Franco Basaglia (1924–1980) has a particular relevance to psychiatry today as he combined social critique with psychiatric reform. In the new ‘metacommunity’ era in psychiatry, his radical and critical thinking provides important tools, as does his enduring message that ‘freedom is (still today) therapeutic’.

Among the many social determinants of health and mental health, employment and work are getting momentum in the European political agenda. On 30–31 January 2024, a ‘High-level Conference on Mental Health and Work’ was held in Brussels on the initiative of the rotating Belgian Presidency of the European Union. It addressed the issue developing two different perspectives: (1) preventing the onset of poor mental health conditions or of physical and mental disorders linked to working conditions (primary prevention); (2) create an inclusive labour market that welcomes and supports all disadvantaged categories who are at high risk of exclusion (secondary and tertiary prevention). In the latter perspective, the Authors were involved in a session focused on ‘returning to work’ for people with mental disorders and other psychosocial disadvantages, with particular reference to Individual Placement and Support as a priority intervention already implemented in various European nations. The themes of the Brussels Conference will be further developed during the next European Union legislature, with the aim of approving in 4–5 years a binding directive for member states on Mental Health and Work, as it is considered a crucial issue for economic growth, social cohesion and overall stability of the European way of life.

Objective - The present study was conducted to determine the excess of mortality in long-term psychiatric inpatients. Setting - Psychiatric hospital, Bologna, Italy. Design – Retrospective study on a cohort of 264 chronic psychiatric inpatients, followed up for ten years since January 1981. Mortality measures were computed by psychiatric diagnosis, length of stay and «still resident at follow-up/discharged» condition. Main measures – Standardized mortality ratios were computed with reference to the mortality by age of the population resident in Bologna in the years 1981- 1991. Presence in the cohort was expressed in person/years. Results – The excess of deaths in the cohort was 2.89 (CI 95%: 2.12-3.86) for males and 2.38 (CI: 1.66-3.31) for females. A remarkable excess of deaths for both sexes was observed in the class of age 15/44 (18.33 for males, CI 9.14-32.81; 60 for females, CI: 21.91-130.6 ) and in association with a diagnosis of personality disorder/alcohol abuse (11.25 for males, CI: 5.13-21.36; 5 for females, CI: 1.35-12.8). Length of stay and age of patients were inversely associated with SMRs. Conclusion – The present study confirms that the excess of mortality is high in psychiatric long-term inpatients and that it may be concentrated in younger classes of age, first years after admission and in subjects with diagnoses of personality disorder/alcohol abuse.

Admission to an Italian Forensic Hospital (OPG) results in formal exit from psychiatric care provided by NHS community based psychiatric services. The length of stay in such facilities is often perceived as a factor negatively affecting the opportunity for reintegration in the community. Method – Factors predicting length of stay in OPG were investigated by means of a survival analysis carried out on a cohort of 118 inmates of three OPGs (Castiglione delle Stiviere, Reggio Emilia and Montelupo Fiorentino), who represent the whole forensic population from 3 different geographical areas at 30.06.97; all discharges occurred in the following 18 months were examined. Results – In survival analyses conducted on individual predictors, five variables predicted a longer stay: type of offence (homicide: 706.6 weeks vs. 307.1 for minor offences and 194.7 for grievous bodily harm, log-rank =31.8, p >0.001), type of admission (RR=0.98, CI 95% 0.97-0.99, p>0.001), the diagnosis of schizophrenia (621.9 weeks vs. 398.9 weeks or less for other diagnoses; log rank=9.08, df=3, p=0.028), BPRS thought disturbance score (RR=0.89, CI 98% 0.81-0.98, p>0.01), hospital of stay (314.6 weeks in Montelupo Fiorentino vs. 706.6 for Reggio Emilia and 621.9 for Castiglione delle Stiviere; log-rank = 9.64, df=2, p>0.001). In a Cox linear regression model three significant factors were selected: type of offence, type of admission, diagnosis of schizophrenia. Conclusions – Judicial factors are relevant in determining the length of stay in OPG. The diagnosis of schizophrenia seems to play an independent role in predicting a longer stay.

Objective - To discuss the ethical and legal basis of ECT use in Italy, one year after the regulation set up by the Minister of Health. Methods - Literature review and presentation of authors' personal opinions. Results - Despite being the oldest somatic therapy still practised in psychiatry, ECT effectiveness has been systematically evaluated only during the last 20 years, and its clinical indications have become progressively restricted. Yet there are wide variations between countries and within each individual country about the extension, the modalities and the indications for its use. ECT seems to be practised mainly in large scale public psychiatric hospitals and in private clinics, but its use in systems following a community approach is very limited. Wide variations exist also with reference to the severity of regulations imposed by governments or suggested by professional associations. The extent of education and auditing by university centres varies considerably, but is generally considered unsatisfactory. There are still some reports about possible political and repressive use of ECT in some countries, especially developing ones. Conclusion - The authors consider that every national system of care should have a clear policy and clear regulations about ECT. The provisions set up by the Italian Minister of Health seem to be consistent with Italian health policies and psychiatric community care.

Objective. In Italy, Residential Facilities (RFs) have completely replaced Mental Hospitals (MHs) for the residential care of mentally ill patients. We studied all patients resident in 265 randomly sampled Italian RFs (20% of the total).

Method. Structured interviews focusing on each patient were conducted by trained research assistants with the manager and staff of each RF. Patients were rated with the HoNOS and the GAF, and comprehensive information about their sociodemographic and clinical status and care history were gathered.

Results. Of the 2962 patients living in the sampled facilities, most were males (63·2%) who had never married, more than 70% were over 40 years; 85% on a pension, most commonly because of psychiatric disability. A substantial proportion (39·8%) had never worked and very few were currently employed (2·5%); 45% of the sample was totally inactive, not even assisting with domestic activities in the facility. Two-thirds had a diagnosis of schizophrenia; co-morbid or primary substance abuse were uncommon. Twenty-one per cent had a history of severe interpersonal violence, but violent episodes in the RFs were infrequent. The managers judged almost three-quarters appropriately placed in their facilities and considered that very few had short-term prospects of discharge.

Conclusions. Italian RFs cater for a large patient population of severely mentally ill requiring residential care. Discharge to independent accommodation is uncommon. Future studies should attempt to clarify how to match residential programmes with patients' disabilities.

La prima parte di questa monografia prende in esame le variabili di tipo strutturale delle SR, ovvero le caratteristiche quanti- e qualitative sia delle SR che dello staff curante. L'importanza delle caratteristiche strutturali delle SR è duplice: da un lato si trattava di comprendere in che misura il cambiamento strutturale innescato e promosso dalla Legge 180 si fosse tradotto in una effettiva e coerente trasformazione del contesto assistenziale, e dall'altro quale fosse il gradiente di variabilità delle strutture sul territorio nazionale (peraltro già messo in luce, in termini generali, nella fase 1 del progetto); è inoltre noto che la presenza di condizioni strutturali di qualità accresce le probabilità di un processo appropriato e quindi di un esito favorevole degli interventi.

Oltre la metà delle 265 SR partecipanti (N=138, 52,1%) è localizzata nel Nord Italia, mentre le altre si distribuiscono in proporzione simile nel Centro (N=64, 24,2%) e nel Sud (N=63, 23,7%) del paese. Le SR del Sud presentano un numero medio di ospiti per struttura significativamente più elevato (14,1±7,2) rispetto a quelle del Nord (N=ll,2±8,6) e del Centro (N=9,4±5,8) (p<0,01; Nord vs Sud p<0,05; Centro vs Sud p<0,001). Il numero medio di residenti nelle SR selezionate è risultato pari a 10 (media 11,4±7,9), con un range piuttosto ampio, che va da un minimo di 4 ad un massimo di 60. La percentuale di SR con un numero di posti-letto superiore a 20 è tuttavia ridotta (N=16; 5,7%). Le SR con maggiore capienza (>20 posti-letto) presentano alcune differenze statisticamente significative rispetto alle SR di minore capacità ricettiva (<20 posti-letto): una percentuale inferiore di dimissioni concordate (12,7% vs 32,3%; p<0,05), ed una percentuale maggiore di fughe di residenti (17,1% vs 5,5%; p<0,01) e di drop-out (14,5% vs 4,2%; p<0,1).

Se le SR devono rappresentare, almeno per una parte dei pazienti che esse ospitano, un setting destinato al trattamento intensivo a lungo termine, l'analisi del processo assistenziale (ossia di ciò che concretamente si fa nelle SR, delle regole che caratterizzano lo svolgersi della vita comunitaria, delle attività condotte dagli operatori) appare una dimensione di fondamentale importanza da comprendere. Nell'ambito del progetto PROGRES, tale dimensione è stata oggetto di una valutazione approfondita, che viene descritta in questa sezione della monografia.

La Scheda Struttura conteneva molti item che esploravano varie caratteristiche e dimensioni del processo assistenziale. L'analisi dei dati ha preso in esame la descrizione dei parametri rilevanti per la comprensione di specifici aspetti del processo assistenziale in atto all'interno delle SR. Si sono anche esplorate eventuali associazioni fra caratteristiche delle SR e dei pazienti ospitati.

È stata inoltre condotta una analisi dei cluster al fine di individuare, sulla base dei dati disponibili, dei raggruppamenti omogenei di SR che consentano di cominciare a delineare una tassonomia di queste strutture e delle loro funzioni. In generale, l'analisi dei cluster classifica i casi in categorie o gruppi relativamente omogenei, basandosi sulla loro somiglianza o dissimiglianza rispetto alle variabili selezionate. Al fine di effettuare l'analisi dei cluster cercando di utilizzare il massimo numero di informazioni disponibili, sono stati messi a punto 4 punteggi sintetici: ciascuno di essi ha il compito di riassumere la presenza o assenza di varie caratteristiche o dimensioni inerenti al processo assistenziale.

Come si è già notato prima, le caratteristiche dei pazienti trattati nelle SR sono state molto poco studiate. In particolare, la maggior parte degli studi condotti sino ad oggi ha preso in esame campioni di limitata ampiezza (Andrews et al., 1990; Mowbray et al., 1992; Rimmerman et al., 1993), quindi poco rappresentativi delle popolazioni di pazienti da cui essi sono stati tratti. I soli studi effettuati su campioni più ampi sono stati condotti negli Stati Uniti (Randolph et al., 1991) ed in Gran Bretagna (Lelliott et al., 1996; Faulkner et al., 1993), ma queste ricerche non prevedevano una dettagliata valutazione individuale dei pazienti stessi.

In questo capitolo verranno quindi riportati i risultati della valutazione dettagliata di 2.962 pazienti ospitati nelle 265 SR campionate nella fase 2 del Progetto Nazionale PROGRES. L'ampiezza del campione preso in esame permette di trarre interessanti indicazioni relative all'assistenza fornita attualmente in Italia a pazienti affetti da malattie mentali gravi a pochi anni dalla chiusura degli O.P., e può fornire dati utili anche per altri paesi impegnati in un analogo processo di cambiamento dell'assistenza psichiatrica.

Italian psychiatry is probably more debated than known in the international arena. Law 180 of 1978, which introduced a radical community psychiatry system, has drawn worldwide attention and debate, with comments ranging from the enthusiastic to the frankly disparaging (Mosher, 1982; Jones et al, 1991). More recently, this interest was marked by a well-attended symposium ‘Lessons Learned from Italian Reforms in Psychiatry’ held at the 2003 annual meeting of the Royal College of Psychiatrists in Edinburgh.