Aim – The aim of this paper is to discuss the study of equity in mental health contexts. Methods – We review major principles and theories of distributive justice, covering various disciplines such as ethics, philosophy, economics, medicine and sociology. Recent literature on empirical analysis of inequalities in the mental health field is also reviewed. Results – The review of literature reveals a general lack of debate on equity principles in relation to mental health. Robust empirical evidence on inequalities in the field is also scarce. Conclusions – There is need for better exposition of the relevance of different equity principles for mental health policy and practice. There is also a need for developing standardised methods for the empirical analysis of equity, to examine the distribution of psychiatric morbidity and use of services by income, socioeconomic group, ethnicity, gender and place of residence, and, of course, to examine how equity can be promoted.

Declaration of Interest: This work was funded by the Department of Health programme grant to the PSSRU.

Aims – The present study is part of a longitudinal project aimed at identifying the personal characteristics and the developmental pathways conducive to successful adaptation from childhood to adulthood. The study examined the concurrent and longitudinal impact of self-efficacy beliefs on subjective well-being in adolescence, namely positive thinking and happiness. Positive thinking has been operationalized as the latent dimension underlying life satisfaction, self-esteem and optimism. Happiness has been operationalized as the difference between positive and negative affects, as they are experienced in a variety of daily situations. Methods – In a group of 664 Italian adolescents, a structural model positing adolescents' emotional and interpersonal self-efficacy beliefs as proximal and distal determinants of positive thinking and happiness has been tested. Results – Findings attest to the impact of affective and interpersonal-social self-efficacy beliefs on positive thinking and happiness both concurrently and longitudinally. Conclusions – Adolescents' self-efficacy beliefs to manage positive and negative emotions and interpersonal relationships contribute to promote positive expectations about the future, to mantain a high self-concept, to perceive a sense of satisfaction for the life and to experience more positive emotions.

Declaration of Interest: none.

This paper describes the development of the clinical practice guideline on schizophrenia from the National Institute for Clinical Excellence (NICE) and outlines its main recommendations. It reviews the evidence on effective implementation of guidelines generally and examines issues specific to the schizophrenia guideline. It describes NICE'S approach to supporting implementation alongside that developed by the National Collaborating Centre for Mental Health (NCCMH) and looks at local implementation examples for schizophrenia.

The paper highlights key considerations for the forthcoming revision of the NICE schizophrenia guideline. It makes recommendations concerning the scope of the guideline and the quality and type of data available to the guideline developers: the lack of data on outcomes such as quality of life and social functioning, the challenges presented by unpublished papers and areas where evidence is limited. Since publication of the schizophrenia guideline, the NICE development process has undergone significant methodological improvements. The grading of evidence has been refined and more recently NICE proposed that grading of recommendations be dropped. Consensus methods are increasingly and more effectively used to deal with areas where the evidence-base is limited. NICE and the NCCMH have developed a more implementation-ready range of guideline products.

The initial NICE guideline on schizophrenia was positively received nationally and internationally. This paper highlights challenges that will be involved in updating the guideline and ways to refine the methodology of development. Ultimately the impact of the guideline will be measured not in its methodological rigor but in how its successful implementation improves patient care.

Declaration of Interest: Stephen Pilling in receipt of funding from NICE for the production of clinical guidelines.

Aims — To describe the mental health system in Albania. Methods — Data were gathered in 2003 and in 2004 using a new WHO instrument, World Health Organization Assessment Instrument for Mental health Systems (WHO-AIMS), designed for collecting essential information on the mental health system of low and middle income countries. It consists of 6 domains, 28 facets and 156 items. Results — The information collected through WHO AIMS covered the key aspects of mental health system in Albania: the mental health policy and the legislative framework, the network of mental health services and the characteristics of the users, the role of the primary health care, the human resources, the public education and the links with other governmental sectors, monitoring and research. Conclusions — The data collection through WHO AIMS represented a needed step for a better in-depth knowledge of the system and for implementing actions to strengthen the system. Examples of planned actions were the improvement of the mental health component in primary care, a clear shift of resources from mental hospitals to community facilities, an increase of the outpatient care and an expansion of the mental health information system.

Declaration of Interest: none.

Aims – To describe the epidemiology of Suicide in Tuscany according to the triad of time, place and person. Methods – The 4, 764 cases of suicide, defined according to categories E950-E959 of ICD-9 in Tuscany over the period 1988–2002, were obtained from the Tuscan Mortality Register. Mortality indicators were calculated and analyzed. The spatial analysis was carried out by deriving Empirical Bayes Estimates for the 287 municipalities. Results – The crude mortality rate in the 2000–2002 is 7.8 per 100000 population (male: 12.4; female: 3.5). The age-standardized rate in the 2000–2002 is 5.8 per 100, 000 population (male: 9.6; female: 2.6). The highest risk for suicide, especially in the case of males, are concentrated in the southern hinterland Tuscany, in a cluster of rural municipalities that represent the old mining district of Tuscany. The SMRs according to residential municipality (population per square kilometre), confirm a greater risk of suicide for males residing in rural communities. Conclusions – The cluster of excessive mortality from suicide in Southern Tuscany could be the consequence of social determinants, related to the urban and social crisis following agriculture decline and mine closure.

Declaration of Interest: none.

Aims – It used to be thought that the problems of psychosis were qualitatively difference from those of other disorders and therefore unamenable to psychological interventions. However more recent evidence will be summarised which suggests otherwise. Methods – A cognitive model of the positive symptoms of psychosis (Garety et al, 2001; Kuipers et al.,2006) is described which builds on work on the dimensions of symptoms of psychosis, the continuum between non-clinical and clinical populations, and the contribution of emotional processes, cognitive reasoning biases and social factors. Results – Evidence from both epidemiological and empirical studies from our research group and others, support some of the pathways of symptom formation and maintenance proposed by the model. Specifically there is evidence for the role of trauma, social adversity and stress. These may trigger emotional responses and unusual experiences and together with reasoning biases lead to appraisals that can be defined as positive symptoms such as delusions and hallucinations. Similar processes interact to maintain symptoms. Conclusions – Cognitive models of psychosis have led to the development of cognitive behavioural treatments for delusions and hallucinations, which show some evidence of efficacy. Such treatments need to be refined in the light of recent research.

Declaration of Interest: none

Aim – To test the efficacy of a Behavioural Family Therapy (BFT) in a routine setting, both short and long term, of a community mental health service (CMHS). Methods – In a randomised clinical trial 24 patients with a diagnosis of schizophrenia, as confirmed by PSE-IX, were assigned to the BFT according to Falloon (n = 12) or to individual usual treatment (n = 12). They were assessed before and at the end of the active treatment (after one year), and after an 11-years follow-up with compared on basic indicators (hospitalisations, length of stay, drop-out rate) and standardised instruments of psychopathological symptoms, social functioning, family burden. Results – At one-year follow-up clinical important and statistically significant differences were observed for psychotic positive symptoms (p<0.01), self-care (p<0.01), autonomy in daily life (p<0.001), subjective/objective family burden (p<0.001). Other psychosocial variables showed positive outcomes non reaching statistical significance. At the 11-year follow-up, marked differences were observed only in hospitalisations and drop-outs. Conclusions – The BFT was rather easy to implement in a CMHS and very cost effective. However, as it has been shown in other studies, to keep all the benefits a consistent program of monitoring with booster sessions is essential.

Declaration of Interest: in the last 2 years, none of the authors has had any interest or he/she has received any form of support, including that from drug companies and “honoraria” for lectures and consultancies, potentially in conflict with this scientific work.

Aims – There is growing demand for economic analysis to support strategic decision-making for mental health but the availability of economic evidence, in particular on system performance remains limited. The Mental Health Economics European Network (MHEEN) was set up in 2002 with the broad objective of developing a base for mental health economics information and subsequent work in 17 countries. Methods – Data on financing, expenditure and costs, provision of services, workforce, employment and capacity for economic evaluation were collected through bespoke questionnaires developed iteratively by the Network. This was augmented by a literature review and analysis of international databases. Results – Findings on financing alone suggest that in many European countries mental health appears to be neglected while mechanisms for resource allocation are rarely linked to objective measure of population mental health needs. Numerous economic barriers and potential solutions were identified. Economic incentives may be one way of promoting change, although there is no one size fits all solution. Conclusions – There are significant benefits and synergies to be gained from the continuing development of networks such as MHEEN. In particular the analysis can be used to inform developments in Central and Eastern Europe. For instance there is much that can be learnt on both how the balance of care between institutional and non-institutional care has changed and on the role played by economic incentives in ensuring that resources were used to develop alternative community-based systems.

Declaration of Interest: none of the authors have received any financial support that presents a conflict of interest.

Aims — Most of the available evidence on the relationship between socioeconomic indicators of social deprivation and patterns of use of mental health services has been produced in the United Kingdom, where the Ministry of Health has developed a resource allocation formula based upon the results of those studies. The main aim of the paper is to evaluate the replicability in the Italian context of such research, and of the resulting allocation strategies. Methods — Detailed description of the resource allocation method currently adopted in the United Kingdom, whose main purpose consists in reaching the best balance between available funding and patterns of need. Detailed description of resource allocation processes in Italy; discussion of the main methodological and statistical limitations restraining the replicability of the British formula in the Italian context. Conclusions — There is a growing interest in Italy towards the introduction of evidence-based methods in health decision making, in order to correct the overwhelming influence of political issues. What is needed is a better understanding of the relationship between higher levels of equity in health services access, and their effects in terms of better outcomes.

Declaration of Interest: the current paper has been developed within a Research Programme funded by the Agenzia Regionale per i Servizi Sanitari, Regione Piemonte (Deliberazione n. 54 del 31.07.02). None of the authors received any additional source of funding for the development of this paper as well as for the related research activities.

Aims – The aims of the study are to evaluate the prevalence rates for headache among an Italian sample of early-adolescents and the role of possible related factors (school stress and social support). Methods – The survey reported here is part of the larger Health Behaviour in School Aged Children (HBSC) trans-national study, which is co-ordinated by the European Office of the World Health Organization. The data were gathered through self-administered questionnaires filled out by a representative sample of 4, 386 (48.4% males) Italian students (11-, 13- and 15-year old). The main areas covered in the questionnaire were health and health behaviour. Results – The overall prevalence of frequent headache (at least once a week) was 40.5%. Boys are less at risk than girls and the prevalence increases with age. Moreover, school demands (positively) and teacher's support (negatively) showed a significant association with the outcome. Conclusions – Compared to other countries, results revealed how this symptom is very common among Italian's early adolescents. Further, results shows the relevance of the school setting, in terms of teacher's demands and support, for the prevention of this symptom among early adolescents.

Declaration of Interest: The HBSC study is partly funded by the University of Padova through a scholarship attributed to Dr. Alessio Vieno (Year 2001 - prot. CPDR013233).

Aim – The purpose of this review is to summarize the evidence base on the effectiveness of (a) screening for depression in primary care; (b) managing depression in primary care employing specific management strategies; (c) treating primary care depressive patients with antidepressants. Methods – Meta-review of all available reviews of the evidence. Results – Screening alone does not improve the recognition, management and outcome of depression in primary care settings. Management strategies, including (a) training primary care staff, (b) consultation-liaison, (c) collaborative care, (d) replacement/referral are supported by insufficient evidence to provide a definite answer as to the clinical effectiveness of individual models. Robust evidence exists to encourage physicians to prescribe effective doses of antidepressants in patients with moderate to severe depression who seek treatment in primary care settings. Conclusion – Population-level screening campaigns have a negative ratio of costs to benefits. However, at an individual-level of care increasing the ability of primary care physicians in recognising depression remains a relevant factor. Primary care physicians should consider whether depression is mild, moderate or severe. This patient categorisation help develop appropriate management and therapeutic strategies.

Declaration of Interest: none

Aims – This study evaluated the frequency and clinical significance of abnormal Thyroid Stimulating Hormone (TSH) and Free Thyroxine Index (FTI) in patients with bipolar I disorder treated primarily with lithium. Method – We evaluated the medical records of 143 participants in the Pittsburgh study of Maintenance Therapies in Bipolar Disorder who did not have a thyroid abnormality at entry. Results – Thirty-six percent of the 143 patients developed abnormal TSH and/or FTI values. Thirty-eight percent of the 135 patients who received lithium developed abnormal TSH and/or FTI, spent significantly longer time in the acute treatment phase (t = -3.6, df = 133, p = .0004), and had significantly higher mean Hamilton Scale for Depression scores over the course of the maintenance phase (t = -2.3, df = 71.6, p = .03). Time on lithium and development of abnormal TSH and/or FTI were positively correlated (r = .25, p = .004). Conclusions – Thyroid dysfunction can be frequent in patients exposed to lithium treatment for bipolar I disorder; it also appears to be correlated with a slower response to acute treatment, and may be related to poorer quality of long-term remission. A prospective study is needed to confirm our findings and determine whether more aggressive thyroid replacement can optimize thyroid function to facilitate clinical recovery.

Declaration of Interest: Supported in part by National Institute of Mental Health Grants MH 029618 (Drs. Frank and Fagiolini) and MH 030915 (Drs. Kupfer and Fagiolini), and the Bosin Memorial Fund of The Pittsburgh Foundation (Drs. Fagiolini, Kupfer, Cook, Scott, Novick and Frank). Dr. Fagiolini is on the advisory board and a consultant to Pfizer Inc, and Bristol Myers Squibb, and is on the speaker bureau of Bristol Myers Squibb, Eli Lilly Italy, Pfizer Inc, and Shire. Dr. Frank is on the advisory board of Pfizer Inc. and Eli Lilly & Company, and is a consultant to Pfizer Italia and Sender Amerique. Dr. Kupfer is on the advisory board of Pfizer, Inc., Forest Pharmaceuticals, Inc., and Solvay-Wyeth Pharmaceuticals, and is a consultant to Servier Amerique.

Aims – To define the epidemiological and clinical characteristics of Post Stroke Depression (PSD) and to evaluate treatment options. Methods – Systematic search using Medline electronic database limited to studies published from year 2000 to 2004, was carried out. Manual search was also performed. Results – Depression after stroke is a common event. The same, stroke incidence in depressed patients is more frequent than by chance. Risk of underdiagnosing a patient with former stroke is high. Disability after stroke is frequent, with compromission of quality of life of patients and relatives. Antidepressants are efficacious in PSD treatment, even if complete remission is difficult to obtain. Conclusions – There is enough evidence concerning epidemiology, pathogenesis, clinical and therapy to justify psychiatrists' interest on relationship between stroke and depression.

Declaration of Interest: in the past two years PP, GSL, PS have received no fees or other financial support from pharmaceutical companies, GM has received speaker fees from Sanofi-Aventis, Lundbeck, Bayer Health Care, Boehringer Ingelheim, Novo Mordisk.

Aims – Psychiatric patients often are not informed about their diagnosis and their involvement in the decision making process is rare. Aim of the study was to explore the informative needs of patients with schizophrenia and the knowledge about their illness. Method – Three focus groups were conducted with 25 long-stay patients with the diagnosis of schizophrenia, attending the Mental Health Centre of the South-Verona Community-based Mental Health Service. The group discussions were audiotaped and transcribed. Results – The authors identified 18 different thematic categories which were used by two raters to classify all patient contributions. The interrater reliability was satisfactory. The qualitative analysis evidenced that patients have little knowledge about their illness. Patients had confuse and vague ideas on schizophrenia but their knowledge on drug names, dosages and side effects appeared precise and detailed. Several patients have looked for information in encyclopedias and medical dictionaries. Conclusion – The findings suggest a need of patients affected by schizophrenia for an information exchange with their psychiatrists that takes into account their informative needs, corrects wrong beliefs and actively involves them in therapeutic decisions.

Background – The patterns of antidepressant and antipsychotìc drag prescribing have rarely been studied in large and geographically defined catchment areas. In the present study we examined the prevalence and distribution of antidepressant and antipsychotic prescribing in Lombardy, a northern Italy region of nine million inhabitants. Methods – This study used the Regional Administrative Database of Lombardy. This database includes all prescriptions reimbursed by the National Health System in the population living in this region. All antidepressant and antipsychotic prescriptions dispensed from the 1st January to the 31st December 2001 were extracted and prevalence data calculated by dividing antidepressant and antipsychotic users by the total number of male and female residents in each age group. In addition, from the Regional database of hospital admissions we extracted all patients aged 65 or above with cerebrovascular-related outcomes for the year 2002. The two databases were linked anonymously with the aim of investigating the relationship between exposure to psychotropics and occurrence of cerebrovascular accidents in the elderly. Results – During the study period 404, 238 individuals were dispensed antidepressants, yielding a prevalence of use of 2.85 (95% CI 2.84, 2.87) per 100 males and 5.92 (95% CI 5.90, 5.94) per 100 females. The prevalence of use progressively rose with age in both sexes, with the highest rates in old and very old individuals. The majority of individuals received a pharmacological treatment with selective-serotonin reuptake inhibitors only, slightly more than 12% received a treatment with tricyclic antidepressants. A total of 86, 187 subjects were dispensed antipsychotic agents, yielding a prevalence of use of 0.87 (95% CI 0.86, 0.88) per 100 males and 1.01 (95% CI 1.00, 1.02) per 100 females. The prevalence of use progressively rose with age in both sexes, with the highest rates in old and very old subjects. Concerning the relationship between exposure to second-generation antipsychotics (SGAs) and occurrence of cerebrovascular (CBV) accidents, the analysis showed a significantly increased risk of CBV events in elderly subjects exposed to SGAs in comparison with those exposed to first-generation antipsychotics (FGAs) (3, 31%, 95% CI 2, 95–3, 69 vs. 2, 37%, 95% CI 2, 19–2, 57). Finally the analysis indicated no differences in the proportion of cerebrovascular events in elderly subjects exposed to TCAs and SSRIs. Conclusions – The very high rates of antidepressant and antipsychotic drug prescribing detected in late life suggest the need of characterising these individuals in terms of medical and psychiatric characteristics, needs and quality of life. It also suggests the need for pragmatic clinical trials, carried out in the general practice, with the aim of assessing whether antidepressants are effective in these conditions. The data provide preliminary epidemiological evidence that exposure to SGAs, in comparison with exposure to FGAs, significantly increased the risk of cerebrovascular accidents in the elderly.

Declaration of Interest: none.

Objective — This study explored the effectiveness of a psychoeducational family intervention for schizophrenia on patients' clinical status and disability and relatives' burden and perceived support. Methods — The study has been carried out in 17 mental health centres. In each of them, 2 professionals were trained in a psychoeducational intervention and applied it for six months with families of users with schizophrenia. At baseline and six months later, patients' clinical status and disability, and relatives' burden, social network and professional support were assessed by validated tools. Results — Of the seventy-one recruited families, 48 (68%) completed the intervention. At six months, a significant improvement was found in patients' clinical status and social functioning, as well as in relatives' burden and social and professional support. In particular, the percentage of patients with poor or very poor global social functioning dropped from 50% to 27% at six months. Forty percent of patients and 45% of relatives reported a significant improvement in their social contacts over the intervention period. Conclusions — The results of this study confirm the hypothesis that psychoeducational family interventions may have a significant effect on social outcome and family burden in schizophrenia when provided in routine conditions.

Declaration of Interest: none of the authors has had any interest or he/she has received any form of support, including that from drug companies and honoraria for lectures and consultancies, potentially in conflict with this scientific work. None of the authors has received any form of fee for his/her participation in this study. This study was supported by grants received from the “M. Lugli” Foundation (grant n. 2/18/8) and from the National Institute of Health, Italy (grant no. 1AL/F3).

Aims – To start a process of Continuous Quality Improvement (CQI) in an Italian Community Mental Health Service by using a quality assurance questionnaire in a self audit exercise. Methods – The questionnaire was administered to 14 key workers and clinical managers with different roles and seniority. One senior manager's evaluation was used as a benchmark for all the others. Changes were introduced in the service practice according to what emerged from the evaluation. Meetings were scheduled to monitor those changes and renew the CQI process. Results – There was a wide difference in the key workers' answers. Overall, the senior manager's evaluation was on the 60th percentile of the distribution of the other evaluations. Those areas that required prompt intervention were risk management, personnel development, and CQI. The CQI process was followed up for one year: some interventions were carried out to change the practice of the service. Conclusions – A self audit exercise in Community Mental Health Services was both feasible and useful. The CQI process was easier to start than to carry on over the long term.

Aims – To obtain a new, well-balanced mental health funding system, through the creation of i) a list of psychiatric interventions provided by Italian Community-based Psychiatric Services (CPS), and associated costs; ii) a new prospective funding system for patients with a high use of resources, based on packages of care. Methods – Five Italian Community-based Psychiatric Services collected data from 1250 patients during October 2002. Socio-demographical and clinical characteristics and GAF scores were collected at baseline. All psychiatric contacts during the following six months were registered and categorised into 24 service contact types. Using elasticity equation and contact characteristics, we estimate the costs of care. Cluster analysis techniques identified packages of care. Logistic regression defined predictive variables of high use patients. Multinomial Logistic Model assigned each patient to a package of care. Results – The sample's socio-demographic characteristics are similar, but variations exist between the different CPS. Patients were then divided into two groups, and the group with the highest use of resources was divided into three smaller groups, based on number and type of services provided. Conclusions – Our findings show how is possible to develop a cost predictive model to assign patients with a high use of resources to a group that can provide the right level of care. For these patients it might be possible to apply a prospective per-capita funding system based on packages of care.

Declaration of Interest: None