In a seminal study, Elizabeth Bott (1957) investigated relationships between family roles and social networks in a small group of families in London. The author was an anthropologist, and the field of social network research, in psychiatry, has received major input from methods of social anthropology. Tolsdorf (1976) investigated social networks of patients with schizophrenia. Since then, many studies have focused different aspects of social networks and social support in patients with psychotic disorders.

Service utilization research is not a homogenous field of research. One might distinguish between the evaluation of treatments and the evaluation of mental health systems. I will restrict myself to the mental health system approach. The first statement that has to be made is that the study of service utilization is not an aim in itself. The ultimate goal is to learn how systems of mental health care function or dysfunction. This knowledge should be helpful for planners to plan services at a more scientific basis.

Another introductory statement is that the objective of system service utilization research is the study of the relationships of a described population with the mental health system available for this population. Otherwise stated, this is an epidemiological approach of service utilization research. In this we will further distinguish between the pathway to care and the pathway through care or patterns of care. The basic questions in the pathway to care are related to the proportion of the population using mental health services; the treated prevalence and incidence. A topic is for example the inequality in service use in different social-economic-status or socio-demographic subgroups. The basic questions in the pathway through care are related to the way in which patients use the mental health system in terms of duration, intensity, setting and relapse for example. In the present paper we will focus on the latter topic mainly.

Psychiatric case registers are systematic health information systems of a geographically delimited area that record the contacts with designated medical and social services of patients or clients from the area. The information is stored in a linked and cumulative file so that the care of any individual or group can be followed over time, no matter how complex the pattern of service attendance (Wing, 1989). They represent the evolution of older systems for recording data of clinical relevance, such as disease registers to which hospitals and physicians used to report all cases of a certain diagnosis and hospital-based registers, which in general are based on aggregate data concerning patients who received care by a particular hospital or clinic (Häfner & an der Heiden, 1986).

Bennett & Trute (1983) pointed out that the term “information” has substantially wider connotations than the term “data”. In order to become “information”, data have to be placed within a framework and interpreted. This is true for all medical information systems, including those that collect limited data set, such as those about births, deaths, admissions to hospital, etc. (Wing, 1986).

A WHO Working Group held in Mannheim provided an agreed definition of a Psychiatric Case Register (PCR) which resulted in the following: “a Psychiatric Case Register is a patient-centered longitudinal record of contacts with a defined set of psychiatric services, originating from a defined population” (WHO, 1983).

La stima del costo annuo di trattamento (CT paz) del paziente psichiatrico all'interno del DSM ha comportato (figura 6.1): a) la descrizione e quantificazione delle prestazioni ricevute nelle strutture delle UOP nel corso del 2000; b) la valorizzazione del trattamento attraverso la determinazione di costi medi standard delle prestazioni. Data l'ampiezza del campione si è optato per un modello di activity based costing, in cui la stima del costo del prodotto è ottenuta come somma dei costi di singole attività generate dall' organizzazione. Nel caso specifico l'organizzazione, il prodotto e le attività sono rappresentati rispettivamente dalla UOP, dal trattamento complessivo ricevuto dal paziente nel corso del 2000 e dalle singole prestazioni erogate dalle strutture della UOP.

La prima fase (punto a) ha utilizzato il flusso informativo regionale Psiche per rilevare le prestazioni erogate nel 2000 per singolo paziente reclutato.

Severe and long term mental disorders, like schizophrenia, show in general a wide range of psychiatric signs and symptoms, psychological and physiological impairments and social disablement (Shepherd, 1994; Wing, 1982) reflecting a variety of mental health needs. Many studies provide only a cross-sectional view of the clinical and social problems of the patient population, for example at intake or admission to a mental hospital. Longitudinal studies following patients after discharge for some period of months or years show in general the expected improvement of functioning (e.g. Nienhuis et al., 1994), but as far as only chronic patients are concerned such a positive change is much less noted. The concept of chronicity of mental disorders would presume that after some time needs are fairly predictable and stable and do not change much over time. Our investigation on the long-term course of schizophrenia (Wiersma et al., 1996; 1997) enables us to study over a period of two years, from 15 to 17 years since first onset of psychosis, the stability or variability of needs in schizophrenic disorder. We are not aware of empirical studies on changes in needs among patients with long-term disorders.

It is tempting to suppose that changes in the mental illness service in one's own part of Europe are taking place elsewhere as well. The asylum era is drawing to a close, and politicians everywhere are closing mental illness beds in order to re-distribute health costs in order to pay for new treatments needing expensive technology, as well as to allow for the needs of a population that is now living longer.

In an attempt to become independent of official figures, key figures with a reputation for epidemiological psychiatry were approached in each European country, and asked to complete a brief questionnaire describing the mental health services in their country. Whether this method produces figures that are more or less accurate than official government figures is a question that cannot be addressed at present.

Lo studio ha coinvolto 10 Unità Operative di Psichiatria (UOP) della regione Lombardia:

– UOP 4 di Busto Arsizio (popolazione residente 172.419);

– UOP 5 di Saranno (popolazione residente 134.029);

– UOP 30 di Crema (popolazione residente 122.043);

– UOP 35 di Vimercate (popolazione residente 154.877);

– UOP 38 di Desio (popolazione residente 218.157);

– UOP 39 di Sesto San Giovanni (popolazione residente 117.355);

– UOP 43 di Legnano (popolazione residente 202.798);

– UOP 47 “Niguarda 2” di Milano (popolazione residente 70.447);

– UOP 51 “San Paolo 1” di Milano (popolazione residente 159.421);

– UOP 53 “San Carlo 1” di Milano (popolazione residente 149.002).

Il bacino di utenza complessivo risulta composto da circa un milione e mezzo di abitanti, pari al 16% della popolazione lombarda.

Le 10 Unità Operative esprimono realtà territoriali e sociali differenziate: includono infatti servizi collocati in area metropolitana, quali quelli della città di Milano, e servizi di aree non urbane quali, per esempio, quelli di Crema, Legnano, Desio.

Gli elementi di cui si dispone per descrivere le caratteristiche cliniche dei pazienti arruolati nello studio sono la diagnosi e la valutazione del livello di gravità del paziente. Entrambe le informazioni sono rilevate dalla scheda HoNOS.

La compilazione delle schede HoNOS richiede agli operatori di riportare la diagnosi principale del paziente, adottando i codici F della classificazione ICD 10. Per questa fase dello studio, si è ritenuto opportuno fare riferimento alla sola prima cifra della diagnosi, limitandosi pertanto a menzionare i gruppi diagnostici dei pazienti arruolati.

La quota principale di assistiti arruolati (tabella 5.1), risulta essere affetta da schizofrenia (F2), rappresentando più di un terzo del totale; seguono gli utenti con sindromi nevrotiche (F4) ed affettive (F3); infine, i pazienti affetti da disturbi della personalità (F6) rappresentano l'ultimo gruppo diagnostico consistente.

Disponendo poi delle diagnosi della popolazione in carico presso le 10 UOP nel 2000 (grazie al sistema informativo regionale) è possibile effettuare un confronto per indagare sulla rappresentatività, anche dal punto di vista clinico, dei pazienti coinvolti nello studio. Dal confronto fra gli utenti arruolati e quelli in carico presso i servizi, emerge una leggera sovra-rappresentazione nel campione di pazienti affetti da patologie considerate più gravi, rispetto agli utenti in carico. Ciò a causa dei pattern di trattamento più continuativi per i pazienti gravi (come i pazienti affetti da schizofrenia), che ha portato ad intercettare un maggior numero di essi nel campione. Il fenomeno opposto riguarda i pazienti con patologia nevrotica. Per i restanti gruppi diagnostici, si registra invece una notevole sovrapposizione fra le due popolazioni confrontate.

Poche ricerche hanno preso direttamente in esame lo stato della salute mentale ed i bisogni di cura delle popolazioni indigene nel mondo. Nello stesso tempo ciò non sorprende ed è singolare. Non sorprende innanzitutto poiché i bisogni e i diritti delle popolazioni indigene sono stati storicamente di scarso interesse per le grandi e assai influenti nazioni che si sono spinte da una parte all'altra del pianeta in cerca di ricchezze.

Singolare, nonostante che durante lo stesso periodo del colonialismo non c'era scarsità di conoscenze intorno alle brutalità a cui le popolazioni indigene del mondo sono state, e continuano ad essere, soggette.

Nel 1552 Bartalomé de las Casas, una frate spagnolo, pubblicò La devastazione delle Indie, una descrizione delle atrocità commesse dagli spagnoli nella loro conquista del Nuovo Mondo. Di Hispaniola così scrive:

Su questa terra di miti reietti giunsero alcuni spagnoli che immediatamente si comportarono come fameliche bestie selvatiche, lupi, tigri o leoni che sono rimasti senza cibo per molti giorni. E gli spagnoli hanno agito sempre nello stesso modo durante gli ultimi quarant'anni fino ad oggi, comportandosi come animali affamati, uccidendo, terrorizzando, affliggendo, torturando e distruggendo i popoli nativi, facendo tutto ciò con le più inconsuete e svariate nuove forme di crudeltà, mai viste o udite prima, e con un simile grado che l'Isola di Hispaniola, un tempo assai popolata (con una popolazione che io ho stimato intorno ai tre milioni di persone) conta ora una popolazione di appena duecento abitanti (las Casas, 1992:29).

It is well known that the prevalence of mental illness is not uniformly distributed. This has practical consequences for the planning, financing and evaluation of public mental health services. Areas likely to have greater morbidity are likely to require more resources. The question is by how much? This essay describes a method devised in the context of the English health service to provide practical help to mental health planners faced with this type of question.

Per attività si intende il complesso di più tipi di intervento, caratterizzati da finalità comuni.

Ciascuno intervento è caratterizzato da contenuti specifici, che ne permettono la differenziazione rispetto ad altri tipi di intervento, inseriti nella medesima attività.

Le attività svolte fanno riferimento a funzioni e aree del DSM:

1. 1. funzione organizzativa

2. 2. area di prevenzione ed educazione sanitaria

3. 3. area terapeutico - riabilitativa

In the United Kingdom, national policy and local service provision both direct provision towards people with a severe mental illness (NHS and Community Care Act, 1990; Department of Health, 1993, 1994). An independent report by the Mental Health Foundation (1994), a leading mental health charity, recommended that the Department of Health “promulgates a practical definition of severe mental illness (SMI) in order to concentrate attention and services on those in greatest need”.

In order to assess the extent to which a provider or a purchaser has focused attention upon the SMI, definitions are being developed in most services in the UK; this will facilitate the quantification of the number and proportion of SMI in contact with services. The definitional approach uses a (variable) number of criteria to determine status as a severely mentally ill person. It is essentially categorical because the individual is placed in one of two categories, SMI or not-SMI.

The policy of any organisation is a setting out of the purposes for which it exists - its mission statement. Governments spend money on mental health services and therefore need a coherent mission statement for the use and goals to which that money is put. Moreover, the consequences of mental illness pervade all aspects of a nation's existence. Therefore a mission statement is needed to tackle mental illness and its consequences, not only by developing and using specialist mental health services to best effect, but also by using other relevant organisations as appropriate.

Mental health policy is formulated at all levels from the community mental health team to the national government and thence to the World Health Organisation and the United Nations. Indeed national and international mental health policies have generally been led by local innovative best clinical practice. At local level, the policy of a community mental health team will identify the types of patients to which it seeks to provide a service, the channels through which referrals will be accepted, the type and nature of assessment and decision making about consequent interventions which will be used and a range of quality standards within which it will seek to operate. It may set out a set of desired goals in terms of the improvement in the health status of clients and the degree of consumer satisfaction it seeks to achieve. Some adverse consequences may be set out. For example, it may seek to minimise readmissions to hospital within a specified period of time or the frequency of violent or self-destructive behaviour on behalf of its clients.

This study was primarily designed as a cost effectiveness analysis, comparing the costs and outcomes of day hospital and in-patient care for acute psychiatric illness. There are a growing number of this type of study in mental health (Knapp et al., 1994; McCrone et al., 1994; Wiersma et al., 1995; Merson et al., 1996). The costing methodology used in such studies is becoming more consistent, but economic evaluation in mental health care is still developing and there remain several unanswered questions which will be considered in this paper. The wide variation in the costs of care of people with mental health problems is a critical factor in these studies (Gray et al., 1996).

The cost effectiveness study is based on a previous randomised controlled trial conducted at Manchester Royal Infirmary which showed the feasibility and effectiveness of day patient treatment for acutely ill patients (Creed et al., 1990). In the current study 187 patients were randomly allocated, 94 to day hospital care and 93 to in-patient care. The method and results of the main cost effectiveness analysis are described in detail elsewhere (Creed et al., 1996a). This paper concentrates on reviewing the methods used to collect cost data, and further analysis of the data exploring variations in costs.

Le interrelazioni tra ambienti socioculturali e salute mentale non devono mai essere dimenticate quando si esamina la salute mentale delle popolazioni indigene.

Ciononostante, una completa disamina di questo argomento esula dagli scopi del corrente resoconto. I lettori possono ritrovare una rilevante panoramica di questa letteratura nel classico lavoro di Leighton, My name is legion, in cui l'autore considera le modalità attraverso le quali gli ambienti socioculturali possono facilitare o arrestare i bisogni umani verso “la conquista degli elementi primari” come la sicurezza fisica, l'identificazione o un senso di appartenenza all'ordine morale (Leighton, 1959). Un'altra pietra miliare è l'articolo dei Dohrenwend che esplora le influenze sociali e culturali sulla psicopatologia (Dohrenwend & Dohrenwend, 1974), mentre il volume Rethinking psychiatry di Kleinman (Kleinman, 1988) offre un eccellente rassegna di questo argomento. Infine, le riflessioni di Fullilove sull'importanza del “luogo” per il benessere psicologico è di speciale interesse per quanto concerne il fenomeno dello spopolamento conosciuto dalle popolazioni indigene (Fullilove, 1996).

In breve, la salute mentale deve essere considerata tanto profondamente avviluppata con gli interessi economici e politici quanto con la povertà, la fame e la malnutrizione, il cambiamento sociale, la violenza e la dislocazione (Desjarlais et al., 1995).

It is no longer a pleasant surprise (to most health economists) or an unwelcome shock (to most non-economists) to find costs on the core conference agenda of a mental health conference. In the Amsterdam ENMESH conference in 1994, economics appeared as a late but welcome addition to the programme, effectively on the margins but - and this was unusual at the time - it had formal representation. In Verona in 1996, as at a growing number of conferences (and in more books and academic journals), economics has moved rather closer to the mainstream. In this paper I offer a short historical account of this ‘mainstreaming’ and tease out its implications for mental health care evaluation.

In many European countries today there are rapidly growing demands for cost information, cost-effectiveness evaluation, and analyses of systems and the incentives within them. It is useful to distinguish between underlying needs for a costs perspective linked to scarcity of resources (latent demands) and expressed wants for actual cost or cost-effectiveness evaluations or insights (manifest demands) (Knapp, 1997). The latent demands stem from scarcity, in turn linked to a variety of factors.

An abundant literature has been published about mental services evaluation and was used for purpose of comparisons between services.

Comparisons have mainly concerned care in the traditional psychiatric hospital based mode versus community mental health (Tansella et al., 1982; Kraudy et al., 1987; Kovess et al., 1995) or care in different areas or countries (Sytema et al., 1989).

Those comparisons have to rely on crude description of services (Tansella et al., 1986) like psychiatric hospitalisation, day hospitalisation or out patient intervention. Intensive international collaboration underpinned the importance of a more precise description about services which could have extremely different components under the same label.

In fact services in mental health are complex to describe to allow meaningful comparisons because they cover many different actions given by a variety of providers and grouped into various structures as:

• • hospitals: specialised or general, large or small;

• • day hospitals and centre;

• • out patients clinics, crisis centres.

Care could also be provided by independent workers from the diverse medical and non medical professions involved in the mental health fields in private practice settings.

The concept of need and the development of methods for measuring population needs represent, in a way, a new paradigm in evaluative research and planning of mental health services.

As with all new paradigms, this one has arisen as a way of overcoming a conceptual crisis: the crisis that has resulted from the application of the curative and medical model to the organisation and evaluation of mental health care, and from the traditional way of planning mental health services according to factors more centred on services and staff problems than on the actual problems of the populations.

As is the case with all new paradigms, the concept of needs also represents a radical change at the epistemological level. In fact, this concept integrates a new perspective on: 1. The nature and range of the problems experienced by the mentally ill (seen not only in terms of symptoms and behavioural problems but also in terms of social disability problems); 2. The interventions required to reduce or contain those problems(integrating the dimension of treatment in a more comprehensive dimension of care); 3. The principles of mental health services organisation (seen from a more community-centred perspective).

La ricerca “Pattern di trattamento e costi nei Dipartimenti di Salute Mentale della Regione Lombardia”, che per brevità chiameremo HoNOS 2, rientra nei “Programmi Speciali” ex Art. 12 DL 502/92.

La ricerca intende contribuire al dibattito su possibili modalità di finanziamento della psichiatria alternative al sistema tariffario per prestazione. Essa approfondisce, in un settore specifico, un problema che riguarda l'intero sistema sanitario e che sembra non avere ancora trovato una risposta definitiva soddisfacente.

Nello scorso decennio il Servizio Sanitario Nazionale è passato, attraverso due fasi di generale riordino, governate a livello nazionale dai Decreti Legislativi 502/92 e 229/99, e ha conosciuto varie leggi regionali di riordino. Siamo solo all'inizio del nuovo decennio e già si preannunciano ulteriori modifiche sulla spinta dell'evoluzione federalista dello Stato.

The setting of priorities in mental health care evaluation requires considering future trends in mental health services. Three areas of change are mentioned in this paper: the development of services, the increase of the burden of illness, and reform processes in health care systems. Economic evaluation of mental health services has to consider the different roles of the agents acting in mental health care, policy-makers, companies, researchers and care professionals, and patients and their relatives.

Despite the increasing work done, most mental health care interventions have either not been evaluated or have been ill evaluated. There is a sense of paucity of measurement that has to be enriched with more and better evaluative research. Some unresolved methodological issues are commented on in this paper. In particular, direct costs outside the health care sector, indirect costs and quality of life measurement are briefly analysed.