Обсуждение:Психиатрическая реформа в Италии

Неясно, что делается с опасными больными

Как решаются проблемы с острыми агрессивными приступами (состояниям)? И что насчет псих-больниц для лиц опасных для окружающих? Т.е. лиц, совершивших преступления, но признанных невменяемыми, притом что нет уверенности в отсутствии у них рецидива (точнее, обычно серьезен риск обязательного наступления рецидива). AntonMih 14:36, 28 июля 2011 (UTC)

Ответ на Ваш вопрос содержится в статье Закон Базальи:

Итальянское законодательство делит психиатрическую помощь на два вида: в качестве кредита доверия оно предоставляет законопослушным лицам, страдающим психическими расстройствами, право отказаться от лечения и делает невозможными все дальнейшие госпитализации таких психически больных пациентов; в то же самое время оно позволяет помещать психически больных людей, нарушающих закон, в специализированные учреждения по приговору к тюремному заключению с нефиксированным сроком, в результате чего они лишаются всех гражданских прав.

Как следует из статьи о психиатрической реформы (и Вы могли это заметить, её читая), понятие социальной опасности уже не связывается автоматически с понятием психического заболевания. V for Vendetta 16:17, 28 июля 2011 (UTC)

Источники

Ниже будут приводиться источники, доступные в сети только после оплаты или регистрации и предназначенные для последующего использования в статье. Psychiatrick 01:01, 26 августа 2010 (UTC)

Источники

Discharges of patients from public psychiatric hospitals in Italy between 1994 and 2000

D’Avanzo B., Barbato A., Barbui C., et al.

ABSTRACT
Background: Psychiatric hospitals in Italy had to be closed under a law dated 1994.
Aims: To investigate the discharge of patients from public psychiatric hospitals.
Methods: A total of 4492 patients from 22 psychiatric hospitals were described at recruitment and followed during the period 1994-2000. Their characteristics were investigated as determinants of discharge to community residential facilities for psychiatric patients versus other settings.
Results: All 22 psychiatric hospitals closed between 1994 and 2000; 678 patients had died, and the remainder were discharged. Of these, 39% went to nursing homes, 29% to community residential facilities for psychiatric patients, 2% joined their family, less than 1% were settled in private independent accommodation, and 29% remained in the psychiatric hospital, although defined as discharged. Ten patients were recorded as missing when still in the psychiatric hospitals, none after discharge. Younger, more educated patients and patients from two of the four regions studied were more likely to be discharged to community residential facilities.
Conclusions: The majority of patients were discharged to highly supervised settings. The potential risk of abandonment due to deinstitutionalization was not observed in this population. The wide use of highly supervised settings can be explained by the patients' old age, but different local policies may have affected the discharge process.

INTRODUCTION

The number of residents in public psychiatric hospitals in Italy has been declining since 1965. The downsizing of psychiatric hospitals was speeded up by a prohibition on new admissions (under Law 180 issued in 1978), but few long-stay patients were discharged, few psychiatric hospitals were closed and the number of residents mainly dropped because of deaths (De Salvia & Barbato, 1993).

At the end of 1994, a law was passed obliging all psychiatric hospitals to be closed down (De Girolamo & Cozza, 2000). About 20,000 patients were still resident in those hospitals (Istituto Nazionale di Statistica, 1996). Since then, other laws have specified how the psychiatric hospital closure was to be achieved. Facilities in the psychiatric hospital areas could be used for the residential care of geriatric and mentally retarded patients, but these facilities had to belong to social services and be run by them. The psychiatric hospitals were required to plan discharges and to use or create community residential facilities for psychiatric patients.

Between 1995 and 2000, the 67 psychiatric hospitals still open in 1994 closed. In order to monitor the fate of patients and to assess what facilities were used for discharges, we conducted a prospective study, the Qualyop Project, in a sample of Italian psychiatric hospitals, assessing:

1. how many patients died while still resident in the psychiatric hospitals;
2. the placements of all discharged patients; and
3. since we assumed discharge to community residential facilities as an indicator of the psychiatric services' efforts at rehabilitation and integration of patients into the community, we identified the determinants of the probability of discharge to community residential facilities rather than to any other setting, on the basis of patients' characteristics at recruitment.

The regions involved were Lombardy (12 psychiatric hospitals), Liguria (two) and Emilia-Romagna (seven) in the North, and Lazio (the psychiatric hospital of Rome) in Central Italy. The characteristics of the psychiatric hospitals, in terms of quality of facilities, organization and activities in the wards, have already been described, as have the features of the 4492 patients at baseline (Frattura & D'Avanzo, 1998; Barbui et al., 1999; D'Avanzo et al., 1999), and mortality (D'Avanzo et al., in press).

METHODS

The recruitment phase of the Qualyop Project started in 1994 and the follow-up finished on discharge of each patient. The whole sample resident in the 22 psychiatric hospitals consisted of 4492 patients.

At recruitment, patients were described with regard to socio-demographic characteristics, clinical characteristics and history, autonomy in daily life activities, social support, work, psychopharmacotherapy, and physical health (Barbui et al., 1999; D'Avanzo et al., 1999).

Information was collected by means of an ad hoc questionnaire completed by the psychiatrist or head nurse of the ward. The questionnaire was presented and explained to the staff of each psychiatric hospital, in order to obtain standardized and homogeneous answers. Diagnosis was asked about according to the Tenth International Classification of Diseases (ICD X), behavioural problems were asked about by means of a checklist investigating attempts to escape, autolesionism, aggressive behaviour with people, disruptive behaviour against objects, suicide risk, and alcohol abuse.

Social support was derived from a more complex item, in which the care provider had to score the collaboration of relatives, friends or volunteers with the staff in any plan for the patient. Autonomy in daily life was derived from items measuring ability to wash, dress and eat by him/herself (complete autonomy); able but needing to be pushed, some help necessary (partial); substantial help necessary (absent).

Discharges and deaths of patients after recruitment were recorded on a 'Discharge/Death Form', showing the date of discharge and the new placement, or the date and cause of death. The cause was defined as natural or non-natural (suicide, homicide, accident), and had to be taken from the form sent to the National Institute of Statistics.

Discharged patients were classified into the following placement groups: 1) facility inside a psychiatric hospital; 2) nursing home; 3) community residential facility for psychiatric patients; 4) family; 5) on their own; and 6) other or unknown placement (including 'missing' patients, i.e. those who went out by themselves and never came back). The 'nursing home' group included any institution where patients could be housed for long stays, highly assisted and with full medical cover. Community residential facilities for psychiatric patients are group homes with a therapeutic/rehabilitative purpose and different levels of supervision and staff presence (< 8 hours a day, ≥ 8 to < 24, 24 hours) (Decreto del Presidente della Repubblica, 1999). They basically correspond to the definition of 'supported housing' given by Trieman (1997).

In the analysis we estimated the probability of discharge to community residential facilities rather than to any other setting, according to various factors. To do this, we computed odds ratios (OR) with 95% confidence intervals (CI), by means of a logistic regression. The equation included terms for sex, age (< 40, 40-49, 50-59, 60-69, ≥ 70 years), diagnosis (schizophrenia, personality disorders, affective disorders, alcohol abuse, mental retardation, organic mental disorders, according to the ICD X), educational level (illiterate, read and write, elementary school, more than elementary schooling), number of behavioural problems (0, 1, ≥ 2), degree of autonomy in daily life activities (absent, partial, complete), social support (adequate and almost adequate versus absent or inadequate) and region (Lombardy, Emilia-Romagna, Liguria, Lazio). Therefore, the OR estimates displayed in Table 1 in the 'Results' section were mutually adjusted for all the factors presented.

A subsample of 2918 patients was followed also after first discharge from the psychiatric hospital: these patients were those from the 12 psychiatric hospitals (10 in Lombardy and two in Liguria) which remained in strict contact with the discharged patients for a sufficient length of time, thus assuring a good quality of data collection about patients' movements from one facility to another.

RESULTS

The 22 psychiatric hospitals recruited in the study housed only long-stay patients. At recruitment, the 4492 patients showed a mean length of stay of 30 years, and 49% had been in the psychiatric hospitals for 30 years or more; mean age was 61 years, 55% were males, 51 % had a diagnosis of schizophrenia and 26% of mental retardation; 35% were not autonomous in daily life activities.

Between 1994 and 2000 all 22 psychiatric hospitals closed. Seventy-five percent of discharges were made in a two-year period. A total of 678 patients had died, for 24 we had no information, and 3790 were discharged. Among the latter, nearly 30%, although considered discharged, actually remained inside the psychiatric hospitals, and 39% were discharged to nursing homes; another 29% went to community residential facilities for psychiatric patients. In most cases, the facilities inside the psychiatric hospitals were run by social services and hosted geriatric and mentally retarded patients.

Ten patients were recorded as missing (i.e. they went out alone and never came back) when still resident in the psychiatric hospitals and were classified as discharged to an unknown place. No patient was recorded as missing after discharge from psychiatric hospital.

A subsample of 2918 patients were followed after the first discharge from psychiatric hospital and until 30 June 2000. Of these, 336 (14%) had moved from the first placement after discharge and 44 moved more than once. Most moves were to nursing homes, from one nursing home to another or from one community residential facility to another. Thus, in this subsample, a total of 656 patients were referred to community residential facilities; these patients could also be divided according to the level of supervision of the facility: 57% were referred to highly supervised facilities, 11 % to medium and 13% to low supervision ones.

The determinants of discharge to community residential facilities or any other setting are shown in Table 1. The probability of being placed in a community residential setting was associated with younger age, higher educational level, a diagnosis of schizophrenia, complete or sufficient autonomy in daily life activities, and, compared to Lombardy, it was half in Liguria and double in Emilia-Romagna and Rome.

DISCUSSION

The main findings of this study are the large proportion of psychiatric hospital patients who were moved to non-psychiatric services for chronic long-stay patients, the widespread use of facilities inside the former psychiatric hospitals, and the marked difference in discharge setting by region.

The facilities for old and mentally retarded people or people with organic mental disorders do not aim at rehabilitating and discharging them, and are meant to provide life-long assistance. The law allowed the use of psychiatric hospital facilities run by social services for the care of geriatric and mentally retarded patients, but forbade it for psychiatric cases. Nonetheless, a few facilities for psychiatric patients were located inside the psychiatric hospital areas: in some cases they provided temporary accommodation and hosted patients scheduled to be moved out to community residential facilities for psychiatric patients supposed to be ready in a short time.

Very few patients moved to their own or their family's home. This confirms that discharges to the 'community' were mainly to other staffed settings. The limited proportion of patients who were moved from their first placement after discharge to another placement suggests that discharges had been carefully planned.

Thirty percent of patients moved to community residential facilities for psychiatric patients. These facilities are designed to have a therapeutic and rehabilitative approach and mission, should not be used to accommodate patients for long periods or permanently, and should be strictly integrated with community psychiatry and social services and other resources in the community to provide recreational activities, social relationships, accommodation and occupation. They should not mimic the psychiatric hospitals' style of care (Decreto del Presidente della Repubblica, 1999). For this reason, we took discharges to community residential facilities for psychiatric patients as the outcome variable for analysis of the determinants of discharge.

In a study aimed at defining the amount and the main features of these facilities in Italy, it emerged that half have been set up since 1998, corresponding with the closure of psychiatric hospitals, and that nationwide patients discharged from psychiatric hospitals account for about 40% of the residents of these facilities (De Girolamo et al., 2002). Since most patients coming from psychiatric hospitals are unlikely to be discharged in the next few months or even years, the beds in these facilities will probably be filled by them, and may prove insufficient for patients from the community.

The use of various types or facilities for discharge of patients differed across regions. Compared with the other regions, Liguria made much more limited use of community residential facilities. The high comparability of the characteristics of patients of psychiatric hospitals in the various regions (D'Avanzo et al., 1999) suggests that discharges were influenced only partly by the patients' clinical features, and more by the availability of facilities and by psychiatric service policies in the different areas.

In this study, social support did not emerge as a determinant of discharge to community residential facilities for psychiatric patients. This may be due to the inadequacy of support from families or other key persons once patients were no longer confined in the psychiatric hospital, thus requiring more collaboration and support, and to the limited ability of services to engage the carer when planning the discharge to the community. We cannot rule out, anyway, some unreliability of the information collected.

Also numbers of behavioural problems lack predictive power in our analysis of determinants of discharge. This effect may be true and indicate that the choice of setting for patients' discharges was not influenced by the presence of behavioural problems or, alternatively, that some misclassification was present in data collection. Autonomy in daily life activities showed a stronger association with probability of discharge to community residential facilities, probably because it better discriminated between patients. Nonetheless, 62% of those defined as completely autonomous were not discharged to community residential facilities, underlining that even this indicator explains only part of the mechanisms through which discharges were determined, and that characteristics of patients were less influential than characteristics of the organization and resources of services. It should also be remembered that the score of 'complete autonomy' given to some patients corresponded only to a relative level of autonomy, since it pertained to very basic abilities, like eating and washing and dressing themselves, which would not be enough to place some patients in community residential facilities.

Other studies which evaluated the closure of psychiatric hospitals have described similar pictures. In a follow-up study in Australia (Andrews et al., 1990), large proportions of patients were in group homes (61%) and private accommodation (11%), with more limited numbers in nursing homes (8%). In the TAPS Project (Trieman et al., 1999), which excluded patients over 65 with a diagnosis of dementia, 78% of patients went to residential staffed homes, 7% to unstaffed group homes, 11% on their own, and 4% to their family.

In a Canadian study (Lesage et al., 2000) on the closure of one large public psychiatric hospital, 23% of patients were placed in nursing homes, 54% in other highly supervised settings, 10% in psychiatric or forensic hospitals, 4% in low supervised apartments, and 8% on their own or with the family; two patients were probably vagrant.

In Finland (Räsänen et al., 2000), 29% of the 253 patients followed after discharge from psychiatric hospitals were in other psychiatric hospitals at the end of follow-up, 28% were in supported houses with no staff or only daytime staff, 13% were on their own or with the family, 8% were in nursing homes, and none was missing or vagrant.

Direct comparison of these findings with those of the present study is difficult for two reasons: in some cases, diagnosis, age, length of stay in the psychiatric hospital and level of autonomy or physical health were not comparable, and definitions of facilities tended to differ across studies and countries. In this population, periods of stay in psychiatric hospitals were longer, and there was a greater proportion of mentally retarded patients and patients with dementia.

The weaknesses of this study are those of a naturalistic one. In particular, the observation periods in the various regions were different. Although the law providing for closure was issued in 1994, the process actually started in 1996; we could therefore monitor it from its beginning and the different periods of observation should not have affected our findings and their comparability among psychiatric hospitals and regions.

Moreover, no standard instruments were used to measure clinical characteristics at baseline. Although this raises some concern about comparability with reports of other similar populations, we chose to measure a patient's level of autonomy, behavioural problems and social support as directly perceived by the staff who were in charge of the patient. Standard instruments, given the time necessary to learn how to use them and to administer them, could not be applied in such a large sample, which was about a third of the population resident in Italian psychiatric hospitals when the study started; to our knowledge, this is in fact the largest sample of psychiatric hospital patients ever described and followed up.

CONCLUSION

On the whole, the psychiatric hospital closure process moved patients to highly staffed, smaller settings. The risk of abandonment that deinstitutionalization suggested was not observed. Although the widespread use of highly supervised institutional settings for chronic and geriatric patients can be explained by the old age of many patients, different regional policies are likely to have affected the process of discharge.

The psychiatric hospitals seem to have been replaced only partly by community residential facilities for psychiatric patients, in which rehabilitation, reduction of disability and integration into the community should be the main objectives. The closure of psychiatric hospitals was an important step on the way to deinstitutionalization. Evaluation of the process must, however, take into account the quality of care delivered in the facilities where patients were placed. It should be assessed whether the highly supervised settings of most of the community residential facilities for psychiatric patients provide adequate means of rehabilitation, and the extent to which community integration of at least the better-functioning patients is accomplished (Dewees et al., 1996). Quality of care, quality of life and satisfaction of patients in nursing homes also need to be verified.

ACKNOWLEDGEMENTS

The Qualyop Project was supported by a grant from the Istituto Superiore di Sanità (contract no. 96/Q/T/25). The Qualyop Project was possible thanks to the work of the monitors of the 22 psychiatric hospitals: S. Bellingeri (Colorno), C. Bellotti (Como), M. Biza (Bergamo), O. Brunelli (Brescia), P. Ciliberti (Quarto), C. Cuscini (Budrio), F. Ferraresi (Ferrara), P. Gabriele (Quarto), A. Galassi (Imola), G. Gozzo (Varese), E. Jori (Mantova), D. Lam-pugnani (Limbiate), L. Maccioni (Cogoleto), M. Mastrolorenzo (Como), L. Mauri (Reggio Emilia), G. Mezzadri (Piacenza), E. Monzani (Milano), A. Novelli (Codogno), L. Piaggi (Voghera), G. Santamaria (Sondrio), T. Sebastiani (Cogoleto), L. Serena (Cremona), S. Simmi (Roma), M. Vantini (Castiglione delle Stiviere), M. Zuffi (Bologna).

— D’Avanzo B., Barbato A., Barbui C.; et al. (2003). "Discharges of patients from public psychiatric hospitals in Italy between 1994 and 2000" (PDF). The International Journal of Social Psychiatry. 49 (no.1): 27—34. doi:10.1177/002076400304900104. {{cite journal}}: |issue= имеет лишний текст (справка); Неизвестный параметр |month= игнорируется (справка); Явное указание et al. в: |author= (справка)Википедия:Обслуживание CS1 (множественные имена: authors list) (ссылка)

References

ANDREWS, G., TEESSON, M., STEWART, G. & HOULT, J. (1990) Follow-up of community placement of the chronic mentally ill in New South Wales. Hospital and Community Psychiatry, 41, 184—188.
BARBUI, C., D'AVANZO, B., FRATTURA, L. & SARACENO, B. (1999) The Qualyop Project 2: monitoring the dismantling of Italian psychiatric hospitals. Psychotropic drug use in 1072 inpatients. Pharmacoepidemiology and Drug Safety, 8, 331—337.
D'AVANZO, B., FRATTURA, L., BARBUI, C. et al. (1999) The Qualyop Project 1: monitoring the dismantlement of Italian public psychiatric hospitals. Characteristics of patients scheduled for discharge. International Journal of Social Psychiatry, 45, 72—92.
D'AVANZO, B., LA VECCHIA, C. & NEGRI, E. (in press) Mortality in long-stay patients in psychiatric hospitals in Italy. Results from the Qualyop Project. Social Psychiatry and Psychiatric Epidemiology.
DE GIROLAMO, G. & COZZA, M. (2000) The Italian psychiatric reform. A 20-year perspective. International Journal of Law and Psychiatry, 23, 197—214.
DE GIROLAMO, G., PICARDI, A., MICCIOLO, R. et al. (2002) Residential care in Italy. British Journal of Psychiatry, 181, 220—225.
DE SALVIA, D. & BARBATO, A. (1993) Recent trends in mental health services in Italy: an analysis of national and local data. Canadian Journal of Psychiatry, 38, 195—202.
DECRETO DEL PRESIDENTE DELLA REPUBBLICA, PROGETTO OBIETTIVO 'TUTELA DELLA SALUTE MENTALE' (1999) Gazzetta Ufficiale della Repubblica Italiana, 274, Rome.
DEWEES, M., PULICE, R.T. & MCCORMICK, L.L. (1996) Community integration of former State hospital patients: outcomes of a policy shift in Vermont. Psychiatric Services, 47, 1088—1092.
FRATTURA, L. & D'AVANZO, B. (1998) Monitoring the Italian psychiatric hospitals closure process: the Qualyop Project. Mental Health Care, 10, 334—336.
ISTITUTO NAZIONALE DI STATISTICA (1996) Statistiche della Sanità. Anno 1994, Rome: ISTAT.
LESAGE, A., MORISSETTE, R., FORTIER, L. et al. (2000) Downsizing psychiatric hospitals: needs for care and services of current and dicharged long-stay patients. Canadian Journal of Psychiatry, 45, 526—531.
RÄSÄNEN, S., HAKKO, H., HERVA, A. et al. (2000) Community placement of long-stay psychiatric patients in Northen Finland. Psychiatric Services, 51, 383—385.
TRIEMAN, N. (1997) Residential care for the mentally ill in the community. In Care in the Community. Illusion or Reality? (ed. J. Left). Chichester: John Wiley and Sons.

TRIEMAN, N., LEFF, J. & GLOVER, G. (1999) Outcome of long-stay psychiatric patients resettled in the community: prospective cohort study. British Medical Journal, 319, 13—16.

Thirtieth birthday of the Italian psychiatric reform: research for identifying its active ingredients is urgently needed

Barbui C., Tansella M.

In 2008 Italian psychiatry celebrates 30 years since the passing of Italian Law Number 180, the reform law that marked the phasing out of psychiatric hospitals and the gradual development of a community-based system of psychiatric care. After 30 years of implementation, Law 180 is still unique in the international scenario, considering that Italy remains the only country in the world where traditional mental hospitals are outside of the law.

Italian psychiatric reform has been criticised over the years, and it is still difficult to make a fair judgement. It is nevertheless possible, after 30 years, to highlight the main long-term consequences of its implementation in terms of psychiatric resource availability and use. The first consequence of Law 180 is that patients who were living in psychiatric hospitals before 1978 were placed progressively into the community. From 1978 to 1987 the inpatient population dropped by 53% and the final dismantling of psychiatric hospitals had been completed by 2000. A second consequence is that the availability of psychiatric beds in Italy is lower than in other comparable countries. For every 100 000 inhabitants Italy has 46 psychiatric beds, compared with 58 in the UK and 77 in the USA. In terms of mental health professionals, for every 100 000 inhabitants Italy has a number of psychiatrists similar to the UK (9.8 vs 11, respectively), but substantially fewer psychiatric nurses (32.9 vs 104), psychologists (3.2 versus 9) and social workers (6.4 vs 58).

Clearly, the impact of these differences in terms of patient outcomes is difficult to quantify. In England a decrease in psychiatric beds has been suggested as one explanation of the rise in both the absolute number and the proportion of compulsory admissions. In Italy the proportion of all admissions that were compulsory decreased between 1979 and 1997, and in 2004 there were 18 compulsory admissions per 100 000 inhabitants. In other European countries the situation is very heterogeneous, with rates ranging from 6 per 100 000 in Portugal to 218 per 100 000 in Finland. In terms of suicides, according to World Health Organization data, Italy has rates similar to the UK and lower than Spain, Germany and the USA (who.int/topics/suicide/en). Finally, in terms of psychotropic drug use, in 2004 there were nearly 4 people per 1000 of the population who received a standard dose of antipsychotic drug daily. This indicates an overall lower use in Italy than in other countries.

In general, these indicators highlight that “the country-wide change from a repetitive hospital-centred system to an open community project, where chronicity is an indicator of failure and not the expected natural outcome” has now been maintained throughout 30 years. The new standard of psychiatric care, set at a substantially higher level of quality in 1978, is still our reference framework in 2008.

There are, however, reasons for concern. Although residential facilities have been developed in the public sector, in some regions private facilities providing long-term care to those who are not able to live independently in the community have been progressively developed. In several cases, these facilities are not part of the network of psychiatric services of a given catchment area, making continuity of care very difficult. A second reason for concern is that there is still too much heterogeneity in the availability of resources for mental health throughout the country. In regions and areas where only a few mental health resources are available the burden of mental disorders has been inevitably and almost entirely sustained by families alone, with a negative attitude towards the law in the media. Another problem is the difficulty of Italian community mental health services of developing and/or implementing innovative ways of treatment. In most cases the organisation of services is very similar to that implemented 30 years ago. Finally, the attitude of documenting, analysing and assessing mental health services and mental health system development is very weak. Research on the impact of mental health systems on the course and outcome of mental disorders is urgently needed. We are still looking forward to high-quality research projects able to identify, in various regional settings, the active ingredients of the Italian experience.

— Barbui C., Tansella M. (2008). "Thirtieth birthday of the Italian psychiatric reform: research for identifying its active ingredients is urgently needed". Journal Epidemiology and Community Health. 62 (12): 1021. doi:10.1136/jech.2008.077859. PMID 19008365. {{cite journal}}: Неизвестный параметр |month= игнорируется (справка)

References2

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В статье вот уже более года стоит шаблон «Эта статья или раздел нуждается в переработке», по поводу которого не было никаких пояснений ни на СО, ни в комментарии к правке. Необходимо либо обосновать наличие шаблона в статье, либо снять его. V for Vendetta 06:49, 11 апреля 2013 (UTC)