L’INTEGRAZIONE FUNZIONALE PSICHIATRICO-FORENSE NELLA RISOLUZIONE DELLE “LISTE D’ATTESA”: L’ESPERIENZA DELLA REMS DEL VENETO

The transition from the old model of the Judicial Psychiatric Hospitals to the reformed system of the REMS (territorial residences forthe execution of detention security measures) has produced a decrease of about half the number of places available in Detention SecurityMeasures. Predictably, in these 4 years of operation of the new system, there has been an imbalance between demand and availability ofthese places, thus creating the phenomenon of so-called “waiting lists”. These are subjects already assigned to a custodial measure, whichthey await in prison or in the territory until a place is freed in the REMS.In this paper we will examine how the Veneto regional governmental health system has developed strategies to implement care pathwayswithin the detention security measures circuit during these years. First of all through the drafting of a Memorandum of Understandingbetween the judicial system and the mental health protection system. The first, partial data on the flows indicate the possibility of dealingwith the sustained request for the implementation of custodial Security Measures, as required by Law 81/2014, through a continuouswork to improve the regional network that involves all the interested parties.Il passaggio del vecchio modello degli OPG al riformato sistema delle REMS ha comportato una diminuzione di circa la metà dei postiletto in Misura di Sicurezza detentiva. Com’era prevedibile, in questi 4 anni di esercizio del nuovo sistema, si è venuto a creare unosquilibrio tra domanda e disponibilità di posti letto, venendosi così a creare il fenomeno delle cosiddette liste d’attesa. Si tratta di soggettigià destinati ad una misura detentiva, che attendono in carcere o sul territorio, di poter fare ingresso in REMS. In questo lavoro, esamineremocome il sistema governativo, sanitario e giuridico regionale del Veneto abbia sviluppato nel corso di questi anni strategie di implementazionedei percorsi di cura all’interno del circuito delle misure, attraverso in primo luogo la stesura di un protocollo d’intesa. Iprimi, parziali dati sui flussi indicano la possibilità di far fronte alla sostenuta richiesta di attuazione di Misure di Sicurezza nel rispettodelle indicazioni contenute nella Legge 81/2014, mediante un continuo e necessario lavoro di miglioramento del network regionale checoinvolge tutti gli interlocutori interessati

Quale rapporto tra stile di cure genitoriali, caratteristiche premorbose e presentazione clinica nei pazienti psicotici all\u2019esordio di malattia ?

Scopo: La letteratura che si richiama alla teoria dell\u2019attaccamento ha da tempo evidenziato che il rapporto madre-figlio costituisce una base sicura da cui il bambino parte per fare esperienza del mondo (Bowlby, 1969). La delicata questione del legame genitori-figli e soprattutto la specificit\ue0 della relazione di attaccamento sembra avere un impatto fondamentale, sia nello sviluppo delle relazioni interpersonali che sullo sviluppo della psicopatologia nell\u2019arco della vita (Bowlby 1971, 1973,1980, 1982). Un legame disfunzionale con le figure genitoriali pu\uf2 essere concettualizzato come un evento traumatico di per s\ue9 o agire da fattore di vulnerabilit\ue0 nei confronti degli eventi traumatici di vita. Successivamente a Bowlby, un numero crescente di ricerche ha dimostrato l\u2019associazione tra lo stile di attaccamento insicuro e diverse forme di psicopatologia (Dozier, Stovall & Albus, 1999). Molti autori si sono concentrati sull\u2019approfondimento delle tematiche riguardanti il significato delle relazioni precoci nelle psicosi (Berry et al., 2007, Fairleyet al., 1982; Vaughn & Leff, 1976). Recenti sviluppi di ricerca in quest\u2019ambito hanno permesso di approfondire ulteriormente le possibili implicazioni dell\u2019attaccamento nella psicopatologia e nel trattamento dei disturbi psicotici. Il presente lavoro vuole indagare se uno stile genitoriale disfunzionale si associ a: 1. un peggiore adattamento premorboso 2. una maggiore gravit\ue0 psicopatologica 3. una maggiore disabilit\ue0 sociale. Metodo: Il presente lavoro \ue8 stato condotto all\u2019interno del Progetto PICOS-Veneto (Psychosis Incident Cohort Outcome Study), uno studio multicentrico regionale che ha tra gli obiettivi quello di caratterizzare il decorso delle psicosi all\u2019esordio e sviluppare un modello predittivo dell\u2019esito. Lo studio si svolge su un\u2019area di 3.800.000 abitanti, ed \ue8 uno degli studi pi\uf9 ampi presenti in letteratura. Il periodo di reclutamento \ue8 iniziato nel 2005 ed \ue8 durato fino al 2008. I criteri di inclusione sono stati: et\ue0 compresa tra i 15 ed i 54 anni, risiedere nell\u2019area del Veneto, avere almeno uno dei sintomi positivi della PANSS e/o due sintomi negativi, essere al primo contatto con i servizi psichiatrici, non avere malattie organiche. \uc8 stato ottenuto di volta in volta un consenso informato firmato dal paziente, che includesse anche il permesso di contattare i familiari per la parte relativa alla compilazione delle scale di misura di loro pertinenza. Il Progetto \ue8 realizzato con un disegno longitudinale prospettico, che prevede una serie di valutazioni al baseline, a 1 anno, a 2 anni, a 5 anni ed \ue8 composto da una struttura \u201cmodulare\u201d che si articola su tre differenti aspetti. I soggetti all\u2019esordio sono stati valutati con una serie di strumenti, tra cui il Parental Bonding Instrument (PBI) per la valutazione dello stile genitoriale. L\u2019adattamento premorboso \ue8 stato valutato mediante la Premorbid Adjustment Scale (PAS), la psicopatologia con la Positive and Negative Sindrome Scale (PANSS) e la disabilit\ue0 con la Disability Assessment Schedule (WHO-DAS II). Risultati: Rispetto al campione complessivo PICOS, una sottopopolazione di 249 pazienti ha compilato lo strumento per la valutazione degli stili parentali (PBI) e rappresenta il campione sul quale sono state condotte le analisi della presente trattazione. Come ci si poteva attendere, una differenza significativa \ue8 stata osservata per la nazionalit\ue0, con un tasso di compilazione del PBI nettamente pi\uf9 elevato per i soggetti di nazionalit\ue0 italiana (73.7%) rispetto ai soggetti di nazionalit\ue0 non italiana (48.7%). Per quanto riguarda l\u2019et\ue0 d\u2019esordio e la DUP, \ue8 stata osservata una differenza significativa tra coloro che hanno compilato il PBI e coloro che non l\u2019hanno compilato. Complessivamente sembra di poter concludere che elementi legati ad una predominanza di sintomatologia negativa (et\ue0 d\u2019esordio elevata, DUP lunga e DAS elevata in aree specifiche), si relazionino ad una propensione minore del paziente a fornire informazioni rispetto al legame genitoriale materno. Conclusioni: Il ruolo dello stile di attaccamento potrebbe rivelarsi fin dalle prime fasi dello sviluppo, evidenziando un deficit di funzionamento nei soggetti che abbiano sviluppato uno stile di attaccamento disfunzionale con la figura di riferimento principale. I patterns di attaccamento insicuro (affectionless control) costituiscono la maggioranza del campione ed \ue8 pertanto ragionevole ipotizzare una relazione eziopatologica con le psicosi. Inoltre, abbiamo osservato che la combinazione di accudimento/controllo influisce sul funzionamento nelle prime fasi dello sviluppo. Il gruppo pi\uf9 rappresentativo nel nostro campione \ue8 l\u2019affectionless control, ma molte variabili, sia dell\u2019ambiente familiare, come alti livelli di emotivit\ue0 espressa, che sociale, correlano con la patologia psicotica. I nostri dati confermano l\u2019importanza dello stile di relazione genitoriale, in particolare quello materno, nel condizionare le fasi di vita premorbosa dei pazienti che sviluppano una psicosi e l\u2019importanza, ai fini di prevenzione primaria e secondaria, di avviare iniziative mirate alla genitorialit\ue0.Aims: Attachment theory had a significant impact on research and may help us in understanding the relationship deficit observed in psychotic patients. In the last years, research and clinical practice focused on a critical intervention area represented by early onset psychosis. The psychosis are characterized, since the onset, by symptoms and social disability, by a worsening trend while the disease advances. The attachment patterns are significantly related with the development of psychosis, and they can condition the course and onset of the illness. For instance, different attachment styles during the childhood could influence, on the adulthood, the mode of illness onset and, ultimately, the prognosis. The concept of attachment derives from Bowlby\u2019s attachment theory, which has had considerable impact on research in developmental psychology. Based on the attachment theory, specific bonding patterns in the early life stages may be key factors for the development of mental disorders in the adulthood. Few research has been conducted on the relationship between parental bonding and the development of psychosis. This study aims to evaluate, in first-episode psychosis patients, if a dysfunctional parental style is associated with: 1) a worse premorbid functioning in childhood and adolescence 2) greater severity in psychopathology 3) a worse social disability since the illness onset. Method: Patients were assessed with a set of standardized measures:Parental Bonding Instrument (PBI), the Premorbid Social Adjustment Scale (PSA), the Positive and Negative Syndrome Scale (PANSS) and the Disability Assessment Schedule (WHO-DAS II), to assess, respectively, perception of parental styles, premorbid adjustment, psychopathology and social disability. Parental Bonding Instrument (PBI; Parker et al., 1979; Favaretto et al., 2001), for parental behavoiur and style evaluation About the Parental Bonding Instrument (PBI), the main instrument investigated, it\u2019s a measures the perception of being parented up to the age of 16 years. Low scores on the care dimension and high scores on the overprotection dimension are considered to be risk factors of depression. While the PBI has been shown to be a reliable and valid instrument, the stability of the PBI over extended periods (taking into account individual characteristics and life experience) has yet to be demonstrated. Two scales termed \u2018care\u2019 and \u2018overprotection\u2019 or \u2018control\u2019, measure fundamental parental styles as perceived by the child. The measure is \u2018retrospective\u2019, meaning that adults (over 16 years) complete the measure for how they remember their parents during their first 16 years. The measure is to be completed for both mothers and fathers separately. There are 25 item questions, including 12 \u2018care\u2019 items and 13 \u2018overprotection\u2019 items. Results: according with literature date, in our sample, the affectionless control style, (high protection e low care) is the most representative in the psychotic patients, (n=120 that is the 48.4%). The optimal style called in literature optimal parenting, characterized by high care e low protection, in our sample is reported only by 44 subjects, that are 17.7% . High care\u2019s levels and high protection\u2019s level, characterizing the affectionless control style, are reported by 53 subjects, that\u2019s the 21.4% of our sample. Low care and low protection, negletful parenting style, characterize the 31 subjects, that\u2019s the 12.5% of our sample. The four quadrants of Parker are represented here, considering the cut-off expected in the literature, or 27 for size 13.5 for the care and protection dimensions. Conclusions: This preliminary results seem to confirm the relevance of the maternal care style in conditioning the first phases of premorbid life in the patients that later will develop a psychosis. In our sample, the so called Affectionless Control style seems to characterize high psychopathology levels and disability at the onset, and is associated with more severe symptoms in specific areas. It is important to note that Care dimension, described by Parker, is the common indicator at the bottom of the psychopathology. This preliminary results, suggest the opportunity to start educational programs focusing on parental style. Psychosis vulnerability is a complex puzzle with many parts still unexplored. More research is needed to clarify the role of each single risk factor and the links between them

Predictors of changes in needs for care in patients receiving community psychiatric treatment: a 4-year follow-up study

OBJECTIVE: This study aimed to investigate changes and predictors of change in needs for care, as assessed by both patients and mental health professionals, in a sample of subjects receiving community-based psychiatric care. METHOD: The study was conducted using a 4-year prospective longitudinal design. A cohort of patients from the South-Verona Community Mental Health Service (CMHS) was assessed at baseline and follow-up using the Camberwell Assessment of Need, both staff and patient versions. Predictors of changes in needs were explored using block-stratified multiple regression analyses. RESULTS: An overall stability for both patient-rated and staff-rated needs was found over time; however, significant changes in some specific need domains were found, such as self-rated health needs (improvement), self-rated social needs (deterioration) and staff-rated health needs (deterioration). Changes over time in self-rated and staff-rated needs are influenced by different and specific set of predictors, thus indicating that the two measures are not overlapping and convey different types of information. CONCLUSION: Our data support the adoption of a negotiated approach in which both staff and users' views should be given equal weight when planning and providing needs-led mental health care

Dietary habits and physical activity in first-episode psychosis patients treated in community services. Effect on early anthropometric and cardio-metabolic alterations

People with psychosis often develop metabolic and cardiovascular disorders, due to several factors including unhealthy lifestyle and antipsychotic treatment. This study aims to evaluate in a sample of first episode psychosis (FEP) patients lifestyle factors, with a specific emphasis on dietary habits and physical activity, and cardio-metabolic and anthropometric profile at illness onset and at 9 months. Moreover, this study aims to evaluate the impact of lifestyle factors on short term changes in cardio-metabolic and anthropometric profile. A 9-month follow-up study was conducted on a sample of 96 FEP patients recruited within the context of the GET UP program. Standardised assessments of dietary habits (EPIC) and physical activity (IPAQ) were retrospectively performed at 9 months; cardiovascular measures (blood pressure, heart rate), metabolic parameters (glucose, cholesterol, triglycerides), BMI and antipsychotic treatment were assessed at illness onset and at 9 months. We found that most FEP patients (60%) displayed poor dietary habits, as defined in terms of adherence to the Mediterranean diet. A significant increase for both BMI and cholesterol levels was found in the overall sample over 9 months. However, when considering the effect of lifestyle factors, BMI and total cholesterol were specifically raised in patients with low adherence to Mediterranean diet. The association with antipsychotic medication was found for SGA only, with a significant increase in both BMI and total cholesterol overtime. Our findings confirm the need to implement specific and early strategies to promote healthy lifestyle in people with FEP, since metabolic alterations occur within the first months of treatment

The influence of gender on clinical and social characteristics of patients at psychosis onset: A Report from the Psychosis Incident Cohort Outcome Study (PICOS)

BACKGROUND: This paper examined the hypothesis that males with first-episode psychosis (FEP) experience lower pre-morbid adjustment, greater social disability and more self-perceived needs at illness onset than females (by controlling for duration of untreated psychosis, diagnosis, age and symptoms at onset). Results disconfirming this hypothesis were thought to suggest the potentially mediating role of social context in determining the impact of symptoms and disability on the everyday lives of male patients in the early phase of psychosis.MethodA large epidemiologically representative cohort of FEP patients (n=517) was assessed within the Psychosis Incident Cohort Outcome Study (PICOS) framework - a multi-site research project examining incident cases of psychosis in Italy's Veneto region.RESULTS: Despite poorer pre-morbid functioning and higher social disability at illness onset, males reported fewer unmet needs in the functioning domain than females did. An analysis of help provided by informal caregivers showed that males received more help from their families than females did. This finding led us to disconfirm the second part of the hypothesis and suggest that the impact of poorer social performance and unmet needs on everyday life observed in male patients might be hampered by higher tolerance and more support within the family context.CONCLUSIONS: These findings shed new light on rarely investigated sociocultural and contextual factors that may account for the observed discrepancy between social disability and needs for care in FEP patients. They also point to a need for further research on gender differences, with the ultimate aim of delivering gender-sensitive effective mental health care

The acceptability of the NICE recommendations for schizophrenia in the Italian Departments of Mental Health. The SIEP-DIRECT'S Project on the discrepancy between routine practice and evidence.

AIMS: This paper aims at presenting the most significant results emerging from the work carried out by the focus groups of the multi-centre Project SIEP-DIRECT'S. The Project is aimed at assessing the existing discrepancies between the evidence-based NICE guidelines for schizophrenia and the usual practices of care given by Italian mental health services. Each focus group was requested to give an evaluation on: (a) appropriateness of the English NICE guidelines in the context of the Italian mental health services; (b) clarity and usefulness of the 103 indicators developed on the basis of the NICE recommendations to measure their level of application within the services. METHODS: In each of the 19 mental health departments or psychiatric services participating in the Project there were organized "multidisciplinary" focus groups and "specialistic" focus groups. The former included, amongst others, professional operators of the mental health services, patients, their relatives, representatives of patient organizations and general practitioners. They examined the recommendations and indicators upon which the participants could express their opinion or judgment based on their knowledge, experience or information in their possession. The latter group, composed only of psychiatrists, examined the recommendations and indicators relative to pharmacological treatments that regarded the specific competences of their professional category. RESULTS: Most NICE recommendations seemed appropriate to the working context of the Italian services. However, some perplexity emerged as regards specific organizational models of the services, such as the specific services for psychotic onsets or the assertive outreach teams, which were believed not to be strictly pertinent to the traditional organization of mental health care in our Country. There were also some criticisms regarding the cognitive-behavioural treatments which the NICE Guidelines recommend as the principle psychotherapeutic option for patients with schizophrenia, since in many Italian services, when the use of psychological interventions are needed, the tendency is to prefer interventions based on psychodynamic theories. The SIEP indicators were generally held to be clear and acceptable. CONCLUSIONS: In the view of the focus groups, the NICE guidelines are on the whole useful and suitable for orientating the services in the choice of more efficacious practices in the treatment of patients with schizophrenia. Moreover, the results obtained legitimate the use of the set of SIEP indicators for the evaluation of good practices and the quality of care offered by Italian services. Finally, the use of focus groups delines to a different context as well as the verification of the comprehensibility and applicability of SIEP indicators

Feasibility and Effectiveness of a Multi-Element Psychosocial Intervention for First-Episode Psychosis: Results From the Cluster-Randomized Controlled GET UP PIANO Trial in a Catchment Area of 10 Million Inhabitants.

Integrated multi-element psychosocial interventions have been suggested to improve the outcomes of first-episode psychosis (FEP) patients, but they have been studied primarily in experimental settings and in nonepidemiologically representative samples. Thus, we performed a cluster-randomized controlled trial, comparing an integrated multi-element psychosocial intervention, comprising cognitive behavioral therapy, family intervention, and case management, with treatment as usual (TAU) for FEP patients in 117 community mental health centers (CMHCs) in a large area of northern Italy (10 million inhabitants). The randomized units (clusters) were the CMHCs, and the units of observation the patients (and, when available, their family members). The primary hypotheses were that add-on multicomponent intervention: (1) results in greater improvements in symptoms, as assessed with positive and negative syndrome scale and (2) reduces in-hospital stay, based on days of hospitalization over the 9-month follow-up. Four hundred and forty-four FEP patients received the intervention or TAU and were assessed at baseline and 9 months. Based on the retention rates of patients (and families) in the experimental arm, multi-element psychosocial interventions can be implemented in routine mental health services. Regarding primary outcomes, patients in the experimental arm showed greater reductions in overall symptom severity, while no difference could be found for days of hospitalization. Among the secondary outcomes, greater improvements were detected in the experimental arm for global functioning, emotional well-being, and subjective burden of delusions. No difference could be found for service disengagement and subjective burden of auditory hallucinations. These findings support feasibility and effectiveness of early interventions for psychosis in generalist mental health services

A multi-element psychosocial intervention for early psychosis (GET UP PIANO TRIAL) conducted in a catchment area of 10 million inhabitants: study protocol for a pragmatic cluster randomized controlled trial

Background Multi-element interventions for first-episode psychosis (FEP) are promising, but have mostly been conducted in non-epidemiologically representative samples, thereby raising the risk of underestimating the complexities involved in treating FEP in \u2018real-world\u2019 services. Methods/Design The Psychosis early Intervention and Assessment of Needs and Outcome (PIANO) trial is part of a larger research program (Genetics, Endophenotypes and Treatment: Understanding early Psychosis - GET UP) which aims to compare, at 9\u2009months, the effectiveness of a multi-component psychosocial intervention versus treatment as usual (TAU) in a large epidemiologically based cohort of patients with FEP and their family members recruited from all public community mental health centers (CMHCs) located in two entire regions of Italy (Veneto and Emilia Romagna), and in the cities of Florence, Milan and Bolzano. The GET UP PIANO trial has a pragmatic cluster randomized controlled design. The randomized units (clusters) are the CMHCs, and the units of observation are the centers\u2019 patients and their family members. Patients in the experimental group will receive TAU plus: 1) cognitive behavioral therapy sessions, 2) psycho-educational sessions for family members, and 3) case management. Patient enrolment will take place over a 1-year period. Several psychopathological, psychological, functioning, and service use variables will be assessed at baseline and follow-up. The primary outcomes are: 1) change from baseline to follow-up in positive and negative symptoms\u2019 severity and subjective appraisal; 2) relapse occurrences between baseline and follow-up, that is, episodes resulting in admission and/or any case-note records of re-emergence of positive psychotic symptoms. The expected number of recruited patients is about 400, and that of relatives about 300. Owing to the implementation of the intervention at the CMHC level, the blinding of patients, clinicians, and raters is not possible, but every effort will be made to preserve the independency of the raters. We expect that this study will generate evidence on the best treatments for FEP, and will identify barriers that may hinder its feasibility in \u2018real-world\u2019 clinical settings, patient/family conditions that may render this intervention ineffective or inappropriate, and clinical, psychological, environmental, and service organization predictors of treatment effectiveness, compliance, and service satisfactio