lmernab0n.4 Journal ot L&w and Psychiatry,

Printed in the U.S.A. All nghts reserved.

VOI. 7, pp 207.214. 1964 0160-2527184 $3.00 + .OO CopyrIght 0 1985 Pergamon Press Ltd

The Therapy of Mental Disorders in Italy

The R6le of Hospitals after the 1978 Reform

Andrea Arata*, Anna Maria Del Brenna *T, Daniela Lo Nano**, Silvana Sorbo***

At the beginning of the 20th Century, psychiatric care in Italy was disciplined by the Act no36 of 1904 and by its application Rules issued in 1909. According to these Rules: “any persons suffering from mental derangement such as to become a menace to themselves and to society or giving public scandal must be hospitalized and taken care of in mental hospitals.” The final evaluation of their dangerousness was entrusted to the Court based upon a medical Report after an observation period which could not exceed 30 days. If the patient was thought to be a menace (and this happened very easily), a Court Order was issued authorizing his hospitalization for an unspecified date.

Hospitalization in psychiatric hospitals involved in almost all cases an emergency procedure (as can be noticed from the available statistical data); it was enough to produce a medical certificate issued by any doctor, even if not a specialist, or an Order from the Maire or Magistrate or from any other public safety authority. Care of the mentally ill was performed essentially in mental hospitals which soon became crowded and were isolated from all other health services, in terms of both location and administration. In the 196Os, there were 70 public and 20 private psychiatric hospitals in Italy, hospitalizing about 130,000 patients.

Hospitalization in psychiatric hospitals was much feared which was the reason why some patients suffering from less serious mental disorders were sometimes admitted, on false diagnosis, in civilian hospitals. They were usually kept in neurology wards, although this was against the law.

Italian Reform Acts

In 1968, Act no43 1 permitted voluntary hospitalization in psychiatric hos- pitals, for diagnosis and treatment on the patient’s own request and authorization from the physician on duty. In such cases the discrimination provided by law for coercive hospitalized mentally ill patients was no longer applicable. Act no431 made it possible to convert compulsory hospitalization into voluntary

* Head of Psychiatry Department, Galliera Hospital, Professor of Psychopathology at the School of Specialization of Clinical Criminology, University of Genoa. Address correspondence to: Servizio di Psichiatria, Ospedale Galliera, Mura delle Cappuccine 14, 16129 GENOVA (Italia).

** Psychiatrist, Department of Psychiatry, Galliera Hospital, Genoa. *** Psychologist, Department of Psychiatry. Galliera Hospital, Genoa.

207

208 A. ARATA, A. M. DELBRENNA, D. LO NANO, AND S. SORB0

hospitalization which permitted to discharge a considerable number of pa&l;r.,, while legalizing the existence of mental health centres in Italian Territory. This Act brought, however, no innovation concerning the hospitalization of the mentally ill in civilian hospitals.

Act no180 in 1978 decreed that hospitalization in mental hospitals was no longer permitted except in the case of relapse, and psychiatry wards for diagnosis and therapy were organized in civilian hospitals for both voluntary and coercive treatment. The Act of 1904 was repeated and the “menace” principle remained valid only for the mentally ill who had committed a crime. When this act came into force on May 16, 1978, there were still 5 1,853 patients in the psychiatric hospitals.

In December of the same year, Act no833 was enacted introducing in Italy the national health service legislation, assimilating the innovations already introduced by the Act no180 in articles n”34, 35 and 65. According to these new regulations, diagnoses and therapy are to be voluntary as a rule and mental health care is entrusted to departmental structured health services created by the Italian regions. Compulsory hospitalization of the mentally ill is only possible “if the patients psychical alterations are such as to require urgent therapeutical actions, if these are not accepted by the patient and if local conditions and circumstances do not allow for timely and appropriate health care outside the hospital.” Compulsory hospitalization requires an order from the Maire (no longer from the Penal Magistrate) on the physician’s proposal which must be corroborated and confirmed by another doctor belonging to the national health service staff. Italian Magistrature only provides for juris- dictional protection by confirming the action, confirmation to be decreed by the Tutelary Judge within 48 hours. The therapy is to last seven days but this period can be further extended on motivation by the doctor in charge of the case. Hospitalization ceases to be coercive if revoked by the Maire. Revocation can be anticipated if the patient accepts the therapy from his own free will.

A survey made by the Ministry of Health showed that 2 16 psychiatric health service centres were operating in Italian territory in the first half of 198 1, providing for diagnosis and care in general hospitals totalling 2740 beds. During the same six-month period, 30,596 patients were hospitalized, the average duration of their stay at the hospital ranging from 8.5 to 14.7 days according to the various regions.

On June 30, 1981, 35,956 patients were still kept in the old mental hospitals.

Actuation of the Reform in the Ligurian Region

On July 17, 1978, compliance with the new legislation brought about a thorough transformation of the psychiatric facilities existing in the Ligurian region where as many as eight mental health service centres were inaugurated at the same time in as many civilian hospitals, totalling 96 beds.

The foundations for these innovations had been laid by the cooperation of a multiprofessional team which, from 1975, had split up the territorial com- petence of the hospital into user areas while correlating one sector of the territory to one psychiatric hospital division. Within a few years, the number

THERAPY OF MENTAL DISORDERS IN ITALY 209

of patients in the .mental hospital considerably decreased while the number of those to be taken care of at home increased. This was especially true in the Provinces of Genoa and Savona. The innovation process suffered some delay in the coastal and inland peripheral zones of the territory, mainly due to its orographic configuration, to the old custom in these areas of sending their mental patients to far-away hospitals, as well as to the backwardness and cultural isolation of the population.

When Act no 180 came into force, we had to tackle the problem of how to homogenize mental health care in its three new moments, i.e. civilian hospital, psychiatric hospital and external health services (out-patient treatment). This therapeutical continuity process has not yet been solved in a satisfactory manner because of the excessive separation still existing in the management of the three health service structures.

Another problem that has still to be solved concerns the delimitation between contingent public assistance and actual therapeutic response from a clinical viewpoint. The meagre resources available and the urgent needs often made it impossible to widen our knowledge about diagnosis, therapy, professional follow-up and training.

Public opinion and mass media have still only partly overcome their atavistic mistrust towards the “insane” that have been set free. Advantage has been taken of some accidents to deny the validity of this reform, although no real increase in criminal behaviour could be proved for which these insane people could be made fully responsible. The law has freed mental patients from the hospitalization court order but not from need, since many of them are living in extreme poverty, totally uprooted from their original social environment. The patients’ progressive awareness that they would never more be forced to return to the mental hospital against their will has proved to be of the utmost importance.

In the Ligurian region with a population of 1,854,000, about 3800 patients suffering from mental disorders are hospitalized every year in public general hospitals with an average occupation index of the available beds of 94.4 and an average stay of 8.65 days at the hospital. Hospitalization in private clinics is of negligible statistical relevance, since the only two existing private clinics have but a few beds and are not qualified for treatment of non-voluntary patients. At present, patients hospitalized in psychiatric wards are amounting to about 2%0 of the population, but, as already explained, their stay at the hospital is very short.

In 1960, the Ligurian region reached its peak value with 2.01 people per thousand inhabitants permanently hospitalized in psychiatric hospitals, a number well above the national average. In 1970, this ratio dropped in Liguria to 1.88%0 against a national average of 1.54%0. On June 30, 1981, there were still 1630 patients in the two Ligurian psychiatric hospitals although no new patients had been taken on. The average stay of patients was almost the whole year; patients still staying in the psychiatric hospital are over sixty years old and suffering from psychotic or senile mental disorders or from irreversible brain injury or they are drop-outs because they have no income, means, family or personal resources with which to face everyday life.

210 A. ARATA, A. M. DELBRENNA, D. LO NANO, AND S. SORB0

Our Experience in a Civilian Hospital

Our experience reflects life in a large town in Northern Italy, where behaviors of various natures and origins, not only from the Ligurian region of which Genoa is the capital, but also from Northern industrialized cities and from low-income agricultural Southern regions, converge downtown.

Here, in the historical centre of Genoa, emargination, delinquency, alco- holism, drug addiction, prostitution, poverty are more widespread than in other town districts and represented at a higher ratio than the national average.

The psychiatric health department of Galliera Hospital hospitalizes patients from four of the Genoa districts, including the downtown. The administration authorities allocated eight beds to this psychiatry ward, but day to day experience soon made it clear that at least twelve beds were needed, i.e. 0.1 bed for every thousand inhabitants. This is indeed the percentage deemed indispensable in Italy for application of the reform. But for us, even 0.1 per thousand is insufficient because patients requiring hospitalization here outnumber by three to one those in the remainder of the Ligurian region. On the other hand, only one department, if too crowded, would oppose the qualifying elements of the new health service, i.e.: (1) open wards; (2) no constrictions; (3) multi- professional team-work.

As far as possible, we try to keep the door of our ward open. Our department is located in the central part of the hospital and opens up on a large corridor shared with other medicine or surgery wards. Visitors are not discouraged and psychiatry male nurses who constantly attend to the personal problems and pathological endurances of patients, usually permit them to take a walk in the corridor, to make calls from the coin-box phones and to attend Chapel. There have never been any serious accidents and tolerance towards psychical disorder, which was initially much feared, has considerably improved in our hospital.

Containment measures were adopted only very rarely and for as short a time as possible. The department is conceived rather with the patient as a measure; the lesser his anxiety, the more the patient is likely to reduce his aggressive reactions as a defense mechanism. The dosage of psychotrope drugs as an average is lower than normally used in mental hospitals five to ten years ago.

Compulsory mental health care ranges between 2% and 4% of the total annual number of hospitalized patients. This figure is highly significant since it is much lower than the national average which is about 25%. We believe that our favourable figure is due to the creation of an environment, inside our department, ensuring prompt and willing acceptance of the therapy. We are also persuaded that this result can only be achieved through the commitment and qualification of our nursing staff. It is essential that patients are subjected to the smallest possible number of coercive regulations and constraints while they must at the same time be properly assisted and guided according to their needs.

Critical Observations and Indicatory Therapy

The psychiatry department created in Galliera Hospital in Genoa in July 1978 has been used by patients who were hospitalized for the first time, as

THERAPY OF MENTAL DISORDERS IN ITALY 211

weli as by patients with numerous and lengthy experiences in mental hospitals. It is certainly much easier to cure an acute psychical disorder in a patient without psychopathological records. But even chronic patients used to go to the psychiatric hospital for treatment of their periodical psychotic decompen- sations, proved to benefit by the new mental health care system, by shortening their stay and by reducing the destructuration level of their personality thus obtained. This has led to an increased demand for hospitalization in civil hospitals, expressed both by the patients and by their families.

Initially, psychiatric aid had to choose between its role as a structure replacing the former mental hospital and as a selector of user demand. Our psychiatry department initially took on all new cases while sending recidivous cases to the mental hospital. However, this practice has been abandoned in the last two years, not because the number of available beds in our department has increased, but because of the improved tolerance by society, the patients’ families, common organization institutes and other hospital departments towards the disturbing behaviour of the mentally ill.

At present, in a population of 117,000 entrusted to our care, only 65 patients permanently reside in the old psychiatric hospital while another 20 return there at regular intervals. Since we had found that long stays at the mental hospital exacerbated and even made chronic initially slight mental disorders, we are gratified with our results. On the other hand, the fact that no new alternative facilities were made available for mental health care means that the care of these patients rests mainly on their families.

The psychiatry department at a General Hospital should essentially be able to meet diagnosis requirements and the formulation of therapies. It is not appropriate for long-term treatment; it cannot make up for the lack of family or replace the family when it is pathologic for the patient. It cannot meet all First Aid cases due to the high number of inappropriate requests which don’t require psycho-pharmacological or psychotherapeutical response, but other actions and aid. For instance, the request for hospitalization in a civil hospital may conceal the need for other assistance such as, for instance, placing a social misfit with a long institutionalization history in a protective environment.

The limitation of the Italian reform lies in the fact of having given prescriptive instructions only for hospital services and facilities, while leaving undefined mental health care outside the hospital. Our experience taught us that an ex- pansion of hospital facilities - more beds, and a larger well qualified Staff - is certainly necessary but that it is false to believe that an improved hospital organization, whether along the old or new lines, would be enough to eliminate the patients’ discomfort or really modify public psychiatric assistance. There- fore, the civil hospital should not provide for long-term psychiatric hospi- talization or be equipped for community treatment of socially maladjusted patients due to economic difficulties, lack of assistance or of family relations.

All these requirements should be met by territorial organizations and agencies other than the psychiatry department, which should take care only of diagnosis and therapy. It is, however, possible and already often achieved in practice, to replace hospitalization by out-patient treatment, for instance in day-hospitals (adjustment of protracted treatment with psychotrope drugs, daily phleboclyses of drug addicts, soothing of anxiety crises.) The hospital is indeed operating as a first level public assistance service since it has become a habit to apply

212 A. ARATA, A. M. DELBRENNA, D. LO NANO, AND S. SORB0

directly to the hospital for all kinds of needs which should be directed instead to general practioners, social welfare, family advisory bureaux and police authorities. These cases may include outbursts of family conflicts, people locked out of their homes, requests of acknowledgment of alleged psychic disorders to justify absence from the work place or to dodge conscription or to obtain sickness benefits or disability pension. On other occasions they bring to our department or to First Aid aged people in mentally deficient conditions whose families want somehow to get rid of them.

A successful operation of the psychiatry department in civil hospitals requires a proper selection of all incoming First Aid cases. Sometimes, it is sufficient to direct the request to the exact recipient whenever it is clearly inappropriate, while in other cases it may be possible to avoid hospitalization through psy- chiatric advice at First Aid or by a properly protracted assistance, including the skills of various professionals (psychiatrist, psychologist, welfare officer, nursing staff, social workers who will assist the patient at home, after con- sultation.) Our First Aid survey provides documentation on about 1000 requests for hospitalization in mental hospitals received every year. One out of three requests, as an average, is not met by hospitalization.

Training of medical and paramedical staff operating in First Aid is essential for a correct answer which cannot be delegated only to psychiatrists. On the other hand, psychiatry is very important, especially during the starting-up stage of the service, to modify wrong somatic pathology diagnoses which were taken for psychosomatic (subarachnoidal hemorrhage instead of catatonic crisis; myocardial infarction instead of agitated depression; transient cerebral ischemia instead of exhaustion psychosis; neoplasia of the brain instead of dysthymia or insanity). Our psychiatry department is also qualified by its consulting service to other departments hospitalizing patients suffering from psychical extra-cerebral somatic disorders.

No doubt, it is in the patients’ interest to receive proper medical or surgical care; he will feel much better and reassured if he is receiving this care in the most qualified department; we never should forget the frightful backwardness of the old mental hospitals in Italy.

On the other hand, mental patients may be a nuisance for their bedmates, intolerable and therefore unwillingly accepted by non-psychiatric staff who has always been prone, at the earliest to get rid of any patient disturbing their ward by sending him to the psychiatric hospital which guaranteed restoration of order and formal correctness. This problem cannot be solved by any en- actment; only prompt theoretical information and progressive emotional training of the whole hospital staff in copmg with the uneasiness caused by patients suffering from mental disorders can be of some help.

Conclusions

The psychiatry department in general hospitals is not alone sufficient as an alternative for conventional psychiatric hospitals since it cannot take care on a long-term basis of the conditions of misadjusted people or change their lives. It can. however, prevent, with the help of outside services, the formation of new long confinements and oppose the patient’s evolution towards chronicity

THERAPY OF MENTAL DISORDERS IN ITALY 213

through a correct response to urgent hospitalization and to the “revolving door” phenomenon.

The inclusion of a psychiatry department represents for the general hospital a completion of its diagnostic and therapeutic potential. Nor should it be considered a misfortune. It is indispensable for the psychiatric staff to form a perfectly cohesive team, respectful of the personality of its members and amalgamated by a continuous critical analysis of their work. More importance should be given to the psychotherapeutic climate and listening capacity than to teaching of techniques. The patient should not be transformed into an object. The environment should permit a therapeutical relationship involving also the patient’s family which should continue after his stay in the hospital.

The 1978 Reform Act has put an end in Italy to indeterminate confinement of people who have committed no crime. The last five years have shown that Mental Health Care as introduced by the Act No180 is technically feasible. It is, however, more expensive than the previous system because it requires larger and more infrastructures between family and hospital. Without day- hospitals, communities, residence-hotels, some patients risk to be left to their fate. The economic slump and inflation considerably reduced the possibility for Government creation of such facilities. The growing deterioration of the drug addict problem is draining many resources from social welfare and health services which otherwise could have been used to the benefit of mental patients.

Enforcement of the Law has been easier in areas where the social texture is less deteriorated and where there is less need for intermediate structures between hospital and territory. In less crowded towns and rural areas, it was certainly much easier to reverse the expansionary trend of mental hospitals. However, despite the encountered difficulties, our experience here in Genoa allows us to affirm that even large cities with strong social disproportions can manage without a mental hospital, provided the operators are seriously mo- tivated and the population is awakened to these aims.

The Reform Act is better safeguarding the rights of mental patients while limiting the duration of their stay at the hospital and making available diagnosis and therapeutic facilities; this Act also confers the necessary powers on civil authorities (Major) and not on the police or penal magistrates, to ensure hos- pitalization of non-voluntary patients. For these reasons it must be observed and defended as an achievement of civilization.

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