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WHO declared that mental health care should be considered one essential health service to be maintained during the coronavirus disease 2019 (COVID-19) pandemic. This study aims to describe the effect of lockdown and restrictions due to the COVID-19 pandemic in Italy on mental health services’ utilisation, by considering psychiatric diagnoses and type of mental health contacts.
The study was conducted in the Verona catchment area, located in the Veneto region (northeastern Italy). For each patient, mental health contacts were grouped into: (1) outpatient care, (2) social and supportive interventions, (3) rehabilitation interventions, (4) multi-professional assessments, (5) day care. A ‘difference in differences’ approach was used: difference in the number of contacts between 2019 and 2020 on the weeks of lockdown and intermediate restrictions was compared with the same difference in weeks of no or reduced restrictions, and such difference was interpreted as the effect of restrictions. Both a global regression on all contacts and separate regressions for each type of service were performed and Incidence Rate Ratios (IRRs) were calculated.
In 2020, a significant reduction in the number of patients who had mental health contacts was found, both overall and for most of the patients’ characteristics considered (except for people aged 18–24 years for foreign-born population and for those with a diagnosis of schizophrenia. Moreover, in 2020 mental health contacts had a reduction of 57 096 (−33.9%) with respect to 2019; such difference remained significant across the various type of contacts considered, with rehabilitation interventions and day care showing the greatest reduction. Negative Binomial regressions displayed a statistically significant effect of lockdown, but not of intermediate restrictions, in terms of reduction in the number of contacts. The lockdown period was responsible of a 32.7% reduction (IRR 0.673; p-value <0.001) in the overall number of contacts. All type of mental health contacts showed a reduction ascribable to the lockdown, except social and supportive interventions.
Despite the access to community mental health care during the pandemic was overall reduced, the mental health system in the Verona catchment area was able to maintain support for more vulnerable and severely ill patients, by providing continuity of care and day-by-day support through social and supportive interventions.
Healthcare workers exposed to coronavirus 2019 (COVID-19) patients could be psychologically distressed. This study aims to assess the magnitude of psychological distress and associated factors among hospital staff during the COVID-19 pandemic in a large tertiary hospital located in north-east Italy.
All healthcare and administrative staff working in the Verona University Hospital (Veneto, Italy) during the COVID-19 pandemic were asked to complete a web-based survey from 21 April to 6 May 2020. Symptoms of post-traumatic distress, anxiety and depression were assessed, respectively, using the Impact of Event Scale (IES-R), the Self-rating Anxiety Scale (SAS) and the Patient Health Questionnaire (PHQ-9). Personal socio-demographic information and job characteristics were also collected, including gender, age, living condition, having pre-existing psychological problems, occupation, length of working experience, hospital unit (ICUs and sub-intensive COVID-19 units vs. non-COVID-19 units). A multivariable logistic regression analysis was performed to identify factors associated with each of the three mental health outcomes.
A total of 2195 healthcare workers (36.9% of the overall hospital staff) participated in the study. Of the participants, 35.7% were nurses, 24.3% other healthcare staff, 16.4% residents, 13.9% physicians and 9.7% administrative staff. Nine per cent of healthcare staff worked in ICUs, 8% in sub-intensive COVID-19 units and 7.6% in other front-line services, while the remaining staff worked in hospital units not directly engaged with COVID-19 patients. Overall, 63.2% of participants reported COVID-related traumatic experiences at work and 53.8% (95% CI 51.0%–56.6%) showed symptoms of post-traumatic distress; moreover, 50.1% (95% CI 47.9%–52.3%) showed symptoms of clinically relevant anxiety and 26.6% (95% CI 24.7%–28.5%) symptoms of at least moderate depression. Multivariable logistic regressions showed that women, nurses, healthcare workers directly engaged with COVID-19 patients and those with pre-existing psychological problems were at increased risk of psychopathological consequences of the pandemic.
The psychological impact of the COVID-19 pandemic on healthcare staff working in a highly burdened geographical of north-east Italy is relevant and to some extent greater than that reported in China. The study provides solid grounds to elaborate and implement interventions pertaining to psychology and occupational health.
Despite international guidelines, cognitive behavioural therapy for early psychosis (CBTep) is still under-used in daily clinical practice, mainly due to the lack of specific skills among mental health professionals. The aim of the study was to evaluate the feasibility and efficacy of a CBTep training course and to investigate the impact of trainees’ variables on the level of skills acquisition. An intensive and graded CBTep training programme consisting of 112 hours of plenary lectures, 30 hours of group supervision and 3 months of practical training was offered to mental health professionals of 65 Italian community Mental Health Centers (CMHCs). CBT expert psychologists were used as the comparison group. Participants underwent pre-planned exams to test the level of skills acquisition and were requested to complete a satisfaction survey. The vast majority of participants (93%) completed the training with medium–high evaluation scores and reported to be highly satisfied with the course. CMHCs staff members achieved high scores in the examinations and no major differences between them and CBT expert psychologists were found in most of the final exam scores. Our results support the feasibility and the efficacy of the training to build specific CBTep capacity in a large cohort of professionals working in Italian Generalist Mental Health Services.
Key learning aims
(1) To understand the capacity building of a short training programme in CBT for early psychosis dedicated to community mental health professionals.
(2) To consider the optimal characteristics of a CBT training programme for early psychosis.
(3) To reflect on the feasibility of a CBT training programme for early psychosis in the context of Italian Community Mental Health Services.
The quality of mental health services is crucial for the effectiveness and efficiency of mental healthcare systems, symptom reduction, and quality of life improvements in persons with mental illness. In recent years, particularly care coordination (i.e., the integration of care across different providers and treatment settings) has received increased attention and has been put into practice. Thus, we focused on care coordination in this update of a previous European Psychiatric Association (EPA) guidance on the quality of mental health services.
We conducted a systematic meta-review of systematic reviews, meta-analyses, and evidence-based clinical guidelines focusing on care coordination for persons with mental illness in three literature databases.
We identified 23 relevant documents covering the following topics: case management, integrated care, home treatment, crisis intervention services, transition from inpatient to outpatient care and vice versa, integrating general and mental healthcare, technology in care coordination and self-management, quality indicators, and economic evaluation. Based on the available evidence, we developed 15 recommendations for care coordination in European mental healthcare.
Although evidence is limited, some concepts of care coordination seem to improve the effectiveness and efficiency of mental health services and outcomes on patient level. Further evidence is needed to better understand the advantages and disadvantages of different care coordination models.
Issues of organisational structure and commitment, resource development, and clarity of roles and responsibilities must be addressed before proceeding with any attempt to implement evidence based interventions in a specific service.
Evidence suggests that the management of most mental disorders and especially of psychoses is frequently suboptimal. This trend might reflect instances of inadequate resource allocation, but might also reflect the effects of stigma, discrimination, and social exclusion that people with psychosis often experience. It might also indicate poor management of available resources or deficiencies in knowledge or practice.
Multi-element psychosocial interventions in the first 5 years from psychosis onset have proved to facilitating recovery and reducing long-term disability. However, most studies often do not test efficacy against a control group and have been conducted in non-epidemiologically representative samples. The presentation will be focussed on process of assessment of acceptability and discrepancies between evidence and clinical practice in the treatment of schizophrenia in community care.
Methods and Results
Trials - such as the GET UP Trial (National Coordinator: Mirella Ruggeri) that is part of the Strategic Research Programs of the Italian Government - that are being conducted in the routine practice and that aim to test the feasibility and cost-effectiveness of evidence-based psychosocial interventions will be presented and discussed.
Verify the barriers to application and situations when evidence-based interventions practice might be ineffective or inappropriate, understanding their advantages and limitations is a crucial challenge in the area of early psychosis treatment.
Social disability is a key outcome measure for severe mental illness, being a pivotal variable, that modulates the effectiveness of treatments and might be modified by the treatments themselves.
The aims of the studies presented were: 1) to determine changes overtime in symptoms and social disability in a 1 year treated prevalence cohort of subjects affected by psychosis vs. those affected by non psychotic disorder receiving community-based mental health care, and to explore 2) predictors of clinical and social outcome; 3) the effect of clinical course on disability and quality of life.
Three hundred fifty four patients treated in the South-Verona CMHS were followed-up over 6 years (with assessments made at baseline, at 2 and 6 years) by using a set of standardised measures exploring psychopathology (BPRS), social disability (WHO-DAS) and quality of life (LQoLP). GLLAMM models were used to explore longitudinal predictors of clinical and social outcome. The effect of clinical course on disability was explored by consulting retrospectively the clinical records.
In psychotic patients relationships with partners were more frequently severely impaired, followed by dysfunction in the occupational and parental role. Longitudinal analyses displayed a clinical and social outcome characterized by complex patterns of exacerbation and remission over time; however a clear trend towards a deteriorating course was not found, thus challenging the notion that psychotics are not fatally prone to a destiny of chronicity. Models explained 69% of the total variance for social disability. Predictors for disability were clearly differentiated from those for clinical status, but the two domains appeared entwined: the main clinical predictor of social disability was the negative component of psychotic symptoms (the higher negative symptoms, the lower social functioning) and higher disability predicted in turn a worsening of negative symptoms. Continuous course was associated with higher disability and lower quality of life.
Psychopathology and disability are distinct outcome domains only partially overlapping, which do not directly co-vary overtime and are influenced, at least in part, by separate predictors susceptible to specific interventions. However, they are entwined in a vicious cycle leading overtime to a progressive reciprocal worsening with deleterious effect on patients' daily living and independence. Modern mental health services should be capable of shaping treatments to address these patients' multifaceted problems.
To advance the quality of mental healthcare in Europe by developing guidance on implementing quality assurance.
We performed a systematic literature search on quality assurance in mental healthcare and the 522 retrieved documents were evaluated by two independent reviewers (B.J. and J.Z.). Based on these evaluations, evidence tables were generated. As it was found that these did not cover all areas of mental healthcare, supplementary hand searches were performed for selected additional areas. Based on these findings, fifteen graded recommendations were developed and consented by the authors. Review by the EPA Guidance Committee and EPA Board led to two additional recommendations (on immigrant mental healthcare and parity of mental and physical healthcare funding).
Although quality assurance (measures to keep a certain degree of quality), quality control and monitoring (applying quality indicators to the current degree of quality), and quality management (coordinated measures and activities with regard to quality) are conceptually distinct, in practice they are frequently used as if identical and hardly separable. There is a dearth of controlled trials addressing ways to optimize quality assurance in mental healthcare. Altogether, seventeen recommendations were developed addressing a range of aspects of quality assurance in mental healthcare, which appear usable across Europe. These were divided into recommendations about structures, processes and outcomes. Each recommendation was assigned to a hierarchical level of analysis (macro-, meso- and micro-level).
There was a lack of evidence retrievable by a systematic literature search about quality assurance of mental healthcare. Therefore, only after further topics and search had been added it was possible to develop recommendations with mostly medium evidence levels.
Evidence-based graded recommendations for quality assurance in mental healthcare were developed which should next be implemented and evaluated for feasibility and validity in some European countries. Due to the small evidence base identified corresponding to the practical obscurity of the concept and methods, a European research initiative is called for by the stakeholders represented in this Guidance to improve the educational, methodological and empirical basis for a future broad implementation of measures for quality assurance in European mental healthcare.
Pragmatic abilities play a crucial role in daily functioning and have been suggested to be impaired in schizophrenia. Nevertheless, patterns of such deficits at the onset of the illness still needs to be elucidated.
To outline pragmatic abilities in the first episode of psychosis (FEP).
To evaluate pragmatic verbal performance and its relationship with pre-frontal abilities in FEP subjects recruited in a large randomized multi-center controlled study (GET UP).
58 FEP (mean age±SD:34±9 years; 46% males) and 58 1:1 matched healthy controls (HC) were assessed on the metaphor and idiom comprehension subtask of the MEC Protocol and with WCST. A PAF Analysis with Promax rotation of open (=spontaneous explanations) and closed (=multiple choice) metaphors/idioms and WCST variables was conducted.
A 3-factor latent structure emerged in both groups but partially different patterns emerged. As for FEP, open metaphor/idiom explanations loaded into Factor 1 (Self-generated inferences); Factor 2 (Feedback-generated inferences) was loaded by WCST perseverative errors and by closed metaphor explanations. Finally, closed metaphors/idioms loaded into Factor 3 (Inhibition). As for HC, Factor 1 was similarly loaded but explained less variance; Factor 2 was qualitatively different (Reasoning, self+feedback-generated inferences), being loaded by the WCST number of categories and by open metaphors/idioms. Factor 3 was loaded by closed metaphors.
Findings suggest a shared underlying cognitive construct in self-generating perceptual inferences both for verbal pragmatics and pre-frontal skills in HC and patients, while a failure to integrate different sources of perceptual evidence is found only in FEP.
Vascular changes in the brain are relevant in schizophrenia [e.g. 1] and in bipolar disorder . The study of first episode psychosis (FEP) allows the analysis of brain morphology and function without confounds due to chronicity.
To characterize brain perfusion in FEP.
To see if FEP exhibit modified perfusion in respect to healthy controls (HC), and identify the most affected brain areas.
We acquired T1 and DSC images of 35 FEP patients (45 +/- 10 years old) and 35 HC (42 +/- 8), using Gadolinium (0.1 mmol/Kg). We computed cerebral blood volume (CBV), cerebral blood flow (CBF) and mean transit time (MTT)  in the whole brain and in left and right frontal, parietal, temporal and occipital lobes, insula, caudate and cerebellum
Mean values of all quantities resulted lower in patients, up to 12% for CBV in right frontal lobe, 11% for CBF in left cerebellum and 16% for MTT in right frontal lobe. We used a support vector machine (SVM) to classify subjects on the basis of the histogram of perfusion values. We found that the classification reached accuracies over 80%, especially in the frontal brain areas.
FEP show altered perfusion parameters, which allow automatic classification with good accuracy, showing that brain vascular characteristics can be considered as marker of psychosis.
 Peruzzo et al (2011). J Neural Transm, 118, 4:563-70.
 Agarwal et al (2008). J Affect Disord, 110, 1-2:106-14.
 Ostergaard et al (1996). Magn Reson Med, 36, 5:715-25.
The excess of psychosis among migrants and ethnic minorities is a well defined phenomenon in North Europe, while it should be still demonstrated in south Europe. Because of the variation in prevalence and distribution of risk factors in different national contexts, similar studies in different countries are needed to test the hypotheses and to ensure the generalizability of the findings. Moreover, available studies have been mostly focused on risk factors of psychosis during the post migration phase (such as ethnic fragmentation, unemployment, etc) and among well established ethnic minorities (second and further generations of migrants). In Italy, first generation migrants are still the larger component of the ethnic minorities’ populations and we can evaluate risk factors of psychosis related to the migration history as whole considered (pre-migration, migration and post migration phases). I will present results on risk factors of psychosis among first generations migrants in the three sites involved in the EU-GEI Project in Italy (Bologna, Palermo and Verona) (European Network of National Schizophrenia Networks Studying Gene Environment Interactions Project EU-GEI European Community's Seventh Framework Program, grant agreement No. HEALTH-F2-2009-241909). Particularly, I will discuss our efforts to understand the role of the migration process characteristics in the development of psychosis.
Anatomical alterations in the Superior Temporal Gyrus (STG) have been reported in schizophrenia. The STG is one of the most asymmetric and lateralized structure of the brain, and the process of lateralization seems to vary according to gender. Although it has been suggested that patients with schizophrenia do not show normal brain lateralization, only few studies investigated it in the STG considering the effects of sex.
The objective of this study is to evaluate sexual dimorphism in STG volumes in a sample of patients with schizophrenia compared to age-and sex-matched healthy controls.
Seventy-two right-hander males (40 schizophrenia patients and 32 controls) and 45 right-hander females (18 schizophrenia patients and 27 controls) underwent clinical evaluation and a 1.5 T MRI scan. Gray and white matter volumes of regions of interests within the STG were detected, including the Heschl's Gyrus (HG) and the planum temporale (PT).
Female patients with schizophrenia presented a reduction in left PT gray matter volumes (F = 4.58, P = 0.03) and a lack of the normal PT asymmetry index (t = 0.27; P = 0.79) compared to female controls (t = 5.47; P < 0.001). No differences were found between males for volumes or laterality. Also, in patients with schizophrenia STG gray and white volumes negatively correlated with positive symptoms (r = −0.33, P = 0.02 and r = −0.29, P = 0.03 respectively), whereas left PT gray matter volumes were negatively associated to duration of illness (r = −0.27, P = 0.04).
Sexual dimorphism plays a key role on PT in schizophrenia, underlying the importance of gender as a modulator of brain morphology and lateralization of schizophrenia.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Researches show that the period of migration, or the migration process itself, may confer an increased risk for psychosis. Some studies have addressed whether the high rates of psychosis found in migrants could be due to higher genetic or environmental risk factors. Facing severe or chronic stress such as trauma, social isolation, low socio-economic status, late-life social adversity may result in long term, sometimes permanent, alterations of the biological stress response system, leading to the onset of psychosis.
This study aims to examine, in a large sample of first episode psychosis patients, whether negative social experiences like stressful life events and difficulties, trauma and isolation have significantly higher frequencies in migrants with respect to natives.
The present study is conducted within the framework of the EUGEI (European Network of National Schizophrenia Networks Studying Gene Environment Interactions) study, a Europe-wide incidence and case–control study of psychosis conducted in 12 centers chosen to include areas with large first and subsequent generation migrant populations.
Data about age, gender, migration history, trauma, life events, ethnicity, social class and family history of mental disorders have been collected.
Preliminary data on the relationship between trauma and migration in first episode psychosis will be presented.
Since migration is an important stressful life event, and difficulties in integration in host countries may remain chronic, it is important to identify in each context the most vulnerable minority groups in order to implement targeted prevention interventions.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
In Italy, considerable variations exist in the organisation of out- and in-patient mental health care. One main issue is whether to prioritise specialisation (distinct clinicians for inpatient and outpatient care) or personal continuity of care (same primary clinician for a given patient within the two settings).
To study the use of psychiatric in-patient units in the Veneto region (Italy) and to evaluate differences between personal continuity of care and specialization systems.
Study conducted in the context of the COFI, multisite naturalistic EU-funded research aiming to compare the two care approaches in 5 European countries. In Italy, baseline data collection was carried out in 14 in-patient units. Data on hospitalisation, diagnosis, severity of the illness (Clinical Global Impression Scale- CGI) and patients’ appraisal of inpatient care (Client Assessment of Treatment Scale- CAT) were collected.
Overall, 1118 patients were assessed. Most frequent diagnostic categories were mood (41.6%) and psychotic (38.3%) disorders, while anxiety disorders were less represented (11.9%). The majority of patients were at least at their second admission (69.4%) and had been voluntary admitted (91.5%). Length of stay and CGI scores were significantly higher for patients with mood and psychotic disorders. No difference in CGI score between the two systems was found. Patients in the continuity of care systems reported higher level of satisfaction with initial treatment and longer hospital stay (P < .001).
These preliminary findings suggest higher service satisfaction for personal continuity system, possibly reflecting a more individualised and comprehensive focus on the patient's needs, rather than on symptoms reduction only.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Although some magnetic resonance imaging (MRI) studies have investigated the existence of a relationship between clinical severity and neuroanatomical alterations in patients with schizophrenia (SCZ), the biological signature associated with illness severity in schizophrenia is still uncertain.
This study aims to investigate structural brain abnormalities in SCZ with particular regards to the identification of potential deficits associated to the severity of illness.
1.5 T MRI data were acquired for 61 subjects with SCZ and 59 matched healthy controls (HC). The patient group was divided in two subgroups based on clinical severity, one composed by 34 mild-to-moderately ill patients and the other one by 27 severely ill patients, and compared with matched HC.
The whole group of patients with SCZ had significantly reduced gray matter (GM) volumes in left inferior and middle temporal gyrus compared to HC (P < 0.05, pFWE corrected). Furthermore, compared to HC, patients with mild-to-moderate illness showed decreased GM volumes in inferior temporal gyrus (P < 0.05, pFWE corrected) whereas those with severe illness had reduced right cerebellum (P < 0.05, cFWE corrected). No differences were observed between the two subgroups of patients.
Our results showed significant GM volume reductions in left inferior and middle temporal gyrus in patients with SCZ compared to matched HC, confirming the role of this region in the pathophysiology of SCZ. Furthermore, we identified specific cerebellar gray matter volume reductions in patients with severe illness, which may contribute to stratify patients with SCZ according to their clinical phenotype expression, ultimately helping in guiding targeted therapeutic/rehabilitation interventions.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
International treatment guidelines recommend that key elements to reduce the burden of psychosis are the early identification of people and the adoption of specific evidence based interventions.
To investigate the pathway to care and patterns of interventions provided by community based-mental health services (CMHS) to a cohort of first-episode psychosis (FEP) patients over 5-years period, exploring in which degree guidelines are met in routine clinical practice.
Study conducted in the context of the Psychosis Incident Cohort Outcome Study (PICOS), a multisite naturalistic research conducted in the Veneto Region (Italy) on FEP patients in a 4.6 million inhabitants catchment area. A comprehensive set of standardized measures was used, including ad hoc schedules to collect information on referrals to psychiatric services and on pharmacological and psycho-social treatments according to a multiwave follow-up design (1-, 2- and 5 years).
Three hundred and ninety-seven FEP patients were assessed at BL, 286 at 1 year, 233 at 2 years and 205 at 5 years. 47.4% of patients were helped to seek care by a relative and more than one half entered the treatment route through an emergency access. Regarding the interventions received, 96% of patients had been prescribed neuroleptics and atypical were the most prescribed class (66.9%). Only half received a psychosocial intervention during the first year and this percentage progressively decreased at each FU.
Findings highlight discrepancies between interventions provided by CMHS and the best treatment options recommended by guidelines, suggesting the need to implement specific initiatives aiming to close the gap between research and clinical practice.
First-episode psychosis (FEP) is a major life event and can have an adverse impact on the diagnosed individual and their families. The importance of intervening early and providing optimal treatments is widely acknowledged. In comparison to patient groups, literature is scarce on identifying treatment predictors and moderators of caregiver outcomes. This study aimed to identify pre-treatment characteristics predicting and/or moderating carer outcomes, based on data from a multi-element psychosocial intervention to FEP patients and carers (GET-UP PIANO trial).
Carer demography, type of family relationship, patient contact hours, pre-treatment carer burden, patient perceptions of parental caregiving and expressed emotion (EE) were selected, a priori, as potential predictors/moderators of carer burden and emotional distress at 9 months post treatment. Outcomes were analysed separately in mixed-effects random regression models.
Analyses were performed on 260 carers. Only patient perceptions of early maternal criticism predicted reports of lower carer burden at follow-up. However, multiple imputation analysis failed to confirm this result. For treatment moderators: higher levels of carer burden at baseline yielded greater reductions in carer emotional distress at follow-up in the experimental group compared with treatment as usual (TAU). Higher levels of perceived EE moderated greater reductions in carer reports of tension in experimental group, compared with TAU, at follow-up. In younger caregivers (<51 years old), there were greater reductions in levels of worry during the baseline to follow-up period, within the experimental group compared with TAU.
The study failed to identify significant treatment predictors of FEP carer outcomes. However, our preliminary findings suggest that optimal treatment outcomes for carers at first episode might be moderated by younger carer age, and carers reporting higher baseline levels of burden, and where patients perceive higher levels of negative effect from caregivers.
In this study, we describe the results of virological investigations carried out on cases of gastroenteritis reported in different communities within a 2-year pilot surveillance programme (January 2012 to December 2013) in the autonomous province of Bolzano (Northern Italy). Among the 162 norovirus (NoV)-positive cases out of 702 cases investigated, 76 were grouped in nine suspected outbreaks, 37 were hospital-acquired and 49 were community-acquired sporadic cases. NoV infections were found in all age groups in outbreak and community-acquired cases, while the highest peak of hospital-acquired infections occurred in the elderly. Sequence analyses helped to identify suspected outbreaks both in the community and in hospital wards. Although GII.4 is the predominant genotype, sequence data confirmed that at least seven genotypes circulate causing sporadic cases. Findings in this study confirmed the relevance of NoV infections as a cause of outbreaks, and impact of NoV infections in community-acquired sporadic cases in adults that are rarely described because of a lack of reporting.