonging to the EXP arm experienced a significantly greater change in 10 IEQ items (mainly pertaining to the “Tension” dimension) and in GHQ items. Due to the low sample size, a significant effectiveness was only observed for 2 IEQ items and 1 GHQ-12 item. With respect to VSSS data at follow-up, caregivers in the EXP arm experienced significantly greater satisfaction in 8 items, almost all pertaining to the dimensions “Relatives' Involvement” and “Professionals' Skills and Behavior.” Conclusions: The Family intervention for psychosis delivered in the GET UP PIANO trial reduced family burden of illness and improved emotional distress and satisfaction with services. These results should encourage to promote FIs on caregivers of first-episode psychosis patients.

Background: The international literature reports that for every completed suicide there are between 8 and 22 visits to an Emergency Department (ED) for attempted suicide/suicidal behavior. Aims: To describe the characteristics of admission to emergency departments (EDs) for suicide-related presenting complaints in the metropolitan area of Bologna; to estimate the risk for all-cause mortality and for suicide; to identify the profiles of subjects most at risk. Method: Follow-up of patients admitted to the EDs of the metropolitan area of Bologna between January 2004 and December 2010 for attempted suicide. A Cox model was used to evaluate the association between sociodemographic variables and the general mortality risk. Results: We identified 505 cases of attempted suicide, which were more frequent for female subjects, over the weekend, and at night (8:00 p.m./8:00 a.m.). The most used suicide methods were psychotropic drugs, sharp or blunt objects, and jumping from high places. In this cohort, 3.6% of subjects completed suicide (4.5% of males vs. 2.9% of females), 2.3% within 1 year of the start of follow-up. The most common causes of death were drug use and hanging. In the multivariate analysis, those who used illicit drugs 24 hr prior to admission to the ED (hazard ratio [HR] = 3.46, 95% CI = 1.23–9.73) and patients who refused the treatment (HR = 6.74, 95% CI = 1.86–24.40) showed an increased mortality risk for suicide. Conclusion: Deliberate self-harm patients presenting to the ED who refuse treatment represent a specific target group for setting up dedicated prevention schemes.

Topic: Individual Placement and Support (IPS) is a psychosocial intervention with a considerable body of evidence for its effectiveness in helping people with severe psychiatric disorders to obtain and maintain competitive jobs. In the last decades several European studies have replicated earlier American outcomes, generating widespread interest about its implementation in Europe. Purpose: This article describes and compares details about achievements and challenges of IPS in 4 European countries: the United Kingdom, Italy, The Netherlands, and Spain. Sources Used: This description draws from published and nonpublished material about policy, development of services, and services evaluation. Results: In the United Kingdom and in The Netherlands, empirical studies exploring the consistency of results over time and the effectiveness of IPS adaptations to local needs and special population are in course. In the United Kingdom, IPS has become national policy, as well as in some regions of Italy and Spain. Training is quite extensive in the United Kingdom and in The Netherlands, developing well in Italy and Spain. Implementation seems to be less straightforward, mostly because of deeply rooted cultural values regarding both work and mental health care. Strong local leadership is still required. In all countries contingencies related to the current economic crisis seems to have increased interest in IPS. Conclusions and Implications for Practice: With the converging forces of strong local leadership, rapid economic changes, and slow cultural shifts, IPS may soon become a priority intervention in Europe for ensuring that people living with serious mental illnesses are able to obtain competitive employment. © 2014 American Psychological Association.

Background: This study analyzes data related to Hospital (HOS), Public Treatment Service Dedicated to Drug Addicts (SERD), or Community Mental Health Center (CMHC) clients with a first diagnosis of Pathological Gambling (PG) in the period 2000/2016 in Northern Italy. The aims were to describe trends and characteristics of pathological gamblers (PGs) and to estimate the prevalence of other diagnoses before or after the diagnosis of PG. Methods: Participants aged over 17 years with an ICD-9 or ICD-10 PG diagnosis were selected. Results: 680 PGs were identified, mean age 47.4 years, 20% female, 13% non-natives, 30% had other mental disorders diagnoses, 9% had alcohol dependence syndrome, and 11% had drug dependence. Most participants with comorbid disorders were diagnosed before PG, with a more elevated prevalence regarding mental disorders. Almost seven years had elapsed on average between the first admission and the diagnosis of PG. Conclusions: The results of this study highlight a growing demand for PG treatment addressed not only to SERD, but also to psychiatric and hospital services, based on the increase in SERD attendance from 2013. Many of them had already been treated for mental health problems before, but their percentage remained costant over time.

Discharge from a psychiatric forensic institution is a critical moment for patients with severe mental disorders; often it leads to relocation to a non-forensic residential facility (RF) where treatment and support needs can be met. The present study used data from the Italian PROGRES project (aimed at studying the country's residential mental health care system) to investigate the characteristics of a large sample of patients formerly admitted to forensic mental hospitals (FMH) living in a psychiatric RF, and to compare them with RF patients never admitted to FMH. Structured interviews were conducted with the managers and staff of a representative sample of Italian RFs (n = 265); residents were also evaluated using standardized rating instruments. Among 2,962 surveyed residents, a total of 193 patients (6.5%) had previously been admitted to a FMH. The majority had a diagnosis of schizophrenia or a related disorder (n = 149, 78.0% of FMH patient vs. 1830, 66.8% of non-FMH patients). Overall, the symptom p...

Summary Background The value of the individual placement and support (IPS) programme in helping people with severe mental illness gain open employment is unknown in Europe. Our aim was to assess the effectiveness of IPS, and to examine whether its effect is modified by local labour markets and welfare systems. Methods 312 patients with severe mental illness were randomly assigned in six European centres to receive IPS (n=156) or vocational services (n=156). Patients were followed up for 18 months. The primary outcome was the difference between the proportions of people entering competitive employment in the two groups. The heterogeneity of IPS effectiveness was explored with prospective meta-analyses to establish the effect of local welfare systems and labour markets. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, with the number NCT00461318. Findings IPS was more effective than vocational services for every vocational outcome, with 85 (55%) patients assigned to IPS working for at least 1 day compared with 43 (28%) patients assigned to vocational services (difference 26·9%, 95% CI 16·4–37·4). Patients assigned to vocational services were significantly more likely to drop out of the service and to be readmitted to hospital than were those assigned to IPS (drop-out 70 [45%] vs 20 [13%]; difference −32·1% [95% CI −41·5 to −22·7]; readmission 42 [31%] vs 28 [20%]; difference −11·2% [−21·5 to −0·90]). Local unemployment rates accounted for a substantial amount of the heterogeneity in IPS effectiveness. Interpretation Our demonstration of the effectiveness of IPS in widely differing labour market and welfare contexts confirms this service to be an effective approach for vocational rehabilitation in mental health that deserves investment and further investigation.

Objective To establish whether reinstitutionalisation is occurring in mental health care mid, if so, with What variations between Western European countries.Design Comparison of data on changes in service provision.Setting Six European countries with different traditions of mental health care that have all experienced deinstitutionalisation since the 1970s - England, Germany, Italy, the Netherlands, Spain, mid Sweden.Outcome measures Changes in die number of forensic hospital beds, involuntary hospital admissions, places in supported housing, general psychiatric hospital beds, and general prison population between 1990-1 mid 2002-3.Results Forensic beds and places in supported housing have increased in all countries, whereas changes in it involuntary hospital admissions have been inconsistent. The number of psychiatric hospital beds h is been reduced in five countries, but only in two countries does this reduction outweigh the number of additional places in forensic institutions and supported housing The general prison population has substantially increased in all countries.Conclusions Reinstitutionalisation is taking place in European countries with different, traditions of health care, although with significant variation between the six countries studied. The precise reasons for the phenomenon remain unclear. General attitudes to risk containment in a society, as indicated by the size of the prison population, may be more Important than changing morbidity and new methods of mental healthcare delivery.

Italian psychiatry is probably more debated than known in the international arena. Law 180 of 1978, which introduced a radical community psychiatry system, has drawn worldwide attention and debate, with comments ranging from the enthusiastic to the frankly disparaging (Mosher, 1982; Jones et al, 1991). More recently, this interest was marked by a well-attended symposium ‘Lessons Learned from Italian Reforms in Psychiatry’ held at the 2003 annual meeting of the Royal College of Psychiatrists in Edinburgh.

Integrated multi-element psychosocial interventions have been suggested to improve the outcomes of first-episode psychosis (FEP) patients, but they have been studied primarily in experimental settings and in nonepidemiologically representative samples. Thus, we performed a cluster-randomized controlled trial, comparing an integrated multi-element psychosocial intervention, comprising cognitive behavioral therapy, family intervention, and case management, with treatment as usual (TAU) for FEP patients in 117 community mental health centers (CMHCs) in a large area of northern Italy (10 million inhabitants). The randomized units (clusters) were the CMHCs, and the units of observation the patients (and, when available, their family members). The primary hypotheses were that add-on multicomponent intervention: (1) results in greater improvements in symptoms, as assessed with positive and negative syndrome scale and (2) reduces in-hospital stay, based on days of hospitalization over the 9-month follow-up. Four hundred and forty-four FEP patients received the intervention or TAU and were assessed at baseline and 9 months. Based on the retention rates of patients (and families) in the experimental arm, multi-element psychosocial interventions can be implemented in routine mental health services. Regarding primary outcomes, patients in the experimental arm showed greater reductions in overall symptom severity, while no difference could be found for days of hospitalization. Among the secondary outcomes, greater improvements were detected in the experimental arm for global functioning, emotional well-being, and subjective burden of delusions. No difference could be found for service disengagement and subjective burden of auditory hallucinations. These findings support feasibility and effectiveness of early interventions for psychosis in generalist mental health services.

(2002). Impact of the Community on Intensive Community Care. International Journal of Mental Health: Vol. 31, Mental Health and Disability in Europe—2, pp. 66-77.

BackgroundIn Italy, where all mental hospitals have been gradually phased out since 1978, psychiatric patients requiring long-term care are being treated in non-hospital residential facilities (NHRFs). However, detailed data on these facilities are sparse.AimsThe Progetto Residenze (PROGRES) residential care project is a three-phase study, the first phase of which aims to survey the main characteristics of all Italian NHRFs.MethodStructured interviews were conducted with the manager of each NHRF.ResultsOn 31 May 2000 there were 1370 NHRFs with 17138 beds; an average of 12.5 beds each and a rate of 2.98 beds per 10 000 inhabitants. Residential provision varied ten-fold between regions and discharge rates were very low. Most had 24-hour staffing with 1.42 patients per full-time worker.ConclusionsThere is marked variability in the provision of residential places between different regions; discharge rates are generally low.

The psychiatric reform in 1978 assigned the regions the task of implementing community mental health (MH) services; 30 years on in Italy, there are as many MH systems as there are Italian regions and all completely differentiated. Three Italian regions (Lombardy, Emilia-Romagna, and Campania) in different geographic areas are here chosen as representing three different models of community care implementation as well as certain similarities and differences at a regional level. For each region, the article focuses on MH policy, financing, the network of community health facilities, service provision, MH staff, and the information system.

Mental health (MH) care for Italian prisoners and offenders with mental illness is a paradoxical issue. Theory and practice remained unchanged throughout the 20th century, despite radical changes to general psychiatric care. Until recently, Italy had one of the most advanced National Health Service (NHS)-run community psychiatry care systems and a totally obsolete system of forensic psychiatry managed by criminal justice institutions. Not until 2008, after substantial pressure by public opinion and International Human Rights bodies, did the government approve a major reform transferring health care in prisons and forensic hospitals to the NHS. Forensic hospitals were to be progressively closed, and specialized small-scale facilities were to be developed for discharged offenders with mental illness, along with diversion schemes to ordinary community care. Despite some important achievements, three major problem areas remain: this reform happened without changes to the Criminal Code; regions differ in organization and resources for ordinary psychiatric services; and legal/criminological expertise among NHS MH professionals is limited.

OBJECTIVE: Case management studies from Europe and the United States continue to yield conflicting results. At a symposium at the World Psychiatric Conference in Hamburg in 1999, researchers from four European countries explored the possible reasons for differences in outcome. They also examined reasons for the differing foci of case management studies across the different cultures. The authors summarize the symposium's findings. METHODS: Individual case presentations were given of studies and services from the United Kingdom (three studies), Sweden (two studies), Germany, and Italy (one each). Outcomes, methodologies, and national service context were examined. RESULTS AND CONCLUSIONS: A significant influence of national culture is evident both in the acceptability of case management and in approaches to researching it. Case management is perceived as an "Anglophone import" in Italy but is now national policy for persons with severe mental illness in the other three countries. Studies from the United Kingdom emphasized methodological rigor, with little attention to treatment content, whereas those from Sweden accepted a less disruptive research approach but with a more prescriptive stipulation of treatment content. Studies from Italy and Germany emphasized the importance of differing descriptive methodologies. Marked differences in the range of social care provision were noted across Europe. Overall, European researchers are less concerned than U.S. researchers with studying the impact of case management on hospital use.

Maximum-security forensic hospitals, or Ospedali Psichiatrici Giudiziari (OPGs), are the only facilities in Italy providing care and custody for mentally ill offenders. This article aims to describe clinical, criminological and psychosocial features of their population. The method was an assessment of 118 patients admitted to three forensic hospitals and a matched control group from community non-forensic services. Of the subjects, 72% had a diagnosis of non-affective psychosis, and 75.2% had committed serious crimes against other people; 54% of these crimes were homicide or attempted homicide. At the time of committing the index crime, 60% were being treated by a community service, and 68.9% had been compulsorily admitted previously. OPG inmates more frequently had a history of substance abuse, had committed more crimes and had lower social disability than controls. The needs and problems of this population seem quite specific and often fall beyond the scope of ordinary psychiatric services. The project ...

The aim of the study was to compare the quality of life (QOL) and needs of people with schizophrenia in comprehensive treatment systems in two countries. One hundred people with schizophrenia and schizoaffective disorder were randomly selected from the caseload of a community mental health center in Boulder, Colorado, and 70 were similarly selected from public psychiatric treatment services in and around Bologna, Italy. Subjects were interviewed with QOL and needs assessment instruments and rated with the Brief Psychiatric Rating Scale. Objective QOL measures favored Bologna subjects over Boulder subjects, particularly with respect to employment, accommodation, and family life. In a factor analysis, objective QOL variables sorted separately from subjective satisfaction ratings, suggesting that they measure different underlying constructs. Patient needs in both Boulder and Bologna samples were primarily psychological and social rather than basic survival issues. Boulder subjects were more likely to report accommodation needs. Many apparent QOL advantages for Bologna subjects could be attributed to the greater frequency with which the Italian patients lived with family of origin. Living with family also appeared to confer practical benefits in meeting needs. Objective QOL measures discriminated between patient populations better than subjective ratings of satisfaction and well-being.

Objective: The authors sought to evaluate how the services required by the Italian Psychiatric Reform of 1978 were implemented in Emilia-Romagna, a region of 4 million inhabitants in Northern Italy. Method: All psychiatric facilities were monitored from 1978 to 1994 to determine the number and rates of admissions, average duration of stay, average intake, and percent of beds occupied at inpatient facilities as well as the number of patients residing in former mental hospitals and the number and rates of first contacts with mental health community centers. Results: Three mental hospitals out of nine were closed during the period, and the number of patients who resided in mental hospitals declined from 4,798 to 655. By 1994, there were 145 community centers, 48 day treatment centers, 12 general hospital psychiatric wards, three university psychiatric clinics, seven private psychiatric clinics, 24 psychiatric residences, and 123 supervised apartments that were operating as alternatives to asylums. The overall rate of inpatient admissions remained stable, but compulsory admissions gradually decreased by 35% throughout the period. First contacts at outpatient centers increased by 17.9% from 1984 to 1991. Conclusions: The shift from a hospital-based to a communitybased psychiatric system of care, as foreseen by the Italian psychiatric reform, seems feasible. Some general political, administrative, and social backup conditions appear crucial to ensure the good outcome of this process. (Am J Psychiatry 1997; 154:94‐98)

Trial design This was a multicenter cluster-randomized controlled trial. Participants A total of 227 patients ≥ 18 years old with a new onset of depressive symptoms who screened positive on the first two items of the Patient Health Questionnaire-9 (PHQ-9) were recruited by primary care physicians (PCPs) of eight health districts of three Italian regions from September 2009 to June 2011. Intervention PCPs of the intervention group received a specific collaborative care program including 2 days of intensive training, implementation of a stepped care protocol, depression management toolkit and scheduled meetings with a dedicated consultant psychiatrist. Objective The objective was to determine whether a collaborative care program for depression management in primary care leads to higher remission rate than usual PCP care. Outcomes Outcome was clinical remission as expressed on PHQ-9 Randomization An independent researcher used computer-generated randomization to assign involved primary care groups to the two alternative arms. Blinding PCPs and research personnel were not blinded. Results The 223 PCPs enrolled recruited 227 patients (128 in collaborative care arm, 99 in the usual care arm). At 3 months (n= 210), the proportion of patients who achieved remission was higher, though the difference was not statistically significant, in the collaborative care group. The effect size was of 0.11. When considering only patients with minor/major depression, collaborative care appeared to be more effective than usual care (P= .015). Conclusions The present intervention for managing depression in primary care, designed to be applicable to the Italian context, appears to be effective and feasible.

A high proportion of people with severe mental health problems are unemployed but would like to work. Individual Placement and Support (IPS) offers a promising approach to establishing people in paid employment. In a randomized controlled trial across six European countries, we investigated the economic case for IPS for people with severe mental health problems compared to standard vocational rehabilitation. Individuals (n=312) were randomized to receive either IPS or standard vocational services and followed for 18 months. Service use and outcome data were collected. Cost-effectiveness analysis was conducted with two primary outcomes: additional days worked in competitive settings and additional percentage of individuals who worked at least 1 day. Analyses distinguished country effects. A partial cost-benefit analysis was also conducted. IPS produced better outcomes than alternative vocational services at lower cost overall to the health and social care systems. This pattern also held in disaggregated analyses for five of the six European sites. The inclusion of imputed values for missing cost data supported these findings. IPS would be viewed as more cost-effective than standard vocational services. Further analysis demonstrated cost-benefit arguments for IPS. Compared to standard vocational rehabilitation services, IPS is, therefore, probably cost-saving and almost certainly more cost-effective as a way to help people with severe mental health problems into competitive employment.

This study, carried out in the context of a collaborative care program for common mental disorders, is aimed at identifying the predictors of Primary Care Physician (PCP) referral to Community Mental Health Center (CMHC) and patterns of care. Patients with depression or anxiety disorders who had a first contact with CMHCs between January 1, 2007–December 31, 2009 were extracted from Bologna Local Health Authority database. A classification and regression tree procedure was used to determine which combination of demographic and diagnostic variables best distinguished patients referred by PCPs and to identify predictors of patterns of care (consultation, shared care, and treatment at the CMHC) for patients referred by PCPs. Of the 8570 patients, 57.4% were referred by PCPs. Those less likely to be referred by PCPs were living in the urban area, suffered from depressive disorder, and were young. As to the pattern of care, patients living in the urban area were more likely to receive shared care compared with those living in the nonurban area, while the reverse was true for consultation. Predictors of CMHC treatment were depression and young age. Prospective studies are needed to assess length, quantity, and quality of collaborative treatment for common mental disorder delivered at any step of care.

RiassuntoScopo - Il presente studio è stato condotto per determinare il rischio di mortalità nei pazienti psichiatrici lungo-degenti. Setting - Ex ospedale psichiatrico provinciale «F. Roncati» di Bologna. Disegno - Studio di coorte retrospettivo con un follow-up di dieci anni in cui si è calcolato il tasso di mortalità complessivo e disaggregato per diagnosi psichiatrica, durata del ricovero e condizione «ricoverato al termine del follow-up/dimesso», dei 264 pazienti degenti presso l'istituto l'1.1.1981. Misure utilizzate - I tassi di mortalità sono stati calcolati e successivamente confrontati utilizzando il Rapporto Standardizzato di Mortalità (Standardized Mortality Ratio - SMR). La standardizzazione per sesso e classi di età è avvenuta prendendo come riferimento la mortalita della popolazione residente a Bologna nel decennio 1981-1991. La presenza nella coorte dei singoli soggetti è stata misurata in anni-persona. Risultati - La condizione di de- gente comporta un eccesso di mortalità di 2.89 per gli uomini (IC 95%: 2.12-3.86) e di 2.38 (IC: 1.66-3.31) per le donne. Si è registrato inoltre un forte eccesso di mortalità per la classe di eta dai 15 ai 44 anni sia per gli uomini (18.33; IC: 9.14-32.81) che per le donne (60; IC: 21.91-130.6) e nei soggetti con diagnosi di caratteropatia/alcolismo (uomini, 11.25; IC: 5.13-21.36; donne, 5; IC: 1.35-12.8). Si è registrata infine una diminuzione dell'eccesso di mortalita al crescere della durata del ricovero e della eta dei pazienti. Conclusioni - Lo studio conferma l'esistenza di un forte rischio di mortalita associato alia condizione di paziente psichiatrico istituzionalizzato, concentrato soprattutto nelle classi d'età piu giovani, nei primi anni di ricovero e nei soggetti con diagnosi di caratteropatia/alcolismo.

Therapeutic relationships between clients and vocational rehabilitation workers have been shown to predict entering competitive employment. We aimed to determine predictors of good relationships, using data from an international randomized controlled trial of supported employment (n = 312). Baseline predictors of early therapeutic relationships with vocational workers were assessed, along with the impact of vocational status and changing clinical and social functioning variables on relationship ratings over time. Associations between client and professional relationship ratings were also explored. Better early client-rated therapeutic relationship was predicted by better baseline relationship with the clinical keyworker, being in the Individual Placement and Support (IPS) service, the absence of work history and a greater proportion of care needs being met, whereas over time it was predicted by being in the IPS service. Professional-rated early relationship was predicted by social disability and remission, while over time it was predicted by being the same sex as the client, duration of the relationship and the client's increasing anxiety. Client and professional ratings were positively associated but clients' ratings were higher than professionals', particularly in the IPS service. Relationships were better where clients may have been more motivated to engage, including by their prior experience of a good therapeutic relationship with the clinical keyworker. (C) 2010 Elsevier Ireland Ltd. All rights reserved.

Aims and Background According to the USA Food and Drug Administration, quality of life (QOL) and/or survival are a priority for new anticancer drug approval. This study was performed to review approaches to QOL in randomized controlled clinical trials (RCCTs) and to survey the use of such measures in trials. Material and Methods A literature survey was carried out using the Medline/Medscape, Embase, Cochrane Library, and Ovid databases. Included in the survey were all publications in the set period (from 1966 to June 2005) with “quality of life” in the title or in the abstract in the field of “randomized, controlled clinical trials”. Each trial was evaluated according to the level of importance of QOL as a measure of outcome (primary, important and secondary) and was analyzed using the quality scoring system reported by Nicolucci et al. with some items regarding QOL. Results Four hundred and five RCCT articles in the oncology setting were found. Fifty-six of the 405 (13.8%) publications had QOL as primary end point. The overall quality score of these trials ranged from 40% to 100%, with a median overall score of 80%. The overall score was correlated with the year of publication (P = 0.007), the type of journal (P = 0.05), the presence of a biostatistician among the authors (P = 0.001), and the number of participating institutions (P = 0.009). Conclusions More attention to QOL in all components of RCCTs (design, choice of instruments, data management and processing) is required from both clinicians and statisticians.

Objective. In Italy, Residential Facilities (RFs) have completely replaced Mental Hospitals (MHs) for the residential care of mentally ill patients. We studied all patients resident in 265 randomly sampled Italian RFs (20% of the total).Method. Structured interviews focusing on each patient were conducted by trained research assistants with the manager and staff of each RF. Patients were rated with the HoNOS and the GAF, and comprehensive information about their sociodemographic and clinical status and care history were gathered.Results. Of the 2962 patients living in the sampled facilities, most were males (63·2%) who had never married, more than 70% were over 40 years; 85% on a pension, most commonly because of psychiatric disability. A substantial proportion (39·8%) had never worked and very few were currently employed (2·5%); 45% of the sample was totally inactive, not even assisting with domestic activities in the facility. Two-thirds had a diagnosis of schizophrenia; co-morbid or primary substance abuse were uncommon. Twenty-one per cent had a history of severe interpersonal violence, but violent episodes in the RFs were infrequent. The managers judged almost three-quarters appropriately placed in their facilities and considered that very few had short-term prospects of discharge.Conclusions. Italian RFs cater for a large patient population of severely mentally ill requiring residential care. Discharge to independent accommodation is uncommon. Future studies should attempt to clarify how to match residential programmes with patients' disabilities.

Objective To identify distinctive clinical and social features of the psychiatric patients who committed homicide among inmates of Italian forensic hospitals. Method Clinical and social characteristics of four cohorts of patients were compared: 64 inmates who committed or attempted homicide (Hs), their 64 matched controls from community services caseloads, 54 inmates who committed other crimes and their 54 matched controls from community services caseload. Results When compared with other inmates, patients who committed or attempted homicide showed less severe psychopathology (later onset of mental disorders, later contact with mental health services, lower disability scores) except for higher scores at BPRS “hostility” and “suspiciousness” factors; they also showed better premorbid adjustment (socioeconomic status, employment), and surprisingly better behavioural profile (fewer compulsory admissions, fewer previous criminal records, less substance abuse, less frequently in caseloads of community services). When compared with their matched controls, Hs had lower psychopathology, better adjustment, and a similar behavioural profile. Conclusions Italian inmates of forensic hospitals who committed or attempted homicide have clinical features and personal histories which are far from the stereotype of the violent and dangerous psychiatric patients. The risk assessment procedures routinely performed in several countries may detect violent, but not homicidal behaviour.

RIASSUNTOScopo - Discutere gli dementi etici, deontologici e normativi alia base della regolamentazione nella pratica dell'elettroschock ad un anno dalla emanazione della circolare ministeriale 15.2.1999 in merito. Metodo - Revisione della letteratura e presentazione delle opinioni degli autori. Risultati - Nonostante l'ESK sia la terapia biologica da più tempo praticata in psichiatria, solo negli ultimi 20 anni essa è stata sottoposta al vaglio di studi scientifici controllati con risultati contraddittori che hanno comunque prodotto un progressivo restringimento delle indicazioni cliniche. Sussistono a tutt'oggi ampie variazioni tra paesi diversi ed all'intemo dello stesso paese circa l'estensione dell'utilizzo, le modalità tecniche impiegate, le indicazioni al trattamento. In varie parti del mondo l'ESK sembra essere praticato prevalentemente in grandi strutture asilari o in cliniche private, mentre il suo uso è più ristretto nei servizi che hanno un filosofia territoriale, così come esistono grandi differenze circa il livello di restrittività imposto dai governi o consigliato dalle associazioni professionali; anche l'insegnamento e l'auditing presso gli istituti universitari riconosce ampi gradi di differenza. Infine esistono recenti rapporti da vari paesi, so prattutto in via di sviluppo, che testimoniano un uso corrente per scopi politici o repressivi nelle grandi istituzioni manicomiali. Conclusioni - Gli autori considerano legittimo ed anzi auspicabile che l'insieme di norme e regolamenti alia base dell'attività psichiatrica esercitata nel nostro paese contempli anche disposizioni in materia di ESK. Gli Autori ritengono che la circolare ministeriale 15.2.1999 sia un documento equilibrato e rappresentativo dei valori alia base della politica sanitaria e psichiatrica del nostro paese.

Objective: To determine the rate of choking incidents among the psychiatric population of 4 inpatient facilities, classifying the incidents according to their probable etiology. Method: All incidents recorded over 18 months were retrospectively analyzed for demographic variables, psychiatric and medical diagnoses, and drug therapy at the time of incident. Where possible, patients underwent psychiatric, neurological, and medical examination. Results: Thirty-one incidents were recorded involving 18 patients at a rate of one incident every 56.32 months' hospitalization per person. One case proved fatal, one patient died several weeks after the incident from aspiration pneumonia, and 5 patients needed reanimation or the Heimlich manoeuvre. Etiological classification showed that incidents due to bradykinetic dysphagia and “fast eating” were the most numerous, even among the fatal or grave cases. Conclusions: Various simple, effective preventive measures emerge from the study.

Background. Disparities among ethnic groups are reported in the epidemiology and outcomes of cardiovascular diseases. Given the growing prevalence of migrant populations in Italy and the “epidemic” of cardiovascular diseases, the aim of this study was to evaluate the characteristics and outcomes of patients with acute coronary syndrome (ACS) in relation to country of origin. Methods. This retrospective study includes patients living in Emilia-Romagna, Italy, and discharged from 2012 to 2014 with a diagnosis of acute myocardial infarction (AMI, STEMI and non-STEMI). Primary outcomes were percutaneous coronary intervention (PTCA) within 48 hours of admission for STEMI and 30-day all-cause mortality, and secondary outcomes 1-year adherence to post-AMI medications, major adverse cardiac and cerebrovascular event (MACCE) and all-cause mortality. The relationship between outcomes and citizenship was analyzed using multiple regression models. Potential confounders were age, gender and comorbidities recorded in the index and prior two years hospitalizations. Results. The study population comprised 23,884 patients of which 647 (2.7%) are migrants. The mean age of onset of ACS was lower among migrants than among Italians (56 vs 73 years) and immigrants had a higher prevalence of STEMI (50.1% vs 44.9%; χ2 = 6.8, p = 0.009). Compared with Italians, patients from Africa and Asia had a lower likelihood of undergoing PTCA and were less adherent to medications. Adjusted mortality rates were similar between Italians and migrants, however patients from Asia had a 62% increased probability of experiencing a MACCE at 1 year. Conclusions. Migrants with ACS were younger, less likely to undergo PTCA, and less adherent to drug treatment after discharge compared with Italians. Further studies are needed to investigate in depth the determinants of these differences and to develop organizational models tailored to the specific needs of migrant patients.

Background Multi-element interventions for first-episode psychosis (FEP) are promising, but have mostly been conducted in non-epidemiologically representative samples, thereby raising the risk of underestimating the complexities involved in treating FEP in ‘real-world’ services. Methods/Design The Psychosis early Intervention and Assessment of Needs and Outcome (PIANO) trial is part of a larger research program (Genetics, Endophenotypes and Treatment: Understanding early Psychosis - GET UP) which aims to compare, at 9 months, the effectiveness of a multi-component psychosocial intervention versus treatment as usual (TAU) in a large epidemiologically based cohort of patients with FEP and their family members recruited from all public community mental health centers (CMHCs) located in two entire regions of Italy (Veneto and Emilia Romagna), and in the cities of Florence, Milan and Bolzano. The GET UP PIANO trial has a pragmatic cluster randomized controlled design. The randomized units (clusters) are the CMHCs, and the units of observation are the centers’ patients and their family members. Patients in the experimental group will receive TAU plus: 1) cognitive behavioral therapy sessions, 2) psycho-educational sessions for family members, and 3) case management. Patient enrolment will take place over a 1-year period. Several psychopathological, psychological, functioning, and service use variables will be assessed at baseline and follow-up. The primary outcomes are: 1) change from baseline to follow-up in positive and negative symptoms’ severity and subjective appraisal; 2) relapse occurrences between baseline and follow-up, that is, episodes resulting in admission and/or any case-note records of re-emergence of positive psychotic symptoms. The expected number of recruited patients is about 400, and that of relatives about 300. Owing to the implementation of the intervention at the CMHC level, the blinding of patients, clinicians, and raters is not possible, but every effort will be made to preserve the independency of the raters. We expect that this study will generate evidence on the best treatments for FEP, and will identify barriers that may hinder its feasibility in ‘real-world’ clinical settings, patient/family conditions that may render this intervention ineffective or inappropriate, and clinical, psychological, environmental, and service organization predictors of treatment effectiveness, compliance, and service satisfaction. Trial registration ClinicalTrials.gov Identifier NCT01436331