La pena y la cura. Servicios de salud mental en Italia después del cierre de los hospitales psiquiátricos judiciales

El artículo describe el proceso de reforma que tuvo lugar en Italia con el cierre de los seis hospitales psiquiátricos judiciales del país y su sustitución por pequeñas unidades forenses. El uso de los hospitales judiciales se regía por la exclusión de los juicios de las personas con enfermedades mentales graves que dificultaban el ejercicio de su capacidad, las cuales, si eran declaradas "socialmente peligrosas", eran sometidas a un sistema de "medidas de seguridad”. Este cambio significativo, que se llevó a cabo a través de los Ministerios de Salud y de Justicia, y de las Regiones, ocurrió en Italia entre 2011 y 2017, y se entiende como el paso final del proceso de reforma en la atención de la salud mental que comenzó en 1978 y culminó con el cierre completo de todos los hospitales psiquiátricos en 1999.Las nuevas pequeñas unidades forenses/judiciales, con un número limitado de camas para todo el país, se denominan REMS (Residencias para la Ejecución de Medidas de Seguridad). Están gestionadas por las Regiones y se basan en los principios de orientación terapéutica y de recuperación, respuesta transitoria y territorial, y responsabilidad de los servicios de salud mental de la comunidad para facilitar el alta. Las formas de aplicación de la ley en lo que respecta a las características de las REMS fueron diversas, por ejemplo, gestión pública o privada, número de camas, política de puertas abiertas, inclusión en los departamentos de salud mental con fines de prevención y provisión de alternativas por parte de los servicios comunitarios de salud mental. Experiencias significativas, como la de Trieste y la región de Friuli Venezia Giulia, interpretan esta reforma en función del papel que desempeñan los servicios públicos de salud mental en la prevención de delitos mediante una respuesta rápida y eficaz a las crisis, estableciendo vías de atención personalizadas y apoyando a sus pacientes dentro de la prisión y en el sistema judicial. Todavía existe un difícil equilibrio con el sistema judicial y penitenciario, que a menudo hace hincapié en el confinamiento y la función "de custodia" en las REMS como novedoso sustituto de los antiguos hospitales judiciales y ejerce una presión constante para ampliar el uso y la disponibilidad de sus camas en cuanto a las medidas de seguridad temporales, incluido el desvío de personas de las prisiones a las REMS.El riesgo de una reacción contra la reforma ha sido frenado recientemente por la Corte Constitucional, pero persiste un duro debate sobre el futuro de las REMS. Los cambios más radicales y coherentes, según los instrumentos internacionales para la protección de los derechos humanos, solo pueden realizarse con nuevos cambios legislativos, abandonando los conceptos de incapacidad y peligrosidad, que siguen siendo pilares del Código Penal. El artículo ofrece datos generales recientes, prácticas pioneras, observaciones críticas y termina con indicaciones para el cambio en las políticas y las prácticas

A Tale of Two Cities: The Exploration of the Trieste Public Psychiatry Model in San Francisco

According to the World Health Organization (WHO), the “Trieste model” of public psychiatry is one of the most progressive in the world. It was in Trieste, Italy, in the 1970s that the radical psychiatrist, Franco Basaglia, implemented his vision of anti-institutional, democratic psychiatry. The Trieste model put the suffering person—not his or her disorders—at the center of the health care system. The model, revolutionary in its time, began with the “negation” and “destruction” of the traditional mental asylum (‘manicomio’). A novel community mental health system replaced the mental institution. To achieve this, the Trieste model promoted the social inclusion and full citizenship of users of mental health services. Trieste has been a collaborating center of the WHO for four decades with a goal of disseminating its practices across the world. This paper illustrates a recent attempt to determine whether the Trieste model could be translated to the city of San Francisco, California. This process revealed a number of obstacles to such a translation. Our hope is that a review of Basaglia’s ideas, along with a discussion of the obstacles to their implementation, will facilitate efforts to foster the social integration of persons with mental disorders across the world

Study protocol for the development of a European measure of best practice for people with long term mental health problems in institutional care (DEMoBinc)

Background: This study aims to build a measure for assessing and reviewing the living conditions, care and human rights of people with longer term mental health problems in psychiatric and social care institutions. Protection of their human rights is imperative since impaired mental capacity secondary to mental illness can make them vulnerable to abuse and exploitation from others. They also constitute a major resource pressure for mental health services, social services, informal carers and society as a whole.Methods/Design:domains are identified by collating results from: i) a systematic review of the literature on institutional care for this service user group; ii) a review of the relevant care standards in each participating country; iii) Delphi exercises in partner countries with mental health professionals, service users, carers and advocates. Common domains and cross-cutting themes are agreed by the principal researchers and an international expert panel. Items are developed to assess these domains and incorporated into the toolkit which is designed to be administered through a face to face interview with the institution's manager. The toolkit is refined in response to inter-rater reliability testing, feedback from interviewers and interviewees regarding its utility, and feedback from key stakeholders in each country about its ability to deliver information that can be used within each country's established systems for quality assessment and review. Cross-validation of the toolkit ratings against service users' quality of life, autonomy and markers of recovery tests whether it can deliver a proxy-measure of the service users' experiences of care and the institution's promotion of their human rights and recovery. The ability of the toolkit to assess the "value for money" delivered by institutions is investigated by comparing toolkit ratings and service costs.The study will deliver the first international tool for the assessment of the quality of institutional care for people with longer term mental health problems that is accurate, reliable, informative, useful and easy to use

Quality of care and its determinants in longer term mental health facilities across Europe; a cross-sectional analysis.

BACKGROUND: The Quality Indicator for Rehabilitative Care (QuIRC) is an international, standardised quality tool for the evaluation of mental health facilities that provide longer term care. Completed by the service manager, it comprises 145 items that assess seven domains of care: living environment; treatments and interventions; therapeutic environment; self-management and autonomy; social interface; human rights; and recovery based practice. We used the QuIRC to investigate associations between characteristics of longer term mental health facilities across Europe and the quality of care they delivered to service patients. METHODS: QuIRC assessments were completed for 213 longer term mental health units in ten countries that were at various stages of deinstitutionalisation of their mental health services. Associations between QuIRC domain scores and unit descriptive variables were explored using simple and multiple linear regression that took into account clustering at the unit and country level. RESULTS: We found wide variation in QuIRC domain scores between individual units, but across countries, fewer than a quarter scored below 50 % on any domains. The quality of care was higher in units that were smaller, of mixed sex, that had a defined expected maximum length of stay and in which not all patients were severely disabled. CONCLUSIONS: This is the first time longer term mental health units across a number of European countries have been compared using a standardised measure. Further use of the QuIRC will allow greater understanding of the quality of care in these units across Europe and provide an opportunity to monitor pan-European quality standards of care for this vulnerable patient group

Quality of Longer Term Mental Health Facilities in Europe: Validation of the Quality Indicator for Rehabilitative Care against Service Users’ Views

BACKGROUND: The Quality Indicator for Rehabilitative Care (QuIRC) is a staff rated, international toolkit that assesses care in longer term hospital and community based mental health facilities. The QuIRC was developed from review of the international literature, an international Delphi exercise with over 400 service users, practitioners, carers and advocates from ten European countries at different stages of deinstitutionalisation, and review of the care standards in these countries. It can be completed in under an hour by the facility manager and has robust content validity, acceptability and inter-rater reliability. In this study, we investigated the internal validity of the QuIRC. Our aim was to identify the QuIRC domains of care that independently predicted better service user experiences of care. METHOD: At least 20 units providing longer term care for adults with severe mental illness were recruited in each of ten European countries. Service users completed standardised measures of their experiences of care, quality of life, autonomy and the unit's therapeutic milieu. Unit managers completed the QuIRC. Multilevel modelling allowed analysis of associations between service user ratings as dependent variables with unit QuIRC domain ratings as independent variables. RESULTS: 1750/2495 (70%) users and the managers of 213 units from across ten European countries participated. QuIRC ratings were positively associated with service users' autonomy and experiences of care. Associations between QuIRC ratings and service users' ratings of their quality of life and the unit's therapeutic milieu were explained by service user characteristics (age, diagnosis and functioning). A hypothetical 10% increase in QuIRC rating resulted in a clinically meaningful improvement in autonomy. CONCLUSIONS: Ratings of the quality of longer term mental health facilities made by service managers were positively associated with service users' autonomy and experiences of care. Interventions that improve quality of care in these settings may promote service users' autonomy