Closure Of Psychiatric Hospitals Research Articles

The Basaglia Law. Returning dignity to psychiatric patients: the historical, political and social factors that led to the closure of psychiatric hospitals in Italy in 1978.

Law no. 180 of 1978, which led to the closure of psychiatric hospitals in Italy, has often been erroneously associated with one man, Franco Basaglia, but the reality is much more complex. Not only were countless people involved in the movement that led to the approval of this law, but we should also take into account the historical, social, and political factors that came into play. The 1970s in Italy were a time of change and political ferment which made this psychiatric revolution possible there and nowhere else in the world.

A long trip toward REMSs (Residenze per l’esecuzione delle misure di sicurezza): critical issues and perspectives in admitting patients to the Italian forensic psychiatric system

IntroductionREMSs (Residenze per l’Esecuzione delle Misure di Sicurezza, which roughly translates into Facilities for the execution of security measures) are psychiatric residential facilities introduced in Italy following the discontinuation of Forensic Psychiatric Hospitals, a process started between 2012 and 2014 and concluded in 2017. REMSs are forensic psychiatric communities, focusing on treatment and rehabilitation, managed exclusively by the italian NHS. They host psychiatric patients, who have committed crimes, but are not sended into the ordinary jail circuits because judged as mentally impaired and socially dangerous, with the aim that of stabilizing and treating psychiatric symptoms and that of their gradual social re-insertment. After the closure of psychiatric hospitals in 1978, the overcoming of forensic psychiatric hospitals is the big new thing happening in Italy when it comes to mental health. The introduction of REMSs has spotlighted how much is needed a care program used as a prevention tool, putting the mentally impaired with a social danger profile back into their dignity as human beings. Notwithstanding, after 10 years from its greenlight, some remarkable issues about REMSs system are at hand, starting from long waiting lists, which triggers the double risk of illegal jail detention of the mentally impaired; or leaving free without containment socially dangerous subjects.ObjectivesPurpose of the present study is to offer an overview of the italian REMSs system, focusing on its critical issues such as waiting lists to be admitted and treading prospects for improvement.MethodsOur work involves a research review on litterature on REMSs, forensic psychiatric services and admitting procedures.ResultsThere are 33 REMSs in Italy. As of 31st December 2021, 573 in-patients are hosted in REMSs. The most frequent diagnosis is schizophrenia (33%), followed by personality disorders (32%) and substance abuse (21.4%). 80% of the crimes committed involve violence towards human beings. As of 25th March 2022, the REMSs waiting lists include 605 individuals, 42 of whom were already imprisoned and 561 released. The average waiting time for admittance is about 10 months. Positioning on the waiting list follows the exclusive chronological criterion (date of sentence) and is not related to any clinical risk criteria whatsoever. It is estimated that one third of waiting patients remain without adequate care.ConclusionsRethinking the admittance criteria to REMSs is crucial. The use of alternative safety measures, the improvement of community mental health services and a real integration between both legal and heatlh systems in terms of management of the offending psychiatric patient are among ways suggested to avoid breaking the dream of deinstitutionalisation.Disclosure of InterestNone Declared

Reform of Forensic Mental Health Services in Italy: Stigma and Blaming the Messenger: Hermenoia.

About 40 years after the reforms leading to the closure of psychiatric hospitals (Ospedale Psichiatrico [OP]) in Italy in favor of a widespread model with a strong rehabilitation emphasis, Italy has chosen to close High Security Hospitals as well (Ospedale Psichiatrico Giudiziario [OPG]). The new forensic treatment model is expected to be more respectful of the person, including the perpetrators of violent crimes, and aims to be less stigmatizing and more rehabilitative. Despite the favorable premises of the reform (Law n. 81/2014), Italian psychiatrists are now obliged to answer calls to give evidence on strictly legal issues such as the social dangerousness of the mentally ill offender drawing on evidence or paradigms that many believe do not belong to medical knowledge. Psychiatrists must now learn to communicate about the relationship between psychiatry and society as required by law. This public expression engages with the cultural climate of society. Otherwise, the risk is of increasing the level of complexity leading to real misunderstandings that paradoxically may feed the stigma. The Italian reform provides an opportunity for reflection on some issues concerning psychiatric action, on how the public perceives the mentally ill and their psychiatrists, on the relationship between psychiatry and the world of law, on clinical methodologies for structured professional judgment, on public communication regarding severe mental illness, and the risk that psychiatrists may inadvertently be blamed for conveying an unwelcome message about mental illness and social dangerousness-we have called this social sensitivity against psychiatrists "hermanoia," blaming the messenger. The authors do not provide certain solutions but propose good practices.

The Italian reform of treatment of people not guilty by reason of insanity: The closure of forensic institutions

After the closure of Psychiatric hospitals in 1978, in 2014 the Italian government approved a law to definitively close the prisons (OPG) that were used to host and treat psychiatric patients who had committed crimes and were considered Not Guilty by Reason of Insanity. New facilities, the REMS, were built for the patients who were discharged by the forensic hospitals and the new patients who were sentenced to a security measure by the penal code. This paper describes the critical items of the reform and new scenarios about the future.

Franco Basaglia: biography of a revolutionary.

1978-2018: 40 years since the passing of the Basaglia law, which decreed the closure of psychiatric hospitals in Italy (where almost hundred thousand were confined), the primary goal of Franco Basaglia in his lifelong struggle against the violence of total institutions and, in particular, mental asylums. This article offers a reflection on the human, intellectual, and professional trajectory of Basaglia, highlighting his criticisms of the backwardness of university clinics, his interest in the therapeutic dimension of care (Binswanger and Minkowski), the influence on his thinking of European philosophy more open to the complexity of the human being (Husserl, Jaspers, Merleau-Ponty, and Sartre), and his encounter with historical (Foucault), sociological (Goffman), and anti-institutional (Fanon) perspectives on mental health.

Evolution of forensic psychiatry in Italy over the past 40 years (1978–2018)

In Italy, following the closure of psychiatric hospitals in 1978 and the release of psychiatric patients into community care, there was a mismatch between common psychiatric patients and the convicted mentally ill who were sentenced to serve in state forensic psychiatric hospitals. The recent closure of such structures following the Prime Minister's Decree of April 1, 2008, fostered the need to create new structures. These are called “REMS,” and they are based in the community and led by psychiatrists and healthcare staff who may rely on the collaboration of public security staff. This act completed a course of progressive deinstitutionalization of all psychiatric patients. However, some problems remain, and persons regarded as “partially mentally disabled” at the time of crime perpetration must serve part of their sentence in prison and the rest in the aforementioned structures or in psychiatric rehabilitation communities, depending on their claimed “social dangerousness.” Psychiatric services now face the ambiguity of treating persons who are considered dangerous by court orders, while the civil law criteria for involuntary hospitalization is based only on the need of care. The complete closure of forensic hospitals may be considered a decisive step forward in the humanization of society, but there are still some issues to address to make it work better. The implementation of multidisciplinary teams and effective psychotherapy, psychoeducational, and rehabilitation interventions can help.

Photography, Psychiatry, and Impegno: Morire di classe (1969) between Neorealism and Postmodernism

ABSTRACTThe Italian reform of psychiatric health care, which in 1978 brought about the closure of psychiatric hospitals, was the culmination of a process that entailed numerous initiatives to reform the asylum from within, along with public campaigns to involve the general population. This article provides a close reading of one of the most controversial contributions to these campaigns: the photobook Morire di classe. The aim of this study is threefold: first to interpret Morire di classe with reference to the political philosophy of Franco Basaglia, the foremost proponent of the reform; second, to place Morire di classe within the history of Italian visual culture, at a watershed moment marked by the neorealist phototext, the current of concerned photography in Italy, and postmodernism; third, to debunk a number of criticisms that have been recently been leveled at the photobook. This article argues that Morire di classe anticipated strategies of the later postmodern impegno, insofar as it involves its audiences in the construction of meaning rather than imparting a ‘moral lesson'.

Art as a prerequisite for integration and recovery. The former Paolo Pini Psychiatric Hospital in Milan

L’ex Ospedale Paolo Pini a Milano è paradigmatico di un modello morfologico autoreferenziale ed estraneo all’ambiente circostante, che si evidenzia in un sistema a padiglioni secondo un preciso diagramma funzionale per la cura delle malattie mentali. Dopo l’approvazione della legge per la chiusura degli ospedali psichiatrici, un processo di rifunzionalizzazione spontanea genera una profonda innovazione dell’immagine ambientale del luogo per mezzo dell’arte come servizio sociale.

The Closure of the Psychiatric Hospital as an Original Feature of Rehabilitation in Italy

:In this introduction to a special issue on psychosocial rehabilitation in Italy its context is identified in the closure of psychiatric hospitals since 1978 and in the construction of a system based on community psychiatry and on outpatient services. The particular characteristics of psychiatric rehabilitation in Italy, its strengths and its limitations are then analyzed on different grounds, and some of the key reasons for these limits are then proposed in the evolution of Italian society and in a lack of transformation in the psychiatric identity.

The “revolving Door Phenomenon” in an Acute Psychiatric Ward: a 5-year Retrospective Analysis

Introduction The term ‘revolving door (RD) phenomenon” was coined to define recurrent hospitalizations of chronically ill patients after closure of psychiatric hospitals and implementation of community treatments. Objectives Continued readmissions require a large portion of Mental Health Departments’ resources. Aims To analyze the RD phenomenon in an acute psychiatric ward during a 5-year period. Methods We retrospectively selected all patients with 3 or more hospitalizations per year from 01/01/ 2009 to 31/12/2013 in SPDC-Modena Centro. From their medical records we collected selected variables, potential predictors of RD phenomenon. Data were statistically analyzed. Results In the 5-year period, a sample of 105 patients (47 females, 58 males) with an average age of 40.25 years (± 13.47 SD), 5.68 % of all inpatients (n = 1850), realized 778 hospitalizations, 23.94 % of all admissions (n=3250). The most frequent reason for admission was ‘worsening of psychiatric symptomatology” (55.27%). The most frequent diagnoses at discharge were ‘Schizophrenia” (41.26%) and ‘Personality Disorders” (25.32%). Most of RD patients (87%) were Italian, only 15 % were employed and 50 % lived with family. The mean duration of RD hospitalizations (12.23 days ± 18.37 SD) was statistically significantly different from all others in the 5-year period (10.39 days ± 11.09 SD, p=0.0008, t test) as was the frequency of compulsory admissions (RD hospitalizations 18% vs. 26% all others, chi2, p Conclusions Our RD patients represented a small percent of all inpatients but required many and long hospitalizations, probably due to severe and disabling illness.

Long-term course of cognitive function in chronically hospitalized patients with schizophrenia transitioning to community-based living

Schizophrenia is associated with impairments in social interactions, and the conditions under which patients live and undergo treatment appear to have an important role in the course of the disease. However, the influences of care settings on the course of cognition remain controversial. The closure of psychiatric hospitals and the transition to community-based living is a golden opportunity to address this issue. The aims of the present study were to examine (1) the longitudinal course of cognition as well as the psychopathology and social functioning of schizophrenia patients who had been chronically hospitalized and then discharged, and (2) the key cognitive predictors of the functional outcome of such patients. Seventy-eight patients were transferred to the community after the closure of a psychiatric hospital. These patients were followed-up for 5years and underwent annual examinations that included measures of cognition, psychiatric symptoms, and social functioning. Fifty-six patients completed all the assessments. Although consistent improvements were shown in the cognitive domains for attention and memory, the initial improvements in global cognition and processing speed ultimately began to decline. Symptoms and global functioning improved almost consistently over the course of the follow-up period. Stepwise multiple regressions revealed category fluency at baseline predicted social functioning at 5years. However, this correlation was no longer significant when psychopathological variables were included as predictors. These results suggest that care settings affect the course of cognition, and addressing these conditions may lead to a certain degree of cognitive improvement even among schizophrenia patients who have been chronically institutionalized.

Four-Year Follow-Up of Long-Stay Patients Settled in the Community After Closure of Italy's Psychiatric Hospitals

Four-Year Follow-Up of Long-Stay Patients Settled in the Community After Closure of Italy's Psychiatric Hospitals

Twenty-four hour care for schizophrenia

Despite modern treatment approaches and a focus on community care, there remains a group of people who cannot easily be discharged from psychiatric hospital directly into the community. Twenty-four hour residential rehabilitation (a 'ward-in-a-house') is one model of care that has evolved in association with psychiatric hospital closure programmes. To determine the effects of 24 hour residential rehabilitation compared with standard treatment within a hospital setting. We searched the Cochrane Schizophrenia Group Trials Register (May 2002 and February 2004). We included all randomised or quasi-randomised trials that compared 24 hour residential rehabilitation with standard care for people with severe mental illness. Studies were reliably selected, quality assessed and data extracted. Data were excluded where more than 50% of participants in any group were lost to follow-up. For binary outcomes we calculated the relative risk and its 95% confidence interval. We identified and included one study with 22 participants with important methodological shortcomings and limitations of reporting. The two-year controlled study evaluated "new long stay patients" in a hostel ward in the UK. One outcome 'unable to manage in the placement' provided usable data (n=22, RR 7.0 CI 0.4 to 121.4). The trial reported that hostel ward residents developed superior domestic skills, used more facilities in the community and were more likely to engage in constructive activities than those in hospital - although usable numerical data were not reported. These potential advantages were not purchased at a price. The limited economic data was not good but the cost of providing 24 hour care did not seem clearly different from the standard care provided by the hospital - and it may have been less. From the single, small and ill-reported, included study, the hostel ward type of facility appeared cheaper and positively effective. Currently, the value of this way of supporting people - which could be considerable - is unclear. Trials are needed. Any 24 hour care 'ward-in-a-house' is likely to be oversubscribed. We argue that the only equitable way of providing care in this way is to draw lots as to who is allocated a place from the eligible group of people with serious mental illness. With follow-up of all eligible for the placements - those who were lucky enough to be allocated a place as well as people in more standard type of care - real-world evaluation could take place. In the UK further randomised control trials are probably impossible, as many of these types of facilities have closed. The broader lesson of this review is to ensure early and rigorous evaluation of fashionable innovations before they are superseded by new approaches.

Commentary: Interpreting Data on "Institutionalization": Not Simply Counting Beds

Commentary: Interpreting Data on "Institutionalization": Not Simply Counting Beds

Commentary: Interpreting Data on "Institutionalization": Not Simply Counting Beds

The brief report by Priebe and colleagues (1) attempts to demonstrate that institutional care for people with severe mental disorders has increased in several Western European countries during the 21st century, after several decades of deinstitutionalization in the 20th century. The discussion guardedly suggests that such a trend is occurring, implying an underlying political shift toward more restrictive and risk-averse forms of care. Some caution is advised. First, the term “institutionalization” carries many meanings. The lack of a specific definition in the report by Priebe and colleagues matters. Nobody would deny that people need houses to live in and beds to sleep in. It is unhelpful to group all places available for people with mental disorders and categorize these as institutions. Data should differentiate between “community-based facilities” that offer personalized interventions, which likely would include residential facilities, and “institutional places” that impose standardized care. Central to the analyses of the numbers in this report are the time points. The baseline is 1990, which arguably was the end of the Cold War. However, 1990 is not significant as a time point for bed closures. The number of psychiatric beds peaked in the 1950s in most countries, with a rapid fall in the subsequent decades. The challenge of the 1990s, in Western Europe as well as in the United States, was that the decline in the number of hospital beds was not compensated for by the development of community services, including residential care facilities, which left patients who would previously have been institutionalized at high risk of destitution. Since then many countries have invested large sums to support the development of nursing homes and residential care facilities; such investment has occurred at a fast pace, as this brief report illustrates. This line of reasoning points to another conclusion—namely, that we are not dealing with an overdevelopment of beds but, as a result of inadequate planning, with a lag in time between hospital closures and the availability of residential places. The increase in the number of forensic beds in some countries is a different issue. Such beds were established by governments in response to public pressure resulting from highprofile incidents and an inadequate supply of beds after the closure of psychiatric hospitals. The overall figures hide a shift in several countries from a small number of large prison hospitals toward smaller-scale specialty psychiatric units. Also, it should be recognized that even though the number of forensic beds has increased substantially in a few countries, these places make a relatively small contribution to the overall number of psychiatric beds. Relevant to the argument is the in

Evaluation of a special rehabilitation programme for patients who are difficult to place

Difficult-to-place patients are left at the end of programmes of psychiatric hospital closure and need specialised services, the nature of which is still under debate. The aim of this study was to evaluate a rehabilitation programme specially designed for difficult-to-place patients in a psychiatric hospital undergoing closure. Twenty-two difficult-to-place patients were identified and underwent a customised rehabilitation programme. Their outcome after 1 year was compared with that of a similar group of 64 patients from another psychiatric hospital who had not received the main components of the rehabilitation programme. Compared with the control patients, the experimental patients showed a significant reduction in severe problems of social behaviour (p < 0.005) and a borderline significant increase in domestic skills (p < 0.06). The results support the value of individually planned behavioural programmes for difficult-to-place patients, combined with training programmes for the staff and rationalisation of medication regimes.

Closure of a Long-Stay Ward: Five Years Onwards

Closure of psychiatric hospitals has engendered much debate. There is a growing body of literature resulting from such closures. Lamb [ 1 ] in a lecture has pointed out the need for deinstitutionalisation to be clinically driven rather than by pre-conceived ideology. Bachrach [ 2 ] discussed the need to espouse a bio-psycho-social and humanistic approach coupled with the provision of adequate resources. In a limited survey conducted among community homes and long-stay hospitals in London, it was found that the most disabled were still living in hospitals and received the poorest quality care. Whilst there were no overall differences amongst the community facilities, they noted the importance of staff training and morale in order to improve quality of care [ 3 ].

Deinstitutionalization and psychiatric reform in Spain.

The transformation of psychiatric care which has been carried out in Spain since the 1980s, under the name of "Psychiatric Reform", had produced as it most significant achievements: (i) the development of a new organizational structure for mental health care, (ii) the integration of psychiatric patients in the general health care system, (iii) the creation of an extensive community network of mental health centers, and (iv) the adoption by the general public of more positive attitudes towards mental illness and its treatment and the passing of legislative measures aimed at improving the civil rights of these patients. However, the application of the Psychiatric Reform has followed an uneven course in Spain as a whole, with marked differences between the different autonomous communities. The main deficiency has been in the development of intermediate community services and programs to rehabilitate and resettle patients in the community. With regard to deinstitutionalization, the results have also been insufficient and it is still possible to observe a strong tendency, within the system, to maintain the old mental hospitals for both long-term and short-term illness care. Finally, the analysis of the Spanish experience has revealed that (i) many of the criticisms leveled at deinstitutionalization are not aimed at its "conceptual core" but stem from its inadequate implementation, and (ii) it is wrong to equate deinstitutionalization and psychiatric reform with closure of psychiatric hospitals, without the awareness that this process is far more complex.

The closure of The St. Lazarus Psychiatric Hospital in Reggio Emilia

This is not a scientific paper. It is the report of the actions carried out during 1996 and 1997 to close the Psychiatric Hospital S. Lazzaro in Reggio Emilia.

The TAPS Project 42: the last to leave hospital--a profile of residual long-stay populations and plans for their resettlement. Team for the Assessment of Psychiatric Services.

This study aims to assess the service needs of residual hospital populations and the adequacy of the alternative facilities provided for them following the closure of psychiatric hospitals. The remaining 368 long-stay patients in four representative English hospitals scheduled for closure within 1 year were assessed by means of a standardized schedule devised to rate problem behaviours. The residual populations consisted predominantly of elderly, male and very long-stay patients. The most frequent problem behaviours were hostility, physical aggression and incontinence. The one hospital which allowed new admissions to continue indefinitely had the highest proportion of problematic patients. Alternative care facilities were provided by a diverse range of agencies. Large residential homes were the predominant type of provision for most patients, and private nursing homes often accommodated mixed groups of elderly people. NHS trusts catered for most of the 'difficult to place' patients within specialized facilities, based in the community. There were some indications that compromises led to insufficient and understaffed specialist facilities. In view of the increasing demand for long-term intensively staffed facilities, this policy might put an extra burden on the local health services.