Italian Mental Health Services: critical issues and challenges in the management of psychosis. Patterns of care in Residential Facilities and treatment of early psychosis: the two sides of the same coin?

In Italy, the law no.180/78 commanded the gradual closure of all Mental Health Hospitals with the development of a nation-wide network of Departments of Mental Health which actually deliver different types of services, among which Community Mental Health Services and Residential Facilities. The aim of this thesis is to touch on two of the main challenges that these two different types of services have to face. On one hand, in recent years some of the Italian Community Mental Health Services have attempted to provide innovative and youth-friendly services, such as early intervention for people at first episode psychosis. The GET-UP PIANO study was set up with the purpose of testing the effectiveness and the efficacy of a multidimensional early intervention for people at first episode psychosis. In the framework of this large trial, part of this thesis is aimed at identifying possible predictors and moderators of treatment outcomes for first episode psychosis patients. Analyses were performed on 444 patients. Education, duration of untreated psychosis, premorbid adjustment and insight predicted outcomes regardless of treatment. Only age at first contact with the services proved to be a moderator of treatment outcome (patients aged 53.5 years had greater improvement in psychopathology), thus suggesting that the intervention is beneficial to a broad array of patients with first episode psychosis. In conclusion, except for patients aged over 35 years, no specific subgroups benefit more from the multi-element psychosocial intervention, suggesting that this intervention should be recommended to all those with first episode psychosis seeking treatment in Community Mental Health Services. Secondly, the problem of managing chronicity in Residential Facilities. The discharge from Residential Facilities remains a critical issue, often also for young patients who, frequently, have high care needs despite having high chances of benefiting from rehabilitative paths. In this context, the aim of the project VALERE was to assess whether specific facilities designed for different groups of patients, targeted their needs. Results showed that ‘Comunità Terapeutico-Riabilitative Protette’, ‘Comunità Alloggio’ and Group Homes, according with their specific mission hosted patients with different characteristics, above all with different clinical profiles. However, some problems still overlapped among the three types of Residential Facilities: the mean length of stay for each group was longer than permitted; the number of people employed was still low also in Group Homes, where patients had a better level of functioning and less psychopathological symptoms. The number of unmet social need was still high for each group. In conclusion, though a big step forward has been taken in the creation of Residential Facilities with specific missions and maximum length of stay, the type of interventions delivered did not seem to fully target patients’ groups needs.