Nearly two decades after the Italian government approved a law designed to end forever the warehousing of psychiatric patients in psychiatric hospitals, a new government decree aims to make that goal a reality.

The development was reported in the March issue of Nature Medicine. In 1978 Law 180 was passed with the intent of finding a more humane alternative to the Italian mental institution. Italian legislators saw mental hospitals as inhumane warehouses for the chronically psychiatrically ill and passed the law to establish a right for such patients to be admitted to a general hospital instead of a mental institution.

Much like United States legislation of the 1960's, the Italian law called for comprehensive integrated community services.

Whether or not there has been meaningful progress in fulfilling the goals of Law 180 depends on whom you ask.

According to reporter Martina Ballmaier's account in Nature Medicine, as of the end of last year, only 14 of Italy's 90 mental hospitals had closed, and an estimated 17,000 of the most seriously ill patients remained hospitalized in what she described as "often-decayed buildings." Ballmaier told Psychiatric News that the information was provided by the Italian Institute of Forensic Medicine.

But according to Professor Pier Maria Furlan, M.D., a member of the Italian Society of Psychiatry and director of the two largest remaining mental hospitals, all but 15 of the former mental hospitals have been transformed into "small therapeutic communities" or a variety of other alternatives such as halfway houses or private clinics. In a comment e-mailed to Psychiatric News Furlan said: "That means that we have now 10 facilities running as former mental hospitals belonging to a private [concern] and 15 which have not been transformed and require a strong intervention." The disparity in the data stems from different ways of classifying and defining "psychiatric hospitals," with some surveys including private hospitals and others excluding them, according to Furlan.

Furlan said she is "optimistic, because from the 90,000 [institutionalized patients] in the 1960's we have now 19,000, including those in the private mental hospitals and 15,000 in communities. . . ." Half of those in the various facilities are geriatric or handicapped patients.

The 1978 law was designed to integrate psychiatric care into the national health care system through the creation of a variety of comprehensive psychiatric services at the community level. Without such community-based services, including residences, it will be impossible to close the old mental institutions without imposing even greater hardship on patients and their families, say critics of the new decree.

According to the report by Ballmaier, much remains to be done. But Furlan contends that--unlike what happened with massive deinstitutionalization in the U.S. in the 1960's--Italy has created an extensive network to care for the mentally ill. Although the network was created in a somewhat "irregular way," said Furlan, "we have created in the 1980's a net of facilities, halfway houses, therapeutic communities, and even private clinics and hotels, all funded by our welfare state. Consequently, the problem of the homeless mentally ill is nearly absent in Italy, even if many families have been burdened by dehospitalization."

The decree holds a financial stick over the heads of Italy's regional governments, threatening to cut their share of the National Health Fund by 2 percent if they do not either close their mental hospitals or, if lack of alternatives makes that impossible in the short term, present a concrete plan by this June detailing when and how they will close their hospitals.

This is the first time in modern Italian history that the central government has moved to sanction regions that fail to observe a law, according to Ballmaier. Italy spends between $1 billion and $1.3 billion yearly on psychiatric care, according to Minister of Health Rosy Bindi. Responding to critics of the decree, Bindi urged universities and research centers to become involved by helping define the nature and scope of training to be accorded mental health care workers, and how assistance and treatment should be evaluated.

The Italian Society of Psychiatry has prepared a plan that will be discussed at the general conference of regions this June.

Some Italian psychiatrists are not convinced that the new decree will force compliance, and Pier Luigi Scapicchio, M.D., president of the Italian Society of Psychiatry, told Ballmaier that implementing "assistance services alternatives to mental hospitals is much more important than the construction of new residences itself." Neither the Ministry of Health nor the regions have developed ways to monitor service quality and assess further needs, said Scapicchio. --R.B.K.

(Psychiatric News, April 18, 1997)