Survival curves for inpts. episodes in SouthVerona and Groningen Sytema et al, 1996

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Giovanni de Girolamo
COMMUNITY MENTAL HEALTH CARE PROBLEMS AND
PERSPECTIVES. LESSONS FROM THE ITALIAN PSYCHIATRIC
REFORM
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NATIONAL INSTITUTE OF HEALTH
PROGRES
PROGetto RESidenze National Project on
non-hospital Residential Facilities (RFs)
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PROGRES objectives

• PHASE 1 SURVEY OF ALL RFs
• PHASE 2 ASSESSMENT OF 20 OF RFs, OF PTS. AND
  COSTS

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CONCLUSION N. 1 FOR LONG-TERM CARE

• The closing of mental hospitals has not
  prevented the accumulation of new chronic,
  disabled patients, requiring long-term, and often
  lifelong care and support.

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CONCLUSION N. 2 FOR LONG-TERM CARE

• Two potentially contrasting (and currently
  overlapping) objectives of residential
  facilities
• 1. Homes for life for people with severe
  disabilities OR
• 2. Sites of intensive treatment programmes

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Difference between the two regions with the
highest (Abruzzo) and the lowest (Campania)
number of residential beds per 10,000 popn
almost 10 to 1!!
Yellow lt 2 Green 2-3 Blue 3-4 Red gt 4
RF BED RATE/ 10.000 POPN.
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CONCLUSION N. 3 FOR SERVICE PROVISION

• In countries with a federal system of health
  care, there may be as in Italy a tremendous
  geographical variability in terms of service
  provision and quality of services.

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THE EUROPEAN SCENARIO
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TOTAL (acute long-term) psychiatric beds per
10,000 popn. in 16 European countries (Source
WHO Atlas and PROGRES projects)
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CONCLUSION N. 4 PROVISION OF BEDS AND OTHER
SUPPORTS

• The smallest provision of acute or residential
  beds, if not coupled by a DEMONSTRATED increase
  in recovery or remission rates, often leads to an
  heavier burden placed on the family and on other
  social services.

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CONCLUSION N. 5 FAMILY BURDEN

• In too many cases community care means family
  care. Families have faced a very heavy burden of
  informal care, often caused by an unfair
  implementation of community care.

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Family burden has been studied in a nation-wide
survey in 30, randomly selected, catchment areas
family members reported 97 feelings of loss,
83 stated they frequently cried or felt
depressed. 73 had neglected their hobbies and
68 were virtually unable to afford going on any
type of holiday due to the patients situation.
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80 of the families were in regular contact with
mental health services 59 attended general
informative sessions on the patients illness and
its treatment. Yet, only a very small percentage
(8) received any structured psychoeducational
intervention.
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A study has compared the psychopathology and the
Quality Of Life (QOL) in patients suffering from
schizophrenia in Boulder, Colorado, and in
Bologna (Warner et al., 1998). Patients in
Bologna reported several significant QOL
advantages over Boulder patients patients in
Bologna also scored lower on some dimensions of
psychopathology.
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However, the QOL advantages reflected the
sociocultural differences between the two
countries, especially in terms of family
structure. As many as 74 of Bologna patients
were living with their families, as compared to a
tiny percentage (17) of patients in the USA.
Therefore outcome data can be misleading for
service evaluation if considered in isolation and
without proper consideration of socio-cultural
and extra-clinical variables.
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CONCLUSION N. 6 SPECIAL POPULATIONS AND SERVICES

• There are special clinical populations (e.g.,
  violent pts, pts with double diagnosis) for whom
  services are ill-equipped. In other areas (e.g.,
  early interventions for first-psychotic patients)
  services show a gap between current knowledge and
  its implementation.

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CONCLUSION N. 7 THE MEANING OF COMMUNITY CARE

• The closure of MHs is feasible however community
  treatment is a service delivery vehicle. It can
  allow treatment to be offered to a patient, but
  is not the treatment itself. This distinction is
  important, as the actual ingredients of treatment
  have been insufficiently emphasized
  (Thornicroft, 2000).

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CONCLUSION N. 8 THE COST OF COMMUNITY CARE

• Community care is not, and will never be, a cheap
  solution. In fact, if community care is to be
  effective, investments must made in buildings,
  staff, staff training, and in backup facilities.

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CONCLUSION N. 9 THE NEED OF MONITORING

• Finally, monitoring and evaluation are important
  aspects of change planning and evaluation should
  go hand in hand and evaluation should, wherever
  possible, have an epidemiological basis
  (Tansella Williams, 1987). Hence, large
  multicentric studies represent important tools to
  fully understand the consequences and the
  characteristics of service changes, and should
  take into account the opinions of all
  stakeholders.