Nature and nurture stand in reciprocity, not opposition. Offspring inherit, along with their parents' genes, their parents, their peers, and the places they inhabit. The ontogenetic niche is a crucial link between parents and offspring, an envelope of life chances. Development is at one and the same time a social and a psychological and a biological process. If we psychiatrists allow ourselves to become mere pill pushers — or psychotherapists who fit all patients into one Procrustean bed — each as the exclusive road to mental health, we will have abandoned the duty we owe our patients and our integrity as physicians.

Objective – The study of the relation between treatment costs and disability of psychiatric patient groups. Design – Perspective assessment of costs and disability of 1371 adult psychiatric patients in charge at two Operative Psychiatric Units (OPU), followed during an average period of 9 months. Data are related to all OPU's psychiatric services, including ambulatory, full or half-residential and psychiatric departments of acute hospital services. Setting — OPUs of Magenta (MI) and Desio (MI). Methods – The disability level has been measured by Health of the Nation Outcome Scales (HoNOS) filled in at the inclusion of the patient in the study and every three—months on average thereafter. Besides other HoNOSs have been filled in both at admission and discharge from psychiatric departments of acute hospitals, Residential Centres of psychiatric Therapies and Rehabilitation and Guarded Communities. All patients have been grouped using the main psychiatric diagnosis (first digit ICD—10) and the maximum disability level shown in the whole period of the study. Direct costs of publicly financed psychiatric services have only been considered. Their attribution to each patient has been made applying standard costs or tariffs (diagnostic procedures) to the data perspectively collected by the regional Register and a purposely designed protocol. Results – Total cost of 1371 patients has been 9771.1 million lire with a cost per patient of 7127000 lire (sd 19499000) and a cost per «day in charge» of 27172 lire (sd 68358). The cost per day has been found unrelated with the length of observed time frame. At the inclusion the mean level of disability has been 4.26 points (sd 3.73) and 3.19 points (sd 3.26) at the end of the study. Its value, measured at maximum level shown by each problem in the whole period of study, has been 6.00 points (sd 4.64). Disability and treatment cost of each patient did result directly related (r = 0.626, p = 0.0001). All patients have been grouped in 12 classes with a significant (p = 0,0001) overall difference on both their disability level and treatment cost. Conclusion – All adult psychiatric patients could be grouped in disability related classes which sometimes have also a different treatment cost. A study on a greater number of patients is needed to confirm these results. It may also provide a more reliable basis for a new financing system of psychiatric services.

Objective – To verify if the foreign population resident in the Canton Ticino, differs in the use of public psychiatric services and in the type of mental disorder presented, with respect to the Swiss population. Design – Research completed on subjects Swiss and foreign, over 19 years old, and resident in the Canton Ticino, who during 1995 spent at least one day admitted at the psychiatric hospital or had at least one contact with the out—patient services. Setting – Public psychiatric services of the Canton's sociopsychiatric organisation. Main outcome measures – For the Swiss, Italian and other non-Italian foreigners, the standardised annual rates of in- and outpatient prevalence and first admission and first outpatient contact were calculated, both totals and per diagnostic categories (ICD-10). Results – The group of non-Italian foreigners presents higher total standardised annual rates of in-patient prevalence and first admission and above all, of first admission, with respect to the Swiss and Italian groups; furthermore, with respect to the other two groups it presents higher first admission rates for the schizophrenic syndromes (F2) in men and for mental disorders due to psychoactive substances (Fl) in women. Whereas for first outpatient contacts the other foreigners present higher rates in neurotic syndromes (F4) in men, and affective syndromes (F3) in women. Conclusions – The results seem to confirm the presence of higher levels of mental disorder in non—Italian foreigners, above all for certain nationalities, with respect to Swiss and Italians. It is possible that the presence of a substantial offer of psychiatric services from the private sector may have caused an underestimation of the actual rate of mental disorder above all in the Swiss group and to a minor extent in that of the Italians.

Objective – To determine the most cost-effective oral therapy for the treatment of Major Depressive Disorder (MDD) in Italy. Method – We conducted a pharmacoeconomic evaluation based on a decision analytic model that examined the treatment of major depressive disorder (MDD) in Italy. The analysis compared the serotonin norepinephrine reuptake inhibitor (SNRI), venlafaxine extended-release (venlafaxine XR), to selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs). A meta-analysis was performed to determine the clinical rates of success. The meta-analytic rates were applied to the decision analytic model to calculate the expected cost and expected outcomes for each anti-depressant comparator. Cost-effectiveness was determined using the expected values for both a successful outcome, and a composite measure of outcome termed ‘symptom-free days’. A policy analysis was conducted to estimate the financial impact to the Servizio Sanitario Nazionale (SSN). Results – Treatment of MDD with venlafaxine XR yielded the highest overall efficacy rates for outpatients (73.7%) versus SSRIs (61.4%) and TCAs (59.3%), and inpatients (62.3%) versus SSRIs (58.6%) and TCAs (58.2%). Venlafaxine XR had the lowest dropout rates due to lack of efficacy (4.8%) versus SSRIs (8.4%) and TCAs (6.8%), and adverse drug reactions (10.9%) versus SSRIs (17.4%) and TCAs (23.1%). Initiating treatment of MDD with venlafaxine XR yielded the lowest expected cost for outpatients and for inpatients. The total resulting savings for the SSN at a 5% venlafaxine XR utilization was estimated between L 963 million and L 3,210 million. Conclusion – This study confirms that venlafaxine XR is generally a cost-effective treatment of MDD. Additionally, the results of this investigation suggest that increased utilization of venlafaxine XR will favorably impact the SSN.