England has set an evidence based mental health strategy which encompasses where and how people are cared for and with what aims and goals in view. It has ensured that policy is well rooted in the known epidemiology of mental disorders, that policy does not only focus on those with severe mental disorders who need specific care, but also on those with less severe disorders in primary care, in the workplace and in prisons, and also on the integration and interface of mental health services with other agencies. It has also rooted policy within a coherent framework of prevention mental health promotion, primary, secondary and tertiary prevention and prevention of mortality), and is driving that policy by measuring health outcomes as well as inputs and processes.

Objective – To describe the trends over time of mental outpatient contacts in the Region Lazio. Design – Descriptive study. Setting – The data are based on information routinely collected by 21 mental health outpatient services during 1989–1992 period. Main outcome measures – Frequency distributions and prevalence and incidence rates. Results – Prevalence and incidence rates of psychiatric patients in treatment have been increasing in the study period. The one–year prevalence rate (per 100.000 residents) was 900 in 1989 and 1020 in 1992, with 13% increase. The incidence and point prevalence rates have increased, from 517 and 410 in 1989 to 564 and 540 in 1992 respectively. Initial diagnostic assessment was the most frequent activity performed during the first contact, accounting for about 55% of total performances. During one year, 25% of patients terminated the treatment with a dropout rate of almost 75%. In 1992, 28% of psychiatric patients terminated the treatment with a diagnosis of neurotic disorders and 69% with a diagnosis of psychotic disorders; a large number of patient terminated the treatment without any diagnosis. Conclusions – The observed increase of prevalence and incidence rates may be due to a number of factors, notably, an increase in true prevalence rates in the study area, more efficient treatment practices and an improvement in the coverage of the information system. The high rate of dropouts points to the need to evaluate the interaction between treatment settings and patient characteristics.

Aims — Monitoring of a community mental health service is presented, aimed at describing patients' demographic and clinical characteristics, pathways to care and decision—making process for the first contacts, distribution of interventions according to diagnoses, patterns of service utilization, and finally variables associated with intensity and duration of care, testing the hypothesis that high and long—term users are the most disadvantaged patients with regard to social and clinical variables. Design — Observational study, based upon first year implementation of the local informative system. Setting — Community Mental Health Service, San Giorgio di Piano, Bologna, Italy. Main outcome measures — The relative risk of being a high long—term user was computed for some socio—demographic and clinical variables against the reference category, i.e. the most favoured group. Confounding effects between social and clinical variables were controlled using stratified analysis. Results — Crude rates are presented for one—day prevalence (635.4/100.000 adult inhabitants) and one—year prevalence (1314.1/100.000). Among patients in contact with service at census day schizophrenic— type psychoses are prevailing, while patients coming for treatment in 1993 have more frequently organic psychoses and neurotic disorders. After the first contact 50% of patients are not taken in care; decision seems to be based on diagnosis and not connected with past psychiatric history or socio—demographic characteristics. Forty—nine per cent of outpatient care is delivered to 20% schizophrenic—type psychoses; moreover, this group of patients is seen to receive a wider range of interventions. Inpatient care is rare even for the most serious diagnoses; the global ratio between nonhospitalized and hospitalized users is 12.5 to 1. Factors significantly associated with long-term high user outcome are: being under 55 years old, unmarried status, living alone or without family, having functional psychosis, and having been long-term patient in 1992. Conclusions ‖ Consistently with the local guidelines for mental health care, service's resources are mainly devoted to most seriously ill patients. Evidence is shown for a strong community tenure and for a higher proportion of long-term users than in other Italian services. The hypothesis that high and long-term users are more disadvantaged is confirmed, even if no significant outcome difference is seen according to sex, educational level and occupational status.

Objective – The QUALYOP study has three objectives: 1) To describe both structural resources and organizational procedures of the 12 Psychiatric Hospitals and to assess the rate of decline in the number of in-patients; 2) to assess the quality of structures, organizational procedures and activities delivered by the hospitals; 3) to describe the socio-demographic, clinical and disability characteristics of the in-patient population. Data regarding this third objective will be presented in a future paper. Design – A transectional design has been adopted. The 12 Psychiatric Hospitals have been visited between July and November 1994. Administrative informations have been collected using an ‘Hospital Form’, filled up by the director of each Hospital; an ‘Hospital Ward Form’, filled up by a group of trained researchers, was adopted to evaluate the quality of each Hospital Ward. A reportage of the structural aspects of the hospitals has also been performed by a professional photographer. Setting – The 12 former Psychiatric Hospitals of Regione Lombardia (Bergamo, Brescia, Castiglione delle Stiviere, Codogno, Como, Cremona, Limbiate, Mantova, Milano, Sondrio, Varese, Voghera). Main outcome measures ‖ We utilized a set of indicators to evaluate the following three dimensions: human and logistic resources, organizational procedures, psychosocial rehabilitation activities. The quality of care has been judged in comparison with explicit reference criteria. Results ‖ 2752 patients are sheltered in the 12 Psychiatric Hospitals of Regione Lombardia. The quality assessment phase of the study has revealed that structures are inadequate in the majority of the wards (70%). In addition, in more than 70% of the wards procedures and rehabilitation activities aiming at decreasing the disability of patients have not been activated. Conclusions ‖ A low degree of consistency between avaliable structures and quality standards has been evidentiated. In addition, soft indicators have documented the inadequacy of organization procedures and activities. These results demonstrated that the dehospitalization policies are often inadequate and that educational policies are warranted to train and motivate mental health professionals. It has been also demonstrated the feasibility of Quality Assurance studies which use a system of reference criteria derived from reliable clinical studies, ethical values, experience, definition of ‘not admissible events’ and common sense.