Objective – The aim of the study was to investigate the attitudes in the decision making process for admitting patients compulsorily under the Italian Law 180/78. Setting – A group of psychiatrists (n=81) working in the area of Cagliari (Sardinia, Italy). Main outcome measures – Three case–vignettes describing different hypothetical clinical situations: 1) a man with depression and psychotic symptoms; 2) a woman with a possible first episode of psychosis; and 3) a man with a history of substance abuse and bipolar disorder. Each vignette was followed by a list of 11 factors reported in the literature as important in the decision to admit compulsorily (current mental state, severity of the disease, dangerousness to self or others, psychiatric history, likely response of the mental state to the medical treatment, age and gender of the patient, owning a home, occupational status, social support available). Psychiatrists were asked: a) whether they would admit the patient compulsorily; and b) to rate 11 factors from the most to the least important in their decision.

Objective. Stress is a term that has become synonymous with modern life. This review aims to appraise the evidence linking stress with disease with particular reference to the major causes of morbidity and mortality in the Western World, cardiovascular disease, cancer, and depression. Changes in immune parameters in stressful situations were reviewed as a possible pathophysiological mechanism for such effects. Method – A Medline search was carried out for the period 1996-2000 to identify recent findings in this field using the terms “stress”, “disease”, “immune system”. Relevant references that were found in all identified publications were also followed up. Results – There is evidence to link stress with the onset of major depression and with a poorer prognosis in cardiovascular disease and cancer. Few small studies suggest that stress management strategies may help to improve survival. Chronic stress appears to result in suppression of the immune response, whereas immune activation and suppression have been associated with acute stress. Inflammatory cytokines, soluble mediators of the immune response, can result in symptoms of depression. Conclusion – Further prospective epidemiologically based studies are needed to clarify the role of stress on disease onset, course, and prognosis. Stress management strategies, aimed at prolonging survival in patients with cardiovascular disease, cancer, and possibly other chronic illnesses, are an exciting area of further research. Immune system changes may account for the relationship between stress and disease. We propose the “stress, cytokine, depression” model as a biological pathway to explain the link between stressful life events and depression.

Objective – This study aimed to describe: a) the interventions received by patients with schizophrenia attending Italian mental health services (MHS); b) the relatives' burden and social network and the professional support received by the families. Design – The study has been carried out in 30 MHS, randomly selected and stratified by geographic areas and population density. 25 patients with a DSM–IV diagnosis of schizophrenia and 25 relatives were recruited in each MHS. Family burden was evaluated in relation to: a) geographic area; b) interventions received by the patients; c) social and professional sup– port received by the families. Main outcome measures – a) patients: Brief Psychiatric Rating Scale (BPRS) and Disability Assessment Interview (AD); b) key-relatives: Family Problems Questionnaire (QPF) and Social Network Questionnaire (QRS); c) interventions received by the patients and their families: Scheda di Rilevazione degli Interventi – Pattern of Care Schedule (SRI). Results – Data on 709 patients and their key-relatives were collected. In the two months preceding the data collection, 35% of patients attended rehabilitative programmes; 80% of the families were in regular contact with the MHS and 8% received family psychoeducational interventions. Family burden was higher in Southern than in Central and Northern Italy. This difference disappeared when rehabilitative interventions and family support were provided. Conclusions – This study highlights that the situation of the families of patients with schizophrenia is more burdensome in Southern Italy and is greatly influenced by the type of interventions provided by the MHS.

Objective – The ‘PROGRES’ (PROGetto RESidenze' Residential Project) project has 3 aims: 1. To survey all Italian psychiatric Non-Hospital Residential Facilities (NHRF) (Phase 1); 2. To assess in detail 20% of the NHRFs and the patients living there (Phase 2); and 3. To carry on training programmes for the mental health workers of these facilities (Phase 3). We report here the results of Phase 1. Methods: – All NHRFs were surveyed using a structured interview administered to the manager of the facility. In some cases, this information was supplemented with data gathered from other mental health workers at the NHRFs. Results – On May 31, 2000, there were in Italy 1,370 NHRFs with 17,138 beds, giving an average number of beds per facility of 12.5 and a rate of 2.98 beds per 10,000 inhabitants. This rate varies greatly between regions, with a ratio of 1:10 between the two regions with the lowest and the highest bed rates. Seventy-three percent of the NHRFs have a 24-hour staff coverage; more than 50% are directly managed by the NHS Departments of Mental Health and more than three-quarters of the NHRFs are directly funded by the NHS. In the course of 1999 38% of the NHRFs discharged no patients, and another 32% discharged fewer than 3 patients. In about half of the NHRFs the most common patient age group was 40-59 years. In the Italian NHRFs there are 11,240 full-time mental health workers, plus several thousand half-time staff. The average number of full-time mental health workers in each NHRF is 8.2. In 58% of the NHRFs the operational chief is a psychiatrist; some 40% of the overall number of mental health workers in the NHRFs have no specific psychiatric training. The total number of patients resident in the NHRFs is 15,943; among them, 58% have never been admitted to a mental hospital, 40% have been admitted and a small percentage (1.6%) has been previously admitted to a forensic mental hospital. The availability of NHRF beds is negatively associated with the availability of non-hospital facilities (e.g., community mental health centres, day-centres) and positively associated with the number of beds in private psychiatric facilities in each region. Discussion – The current rate of NHRF beds is higher than the officially recommended national standard (2/10,000 inhabitants). However, there is a great variability between regions, which is related to the overall provision of different types of psychiatric facilities. Most NHRFs provide intensive care, and the continuum of residential facilities with different types of care, support, degree of autonomy, etc. recommended by several authors for the long-term treatment of severe patients with different disabilities, seem to be lacking. NHRFs have a very low patient turnover rate, and this may create problems in the future. Conclusions – The PROGRES project is the first national study ever carried out in Italy to evaluate a specific type of psychiatric facilities in the context of the new system of psychiatric care. When all the data will be available, it will be possible to assess in detail for the first time a national representative sample of severe, long-stay patients and the care they are receiving; on this basis, it will also be possible to recommend evidence-based policies aimed at improving the care of the severely mentally ill.

Based on the findings of previous studies carried out by our group, which will be briefly summarised, the present paper puts forward several hypotheses to account for the evolution of depressive symptoms and the possible increase observed in risk of depression subsequent to social changes. The particular mood disorders presented by Senegalese emigrants and several protective factors which appear to determine a low risk in these populations, such as a strong social support, will be examined. Based on a previous investigation carried out by our group, which seems to indicate the presence of depressive pictures among poorly westernised populations such as the Peul nomads or Dogon farmers from the Sub-Saharian regions, the hypothesis that “westernalisation” (considered as the loss at an individual level of traditional ways of life, working habits, cultural patterns and languages in favour of different attitudes influenced by western culture) may represent a risk factor for depressive illness, in its clinical expressions commonly observed in western contexts, has been considered. In these populations, with the exception of educated individuals, the albeit rare depressive symptoms appear to be secondary to serious somatic disorders. Research performed identified two well-defined means of clinical expression, which has been termed, respectively, “western style” or “guilty” and “traditional” or “dislocation from the group”. Further studies carried out in rapidly changing areas seem to indicate how environmental factors are able to influence the evolution of depressive symptoms from the first form to the latter and to modify the threshold of onset of emotive, behavioural and depressive patterns. It has been hypothesised that rapid changes in the social organisation tend to exacerbate attitudes of “compulsive hyper-responsibilisation”, a cognitive set of basic assumptions which may be considered at the same time both as a product of “westernalization” at an individual level and a risk factor for depression. Individuals who possess these basic characteristics, subsequent to the opportunities afforded by the social changes, tend to develop new complex systems of interpreting reality, causality, controlling of events and ways of expressing emotions. Accordingly, we herewith propose a reviewal of the entire threshold concept and provide a means of interpreting the transformation in depressive phenomena in view of the fact that, although the new levels of knowledge and learning better equip subjects to face the new situations, they also render them more vulnerable to depression.

Aim — The aim of this paper is to present the results of a citation analysis concerned with the impact on the international literature of Italian researchers in psychiaty and psychology and of sub-fields, within these two disciplines, in 1995-1999 compared to 1985-1989. Method — We used a database prepared by the Institute for Scientific Information (ISI) that included all papers, with at least one Italian author, working in Italy, which appeared in two periods (1995-1999 and 1985-1989) in psychiatric or psychological journals listed in Current Contents. A citation analysis concerning the following years, up to 1999, was performed. Results — In 1995-1999 the most cited researchers were those involved in clinical psychology, psychiatry and psychopharmacology research. Neuropsychology, which dominated the period 1985-1989, underwent a clearcut decline. Conclusions — Citation analysis, concerning relatively short periods of time (five years), appears to be a very helpful tool for monitoring the development of scientific research in specific disciplines and the trend of the scientific production of researchers.

Objective – Aim of the study was to investigate the psychometric properties of the Italian version of the Drug Attitude Inventory (DAI) by exploring its construct validity. Setting – 90 voluntary admitted patients with DSM III-R Schizophrenic (n.72) and Schizoaffective (n.18) disorders, age range between 18 and 50 years, treated with typical antipsychotics, able to participate in the study, were selected. Design – Exploratory factor analyses with alpha factoring and maximum–likelihood methods with Varimax Rotation were used to analyse DAI scores. Results – Extraction methods found 7 factors which explained 62.5% of the total variance. The first 2 factors could be labelled as “subjective response to treatment” construct and factors 3 to 7 as “attitude to medication” contruct. Conclusion – Although preliminarily, the Italian version of the DAI seems to maintain the original psychometric properties and it can be used easily to get a valid measurement of the patients' attitude to neuroleptic medication.

Aims – In the last years, in Italy as well as in many other developed countries, there has been a growing interest for health economics by researchers. As for as the psychiatric care is concerned, more recently, many research's groups have pointed their attention on new possible funding systems for mental health services and on their effects on services' functioning. The aim of this study is to define a new list of services' costs based on services actually delivered by a Community Mental Health Service (CMHS). Methods. – All psychiatric contacts recorded by the South-Verona Psychiatric Case Register during a 7-year period (1992-1998) have been included in the study (125,623 contacts made by 2,819 patients). Contacts were grouped into 19 type of services. The cost function methodology was used to describe, also reporting elasticity values, costs' behaviour in the South-Verona CMHS. The cost of each service includes expenses for professionals involved (directly or indirectly) in the contacts with the patients and capital costs. Results. – For each service were reported a) the cost of the service as it is actually supplied in our CMHS, b) the cost per minute, c) an estimate of the cost of service delivered with standard modalities (duration equal to the mode value registered; staff composition take into account either the actual functioning of the CMHS either indication about a good clinical practice) and, finally, d) cost of the eight services included into the reimbursement system currently in use in Italy. Conclusions. – Our results showed that services' definition used in this study allow to describe different types of psychiatric care supplied from the South-Verona CMHS. The national list currently adopted for the reimbursement in Italy should allowed to describe only 28% of the registered psychiatric contacts (35,230 vs. 125,632). The urgent need for a new list of psychiatric services, accepted at a national level, was confirmed. Cost values obtained clearly show that the funding system currently used underestimates the true costs of care delivered by the CMHS. The cost function makes available a tool to test a prospective per-capita funding system as provided in the Act No. 229 of the Italian Government.

Objective – The aim of the study was to show, trough the calculation of the direct costs of supports and treatments actually provided by a NHS Mental Health Department, the presence of associations between four diagnostic groups (schizophrenia, affective psychosis, paranoia and neurotic disorders) and their overall and items (community care, rehabilitation facilities and in-patients services) costs. Setting – Mental Health Department and CSM “Scalo” (NHS Mental Centre), AUSL “Citta di Bologna”, Emilia-Romagna Region. Design – Yearly direct costs were calculated for a sample (n = 75) of all patients (N = 745) who during 365 days had more than four contacts with CSM and also for four randomised diagnostic groups (n = 30 per group). Main outcome measures – We calculated unit costs of 15 types of services provided by CSM, selected according to the yearly number of services provided and the time spent by each health professional, and the in patient-cost per all days spent in a public or private sector hospital for psychiatric care. Results – The statistic analysis, performed with the help of the Kruskal-Wallis test, showed significantly higher overall costs for the schizophrenic patients than the sample-group and the neurotic disorders-group; besides a significant difference in the item costs for rehabilitation facilities was found between the schizophrenic group and the paranoia, neurotic disorders groups and the sample one, whereas no significant differences in costs of inpatients services and drugs administration were tested between the groups. Conclusions – The results of our study allow to demonstrate that there are cost differences between the diagnosis (direct costs are highest for schizophrenic patients and lowest for those with neurotic disorders) and that the costs evaluation can be used to ensure appropriate provisions to Mental Health Department for support and treatment of a wide range of psychiatric disorders.

Objective – Analysis of figures and characteristics of suicide behaviour in the area of Varese and the neighbouring northern towns (Valceresio, the valleys around Luino and northern Verbano), with the purpose of finding out preventing measures. Design – Epidemiological-descriptive survey. The 1995-1997 ISTAT death cards, included in the death files of the former USSL of Varese have been taken into consideration. Only those people who were resident at the suicide moment have been included in the survey. Afterwards the psychiatric service archives were consulted, to find any possible contact between the subjects in the ISTAT files and the psychiatric services themselves. With regard to these patients, some information such as suicide attempts, psychiatric pathology and first contact with the psychiatric services have been pointed out. Setting – Arcisate, Cittiglio, Luino and Varese districts, where the Community Mental Health Services 1 and 2 of “Azienda Ospedaliera Universitaria Macchi” of Varese operate. Main outcome measures – The suicide rates in the studied area have been reckoned and, through direct standardization, the rates of the single districts have been compared. Results – There were 78 suicides ( 24 females and 54 males): rate of 8.2 per 100.000. In accordance with the national trend, there is evidence of a general reduction of the suicide phenomenon, except among the youngest. Districts of Luino and Arcisate are geographic areas to examine in the time, because a wider sample could reveal a higher risk. Young and elderly people are the most affected among the males and, 55/64- year-old people, both males and females, are at higher risk. Suicide methods vary with the age. A high percentage of subjects are not married and with low education. Less than one third of the subjects had come into contact with the psychiatric service. Conclusions – These data allow a comparison with the national survey and an analysis of the suicide features in the study area. The purpose is to elaborate preventing strategies with multi- dimensional approach whose efficacy may be proved in the future by setting up a provincial observatory.

Objective – To verify the association between schizophrenic symptoms and multidimensional variables of social functioning and to look for a possible classification based on an empirical classification outcome oriented. Design – Forthy chronic schizophrenic patients, with a diagnosis ascertained through clinical interview and diagnostic criteria were enrolled in the study. Setting – All patients were followed in a State Mental Health center and were assessed in a stabilized phase of illness. Principal outcome measures – Psychopathological assessment was made with PANSS and CGI. Psychosocial assessment was made with Life Skills Profile and Global Functioning Scale. Results – A pervasive correlation among symptoms and psychosocial variables emerged suggesting a unitary concept of behavior related to diagnosis. Factor analysis revealed 2 main components able to explain the 79% of variance. Cluster analysis separated the patients in 3 different groups showing that clinical symptoms are aggregated with specific variables of social functioning. Conclusion – Schizophrenic symptoms and social functioning are organized in a tripartite structure. It suggests the existence of three different syndromes that are outcome oriented, and compatible with an unitary concept of schizophrenia.

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.