Italian legal framework for mental health care, Community-based mental health care: a more appropriate approach than the Hospital based one

Dr. Stylianos Nicolaou M.D., Ph.D (Consultant Psychiatrist)

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.

National Health Plan (Piano Sanitario Nazionale) indicated the mental health policy quidelines; policies are 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 is that the reforming process reached a good outcome and confirmed community based care strategy as a better and more appropriate approach for the care and support of psychiatric patients than the previous institutional one.

Italian legal framework for mental healthcare

Under Giolitti government in 1904 was passed the first national legislation regulating psychiatric care," "Norms and regulations for asylums and the mentally alienated" followed by an implementation act in 1909. The main priority of this legal initiative was the public safety that is 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 as follows:

"Persons affected with any form of mental alienation shall be interned and cared for in asylums if they constitute a danger to themselves or others or cause public scandal" (Italian Law n. 36/1904) 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.

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, when 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.

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: describes regulations for voluntary and mandatory psychiatric evaluations and care.

The Law 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.

Law 180 also 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).

In 1994, the first National Mental Health Goals Project represents a milestone in psychiatric care in Italy and subsequently in 1998-2000 the second Goals Project going even further and effectively modifying and emending the Psychiatric Reform Law of 1978 (Law 180) by specifying DSM (Mental Health Department) structures and services in Italy and defining their functions. This Project ended a 20 year cycle of start-up and experimentation of the 1978 Reform, which had been characterised by strong and often bitter opposition and conflict involving operators, families, local administrators, politicians and public opinion.

The Goals Project was, and remains an extremely useful tool for the quantitative and qualitative development of psychiatric care because it:

In terms of organisation, national healthcare, services in Italy were divided into Local Healthcare Units (ULSS) and then in 1995 into Local Healthcare Agencies (ASL). The operational structure of the ASL is the Department. Each Local Agency has a catchment area which varies from a minimum 100 to a maximum of 500 thousands of people, and provides all of the public healthcare services within its territory, including psychiatric care. The government allocates a healthcare budget to the Regions and Regional governments in turn finance the Agencies within their territory based upon the annual national healthcare plans. Beacuase of recent changes in the Italian Constitution, local governments are essentially totally responsible for guaranteeing the quality and quantity of healthcare services for their populations.

The Verona (ULSS 22) Mental Health Department was established in 1996 as the operational structure (of ASL 22) responsible for prevention, diagnosis, care and rehabilitation in the area of psychiatry and for the organisation of interventions aimed at safeguarding the mental health of the local population;

In our Department the basic principles for a community-based mental health strategy confirmed the possibility to set up a network of mental healthcare services which are totally alternative and antagonistic to the psychiatric hospital.

We are describing here the level of implementation of psychiatric reform as well as the characteristics of the two community psychiatric services of our Mental Health Department.