Author: Alessia Caputo, Clara Morelli.
As in the words of the WHO, mental health is defined as: “A condition in which the individual is able to fulfil himself, to cope with the normal tensions of life, to work productively and to make a contribution to the life of the community”. Mental health is essential for the social fulfilment of the individual and his overall state of health. The importance of this dimension, however, is in contrast with the increase in people suffering from mental health problems in the world. In fact, according to the WHO Mental Health action plan 2013–2020, 1 out of 4 people are affected by a mental disorder in their life, and it is estimated that by 2030 depression will become the leading cause of death. Suicide is the second leading cause of death among young people, and every year they number about 900 thousand. 3 out of 4 people suffering from mental illness do not receive any treatment and are more prone to violations of human rights.
The Italian network
In Italy, the support structure for those suffering from these disorders has been modelled over time starting from the Basaglia law of 1978 (Legge 180), which is a national reform of psychiatric care that took the form of a law. It gives the regions the task of establishing and applying the rules, methods, and time planning. Until that time, the Italian mental health care system involved both community care and mental hospital care (Lora, 2009). The Basaglia law enacted that the community care must be anonymous, resulting in the closure of asylums in Italy. This measure marked a turning point in psychiatric care. Indeed, Italy became the first developed country to rely solely on a community network of mental health facilities (Lora, 2009). Still today, Italy is the only country in the EU in which there are no psychiatric hospitals.
The network of services available to those affected by mental disorders is managed on the territory by different Departments of Mental Health (DSM), whose area of competence is the same as the ASLs.
DSM/DMH is responsible for the planning and management of all medical and social resources to prevent, treat, and rehabilitate patients suffering from mental health diseases within a defined catchment area (Lora, 2009). The Mental Health Centers deal with the most widespread diseases, including depression (23%), schizophrenia and other functional psychosis (20%), and neurotic and somatoform syndromes (13%) (Camilli, 2019). In turn, each DSM is divided into CSM (Mental Health Center for daycare), CD (Semi-residential Day Centers), SR (Residential Facilities) - which in turn comprise the therapeutic-rehabilitation and social rehabilitation - and hospital services, whose services are the SPDC (Psychiatric Diagnosis and Treatment Services) and the DH (Day Hospital).
The Day Center (CD) is a semi-residential structure with therapeutic-rehabilitation functions that allows to implement therapeutic pathways and to experiment and learn skills in self-care in daily life activities and in individual and group interpersonal relationships, also with the aim of job placement (Ministero della Salute, 2020). On the other hand, residential facilities (SR) are extra-hospital facilities in which a part of the therapeutic-rehabilitation and social rehabilitation program takes place. It is personalized for each citizen with psychiatric distress (Ministero della Salute, 2020). These structures aim to offer a network of relationships and emancipatory opportunities, within specific rehabilitation activities (Ministero della Salute, 2020). The SR, therefore, should not be understood as a housing solution. There is also a monitoring system of the Italian mental health system, the Sism (Information System for Mental Health).
A study measuring the impact of the burden of mental disorder in Italy has shown that 2978 disability-adjusted life years (DALYs) per 100 000 can be attributed to neuropsychiatric disorders, adding up to the 25% of the overall burden of disease in the country (Lora, 2009). According to the 2017 Sism report, about 851,000 people needed support, with very different rates: if 80 out of 10,000 inhabitants turned to psychiatric services in Sardinia, in Puglia the figure extends to 230 out of 10,000. The territorial differences could be due to the different management that the individual ASLs implement in the different territories and to the different dissemination of information relating to the services themselves. Another important finding is that the time when the mental disorder seems to affect the most is between 45 and 54 years of age both for men and women. A gender disparity emerges instead in the distinction between pathologies: the number of women suffering from depression is almost double that of men (48 against 29 per 10,000 inhabitants), while men seem to suffer more frequently from schizophrenia, personality disorders, and abuse of substances.
Another dramatic finding is that people with common mental disorders tend to make poor use of health care services. Only one-sixth (16.9%) used health services - 20.7% of those with a mood disorder and 17.3% with an anxiety disorder (Lora, 2009).
How is it funded?
Health care expenditures are one of the major items in the total public spending of all countries across the globe. The 2019 Economic and Financial Document estimated that the amount of health expenditure for 2019 would be 118,061 million euros, accounting for 6.60% of GDP (Osservatorio GIMBE, 2019). As for mental health care planning, the regions are in charge of it. According to a 2018 study by the Italian Society of Psychiatry (Sip), Italy invests only 3.5% of the health budget for the mental health sector, compared with 10–15% in other European countries. This generates major shortcomings in staff and services, which currently have a deficit of operators ranging from 25 to 75 percent below the standard.
Among the reasons that contribute to such an underfunding, rationalization of economic resources played a major role, especially after the 2008 economic crisis. In a framework of limited resources and increasing demand for services, effective planning is fundamental.
Where do we need to improve?
Mental health problems represent an unavoidable challenge that the national public health system has to face. Therefore, a reliable estimate of mental health needs and projections of expected demand are key elements in calibrating and organizing effective services and cost-effective interventions (Starace, 2018). This is particularly relevant when it comes to developing operational models to prevent, detect, and treat common psychiatric disorders.
The problems of the Italian health care network go beyond the organization and coordination of the mental health support system. Indeed, due to the characteristic of this type of disease, continuity of therapy over the years is fundamental. This aspect translates into the need for infrastructure availability, especially in the final phase of the therapy in which there is reintegration into society. In this regard, what emerges is that, despite residential structures being temporary solutions in which the patient lives during the transition phase towards an autonomous life in society, often due to difficulties in social integration these centers become real and own permanent abodes. This is not sustainable. As a consequence, the system is currently supported by the “housing communities” managed by private entities for social purposes.
Among the other challenges, more needs to be done to fight the stigma that is associated with mental diseases. In the absence of effective communication strategies seeking to operate at the community and societal level, health care facilities can do little to ensure true social integration. Additionally, to date, there is a lack of a proper follow-up that tracks individuals over time, which is also essential for the design of policies and the evaluation of their impact.
Another major concern relates to priority setting. Along with funding allocation, successful strategies must account for both ethical and scientific aspects. However, finding a balance between the two is not straightforward. On the one hand, resources should be equally allocated based on specific services plans; on the other hand, patient’s needs, demands, and treatment effects must be addressed properly (Amaddeo, Grigoletti, & Montagnani, 2014). As a consequence, economic strategies should encompass all these critical factors, seeking to boost patients’ satisfaction while staying within the budget boundaries.
It is evident that much more needs to be done to improve the Italian health care network. The first step to take is, though, to stop underestimating the issue. Having suicide and depression rates below the European average (Istituto Nazionale di Statistica: ISTAT, 2017) must not be an excuse for poor investments and policy negligence.
References
Amaddeo, F., Grigoletti, L., & Montagnani, I. (2014). Mental Health Care Financing in Italy. Current Situation and Perspectives. J Nerv Ment Dis;202: 464Y468 Camilli, F. (2019, November 21). Italia, i servizi per la salute mentale in numeri | OggiScienza. OggiScienza. https://oggiscienza.it/2019/11/21/servizi-salute-mentale/ Istituto Nazionale di Statistica: ISTAT. (2017). La salute mentale in Italia: cosa ci dicono i dati dell’Istat. Retrieved from: https://www.istat.it/it/files/2015/10/Salute-mentale_Giorgio-Alleva_2017.pdf Lora, A. (2009). An overview of the mental health system in Italy. Ann. Ist. Super. Sanità. Vol. 45, №1: 5–16 Ministero della Salute. (2020). La rete dei servizi per la salute mentale. Salute.Gov.It. http://www.salute.gov.it/portale/temi/p2_6.jsp?lingua=italiano&id=168&area=salute%20mentale&menu=rete Report Osservatorio GIMBE. (2019). Il definanziamento 2010–2019 del Servizio Sanitario Nazionale. n. 7/2019. Retrieved from https://www.gimbe.org/osservatorio/Report_Osservatorio_GIMBE_2019.07_Definanziamento_SSN.pdf Starace, F. (2018, February 12). Il paradosso della salute mentale: aumenta il disagio ma gli investimenti sono al palo. Sanità24. Retrieved from: https://www.sanita24.ilsole24ore.com/art/aziende-e-regioni/2018-02-12/il-paradosso-salute-mentale-aumenta-disagio-ma-investimenti-sono-palo-125215.php?uuid=AEJCjiyD&refresh_ce=1 WHO (2012). DALYs / YLDs definition. Who.Int. Retrieved from https://doi.org//entity/mental_health/management/depression/daly/en/index.html WHO (2013). Mental health action plan. Who.Int. Retrieved from https://apps.who.int/iris/bitstream/handle/10665/89966/9789241506021_eng.pdf WHO (2018). Mental health definition. Who.Int. Retrieved from https://www.who.int/news-room/fact-sheets/detail/mental-health-strengthening-our-response
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