The process of care in residential facilities. A national survey in Italy

Background: Although residential facilities (RFs) have largely replaced mental hospitals (MHs) in most developed countries for the long-term residential care of severely impaired patients, the process of care in RFs has not been well studied. The aim of this paper is to investigate the process of care in 265 RFs, representing 19.3% of all RFs in Italy, and to devise a classification of RFs based on process characteristics. Methods: Structured interviews were conducted with the manager and staff of each RF. Residents were evaluated using standardized rating instruments. Results: Most RFs had specific admission criteria, with one third having a waiting list that averaged about 3 months. There was no formal limitation to the length of stay in three quarters of RFs, and turnover rates were very low. Although a homelike atmosphere was found in many RFs, most facilities had restrictive rules on patients' daily lives and behaviours. RFs carried out several external activities targeted at integrating patients within the local community. Standardized assessment instruments and written treatment plans were rarely used. A cluster analysis based on the levels of restrictiveness and the standardization of the process of care classified RFs into five groups that differed with respect to daily staff coverage, size, geographical distribution and proportion of former MH residents. No significant intercluster differences were associated with the current clinical and psychosocial characteristics of residents, or with several other outcome variables. Conclusions: This study provides naturalistic evidence of the heterogeneity of the process of residential care on a large scale. Future efforts should focus on developing an empirical classification of RFs, as well as on national and international standards of care and staffing to address patients' needs

The Italian PROGRES project on non-hospital residential facilities [Le strutture residenziali psichiatriche in Italia. I risultati della fase 1 del progetto PROGRES]

Objective - The 'PROGRES' (PROGetto RESidenze' Residential Project) project has 3 aims: 1. To survey all Italian psychiatric Non-Hospital Residential Facilities (NHRF) (Phase 1); 2. To assess in detail 20% of the NHRFs and the patients living there (Phase 2); and 3. To carry on training programmes for the mental health workers of these facilities (Phase 3). We report here the results of Phase 1. Methods - All NHRFs were surveyed using a structured interview administered to the manager of the facility. In some cases, this information was supplemented with data gathered from other mental health workers at the NHRFs. Results - On May 31, 2000, there were in Italy 1,370 NHRFs with 17,138 beds, giving an average number of beds per facility of 12.5 and a rate of 2.98 beds per 10,000 inhabitants. This rate varies greatly between regions, with a ratio of 1:10 between the two regions with the lowest and the highest bed rates. Seventy-three percent of the NHRFs have a 24-hour staff coverage; more than 50% are directly managed by the NHS Departments of Mental Health and more than three-quarters of the NHRFs are directly funded by the NHS. In the course of 1999 38% of the NHRFs discharged no patients, and another 32% discharged fewer than 3 patients. In about half of the NHRFs the most common patient age group was 40-59 years. In the Italian NHRFs there are 11,240 full-time mental health workers, plus several thousand half-time staff. The average number of full-time mental health workers in each NHRF is 8.2. In 58% of the NHRFs the operational chief is a psychiatrist; some 40% of the overall number of mental health workers in the NHRFs have no specific psychiatric training. The total number of patients resident in the NHRFs is 15,943; among them, 58% have never been admitted to a mental hospital, 40% have been admitted and a small percentage (1.6%) has been previously admitted to a forensic mental hospital. The availability of NHRF beds is negatively associated with the availability of non-hospital facilities (e.g., community mental health centres, day-centres) and positively associated with the number of beds in private psychiatric facilities in each region. Discussion - The current rate of NHRF beds is higher than the officially recommended national standard (2/10,000 inhabitants). However, there is a great variability between regions, which is related to the overall provision of different types of psychiatric facilities. Most NHRFs provide intensive care, and the continuum of residential facilities with different types of care, support, degree of autonomy, etc. recommended by several authors for the long-term treatment of severe patients with different disabilities, seem to be lacking. NHRFs have a very low patient turnover rate, and this may create problems in the future. Conclusions - The PROGRES project is the first national study ever carried out in Italy to evaluate a specific type of psychiatric facilities in the context of the new system of psychiatric care. When all the data will be available, it will be possible to assess in detail for the first time a national representative sample of severe, long-stay patients and the care they are receiving; on this basis, it will also be possible to recommend evidence-based policies aimed at improving the care of the severely mentally ill

Drug prescription in Italian Residential Facilities [La prescrizione di psicofarmaci nelle Strutture Residenziali Italiane]

Aims - To investigate in a representative national sample (N=2,962) of patients living in Residential Facilities (RFs) patterns of polypharmacy as well as related variables, association between diagnoses and therapeutic patterns, and the rate of adverse events. Methods - Structured interviews focusing on each patient were conducted by trained research assistants with the manager and staff of each RF. Patients were rated with the HoNOS and the SOFAS, and comprehensive information about their sociodemographic and clinical status, and their pharmacological regimes were collected. Results - Conventional antipsychotics and second-generation antipsychotics were prescribed to 65% and 43% of the sample, respectively. Benzodiazepines were prescribed to two-thirds of the sample, while antidepressants were the least-used class of psychotropics. Polypharmacy was common: on average, each treated patient was taking 2.7 drugs (\ub11.1); antipsychotic polypharmacy was also common. Many prescriptions were loosely related to specific diagnoses. Antiparkinsonianian drugs were prescribed to approximately 1/4 of the sample. Mild or severe adverse events in the previous month were reported for 9.9% and 1.4% of the sample, respectively. About 15% of patients suffered from tardive dyskinesia. Conclusions - Psychotropic drug prescription patterns for severe patients living in RFs are only sometimes satisfactory and offer the opportunity of improvement. Specific actions are required to improve prescription patterns for severe patients in RFs

N-3 fatty acids in patients with multiple cardiovascular risk factors

BACKGROUND: Trials have shown a beneficial effect of n-3 polyunsaturated fatty acids in patients with a previous myocardial infarction or heart failure. We evaluated the potential benefit of such therapy in patients with multiple cardiovascular risk factors or atherosclerotic vascular disease who had not had a myocardial infarction. METHODS: In this double-blind, placebo-controlled clinical trial, we enrolled a cohort of patients who were followed by a network of 860 general practitioners in Italy. Eligible patients were men and women with multiple cardiovascular risk factors or atherosclerotic vascular disease but not myocardial infarction. Patients were randomly assigned to n-3 fatty acids (1 g daily) or placebo (olive oil). The initially specified primary end point was the cumulative rate of death, nonfatal myocardial infarction, and nonfatal stroke. At 1 year, after the event rate was found to be lower than anticipated, the primary end point was revised as time to death from cardiovascular causes or admission to the hospital for cardiovascular causes. RESULTS: Of the 12,513 patients enrolled, 6244 were randomly assigned to n-3 fatty acids and 6269 to placebo. With a median of 5 years of follow-up, the primary end point occurred in 1478 of 12,505 patients included in the analysis (11.8%), of whom 733 of 6239 (11.7%) had received n-3 fatty acids and 745 of 6266 (11.9%) had received placebo (adjusted hazard ratio with n-3 fatty acids, 0.97; 95% confidence interval, 0.88 to 1.08; P=0.58). The same null results were observed for all the secondary end points. CONCLUSIONS: In a large general-practice cohort of patients with multiple cardiovascular risk factors, daily treatment with n-3 fatty acids did not reduce cardiovascular mortality and morbidity. Copyright © 2013 Massachusetts Medical Society