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Background Abnormal auditory processing of deviant stimuli, as reflected by mismatch negativity (MMN), is often reported in schizophrenia (SCZ). At present, it is still under debate whether this dysfunctional response is specific to the full-blown SCZ diagnosis or rather a marker of psychosis in general. The present study tested MMN in patients with SCZ, bipolar disorder (BD), first episode of psychosis (FEP), and in people at clinical high risk for psychosis (CHR). Methods Source-based MEG activity evoked during a passive auditory oddball task was recorded from 135 patients grouped according to diagnosis (SCZ, BD, FEP, and CHR) and 135 healthy controls also divided into four subgroups, age- and gender-matched with diagnostic subgroups. The magnetic MMN (mMMN) was analyzed as event-related field (ERF), Theta power, and Theta inter-trial phase coherence (ITPC). Results The clinical group as a whole showed reduced mMMN ERF amplitude, Theta power, and Theta ITPC, without any statistically significant interaction between diagnosis and mMMN reductions. The mMMN subgroup contrasts showed lower ERF amplitude in all the diagnostic subgroups. In the analysis of Theta frequency, SCZ showed significant power and ITPC reductions, while only indications of diminished ITPC were observed in CHR, but no significant decreases characterized BD and FEP. Conclusions Significant mMMN alterations in people experiencing psychosis, also for diagnoses other than SCZ, suggest that this neurophysiological response may be a feature shared across psychotic disorders. Additionally, reduced Theta ITPC may be associated with risk for psychosis.

Following the Covid-19 pandemic, in our country strict containment measures have been put in place to safeguard, first and foremost, vulnerable swathes of the population, including people affected by psychiatric disorders. Nevertheless, a large part of Mental Health Centers activities, territorial rehabilitation, counselling sessions, aid and psychoeducational activities, social skills training, workshops, as well as family support, monitoring and network activities with rehabilitation centers workers and users have been rearranged in another modality, namely the so-called “remote modality”. Despite the undisputed and essential value of human contact and face-to-face relationships, the work reported here shows the importance, for Mental Health Services, of employing communicative modalities, like the current alternative virtual ones which, after the initial difficulties were overcome, have been appreciated, further implemented and widely used by now because of their efficacy, so much so that it is thought that they could eventually be combined with traditional modalities.

Despite its relatively low lifetime prevalence, the health, social, and economic burden of Schizophrenia is very significant. In the last 10 years, several studies have analysed the economic burden of Schizophrenia, even if there is a lack of research that has considered the actual cost for the community as the result of each event in the patient's history.The present study aims to cover this gap by proposing a novel model to evaluate better the cost of Schizophrenia with real data from medical records.We applied (i) a 'real life' analysis of medical database to capture each event of the clinical history and healthcare that could have an economic impact; and (ii) a novel Activity-Based Costing model to quantify the overall annual economic burden of a patient with Schizophrenia treated by public mental health services. We carried out the study with 523 patients with a diagnosis of Schizophrenia in the Department of Mental Health of Bari, in the South of Italy.Our results reveal an overall cost of €41.290 per patient with Schizophrenia per year. Almost half of the cost is due to rehabilitation. The second most important factor is instead related to disability and loss of productivity.We believe that the present approach represents the most effective method to properly estimate actual costs when real-life data are available compared with other studies mainly based on prevalence-based approaches.

Schizophrenia poses a significant economic burden on the healthcare system as well as it has a significant impact on society at large. Reasons for such a high economic burden of schizophrenia include the frequent relapses and hospitalizations occurring in this disorder. We analyze the effectiveness of long-acting injectable antipsychotics (LAIs) compared to oral medications, in terms of "clinical process management" in a sample of patients with a diagnosis of schizophrenia spectrum disorder treated in community mental health centers. An observational, retrospective, mirror-image study was carried out to evaluate the effectiveness of LAIs compared to oral medications in terms of number of hospitalizations, emergency visits and planned visits on a 10-year period (from July 2007 to June 2017). Differences between first and second generation LAIs were also explored. Our findings show that hospitalization and emergency visits are significantly decreased with the use of LAIs, while planned visits are increased in patients treated with LAIs. Our results suggest that LAIs, in particular, second generation ones, reduce hospitalization rates and emergency visits, improving the economic burden of schizophrenia. Therefore, LAIs should be considered a cost-effective treatment in the management of schizophrenia under routine conditions.

Il tema della misurazione e della valutazione delle performance delle attivita sanitarie e oggi centrale non solo a livello aziendale ma anche a livello di singole partizioni organizzative. Dipartimenti, distretti, unita operative sono chiamate a sviluppare sistemi e strumenti di performance management basati sulle proprie esigenze informative, allo scopo di supportare il middle management a migliorarne la gestione e orientare i comportamenti dei clinici. Questo lavoro di ricerca propone un cruscotto di valutazione delle performance costruito per i Dipartimenti di Salute Mentale, che mira a superare i gap riscontrati in letteratura e nell’applicazione pratica di sistemi di performance management destinati a tale tipologia di dipartimenti. La definizione e la validazione del cruscotto ha, inoltre, coinvolto esperti del settore tramite focus group. Nelle conclusioni sono discussi le prospettive e i limiti dell’applicazione del cruscotto multidimensionale.

The continuity of care in the usual context of subject’s life and the multiprofessional care is the approach to psychiatric care of severe mental disorders prototypically implemented in Italy after the Psychiatric Reform of 1978. In this framework, the practice of psychiatric rehabilitation has been gradually refining and consolidating its paradigms, offering procedures and interventions with selective and targeted objectives. In this position paper, promoted by the Italian Society for Psychosocial Rehabilitation, some relevant statements are presented about the definition of psychosocial rehabilitation, the facilities where it is done and the interventions and activities implemented, the professionals involved and their education and training, and issues of management and organization. Limits and perspectives of this area are also discussed.

SUMMARYAims– To evaluate the quality of acute psychiatric care concerning the management of violent behaviour and rapid tran-quilization.Methods– Data concerning 13 indicators, drawn from NICE recommendations, were collected in 19 Departments of Mental Health, in the frame of the SIEP-DIRECT's Project, to evaluate the implementation of NICE recommendations in Italian Mental Health Services.Results– In about two thirds of Departments of Mental Health (DMHs) professionals were trained in the management of violent behaviour, while written procedures existed only in one fourth of DMHs. About a half of the professionals working in Psychiatric Wards in General Hospital were trained in rapid tranquilization, while procedures on this topic are practically absent and specific care for monitoring intensively the heavily sedated patient was not frequent.Conclusions– Management of violent behaviour and rapid tranquilization are two critical areas in the care performed by Psychiatric Wards in General Hospital. Training on these topics is more frequent than implementation of procedures. NICE recommendations and SIEP indicators are useful tools for improving the quality of acute psychiatric care.Declaration of Interest: None.

SUMMARYAims– To evaluate the quality of psychiatric care during the acute psychotic episode and the early post-acute period.Methods– Data concerning 24 indicators, drawn from NICE recommendations, were collected in 19 Departments of Mental Health, in the frame of the SIEP-DIRECT's Project to evaluate the implementation of NICE recommendations in Italian Mental Health Services.Results– The treatment of the acute episode in the Italian Mental Health Services is not based only on admissions in Psychiatric Ward in General Hospitals, but also on intensive home based care. The utilization of day hospital facilities for treating acute episodes is less frequent, as the presence of home based follow up after discharge. About of Departments of Mental Health did not have clinical guidelines concerning the pharmacological treatment in this area. However usually the standard practices followed NICE recommendations in terms of prescribed dosages, monitoring side effects and rationale for shifting to atypical antipsychotic drugs. Antipsychotic drugs, atypical or conventional, were frequently prescribed concurrently, while utilization of atypical antipsychotic drugs was increasing.Conclusions– The results show critical points concerning on one hand the scarce diffusion of clinical guidelines, on other hand the connection between standard practices, clinical guidelines and marketing of atypical antipsychotic drugs. It should be reinforced the role of the community and particularly at service level the capacity of community mental health teams to treat the acute patients.Declaration of Interest:none.

The aim of this work is to present the main discrepancies, as evidenced by the SIEP-DIRECT'S Project, between the evidence-based NICE guidelines for schizophrenia and the usual practices of the Italian mental health services in order to promote the recovery of patients with schizophrenia.Starting from the main NICE recommendations on recovery promotion, 41 indicators were developed. These were experimented in 19 participating Italian Mental Health Departments (MHD) or Psychiatric Services through self-evaluation of the activities carried out to promote patient recovery with the aim of assessing the level of adherence to the recommendations. The data required by most of the indicators were obtained from the psychiatric informative system or from the Direction of the MHD. Moreover, specific research was carried out on the clinical records and on representative patient samples. Furthermore, for 14 indicators, there was requested an assessment by the part of "multidisciplinary" or "specialistic" focus groups who then attributed a score according to a defined "ad hoc" scale.According to the data obtained, although the mental health services seem to care about the physical condition of their patients, they do not routinely examine principle parameters such as blood pressure, glycaemia etc., and collaboration with general practitioners is often complex or not uniformly practiced. Most psychiatrists and psychologists possess the basic communication skills but not enough competences in cognitive-behavioural treatments; such treatments, and every other form of structured individual psychotherapy, are seldom carried out and seem to have become marginal activities within the Services. Also family psycho-educational interventions are under-used. The Services are very active in the care of multi-problem schizophrenia patients, who make up a large percentage (almost a quarter, on average) of the patients in their care. These patients are offered specific and integrated treatment plans with the involvement of other health services and social agencies operating in the territory. The strategies adopted by the services for the pharmacological treatment in the prevention of relapses and for patients with frequent crises or with treatment-resistant schizophrenia are all in line with the NICE recommendations. Finally, the Services promote activities of vocational training and supported employment, but the outcomes of these are often unsatisfactory.The results of the study show a picture of the Italian mental health services with bright yet also dark areas as regards recovery promotion activities. The Services seem to guarantee adequate pharmacological evidence-based treatments, an integrated assistance and good management of multi-problem patients. They have difficulty, however, with respect to the monitoring of the physical health of the patients, psychotherapeutic activities, including those for families, and the promotion of supported employment. Moreover, they still show problems regarding the structuring and formalizing of care processes. To improve this situation, they should make greater use of professional guidelines, protocols and written procedures.

One of the more important aspects of the psychiatric care reform in Italy has been the opening of a great number of psychiatric Non-Hospital Residential Facilities (NHRF). However, 22 years have elapsed since the reform and there are still very scarce data regarding such facilities, the type of patients being accomodated, and the types of treatments provided. The "PROGRES" (PROGetto RESidenze - Residential Project) project is the first national study regarding NHRFs ever carried out in Italy. The objectives of "PROGRES" are to make a survey of all NHRFs in Italy (Phase 1) and to perform a detailed assessment of 20% of the surveyed facilities and of the type of patients being treated (Phase 2). This paper reports the survey (Phase 1) results for the Puglia Region. As of March 31, 2003, 113 psychiatric residential facilities were present in Puglia, with a total of 1.479 beds. This results in an average of 13,08 beds per facility and a rate of 3,86 beds per 10.000 inhabitants. The number of NHRFs present in the territory of each Local Health Unit in Puglia is very variable. Most NHRFs (57%) opened after January 1997. Eighty-three percent have a 24-hour staff coverage while only 5,3% has a 2-hour staff coverage. Eighty five percent of the residential facilities are financed by the Italian National Healthcare System, while a small percentage is privately funded. In over half (69,93%) of the NHRFs the predominant patient age group is 40-59 years; 26,4% of the residential facilities accommodate patients below age 40 and only 3,53% accommodate patients over 60 years old.

SUMMARYAims— To investigate in a representative national sample (N=2,962) of patients living in Residential Facilities (RFs) patterns of polypharmacy as well as related variables, association between diagnoses and therapeutic patterns, and the rate of adverse events.Methods— 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 SOFAS, and comprehensive information about their sociodemographic and clinical status, and their pharmacological regimes were collected.Results— Conventional antipsychotics and second-generation antipsychotics were prescribed to 65% and 43% of the sample, respectively. Benzodiazepines were prescribed to two-thirds of the sample, while antidepressants were the least-used class of psychotropics. Polypharmacy was common: on average, each treated patient was taking 2.7 drugs (±1.1); antipsychotic polypharmacy was also common. Many prescriptions were loosely related to specific diagnoses. Antiparkinsonianian drugs were prescribed to approximately 1/4 of the sample. Mild or severe adverse events in the previous month were reported for 9.9% and 1.4% of the sample, respectively. About 15% of patients suffered from tardive dyskinesia.Conclusions— Psychotropic drug prescription patterns for severe patients living in RFs are only sometimes satisfactory and offer the opportunity of improvement. Specific actions are required to improve prescription patterns for severe patients in RFs.Declaration of Interest: in the past two years GdG has received two speaker fees from Janssen-Cilag and from Eli Lilly; GS has received one speaker fee from Solvay. RM, AP, SF and RT have received no fees or other financial support from pharmaceutical companies.

Il progetto è stato articolato in due fasi. Nella prima, definita di censimento, dopo aver stabilito una intensa rete di contatti con gli Assessorati Regionali competenti, le ASL ed i DSM, è stata somministrata a tutti i responsabili delle SR con almeno 4 posti residenziali una scheda apposita. Attraverso l'elaborazione dei risultati così ottenuti si è ottenuta una ‘fotografia’ complessiva delle SR in Italia: sono state censite, alla data del 30 giugno 2000, 1.370 SR con 17.138 posti residenziali ed un tasso di 2,9 letti per 10.000 abitanti (de Girolamo et al., 2002). La prima fase di questo studio ha anche documentato notevoli variazioni interregionali sia nel tasso di posti-letto che nel numero degli operatori, un'elevata proporzione (circa il 40%) di pazienti dimessi dagli Ospedali Psichiatrici (O.P.) ed un basso turnover dei residenti.Alla fase 2 hanno preso parte tutte le regioni italiane ad eccezione dell'Abruzzo, in cui problemi di carattere organizzativo hanno reso impossibile la valutazione dettagliata delle SR; in fase 1 erano state censite in questa regione 64 SR con 856 ospiti. Sulla base dei risultati della fase 1, si è calcolato che una proporzione pari al 20% circa delle SR avrebbe consentito di selezionare un campione finale comprendente circa 3.000 pazienti, sufficientemente ampio da permettere di comparare sottogruppi differenziati rispetto a caratteristiche sociodemografiche, cliniche ed assistenziali.

Non è semplice riassumere in poche conclusioni un complesso progetto di ricerca come il PROGRES, che ha consentito di raccogliere una gran mole di informazioni. Qui si cercherà solo di riassumere alcune osservazioni di carattere generale.Non esiste alcun semplice e chiaro metodo in grado di valutare in maniera affidabile il bisogno residenziale tra le popolazioni di pazienti con disturbi gravi in trattamento presso i DSM; questo fatto è una delle ragioni che sono all'origine della dimostrata marcata variabilità nei tassi di posti-letto in SR tra regioni, o aree diverse; questi tassi sono poi a loro volta largamente determinati e condizionati da pattern storici di sviluppo (Macpherson et al., 2004).Per risolvere questo problema, dovrebbe essere adottata una prospettiva di ‘sistema’ che consenta di mettere a punto un sistema ben coordinato, chiaramente finalizzato ed efficiente, volto a erogare soluzioni residenziali appropriate (Shepherd, 1998).