Il percorso di superamento dell’OPG e i suoi effetti nell’applicazione delle misure di sicurezza

Law 180/1978 determined the closure of Psychiatric Hospitals and the transition of public services to a model of community psychiatry in Italy. This change did not affect the Forensic Psychiatric Hospitals, which were closed many years later with Law 81/2014. Twenty years of judgments concerning defendants with substantially diminished or excluded criminal responsibility by reason of insanity are evaluated. The authors analyzed the possible relations between the frequency of the application of psychiatric security measures and the jurisprudential pronouncements and actions by the legislator occurred in the same period. Security measures have increased in a manner not specifically related to a single event among those taken into consideration; in particular, non-custodial measures have risen steadily from 8.5% in 2001 to 88.2% in 2019. The consequences of this trend for the activity of the Departments of Mental Health are discussed, also in light of the ongoing debate on the outcomes of the reform.In Italia la legge 180/1978 determinò la chiusura degli Ospedali Psichiatrici e il passaggio dei servizi pubblici ad un modello di psichiatria di comunità. Tale cambiamento non ha interessato gli Ospedali Psichiatrici Giudiziari che sono stati chiusi molti anni dopo con la legge 81/2014. Gli autori, attraverso l’analisi di 20 anni di sentenze riguardanti persone con vizio parziale o totale di mente, hanno messo a confronto le variazioni della frequenza di applicazioni delle misure di sicurezza psichiatrica con le pronunce giurisprudenziali e gli interventi del legislatore registrati nello stesso periodo. Le misure di sicurezza sono aumentate in maniera non connessa specificatamente a un singolo evento tra quelli presi in considerazione; in particolare quelle di tipo non detentivo sono aumentate costantemente passando dall’8,5% del totale nel 2001 all’88,19% nel 2019. Le conseguenze di questo incremento per l’attività dei Dipartimenti di salute mentale sono discusse, anche alla luce del dibattito in corso sugli esiti della riforma.

Psychiatrists’ attitudes towards functional neurological disorders: results from a national survey

IntroductionFunctional neurological disorder (FND) presents motor, sensory, and cognitive symptoms characterized by clinical signs incongruent with known neurological disease. Together with other health professionals, like neurologists, psychiatrists can play an essential role in diagnosing and managing these disorders. Hence, understanding their opinion and clinical experience with FND is of utmost importance to catch potential educational needs and improve healthcare services for patients. This study aims at assessing the knowledge, opinion, and clinical approach of Italian psychiatrists to FND.MethodsMembers of the Italian Society of Psychiatry completed a 14-item web-based survey investigating their approach to FND. Results. Overall, 174 questionnaires were completed. Our main findings suggest that Italian psychiatrists have a psychogenetic conceptualization of FND. “Conversion disorders”, in fact, is the term most frequently used by Italian psychiatrists to refer to FND, thus implying a psychological etiology of these disorders. Congruently with this view, psychotherapy associated with pharmacological therapy is considered the most appropriate treatment by psychiatrists, while physiotherapy is an under-recognized treatment option for FND.DiscussionThe present study highlights that a psychogenetic view of FND dominates among Italian psychiatrists. This could be due to out-of-date knowledge about the pathophysiology of this group of disorders. Promoting education about novel approaches to FND would be of crucial importance to improving care for patients suffering from this condition

The DUNDRUM ToolKit, Italian version and its potenzial use in the italian forensic treatment model

The legislative process that led to the closure of the Judicial Psychiatric Hospitals (OPG), replaced by theResidences for the Execution of Security Measures (REMS), constituted a significant step forward towardsthe establishment of a community model of care of offenders with severe socially dangerous mental disordersmore respectful of human rights. Among the main criticalities that had been identified in the previous forensicpsychiatric treatment system, based on OPGs, were considered the overcrowding, the problematic hygienic-sanitary conditions, the inexistence of treatment programs that were adequate to the levels of social danger that changed over time, the non-therapeutic-rehabilitative nature of the internment in OPG, the“anti-therapeutic” presence of the Penitentiary Police personnel, the hypothetically unlimited duration ofthe internment. The new model has certainly remedied these critical issues, but other issues have arisen thatneed to be worked on. The authors report here the first data of a multicenter research project that developedon the national territory during the years 2021 and 2022 aimed at validating the DUNDRUM Toolkit, a toolfor evaluating the effectiveness of forensic treatment and recovery, in validation course also in other Europeancountries, particularly adaptable to the treatment model that has been developing in Italy with the establishment of REMS.Il processo legislativo che ha portato alla chiusura degli Ospedali Psichiatrici Giudiziari (OPG), sostituitidalle Residenze per l’Esecuzione delle Misure di Sicurezza (REMS), ha costituito un significativo passo inavanti verso l’istituzione di un modello comunitario di cura degli autori di reato affetti da gravi disturbi mentali socialmente pericolosi più rispettoso dei diritti umani. Tra le principali criticità che erano state ravvisatenel precedente sistema trattamentale psichiatrico forense, basato sugli OPG, sono state considerate il sovraffollamento, le condizioni igienico-sanitarie problematiche, l’insussistenza di programmi trattamentaliche fossero adeguati ai livelli di pericolosità sociale modificantisi nel tempo, la natura non terapeutico-riabilitativa dell’internamento in OPG, la presenza “anti-terapeutica” del personale di Polizia Penitenziaria, ladurata ipoteticamente senza termine dell’internamento. A queste criticità il nuovo modello ha certamenteposto rimedio, ma sono sorte altre problematicità su cui bisognerà lavorare. Gli autori riportano in questasede i primi dati di un progetto di ricerca multicentrico che si è sviluppato sul territorio nazionale nel corsodegli anni 2020-2022 teso a validare il DUNDRUM Toolkit, strumento di valutazione dell’efficacia del trattamento forense e della recovery, in corso di validazione anche in altri Paesi europei, particolarmente adattabile al modello trattamentale che si è andato sviluppando in Italia con l’istituzione delle REMS

Healthcare resource consumption and related costs of patients estimated with treatment-resistant depression in Italy

Purpose: To analyse the healthcare resource consumption and related costs for the Italian National Health System of patients estimated to be affected by treatment-resistant depression (TRD) in Italy. Patients and methods: This was an observational retrospective study based on administrative databases, including those related to residential/semiresidential structures, of Veneto Region and the Local Health Unit of Bergamo in Italy (for a total of around 6 million health-assisted subjects). Between July 2011 and December 2017, all adult patients with a third antidepressant (AD) after ≥2 AD (each one with at least ≥4 weeks duration, ≥1 prescription at maximum dosage reported in datasheets, a grace period ≤30 days when switching AD and treatment maintained ≥9 months) were included. Overall and psychiatry-related healthcare resources consumption and related costs were estimated on a 12-months based analysis. Data were re-proportioned to the Italian population. Results: We have previously estimated a total of 101,455 patients with TRD in Italy (130,049 considering the mean maximum dosage of AD). Of them, 44.2% had at least a psychiatric hospitalization/visit or accessed a residential/semiresidential structure, and 31% added another AD or a mood stabilizer/antipsychotic drug. Patients with at least one psychiatry-related hospitalization increased over the number of antidepressant lines from 12.0% during first line up to 24.5% during fourth line. Direct healthcare costs increased from €4,405 for first line to €9,251 from fifth line onwards. Psychiatry-related costs went from €1,817 (first line) to €4,606 (fifth line onwards) and were mainly driven by residential/semiresidential structures and hospitalizations. Conclusion: An upward trend with number of AD lines was observed for all healthcare resource utilization and consequently for all direct costs, thus indicating an increasing burden for patients as they move forward AD lines

Organisational implementation climate in implementing internet-based cognitive behaviour therapy for depression

Internet-based Cognitive Behaviour Therapy (iCBT) for depression have been implemented in routine care across Europe in varying ways, at various scales and with varying success. This study aimed to advance our understanding of organisational implementation climate from the perspectives of implementers and mental health service deliverers. Qualitative and quantitative methods were combined to study the concept of organisational implementation climate in mental health care settings. Based on concept mapping, a qualitative workshop with implementers was used to conceptualise organisational implementation climate for optimizing iCBT use in routine practice. Service deliverers involved in the provision of iCBT were invited to participate in an explorative cross-sectional survey assessing levels of satisfaction and usability of iCBT, and organisational implementation climate in implementing iCBT. The two methods were applied independently to study viewpoints of implementers as well as service deliverers. Corresponding to the explorative nature of the study, inductive reasoning was applied to identify patterns and develop a reasonable explanation of the observations made. Correlative associations between satisfaction, usability and implementation climate were explored. Sixteen implementers representing fourteen service delivery organisations across Europe participated in the workshop. The top-three characteristics of a supportive organisational implementation climate included: (1) clear roles and skills of implementers, (2) feasible implementation targets, and (3) a dedicated implementation team. The top-three tools for creating a supportive implementation climate included: (1) feedback on job performance, (2) progress monitoring in achieving implementation targets, and (3) guidelines for assessing the impact of iCBT. The survey (n=111) indicated that service providers generally regarded their organisational implementation climate as supportive in implementing iCBT services. Organisational implementation climate was weakly associated with perceived usability and moderately with satisfaction with iCBT services. Organisational implementation climate is a relevant factor to implementers and service deliverers in implementing iCBT in routine care. It is not only an inherent characteristic of the context in which implementation takes place, it can also be shaped to improve implementation of iCBT services. Future research should further theorise organisational implementation climate and empirically validate the measurement instruments such as used in this study. [Abstract copyright: © 2022. The Author(s).

Effectiveness of Self-guided Tailored Implementation Strategies in Integrating and Embedding Internet-Based Cognitive Behavioral Therapy in Routine Mental Health Care: Results of a Multicenter Stepped-Wedge Cluster Randomized Trial

BACKGROUND: Internet-based cognitive behavioral therapy (iCBT) services for common mental health disorders have been found to be effective. There is a need for strategies that improve implementation in routine practice. One-size-fits-all strategies are likely to be ineffective. Tailored implementation is considered as a promising approach. The self-guided integrated theory-based Framework for intervention tailoring strategies toolkit (ItFits-toolkit) supports local implementers in developing tailored implementation strategies. Tailoring involves identifying local barriers; matching selected barriers to implementation strategies; developing an actionable work plan; and applying, monitoring, and adapting where necessary. OBJECTIVE: This study aimed to compare the effectiveness of the ItFits-toolkit with implementation-as-usual (IAU) in implementing iCBT services in 12 routine mental health care organizations in 9 countries in Europe and Australia. METHODS: A stepped-wedge cluster randomized trial design with repeated measures was applied. The trial period lasted 30 months. The primary outcome was the normalization of iCBT delivery by service providers (therapists, referrers, IT developers, and administrators), which was measured with the Normalization Measure Development as a proxy for implementation success. A 3-level linear mixed-effects modeling was applied to estimate the effects. iCBT service uptake (referral and treatment completion rates) and implementation effort (hours) were used as secondary outcomes. The perceived satisfaction (Client Satisfaction Questionnaire), usability (System Usability Scale), and impact of the ItFits-toolkit by implementers were used to assess the acceptability of the ItFits-toolkit. RESULTS: In total, 456 mental health service providers were included in this study. Compared with IAU, the ItFits-toolkit had a small positive statistically significant effect on normalization levels in service providers (mean 0.09, SD 0.04; P=.02; Cohen d=0.12). The uptake of iCBT by patients was similar to that of IAU. Implementers did not spend more time on implementation work when using the ItFits-toolkit and generally regarded the ItFits-toolkit as usable and were satisfied with it. CONCLUSIONS: The ItFits-toolkit performed better than the usual implementation activities in implementing iCBT services in routine practice. There is practical utility in the ItFits-toolkit for supporting implementers in developing and applying effective tailored implementation strategies. However, the effect on normalization levels among mental health service providers was small. These findings warrant modesty regarding the effectiveness of self-guided tailored implementation of iCBT services in routine practice. TRIAL REGISTRATION: ClinicalTrials.gov NCT03652883; https://clinicaltrials.gov/ct2/show/NCT03652883. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s13063-020-04686-4

Tailored implementation of internet-based cognitive behavioural therapy in the multinational context of the ImpleMentAll project: a study protocol for a stepped wedge cluster randomized trial.

BACKGROUND: Internet-based Cognitive Behavioural Therapy (iCBT) is found effective in treating common mental disorders. However, the use of these interventions in routine care is limited. The international ImpleMentAll study is funded by the European Union's Horizon 2020 programme. It is concerned with studying and improving methods for implementing evidence-based iCBT services for common mental disorders in routine mental health care. A digitally accessible implementation toolkit (ItFits-toolkit) will be introduced to mental health care organizations with the aim to facilitate the ongoing implementation of iCBT services within local contexts. This study investigates the effectiveness of the ItFits-toolkit by comparing it to implementation-as-usual activities. METHODS: A stepped wedge cluster randomized controlled trial (SWT) design will be applied. Over a trial period of 30 months, the ItFits-toolkit will be introduced sequentially in twelve routine mental health care organizations in primary and specialist care across nine countries in Europe and Australia. Repeated measures are applied to assess change over time in the outcome variables. The effectiveness of the ItFits-toolkit will be assessed in terms of the degree of normalization of the use of the iCBT services. Several exploratory outcomes including uptake of the iCBT services will be measured to feed the interpretation of the primary outcome. Data will be collected via a centralized data collection system and analysed using generalized linear mixed modelling. A qualitative process evaluation of routine implementation activities and the use of the ItFits-toolkit will be conducted within this study. DISCUSSION: The ImpleMentAll study is a large-scale international research project designed to study the effectiveness of tailored implementation. Using a SWT design that allows to examine change over time, this study will investigate the effect of tailored implementation on the normalization of the use of iCBT services and their uptake. It will provide a better understanding of the process and methods of tailoring implementation strategies. If found effective, the ItFits-toolkit will be made accessible for mental health care service providers, to help them overcome their context-specific implementation challenges. TRIAL REGISTRATION: ClinicalTrials.gov NCT03652883 . Retrospectively registered on 29 August 2018

[Guidelines in psychiatry: clinical and forensic issues]

Treatment guidelines (GL) in psychiatry represent a useful and functional tool to be explored and enhanced in terms of the contribution of patient care and the promotion of scientific improvement. However, they show some limitations, both clinical and forensic. The objective of this paper is to examine the objectives, the clinical limitations and the applicability of the GL on professional liability (forensic aspects). From a clinical point of view, the GL have objectives that are functional to the promotion of physical and mental health, among which the constitutional observance of the right to health, the improvement of public health, the implementation of best clinical practices, the promotion of scientific research, the professional training of operators in the field of physical and mental health. However, GL cannot replace a contextualized clinical judgment. GL must be applied, in the single clinical case, in light of their multiple criticalities, including the limits of the methodology used for their formulation, the differences between the GL' recommendations, the difficulty of their application in daily clinical practice, the lack of specific treatment interventions. From a forensic psychiatric point of view, GL, as currently conceived, cannot be used in terms of professional liability without their interpretation on a legal basis with forensic psychiatric methodology, similarly to any other clinical and scientific information, with its qualifications and criticalities