Italian legal framework for mental health care: Community based care: the current state of mental health care in Italy
Dr. Stylianos Nicolaou M.D., Ph.D (Consultant Psychiatrist), Community Psychiatric Services - Mental Health Department, Verona – Italy
In Italy mental health sector has changed significantly, over the past century, after a radical shift from old mental institutions to new community-based psychiatric services. Recently, economic considerations are imposing additional challenges on the health care system in general, with psychiatry facing distinct and peculiar problems due to its unique organisation and objectives.
De-institutionalisation process has taken place in Italy (and in other western Europe countries) for more than 25 years; the guiding principle is the delivering of community based model (services) across all Italian Regions.
The National Health Plan (Piano Sanitario Nazionale) indicated the mental health policy quidelines that are subsequently developed by the Regional Councils and implemented by the Regional Goverments.
The rate of transformation varied markedly between north and south Italy in the past years (clinical experience showed that transformation process is never linear and automatic and must be conceived and carried out with strong personal and collective motivation and initiatives by everyone involved in this work (operators, users, administrators, family members and the general public).
The current situation of mental health care in Italy confirmed that the Italian Reform Law led to the establishment of a broad network of facilities to meet diverse care of needs: a nation-wide network of Departments of Mental Health deliver outpatient and impatient care, but also run semi-residential and residential facilities (the latter with 2.9 beds per 10.000 inhabitants). Hospital care is deliver through small psychiatric units (wards with no more than 15 beds).
Main legislative steps of mental health sector
1904 Law n. 36 The first comprehensive law on mental health in Italy dates back to 1904 (first national legislation regulating psychiatric care): "Norms and regulations for asylums and the mentally alienated" followed by an implementation act in 1909. Was given priority to the public safety (a law for the protection of the society from the mentally ill; with "custody" therefore taking precedence over "care").
The law set forth the criteria for internment in a mental hospital.The internment procedure required certification by a physician and an order by the Questore (chief of the police); within 15 days (the observation period) the asylum director was then required to send a written report to the State Attorney and within 30 days the person would either be released or subjected to a "permanent internment" with severe consequences as legal interdiction, loss of all civil rights and appointment of a legal guardian.
Admission to a mental hospital could be requested by anyone on the basis of a medical certificate. Admissions were compulsory, might last indefinitely and implied the loss of civil and political rights.
It was not until the 1950s and 1960s that the situation changed, thanks to the introduction of psychotropic drugs and the altered social and political climate of those years, with the fight against social discrimination and inequalities, including those suffered by individuals with mental disorders.
Social psychiatry imposed a conceptual reconsideration and practical reorganisation of mental health care. Innovations were introduced based:
on the recognition of patients' needs ; the creation of new services outside the mental hospital; the discharge of long-stay patients to the community; the prevention of new admissions to mental hospitals.
Psychiatric care was administered by the provincial authorities and each province had to establish an asylum. Even if internment was voluntary, it was regulated by the same rigid rules. This procedure remained in effect until 1968.
1968 - Italian Law n. 431 (known as the Mariotti Act) introduced voluntary internment and made it possible, at the patient's request, to convert a mandatory internment into a voluntary one. This law was focusing on:
- the reduction in size of mental hospitals;
- staff members include also psychologists and social workers alongside doctors and nurses;
- the creation of psychiatric wards within general hospitals, bringing psychiatry into the realm of medicine for the first time in Italy;
- the legitimacy of voluntary admissions to mental hospitals (with patients as active partners in the care process, with the preservation of their civil and political rights;
- the establishment of community-based out-patient services to provide treatment and support to patients discharged from mental hospitals.
From here, deinstitutionalisation accelerated. Between 1962 and 1977, patients number in public mental hospitals dropped from 91 237 to 58 445, with a corresponding decrease in the average length of stay from 209 to 142 days.
In spite of these changes, it soon became apparent that standards of care remained inadequate and, therefore, a radical reorganisation of mental health care seemed to be necessary.
1978 (Law n° 180) - From internment to the right to care: the Psychiatric Reform Act (Law 180/833, December 23, 1978) was approved on May 13, 1970 and subsequently (1978) incorporated into the National Healthcare Service Act.
The Law 180
- established the principle that, as with general healthcare, psychiatric care would be based on the individual's right to care and health, and not upon any presumed danger. However, even after an Mandatory Hospital Treatment had been approved, every effort must still had to be made to obtain the patient's consent to voluntary treatment.
- sanctioned that no new patients could be interned in psychiatric hospitals and that existing psychiatric hospitals had to be closed (however, the definitive closure of all psychiatric hospitals in Italy would only be decreed by the Health Ministry in 1999, more than 20 years after Law 180).
Compulsory Healthcare Treatment (TSO)
In case of severe psychiatric episodes, the request must be made by a physician, countersigned by another physician (of the NHS), then submitted to the administrative authority (Mayor) who, in addition to promulgating the actual order for such treatment, also has to notify a Tutelary Judge, whose function it is to guarantee the patient's civil rights. A TSO has the duration of one week only and can only be renewed following the same procedure as for the first instance.
The effects of the reform law
The reform law marked a turning point in mental health care organisation both from a local and an international perspective. Specifically:
- no new admissions and a gradual closure of existing mental hospitals; compulsory admissions to psychiatric wards had to be time-limited;
- prevention, care and rehabilitation in mental health were assigned to new community-based services;
- defined catchment areas related to given multi-disciplinary teams provide patients with continuity of care on a long-term basis;
The number of patients staying in mental hospitals continued to decline over time:
20556 patients in 1994 in 135 public mental hospitals
11803 patients in 1996 in 72 public mental hospitals
4769 patients In 1998 in 39 public mental hospitals.
New community-based services were set up at an accelerating rate. In 1992:
1369 out-patient facilities (3.88 centres per 150 000 inhabitants);
341 general hospital wards with 4285 beds (0.76 beds/10 000 inhabitants);
353 residential facilities with 2905 beds (0.60 beds/10 000 inhabitants);
325 day hospitals and day centres with 1635 beds (0.34 beds/10 000 inhabitants).
SUBSEQUENT INTEGRATIONS of the reform law
Law 180 was promulgated as a national framework law and left to the regions the autonomy for the implementation of the new community based services. Unfortunately, the various Regional laws (Italy has 21 Regions) would be formulated only after considerable delay, and in a fragmentary and often contradictory fashion with respect to the national law. So subsequently two national plans o goals projects for mental health have been promulgated. Every 3 years a Plan of Objectives for Protecting Mental Health (Progetto Obiettivo Tutela Salute Mentale) is presented, with the aim of fulfilling the intentions of Act 180:
The first national plan for mental health was launched in 1994-1996 for a better application of the reform law; later a second national plan was launched for 1998-2000 which had effectively modifying and emending the Psychiatric Reform Law of 1978 by specifying DSM (Mental Health Department) structures and services in Italy and defining their functions.
The goals reached were:
- the implementation of a comprehensive network of mental health services within each local health district (Τοπικές Υγειονομικές Μονάδες);
- the creation of mental health departments: an integrated whole of structures and services with a single management and coordination (is an organisational model best suited for guaranteeing therapeutic continuity and coherent interventions;
- training of staff in light of the complex tasks posed by working in the community;
- the definitive closure of old mental hospitals nationwide (31december 2000);
- standards were set for residential facilities in the community: to facilitate the discharge of patients still resident in mental hospitals.
In May 2000, 1370 non-hospital residential facilities were operating in Italy with a total of 17138 beds. The resulting average rate of 2.98 beds per 10 000 inhabitants was higher than the recommended national standard (2 beds per 10 000 inhabitants). A comprehensive network of community-based services may limit the number of patients staying in residential facilities. About three-quarters of residential facilities had 24-hour staff supervision, provided long-term intensive care and had low patient turnover especially for patients who had previously been admitted to a mental hospital.
Each Local Health Agency (ASL) has a catchment area which varies from a min 100 to a max of 500 thousands of people, and provides all of the public healthcare services within its territory, including psychiatric care.
4The operational structure of the ASL is the mental health department (MHD).
The Verona MHD (established in 1996) is the operational structure of Local Heathcare Unit 22; it’s main function is to promote and coordinate mental health prevention, care and rehabilitation within a defined catchment area.
It is based on a multi-disciplinary team and deals with the full array of mental health needs of the adult population; offers long-term comprehensive interventions and continuity of care.
Four types of services are anticipated within the department:
- the community mental health centre;
- the general hospital in-patient ward;
- semi-residential facilities (day hospital and day centre);
- residential facilities.
The community mental health centre is generally responsible for planning and coordinating interventions across different facilities and settings. It is open for at least 12 hours a day from Monday to Friday and half a day on Saturday. Patients have direct access and referral from primary care doctors is not required. Demands of care are evaluated by the multi-disciplinary team and patients may receive direct interventions or be referred to other mental health facilities or different types of service, where necessary. The team working at the community mental health centre arranges domiciliary visits and is involved in consultation—liaison interventions in the local area.
The general hospital in-patient wards (SPDC): is located within the General Hospital but forms part of the MHD, and therefore functions as an interface between the hospital and the community. It has 12 beds, is open 24hrs and works closely both with the Hospital Emergency Room and the other MHD services. The staff consists of 5 psychiatrists, 2 psychologists and 11 nurses (a psychiatrist is on-call on a rotation system nights and weekends.
Most admissions take place on a voluntary basis and only a minority are compulsory. In keeping with the fundamental principle of a community-based service, the SPDC's primary goal is to reduce the length of hospitalisation.
The close collaboration between SPDC with the MHCs has made possible for even the most severe patients to maintain contact with their own environment, facilitating the resolution of crisis situations.
The day hospital allows complex diagnostic assessments and therapeutic interventions on short- and medium-term bases. It may be located within the general hospital (although separated from the inpatient ward) or outside the hospital and is functionally integrated with the community mental health centre.
The day centre is open for at least 8 hours a day for 6 days a week and implements programmes promoting self-care and the practical and interpersonal skills required in everyday life.
Residential facilities promote patients' psychosocial rehabilitation and integration and may offer different levels of staff supervision and types of intervention in order to meet patients' specific needs. By law, these facilities have a limited number of beds and are placed in urban areas in order to avoid social isolation and ensure intensity of care.
Inpatient ward clinical activity during 2007
Contacts
850 persons were referred to the PDCS, for a total of 960 contacts.
In 19% of cases, the user was sent home after an initial consultation,
in 25% of cases they were sent home and advised to contact the MHC,
in 31% of cases were hospitalised in our inpatient ward
in 25% of cases the person was referred to other local healthcare agencies .
With respect to diagnosis: 209 patients hospitalised in 2007
| Major depression | 52 subjects |
| Bipolar disorder | 48 subjects |
| Schizofrenic disorders | 45 subjects |
| Schizoaffective disorder | 25 subjects |
| Alcohol dependence | 18 subjects |
| Illicit substance dependence | 10 subjects |
| Eating disorders | 3 subjects |
Financing, national and mental health care organization
In Italy, health care is provided by the National Health Service (Servizio Sanitario Nazionale SSN) founded in 1978 and modelled on the English system; each citizen must be registered with a primary care doctor. Citizens have unlimited health care coverage, although they contribute through charges on drug prescriptions, laboratory tests or diagnostic investigations.
Healthcare System in Italy is divided into three levels:
National level: The Ministry of Health and it‘s consulting organs. A national health plan is drawn up every three years.
Regional level: Administrations of the 21 Regions carry out the regional health planning and distribute finances at a local level.
Local level: The operative level of the health services are the Local Health Units Agencies (Azienda Sanitaria, ASS), divided in districts;
The government allocates a healthcare budget to the Regions which in turn finance the Local Agencies within their territory based upon the annual national healthcare plans. Local governments are essentially responsible for guaranteeing the quality and quantity of healthcare services for their populations.
The national healthcare budget was 88.2 billion Euro in 2005 (only 5% of this budget - 4.4 billion Euro - is considered the minimum for mental healthcare. Italy thus ranks 20th in Europe, together with Portugal, Slovakia and the Czech Republic, while Sweden, Great Britain and Germany allocate about 10% of their total healthcare budget to mental health.
In order to be chargeable, health interventions must be:
- produced by services that ensuring the quality of their output (accreditation by a specific agency);
- consistent with operational criteria defining distinct categories of possible interventions (e.g. diagnostic interview, individual psychotherapy, drug administration);
- expressed in cost units (e.g. days of in-patient stay, number of out-patient contacts).
Although these restraints are aimed at containing health expenditures and ensuring a satisfactory quality of health interventions, there are some limitations, particularly in the area of mental health:
First, it soon became apparent that operational standards were difficult to set in psychiatry, owing to lack of agreement in the definition of diagnostic paradigms and therapeutic approaches. Therefore, accreditation of mental health services was based only on structural (i.e. number and types of facilities) and organisational criteria (i.e. availability of personnel, working hours, functional links with other services, etc.).
A second issue is that health services are being urged to undertake more interventions in order to increase their income. This might affect the efficacy of interventions, with the danger that they might be tailored more to their economic value than to patients' needs.
Final considerations
Italy has undergone radical changes in mental health care organisation phasing out old mental hospitals and implementing new community-based mental health services;
Comprehensive long-term interventions are made easily available to individuals in the community and are implemented by multi-disciplinary teams across different settings to ensure continuity of care.
The current situation of mental health care confirm a high degree of implementation of the community based model services.
Studies examining quality of life report the high level of patient satisfaction whereas patient’s families frequently bear a heavy burden.
Throughout the country (Italy) there is still a marked variation in the provision of out- and inpatient care and of service utilization patterns.
Further efforts are required to improve quality of care and outcomes and the coordination of various resources within a more effectively integrated system.
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