Italian Mental Health Services Research Articles

The patient journey project in Italian mental health services: results from a co-designed survey on clinical interventions and current barriers to improve the care of people living with schizophrenia.

The Patient Journey Project aimed to analyze the scenario among Italian Mental Health Services (MHS) to understand the clinical interventions that are properly implemented and the ones deserving further implementation to design an effective treatment plan for patients living with schizophrenia (PLWS). The 60-items survey was co-designed with all the stakeholders (clinicians, expert patients and caregivers) involved in the Patient Journey and focused on three phases of schizophrenia course: early detection and management, acute phase management, long-term management/continuity of care. Respondents were Heads of the Mental Health Departments and Addiction Services (MHDAS) or facilities directors throughout Italian MHS. For each statement, respondents expressed the consensus on the importance and the degree of implementation in clinical practice. Considering the importance of the statement, strong consensus was reached for most of the statements. Good levels of implementation were found on 2/17 statements of early detection and management, on 3/16 statements for acute phase management and on 1/27 statements of long-term management/continuity of care. Poor levels of implementation were found on 1/17 statements of early detection and management, none of acute phase management, and 4/27 statements for long-term management/continuity of care. Moderate levels of implementation were found on 14/17 statements for early detection and management, on 13/16 statements of acute phase management, and on 22/27 statements of long-term management/continuity of care. Thus, among Italian MHDAS, most interventions for PLWS were moderately implemented in clinical practice. Italian MHS have to provide new strategies and structural actions to overcome these current limitations and barriers to effectively improve the journey of PLWS. The areas that deserve most implementation include interventions during the early stage (especially the continuity of care between Child and Adolescent Mental Health Services and Adult Mental Health Services), the evidence-based psychosocial interventions during the chronic stages of the disorder, and the continuity of care after acute hospitalization.

Failure to reduce benzodiazepine prescriptions through the implementation of a psychological intervention for insomnia in an Italian mental health service.

Despite the evidence of higher effectiveness of psychological interventions for insomnia compared to pharmacological ones, drug prescriptions for insomnia remain frequent. This study has assessed patterns of prescriptions of BZDs for insomnia before and after the delivery of a training in psychological interventions to professionals working in the services of a Department of Mental Health in northern Italy. The intervention consisted in two training sessions about psychological interventions for insomnia delivered to professionals of the participating services. The prevalence of users with a prescription of BZDs for insomnia in an index period after the delivery of the training was compared to the prevalence in an index period before the training. Among 727 people assessed for BZDs prescription at pre-intervention, 306 (42.1%, 95% CI 0.39-0.46) had a prescription, and 344 (49.2%, 95% CI 0.45-0.53) had a prescription among 699 people assessed at post-intervention, corresponding to a significant odds ratio of 1.33 to be prescribed with BZDs in the second index period compared to the first one. Psychological interventions were offered to a small group of patients. Prescribing attitudes of BZDs for insomnia were not modified after the training and delivery of a psychological intervention in a mental healthcare outpatient setting. Prescribing habits should be addressed more directly in training, and professionals should be more aware of risks of BZDs assumption. The failure in changing drug prescriptions in this study should prompt more real-world studies of the application of evidence-based strategies, particularly in outpatient mental health settings.

Time will tell: Associations between unbalanced time perspectives and symptom severity in individuals with schizophrenia spectrum disorders.

Patients with schizophrenia spectrum disorder (SSD) experience disrupted temporality on the immediate timescale. However, insufficient information is available for longer time frames, and the interaction of temporal perspectives with the clinical manifestations of SSD is unknown. We explored the association between unbalanced time perspectives and symptom severity. Thirty-seven Italian mental health services participating in the DiAPAson project recruited 620 patients with DSM-5 SSD (68% males, mean age=41.3±9.5years). Time perspective biases were measured using the Deviation from the Balanced Time Perspective-revisited (DBTP-r) indicator, based on Zimbardo Time Perspective Inventory (ZTPI) scores. Psychiatric symptoms were assessed using the Brief Psychiatric Rating Scale (BPRS) and Brief Negative Symptoms Scale (BNSS). Preliminary analyses examined the associations between ZTPI/DBTP-r and BPRS/BNSS total scores. In secondary analyses, we first tested the associations between the ZTPI/DBTP-r and BPRS/BNSS subscales and then compared ZTPI differences between patients with and without hallucinations, delusions, and conceptual disorganisation. Statistical significance was set at Holm-Bonferroni corrected p<0.05. Low-to-moderate positive correlations were found between the DBTP-r and BPRS/BNSS total scores (r=0.29/0.22). The strongest associations were between DBTP-r/ZTPI_Past-Negative and anxiety/depression (r=0.34/0.36), followed by DBTP-r/ZTPI_Present-Fatalistic with thought disturbances (r=0.22/0.20). DBTP-r was associated with BNSS anhedonia and avolition (r=0.21/0.24). DBTP-r was higher in patients with hallucinations (ES=0.391) and conceptual disorganisation (ES=0.397) than in those without these symptoms. Unbalanced time perspective was positively associated with the severity of primary and secondary SSD features. These findings provide a rationale for empirical tests focused on balancing time perspectives in patients with SSD.

The quality of mental health care for people with bipolar disorders in the Italian mental health system: the QUADIM project

BackgroundThe assessment of the quality of care pathways delivered to people with severe mental disorders in a community-based system remains uncommon, especially using healthcare utilization databases. The aim of the study was to evaluate the quality of care provided to people with bipolar disorders taken-in-care by mental health services of four Italian areas (Lombardy, Emilia-Romagna, Lazio, province of Palermo).MethodsThirty-six quality indicators were implemented to assess quality of mental health care for patients with bipolar disorders, according to three dimensions (accessibility and appropriateness, continuity, and safety). Data were retrieved from healthcare utilization (HCU) databases, which contain data on mental health treatments, hospital admissions, outpatient interventions, laboratory tests and drug prescriptions.Results29,242 prevalent and 752 incident cases taken-in-care by regional mental health services with a diagnosis of bipolar disorder in 2015 were identified. Age-standardized treated prevalence rate was 16.2 (per 10,000 adult residents) and treated incidence rate 1.3. In the year of evaluation, 97% of prevalent cases had ≥ 1 outpatient/day-care contacts and 88% had ≥ 1 psychiatric visits. The median of outpatient/day-care contacts was 9.3 interventions per-year. Psychoeducation was provided to 3.5% of patients and psychotherapy to 11.5%, with low intensity. 63% prevalent cases were treated with antipsychotics, 71.5% with mood stabilizers, 46.6% with antidepressants. Appropriate laboratory tests were conducted in less than one-third of prevalent patients with a prescription of antipsychotics; three quarters of those with a prescription of lithium. Lower proportions were observed for incident patients. In prevalent patients, the Standardized Mortality Ratio was 1.35 (95% CI: 1.26–1.44): 1.18 (1.07–1.29) in females, 1.60 (1.45–1.77) in males. Heterogeneity across areas was considerable in both cohorts.ConclusionsWe found a meaningful treatment gap in bipolar disorders in Italian mental health services, suggesting that the fact they are entirely community-based does not assure sufficient coverage by itself. Continuity of contacts was sufficient, but intensity of care was low, suggesting the risk of suboptimal treatment and low effectiveness. Care pathways were monitored and evaluated using administrative healthcare databases, adding evidence that such data may contribute to assess the quality of clinical pathways in mental health.

Criminal behaviors and substance abuse in psychiatric patients

IntroductionPeople with mental illness are overrepresented throughout the criminal justice system. In Italy, an ongoing process of deinstitutionalization has been enacted: the Judicial Psychiatric Hospitals are now on the edge of their closure in favor of small-scale therapeutic facilities (Residenze per l’Esecuzione delle Misure di Sicurezza - REMS). Law 81/2014 prescribes that a patient cannot stay in a REMS for a period longer than a prison sentence for the same index offense. Therefore, when patients end their duty for criminal behaviors, their clinical management moves back to outpatient psychiatric centers. Elevated risks of violent behavior are not equally shared across the spectrum of psychiatric disorders. In the past several years, multiple studies in the field of forensic psychiatry confirmed a close relationship between violent offenders and comorbid substance abuse.ObjectivesIn order to broaden the research in this area, we analyzed sociodemographic, clinical and forensic variables of a group of psychiatric patients with a history of criminal behaviors, attending an outpatient psychiatric service in Milan, with a focus on substance abuse.MethodsThis is a cross-sectional single center study, conducted in 2020. Seventy-six subjects with a history of criminal behaviors aged 18 years or more and attending an outpatient psychiatric service were included. Demographic and clinical variables collected during clinical interviews with patients were retrospectively retrieved from patients’ medical records. Appropriate statistical analyses for categorical and continuous variables were conducted.ResultsData were available for 76 patients, 51,3% of them had lifetime substance abuse. Lifetime substance abuse was significantly more common in patients with long-acting injectable antipsychotics therapy, &gt;3 psychiatric hospitalizations, history of previous crimes and economic crime (Table 1). Additionally, this last potential correlation was confirmed by logistic regression.Table 1.Lifetime substance abusers (N=39)Non-lifetime substance abusers (N=37)Proportion DifferenceP-valueN%N%Depot administrationYes11(28,9%)0(0%)28,9%0,02HospitalizationsFour or more25(64,1%)5(33,3%)30,8%0,04Economic crimeYes15(40,5%)1(6,7%)33,8%0,02Previous crimesYes17(51,4%)2(13,3%)38,1%0,02ConclusionsData emerging from this survey provide new information about offenders in an Italian mental health service with a focus on lifetime substance abuse in these patients. Our preliminary results should be confirmed in larger sample sizes.Disclosure of InterestNone Declared

Real-world experience of esketamine use to manage treatment-resistant depression: A multicentric study on safety and effectiveness (REAL-ESK study)

BackgroundTreatment-resistant Depression (TRD) represents a widespread disorder with significant direct and indirect healthcare costs. esketamine, the S-enantiomer of ketamine, has been recently approved for TRD, but real-world studies are needed to prove its efficacy in naturalistic settings. ObjectivesEvaluate the effectiveness and safety of esketamine nasal spray in a clinical sample of patients with TRD from several Italian mental health services. MethodsREAL-ESK study is an observational, retrospective and multicentric study comprising a total of 116 TRD patients treated with esketamine nasal spray. Anamnestic data and psychometric assessment (MADRS, HAMD-21, HAM-A) were collected from medical records at baseline (T0), one month (T1) and three month (T2) follow-ups. ResultsA significant reduction of depressive symptoms was found at T1 and T2 compared to T0. A dramatic increase in clinical response (64.2 %) and remission rates (40.6 %) was detected at T2 compared to T1. No unexpected safety concerns were observed, side effects rates were comparable to those reported in RCTs. No differences in efficacy have been found among patients with and without psychiatric comorbidities. LimitationsThe open design of the study and the absence of a placebo or active comparator group are limitations. The study lacks an inter-rater reliability evaluation of the assessments among the different centres. Side effects evaluation did not involve any specific scale. ConclusionsOur findings support the safety and tolerability of esketamine in a real-world TRD sample. The later response and the non-inferiority in effectiveness in patients with comorbidities represent novel and interesting findings.

Personal Health Budget: a new rehabilitation approach for severe mental illness within a caring community

IntroductionPersonal Health Budget (PHB) has been provided to consumers with severe mental illness within a policy shift toward a person-tailored mental healthcare treatment based on individual unmet needs. PHB is an amount of money to support patient’s health and wellbeing needs, which is planned and agreed between patients and their local NHS team. It is not new money, but it may mean spending money differently so that patients can get the care that they need. However, evidence of beneficial effects of PHB is still scarce.ObjectivesThe aim of this study was to provide preliminary data on clinical and social benefits of adding PHB to a standard pharmacotherapy in patients with severe mental illness across a 24-month follow-up period.Methods137 individuals with severe mental illness (aged 18–50 years) were recruited in one of the adult mental health services of an Italian Department of Mental Health. They completed the Global Assessment of Functioning scale, the Health of the Nation Outcome Scale and the Brief Psychiatric Rating Scale. Friedman’s test for repeated measure was used to assess the longitudinal stability of functioning and clinical parameters. A linear regression analysis was also performed.ResultsA significant decrease in all GAF scale, HoNOS and BPRS scores along the 24 months of follow-up was observed. Regression analysis results specifically showed a relevant association between a PHB multiaxial intervention and the longitudinal reduction in BPRS ‘Negative Symptoms’ and HoNOS ‘Social Problems’ subscores.ConclusionsOur findings support the useful implementation of a PHB approach for severe mental illness patients within the Italian mental health service network.DisclosureNo significant relationships.

Why Was the Perception of Human Rights Respect and Care Satisfaction So High in Users of Italian Mental Health Services during the COVID-19 Pandemic?

The aim of this study was to compare users’ and mental health workers’ (MHW) perception of respect of human rights and job/care satisfaction in mental health services in Italy during the COVID-19 pandemic. A sample of users and MHW of Sardinia, Italy, fulfilled the “Well-Being at work and respect for human rights questionnaire” (WWRR). The study included 240 MHW and 200 users. Users showed a higher level of satisfaction of care than MHW of work, and a higher perception of the satisfaction of users and human rights respected for health workers. Both user and MHW responses were about 85% of the maximum score, except for satisfaction with resources. Responses were higher for users, but users and MHW both showed high levels of satisfaction. In previous surveys, MHW of Sardinia showed higher scores in all items of WWRR, except for satisfaction with resources, compared with workers from other health sectors of the same region, and with MHW from other countries. The low score for satisfaction with resources (in users and staff) is consistent with a progressive impoverishment of resources for mental health care in Italy. The study, although confirming the validity of the Italian model, fully oriented towards community, sets off an alarm bell on the risks resulting from the decrease in resources.

Rethinking hospital psychiatry in Italy in light of COVID-19 experience.

BACKGROUNDItaly retains a distinctive organization of mental health services according to a community-based model of care with a multidisciplinary team serving a well-defined catchment area under the coordination of the local department of mental health. The coronavirus disease 2019 (COVID-19) pandemic is forcing Italian mental health services to develop new organizational strategies at all levels of care in order to face the associated challenges.AIMTo explore factors associated with changes in psychiatric admissions to an inpatient psychiatric unit located in Lombardia Region, Italy.METHODSAll hospital admissions (n = 44) were recorded to an inpatient psychiatric unit during a three month national lockdown in Italy in 2020 and compared with those occurring over the same time period in 2019 (n = 71). For each admission, a 20-item checklist was completed to identify factors leading to admission. Statistical analyses were performed using Statistical Package for Social Sciences for Windows, release 11.0. Chi-square test (or Fisher’s exact test) and Mann-Whitney U-test were applied, where appropriate.RESULTSHospital admissions dropped by 38% during the COVID-19 pandemic. No significant differences were found in demographics, clinical variables associated with hospital admissions and length of stay between 2019 and 2020. Compared with 2019, a significantly greater proportion of hospital admissions in 2020 were related to difficulties in organizing care programs outside the hospital (chi-square = 4.91, df 1, one-way P = 0.035) and in patients’ family contexts (chi-square = 3.71, df 1, one-way P = 0.049). On the other hand, logistic and communication difficulties pertaining to residential facilities and programs were significantly more common in 2019 than in 2020 (chi-square = 4.38, df 1, one-way P = 0.032).CONCLUSIONAdmissions to the inpatient psychiatric unit dropped significantly during the COVID-19 pandemic in 2020, with difficulties in organizing care programs outside the hospital and in patients’ family contexts occurring more frequently compared with 2019.

Mixed Depression: A Survey on Psychopathological, Diagnostic, and Therapeutic Approaches among a Sample of Italian Psychiatrists

Background: The Diagnostic and Statistical Manual for Mental Disorders (5th edition) introduced the specifier “with Mixed Features” to the diagnosis of Major Depressive Episode to designate the presence of (hypo) manic symptoms as part of the clinical presentation. This change has led to renewed attention on the operational definition, diagnosis, and treatment of Mixed Depression. Objective: To investigate the diagnostic and therapeutic approaches towards Mixed Depression among a representative sample of Italian psychiatrists. Methods: Between March and April 2021, 342 psychiatrists working in Italian adult mental health services were invited to participate in an anonymous online survey comprising 32 questions designed to investigate clinical and psychopathological approaches regarding the management of mixed depression in daily psychiatric practice. Results: 83.74% of participants reported having performed a diagnosis of mixed depression in the last five years, with the majority of respondents affirming that they had not used any diagnostic tool. Only 7,5% of the surveyed psychiatrists considered the DSM-5 criteria to be fully adequate in the description of this clinical entity. The most used pharmacological approach was combined therapy, in particular antipsychotics plus mood stabilizers. For monotherapy, the preferred drugs were Valproate and Quetiapine. Regarding the conceptualization of mood disorders, 199 of the participants chose the Kraepelinian unitary spectrum view; meanwhile, 101 expressed their preference for the binary model. Conclusion: Our results suggest a prominent position of mixed depression in the context of mood disorders. Univocal operational criteria and additional research on pharmacological treatment are also needed to ensure the correct recognition and management of mixed depression.

Adult ADHD: a study on evaluation and treatment pathways in Italian Mental Health Services.

Attention Deficit and Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder that often persists into adulthood. The Italian situation regarding the clinical management of childhood ADHD shows some criticalities, despite the high prevalence rate: diagnostic assessments are often inaccurate, protocols for transition from childcare services are almost non-existent and the Italian National Registry for ADHD in childhood was drawn up only in 2007, hence the first specialized services were created later than the rest of Europe. On the basis of these issues, we investigated the Italian situation with regard to disorders in adulthood, comparing the different European operational models, assuming that these critical issues are reflected in the clinical management of the disorder in adulthood. In fact, unlike other European countries, there are no official guidelines governing the clinical management of the disorder in adulthood and evidence-based pharmacotherapies, available in most European countries, are off-label or not allowed in Italy. The aim of the study is to evaluate the current state of knowledge and working method in relation to adult ADHD in the Italian background and to identify the main evaluation and treatment pathways in Italian Mental Health Services. The study is also an attempt to clarify which services are operational on the Italian territory, with the aim of improving the quality of interventions for the clinical population. Three hundred thirty-eight services have been identified in all Italian Regions and Autonomous Provinces, including Mental Health Centres (CSM), Pathological Addition Services (SERD), Psychiatric Diagnosis and Treatment Services (SPDC). An ad-hoc survey with closed-ended questions was administered by telephone to each selected centre and the results were compared with the European literature.

Easier Said Than Done: The Challenge to Teach “Personal Recovery” to Mental Health Professionals Through a Short, Targeted and Structured Training Programme

This study assesses the effectiveness of our short Personal Recovery Training Program (PRTP) for mental health professionals. Fifty-two healthcare professionals from Italian mental health services and forty students in psychiatric rehabilitation completed the Recovery Knowledge Inventory (RKI) pre- and post-training, divided into two groups: the PRTP (N = 45) and the Family Psychoeducational Training Program (FPTP; N = 47). Participants’ understanding of personal recovery improved more significantly for those in the PRTP than for those in the FPTP group in two domains, “Roles and responsibilities” and “Non-linearity of the recovery process”; the FPTP group showed a significant improvement in the “Role of self-definition and peers in recovery” domain. Two consumers were involved in the PRTP and represented a resource to help participants understand the personal recovery process. Our findings indicate that a brief PRTP supported by consumers can improve staff and students' recovery orientation. The translation of the training into clinical practice remains unevaluated.

Effects of Cognitive Remediation on Cognition, Metacognition, and Social Cognition in Patients With Schizophrenia.

We aimed to evaluate in a sample of outpatients with schizophrenia (SCZ) the effectiveness of a cognitive remediation (CR) program (through the use of the Cogpack software) [computer-assisted CR (CACR)] in addition to standard therapy on cognitive outcomes as compared with that in a control active group (CAG) and to highlight a possible effect on social cognition (SC), metacognition, symptomatology, and real-world functioning. Of the 66 subjects enrolled, 33 were allocated to CACR and 33 to the CAG. Twenty-three patients in the CACR group and 25 subjects in the CAG completed at least 80% of the 48 prescribed CACR sessions, performed twice a week, for a total of 24 weeks of treatment. A significant time × group interaction was evident, suggesting that patients undergoing CACR intervention improved in specific metacognitive sub-functions (understanding others' mind and mastery), some cognitive domains (verbal learning processing speed, visual learning, reasoning, and problem solving) (h2 = 0.126), depressive symptoms, SC, awareness of symptoms, and real-world functioning domains (community activities and interpersonal relationships) more significantly than did patients undergoing CAG. The most noticeable differential improvement between the two groups was detected in two metacognitive sub-functions (understanding others' mind and mastery), in verbal learning, in interpersonal relationship, and in depressive symptomatology, achieving large effect sizes. These are encouraging findings in support of the possible integration of CACR in rehabilitation practice in the Italian mental health services.

First-episode Psychosis and Migration in Italy: Results from a Study in the Italian Mental Health Services (Pep-Ita Study)

Background: Migrants present high rates of psychosis. A better understanding of this phenomenon is needed. Methods: We conducted a multicentre First-Episode Psychosis (FEP) prospective study over two years (January 2012–December 2013) to evaluate first-generation migrants presenting with FEP at the participating Community Mental Health Centers (CMHCs). Results: 109 FEP migrants were identified. Almost half of them were highly educated, employed and in a stable affective relationship. The average age was 32.8 (± 9.8) years, and the average length of stay in Italy was 8.6 (± 8.8) years. About 2/3 of patients were referred to CMHCs following Emergency Department access or psychiatric admission. Conclusions: Our finding of a “high functioning portrait” of FEP migrants allow us to hypothesize that a high burden of negative psychosocial factors is likely to be needed for the FEP onset. Furtherly, mental health services should implement more appropriate resources and organizational methods to respond to migrants’ health needs.

Feasibility and effectiveness of Dialectical-Behavior Therapy for patients with borderline personality disorder in Italian mental health services: a preliminary study.

Dialectical-Behavior Therapy (DBT) is an evidence-based effective psychotherapeutic intervention for patients with Borderline Personality Disorder (BPD). There is a paucity of empirical evidences on the feasibility and the effectiveness of DBT in real-world Italian mental health services. This study aimed at reporting preliminary data on the implementation of DBT for adult patients with BPD attending an Italian mental health service. 28 BPD patients attending a mental health service underwent a 16-session DBT program. Effects of DBT were measured with the Difficulties in Emotion Regulation Scale (DERS) and the Barratt Impulsiveness Scale (BIS-11). 17 patients completed the DBT program, reporting reduced levels of emotion dysregulation and impulsiveness at follow up in comparison with baseline. Higher emotional dysregulation was a risk factor for dropout. In conclusion, this preliminary pilot study suggests that DBT is feasible and effective for BPD patients in Italian adult mental health services.

Personal Health Budget as a new rehabilitation model for severe mental illness within a caring community: An Italian evaluation study of beneficial effects.

Personal Health Budget has been provided to consumers with severe mental illness within a policy shift toward a person-tailored mental healthcare treatment based on individual unmet needs. Evidence of beneficial effects of Personal Health Budget is still scarce. The aim of this study was to provide preliminary data on clinical and social benefits of adding Personal Health Budget to a standard pharmacotherapy in patients with severe mental illness across a 24-month follow-up period. Participants (n = 137) were individuals with severe mental illness, aged 18-50 years, recruited in one of the adult mental health services of the Parma Department of Mental Health. They completed the Global Assessment of Functioning scale, the Health of the Nation Outcome Scale and the Brief Psychiatric Rating Scale. This age range was chosen to limit Personal Health Budget interventions to adults with a non-prolonged illness duration. Friedman's test for repeated measure was used to assess the longitudinal stability of functioning and clinical parameters. A linear regression analysis was also performed. A significant decrease in all Global Assessment of Functioning scale, Health of the Nation Outcome Scale and Brief Psychiatric Rating Scale scores along the 24 months of follow-up was observed. Regression analysis results specifically showed a relevant association between a Personal Health Budget multiaxial intervention and the longitudinal reduction in Brief Psychiatric Rating Scale 'Negative Symptoms' and Health of the Nation Outcome Scale 'Social Problems' subscores. Our findings support the useful implementation of a Health of the Nation Outcome Scale approach for severe mental illness patients within the Italian mental health service network.

Assessing aberrant salience in young community help-seekers with early psychosis: The approved Italian version of the Aberrant Salience Inventory.

Aberrant salience (AS) has a crucial role in the onset of psychosis. The Aberrant Salience Inventory (ASI) is the only self-report instrument specifically developed for the assessment of AS. Aim of this study was to examine the reliability and the validity of the approved Italian version of the ASI in a clinical sample of young help-seekers. The ASI was completed by 204 individuals, aged 13-35 years. Reliability was assessed examining internal consistency and test-retest reliability. Concordant validity was established with CAARMS ("Comprehensive Assessment of At-Risk Mental States"). The ASI showed high test-retest reliability and excellent internal consistency. The ASI total score had significant positive correlations with CAARMS "Positive Symptoms" subscores. The ASI showed satisfactory psychometric properties and seems to be a suitable instrument for early detection of psychosis in Italian mental health services.

Survey on centres and procedures for the diagnosis and treatment of adult ADHD in public services in Italy.

Attention deficit/hyperactivity disorder (ADHD) often persists into adulthood. Although its persistence and relative high prevalence, ADHD in adults is often underdiagnosed and undertreated in Italy, leading to poor clinical and functional outcomes, and higher costs of illness. The aims of the study were to identify the Italian mental health services for ADHD in adults, describe the diagnostic and treatment procedures they follow, and compare this offer with the recommendations of the German and English guidelines. The centres, that adopt a clinical and assessment protocol for adult ADHD diagnosis (carried out by specifically trained personnel) and prescribe pharmacological treatment for adult ADHD, were selected from the list of accredited services provided by the Appendix B.2 of the ISTISAN 16/37 Reports of the ISS. An ad-hoc survey including open-ended and close-ended questions was sent to each selected centre in February 2020. The overall picture resulting from the data analysis was compared with the recommendations of the German and English guidelines. The present survey shows that only a few centres are specialised in the diagnosis and treatment of ADHD in adults in Italy. Furthermore, there are no national guidelines for adult ADHD in Italy. The collected data also suggest that there is no a unified practice shared by the Centres both for the patient's transition from child and adolescent to adult mental health services and for the diagnostic-therapeutic process. It is therefore crucial to create specific protocols and develop national guidelines to better identify and diagnose ADHD in adults and provide targeted and more efficient multimodal treatments.

Pathways to care, DUP, and types of interventions over 5years following psychosis onset: findings from a naturalistic study conducted in routine generalist mental health services.

To describe pathways to care, duration of untreated psychosis (DUP), and types of interventions provided to first-episode psychosis (FEP) patients by routine Italian mental health services over 5years since the first service contact. Naturalistic study conducted in Veneto, within the context of the Psychosis Incident Cohort Outcome Study (PICOS). A comprehensive set of measures was used, including schedules designed to collect information on referrals to psychiatric services and on psychological and pharmacological treatments at 1, 2, and 5years since first service contact. Overall, 397 patients were assessed. Most engaged with services with the help of family members (47.4%) and through emergency routes (60.3%). Those referred by clinicians were more likely to access care in a non-emergency way. Mean DUP was 5.62months (SD 11.8) and longer DUP was associated with poorer functioning at 2 and 5years. Interventions provided over 5years were mainly constituted by antipsychotic medications (95.4% at 1year; 85.8% at 2years; 80.6% at 5years), whereas a lower percentage (69.1% at 1year; 61.5% at 2years; 44.9% at 5years) also received some forms of psychological interventions, mainly consisting of unspecific support sessions. Other structured interventions, such as CBT or family interventions, were seldom provided at each time-point. Mental health services in Veneto seem effective in engaging FEP patients within a short time since illness onset. However, type of care provided does not meet quality standards recommended by treatment guidelines, especially regarding psychological interventions.

Recovery in Italy: An Update

:Since the 1990s, a general reflection has gradually evolved in Italy on the effects of the transformation of psychiatry from being mainly institutional to more community-oriented. Increasingly substantial epidemiological studies and processes of outcome evaluations have focused not only on the clinical aspects, but also on the social and functional level (quality of life, care needs, users’ satisfaction for the treatments received). With a certain delay compared to the Anglo-Saxon countries, in recent years, several elements of the concept of recovery have also increasingly emerged in Italy: hope, expectations, self-esteem, self-efficacy, awareness, personal autonomy, and dignity. The present article describes the most relevant experiences conducted in Italy in the latest years developing a recovery-oriented approach in psychiatry, in different areas: methodology, peer support, education, services transformation, and research. In particular, the Italian Study on Recovery (SIR) is described, a research conducted in the “real world” of service-users of Italian mental health services and their family members. Its quantitative part consists of the validation of the Italian translation of the Recovery Assessment Scale (RAS) and its efficacy in identifying persons in recovery (after University of California–Los Angeles [UCLA] criteria). The qualitative research spotlights the experiences and values of services users in recovery and their families. Conclusions focus on the importance of reshaping psychiatric services based on the principles of recovery and on how this transformation should be guided.