Focus on Mental Health Care Reforms in Europe: A One-Day Census of Acute Psychiatric Inpatient Facilities in Italy: Findings From the PROGRES-Acute Project

The Italian psychiatric reform law was enacted in 1978 with a strong groundswell of public support. The political and cultural climate of the time led to severe criticism of the institution of the outdated mental hospital, which initiated a shift in the care of persons with mental illness from institutionalization to integrated community-oriented treatments ( 1 ). Specifically, the reform law stated that beginning in 1978 no new admissions to existing mental hospitals were allowed and that after 1981 readmissions also had to stop. A progressive shutdown of all mental hospitals was completed by the end of 1999 ( 2 ).

In the meantime, a community-based model of mental health care was developed. In the beginning the reform was planned and implemented without adequate evaluation ( 3 ). Evaluation was further hindered by insufficient attention to the development and maintenance of systematic collection of data on the activities of the developing services. Furthermore, the 1978 reform law set out general principles and guidelines for the new system of care, but it did not provide detailed standards for provision of services and recruitment and training of staff, nor did it allocate an adequate budget for setting up the new services. This led to an uneven implementation of reform throughout the country ( 2 ). During the 1990s, two national mental health plans were launched with the aim of reducing differences between Italian regions in the provision of services and delivery of mental health care ( 2 ). The national plans defined the organizational model of new community-based services and provided some quantitative standards.

Currently, community-based services in Italy have been implemented nationwide. Mental health care is delivered by 211 mental health departments that cover the entire country ( 4 ). These departments are in charge of the management and planning of all medical and social resources related to prevention, treatment, and rehabilitation in mental health within a defined catchment area. Within the departments, mental health centers are the hub of the community-based system. They cover all activities pertaining to adult psychiatry in outpatient settings and manage therapeutic and rehabilitation activities delivered by day care services and nonhospital residential facilities. Acute inpatient care is delivered in general hospital psychiatric units with a maximum of 15 beds, which are closely linked with the mental health centers to ensure continuity of care.

A significant problem is the regional disparity in mental health service provision ( 4 ). The disparities are particularly evident for nonhospital residential facilities, for which a standard of one bed per 10,000 inhabitants was set (the standard is two beds per 10,000 in areas that previously included a mental hospital). In a recent national survey, these facilities accounted for 2.98 beds for every 10,000 inhabitants, with a regional variability ranging from a low of 1.55 to a high of 6.93 beds per 10,000 ( 5 ). Specifically, Italian regions with more extensive provision of outpatient and day care services were found to have lower rates of residential beds. A few studies that have focused on outcomes of care have also indicated inequities in mental health care delivery ( 6, 7 ). In particular, a recent national study found that support for families was provided unevenly; the level of family burden was somewhat lower in Northern Italy as the result of better support ( 7 ).

Since 2001 responsibility for provision and commissioning of health services has devolved from a national level to a regional level. This has resulted in the promulgation of a range of regional policies that might amplify local variations in health care provision and delivery. It was in this framework that the PROGRES-Acute project (PROGetto RESidenze, or Residential Care Project for Acute Patients) was conducted. It was the first nationwide survey of acute psychiatric inpatient facilities. The survey was conducted from 2003 to 2005 by the National Institute of Health and by the Department of Mental Health of Trieste. Physical characteristics, staffing arrangements, admission rules, and activities of all public and private psychiatric inpatient facilities were investigated ( 8 ). Results of the PROGRES-Acute project showed that in 2003 Italy had a total of 1.72 psychiatric inpatient beds per 10,000 inhabitants—.78 public and .94 private inpatient beds.

The data that are presented in this column are from the one-day census, which was conducted within the larger PROGRES-Acute project. The purpose of the census was to estimate the one-day prevalence of hospitalized patients per 100,000 inhabitants in Italy, determine the gender and age distributions of inpatients in public and private psychiatric facilities, examine rates and characteristics of involuntary admissions, and determine the presence and size of waiting lists in facilities operating under a planned admission policy.

This column presents data from the first national one-day census of all inpatients in Italian acute psychiatric facilities. Two notable findings concern the one-day prevalence figures and the data on patients in private facilities. Specifically, the prevalence of hospitalized acute psychiatric patients (18.3 per 100,000 inhabitants) was found to be quite low compared with rates in other Western countries ( 9, 10 ).

Also, the proportion of inpatients who were involuntarily admitted—8.5%—was below the rate of 11.4% reported by Rittmannsberger and colleagues ( 11 ) in a survey of 24 different European sites. The 1978 Italian reform law established need for treatment as the fundamental requirement for involuntary admission ( 12 ). Unlike laws in other European countries, the Italian law does not directly mention of risk of harm to others or self-harm ( 13 ).

Overall, the census findings suggest that development of a comprehensive network of community services has resulted in remarkably low rates of psychiatric admissions and that the change to community-based services has not led to an increase in involuntary admissions ( 8, 14, 15 ).

The findings in regard to private inpatient facilities call for a better definition of the role of the private sector in Italy. On census day the largest proportion of inpatients (54%) were in private facilities, which is consistent with the slightly higher number of beds available in private settings (54.2%). Public and private facilities were found to host different populations. Public facilities admitted mostly young men, whereas one-third of the beds in private facilities were occupied by women age 65 and older. Major differences in the clinical characteristics of these populations can also be assumed: private facilities are not allowed to admit patients involuntarily, and involuntary admission can be considered a proxy of greater illness severity. Thus the differences in the populations of public and private facilities reflect this policy ( 16 ). Furthermore, the frequent use of waiting lists by private inpatient facilities indicates that admissions to these facilities are planned and are not based on emergency needs. Currently, completion of the ongoing accreditation process is expected to increase integration between public and private health services in Italy. This issue is particularly important in a community-based mental health system, where quality of care cannot be split from the functioning and dynamics of the total service system ( 17 ).

Nearly 30 years after the introduction of the 1978 reform law, which prompted a dramatic shift from a hospital-based to a community-based system, these data provide a basic picture of the current state of acute psychiatric inpatient care in Italy. An issue of increasing relevance is the monitoring and evaluation of the newly implemented community services, and a data-driven approach is being recognized as essential for planning and evaluating patient-centered, cost-effective community-based mental health services. This approach requires a strong commitment of the local mental health departments and also calls for more standardized and rigorous evaluative and comparative studies carried out at the local level. At the same time a special concern for the provision and role of national standards and national performance indicators is needed. We consider that implementation of a nationwide minimum data set is an essential tool. Such an approach will provide even more evidence of the remarkable achievements of the reform efforts in Italy.

This study was funded by the Italian Ministry of Health. The names of the national and regional coordinators, consultants, and researchers in the PROGRES-Acute group are available in an online supplement to this column at ps.psychiatryonline.org.

The authors report no competing interests.

Dr. Gaddini is a psychiatrist and Ms. Biscaglia is a psychologist in the Mental Health Unit, Agency for Public Health, Lazio Region, Via di Santa Costanza 53, 00198, Rome, Italy (e-mail: [email protected]). Ms. Bracco is a social worker and Dr. Norcio is a psychiatrist in the Department of Mental Health, ASL (Local Health Trust) Triestina, Trieste, Italy. Dr. de Girolamo is a psychiatrist in the Department of Mental Health, ASL of Bologna, Bologna, Italy. Dr. Miglio is a statistician in the Faculty of Statistics, University of Bologna, Italy. Dr. Rossi is a psychiatrist in the Department of Mental Health, ASL of Perugia, Perugia, Italy. Ms. Rucci is a statistician at the Western Psychiatric Institute and Clinic, University of Pittsburgh. Dr. Santone is a psychiatrist at the Psychiatric Clinic of the United Hospitals of Ancona and at Polytechnic University of Marche, Ancona, Italy. Matt Muijen, M.D., Ph.D., is editor of this column.