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

Mental health care in Italy after the 1978 reform

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 The political and cultural climate of the time led to severe criticism of the institution of the outdated mental hospital, which initiated a shift in the care of persons with mental illness from institutionalization to integrated community-oriented treatments ( 1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.

The one-day inpatient census

Procedures

The one-day census was conducted in all Italian regions except Sicily. The 20 participating regions had a population of approximately 53 million, or 90.5% of the Italian population. The survey, conducted on May 8, 2003, accounted for all inpatients in public and private facilities on that day. Public psychiatric inpatient facilities included 262 general hospital psychiatric units with 3,431 beds (a mean of 13.1 per unit), 23 university psychiatric clinics with 399 beds (a mean of 17.3 per clinic), 16 24-hour mental health centers with 98 beds located in just two regions (a mean of 6.1 per center), and 14 medical wards and crisis centers with 118 beds (a mean of 8.4 per ward or center). Data were available for all but two facilities surveyed.

In addition, 54 private facilities with a total of 4,862 beds (a mean of 90 per facility) were surveyed. The private facilities, which started operating long before the reform law went into effect, are unevenly distributed throughout the country but are mostly concentrated in five regions. The National Health System covers costs for full medical treatment and basic accommodation for patients admitted to private facilities. Involuntary admissions are made only to public facilities.

Each region appointed a coordinator to organize and supervise data collection for that region. One or more research assistants per region were trained to complete the census forms on the index day in collaboration with local mental health professionals. Data were collected on the age and gender of inpatients in each facility on the census day, inpatient status (involuntary or voluntary), the involuntary admission procedures used for each patient (for example, health professional intervention or involvement of law enforcement), and the presence and length of waiting lists.

To calculate the point prevalence of hospitalized patients on the census day, we used data from the most recently conducted census of the resident population of Italy by the National Institute of Statistics (January 1, 2003). Residents of Sicily were excluded from the database. All analyses were performed using SPSS software, version 12.0 for Windows.

Census findings

Census forms were completed for 7,984 patients—3,692 (46%) in public facilities and 4,292 (54%) in private facilities. Only a small number of inpatients under age 18 were in the facilities on the census day (32 patients, or .4% of the total sample). These patients were excluded from hospitalization rate calculations. The hospitalization rate per 100,000 adult population was 18.3. This rate did not vary by gender (18.1 for men and 18.4 for women), but it did vary by age and type of facility. The proportion of elderly patients was larger in the private facilities. [A table summarizing the results is available as an online supplement to this column at ps.psychiatryonline.org.]

Involuntary admissions. Only 289 of the 315 public facilities admit patients involuntarily. On the census day, 305 inpatients (8.9%) had been involuntarily admitted. Of these, 285 were in general hospital psychiatric units. Involuntary admissions accounted for 3.8% of all admissions. The overall prevalence of involuntary admissions per 100,000 adult population was .70. In 30.4% of the cases, involuntary admission was overseen exclusively by health professionals, whereas another 46.8% of cases involved the intervention of metropolitan police. State police intervention was required for 22.9% of all involuntary admissions.

Age and gender. An equal proportion of men and women were found in public facilities. Private facilities had a slightly higher percentage of women (54.7% compared with 45.3%). In public facilities the largest group was men aged 35 to 44 years. In private facilities the proportion of women increased with age, peaking with the over-65 age group.

Waiting lists. Only 64 of the public facilities (20%) reported using admission waiting lists, although it was a common procedure in 37 private facilities (70%). Overall, on the census day 158 persons were on a waiting list for a public inpatient facility, and 595 persons were awaiting admission to private facilities.

Discussion

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.

Acknowledgments and disclosures

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.