Why Mad in Italy?

Marcello Maviglia
51
1336

MAD IN ITALY now joins the “MAD Family” to contribute to the diffusion of a critical and constructive approach to mental health, which highlights the often-neglected principles of recovery and psychosocial context contributing to good emotional wellbeing and good quality of life. We are very thankful to Mad in America and James Moore for the encouragement, precious suggestions and assistance regarding the conceptualization, development and rolling out of the MAD IN ITALY site.

Our core team members, in alphabetic order, are: Francesca Bagaglia, psychologist; Laura Guerra, pharmacologist; Marcello Maviglia, psychiatrist and specialist in addiction medicine. Our bio sketches are available under “About”, for those interested. Although we come from different educational backgrounds and experiences, we share a critically constructive outlook towards the field of behavioral health. We hope to stimulate vivacious and provoking thoughts and exchanges among MAD IN ITALY members, visitors, and contributors.

From the inception, it will be clear that we are opposed to the current biological narrowness dominating western psychiatry which has contributed to the marginalization of psychosocial planning and interventions under the misguided notion that pharmacologic treatments for emotional distress are, absolutely safe, reliable, cost-effective and based on undeniable scientific evidence.1 2 In the same vein, we strongly believe that diagnoses in psychiatry do not indicate the presence of a disease, but rather the occurrence of emotional distress, which is steeped in social, cultural and spiritual aspects and therefore requires a fuller and larger narrative than the one based on the mere regulation of neurotransmitters.3

Moreover, it is pivotal to emphasize that the dependence on the biological model has developed in a context of a progressive and profound weakening of the welfare system around the world, including Italy. The two trends act synergistically. In reality, by focusing on alleged biological brain malfunctioning, this model discourages the development of skills and of social networks so necessary for the personal process of recovery from emotional distress. In the same vein, it is arguable that the current reliance on psychiatric diagnosis, psychotropic medications, inpatient treatment and involuntary commitment, has been kindled and sustained by the intersection of ideological and financial forces which are also responsible for the weakening of the social welfare system in promoting health and preventing sickness.4

These dynamics have created a worldwide overpowering process of medicalization of the experience of emotional distress for all age groups, which gets morphed into symptoms and diagnosis during the medical encounter leading to therapies heavily reliant on medications.5 6 Due to the globalization of health care models and practices, the shift towards the medicalization of emotional distress has been felt considerably in Italy, as well, during the last three decades.7

In this context, it is difficult to understand if the Italian mental health system, which currently shows a strong reliance on medications and hospital-based psychiatric services, is gaining consciousness of this involution with concrete planning strategies on the territory, beyond the confines of workshops, conferences walls and publications on the subject.

Unfortunately, the currently available information does not help developing a clear picture of its efficiency in meeting the needs of the community, due to gaps related to data collection, analysis, conflictual opinions and ideological views which are not unique to the Italian mental health system, but are, more or less, common to all the mental health systems in the world.

Although during the last four decades since the implementation of the Mental Health Law number 180, there has been an expansion of mental health services and a degree of consolidation of community-based interventions, a critical look at the data and close attention to the concerns expressed by advocacy groups and consumers strongly suggest that there are problematic gaps in the continuum of care, interfering with good outcomes, including good quality of life.8 9

Expanding on these issues, the data highlight the reliance on pharmacology and inpatient treatments, the utilization of residential facilities for extended services, insufficient staffing level in acute settings, high variability in access to services and quality of care across the different regions.

The SIEP (Italian Society of Psychiatric Epidemiology) 2018 report provides some pivotal data regarding utilization of services which are very relevant to understanding issues related to quality of care: The overall non-planned readmission rate within 30 days for inpatient services is at a level of 17.7% and the outpatient follow up rate after discharge from inpatient treatment within 14 days is about 40%.10 These data are not very reassuring, as they suggest that the system is not focused on providing efficient community-based treatment, as auspicated by the Italian mental health advocate and reformer Dr. Basaglia, the originator of the Law Number 180, which aimed at creating a community-based mental health care system in which the individual with experience of emotional distress would play a central role in deciding the course of personal recovery.

Actually, the data could be interpreted as a failure of the concept of community-based psychiatric care. As already stated, these gaps come along with the overwhelming diffusion of the psychopharmacologic treatment. In fact, the statistics from AIFA (the Italian drug agency) show that circa 12 million Italians are taking psychiatric drugs.

Also, Italy ranks in fourth place among European countries for the number of prescriptions of psychotropic medications.11 In addition, a survey conducted in 2016 by the Mario Negri Institute of Pharmacological Research in Milan found that about four hundred thousand children and adolescents are treated each year for mental disorders by the Italian National Health Service and that between twenty and thirty thousand of them receive psychiatric drugs.12

Moreover, the data on the utilization of psychiatric drugs in Italy are partial and should be read with caution, since they may represent a conservative estimate. In fact, they may not take into account the number of psychiatric drugs obtained without formal prescriptions. Also, there are regional differences in the methodology of data collection which complicate the picture.13 In the same context, the numbers, with all the reservations already expressed above, show substantial regional differences in the utilization of TSO (Involuntary treatment), not following necessarily the distribution of community-based resources on the Italian peninsula. Statistics from 2016 show that in Sicily almost 30 TSOs were executed per 100,000 inhabitants, compared to a national average of 16 per 100,000. Also, Puglia, Sardinia, Calabria and, surprisingly, Emilia-Romagna showed percentages above average.14 In reality, an analysis comparing the reason for regional differences for the rate of utilization of TSO is extremely challenging as the sequence of events leading to an episode are complex and include availability of resources as well as ideological, sociological and cultural factors conspiring to higher or lower utilization rates.

Another pivotal aspect in the comprehension of the full picture is the suicide rate which is recently reported to be around 7 cases per 100,000, with expectable regional differences. Most of the suicide completion is carried out by men (the ratio is 3 to 1 compared to women), between the 45 and 50 age range. However, there are many cases among adolescents and seniors. Suicide rates have been on the rise in recent years, especially in the age range between 24 and 65, probably because of issues related to the economy. It is the second cause of death among young people.15 These data are pretty consistent with global trends, with the due differences and exceptions.

It is worthwhile to observe again that the utilization of these data towards cogent planning would require ongoing analysis, reflections and discussions among experts, providers and individuals with “lived experience” from the different areas and regions of Italy. As far as the author knows, granting that there are frequent forums across the Italian peninsula focusing on mental health issues, there is not a specific venue for this purpose. For instance, although it is clear that an individual in psychological distress has less mental health resources at her/his disposal in Palermo than in Trento, the information currently available does not indicate with certainty that this variance translates to significantly different outcomes.

Paraphrasing Gisella Trincas, national president of UNASAM (National Union of Associations for Mental Health), the real problem with the Italian mental health system is the lack of continuity of care, the absence or scarcity of treatment paths and lack of integration in the delivery of care.16 In the same vein, recovery approaches emphasizing the importance of “lived experience”, social determinant of health, and cultural issues including the emotional health of immigrants, who are exposed to overwhelming traumatic experiences, do not seem to find a proper and definite place in the daily clinical practice and mental health system yet, although they are addressed during interviews, talks, conferences, as already stated for the other pivotal mental health themes. It is worthwhile to stress that the term recovery applies to those individuals who have experienced emotional distress and strive for a meaningful and rewarding existence in which autonomy, dignity and quality of life play an essential role.17

One of the essential assets to a proper process of recovery is the assistance provided by peer specialists, individuals with a history of emotional distress, who have acquired the skills to manage it and are willing to assist others with their process of recovery. Even though Italy has, without a doubt, a respectable tradition regarding the conceptualization and the promotion of recovery-based systems of care (e.g. the principles stated by Basaglia and his team), these have found scattered implementations across the territory, with the exception of some innovative initiatives in several communities where the principles of recovery and the role of the peer specialists find serious consideration for inclusion in the therapeutic milieu.18 19 20

Another positive development in the area of recovery is the ongoing project regarding the “Open Dialogue intervention” aiming at adapting the Finnish Open Dialogue model to the cultural and social reality of the Italian mental health system. The project, which began in March 2015, involves eight Italian mental health departments from six different cities in Italy (Savona, Turin, Trieste, Modena, Rome and Catania).21 The focus of the project is essentially the treatment of psychiatric crises through the prompt and constructive involvement of the family and social networks, which will assist the individual in developing recovery tools to overcome difficulties interfering with the resolution of the crisis and progress in the path of recovery. It will be interesting to see, in case the project will show positive outcomes, how the intervention will be integrated into the delivery of mental health services.

In summary: at the present, although these issues are discussed in multiple venues, a clear shift from a biological and hospital-based model to a community-based system is not happening, although the path was paved a long time ago. In this context, the Italian mental health system, like the majority of them around the world, struggles with accepting a model based on principles of Recovery, which highlights individual and communal mental health needs, social determinants of emotional distress, integration of physical and psychological care and quality of life. As it can be inferred from what has just been said, we will address on MAD IN ITALY critical issues interfering with the shift to a community-based recovery system of care. In our efforts to conduct an honest and transparent alternative scientific discourse, we will post and publish material and information grounded on reliable evidence. This includes qualitative and practice-based evidence reports and studies, which highlight the knowledge developed, refined, and implemented in a variety of real-world settings as opposed to the artificial venues in the context of randomized clinical trials.22

Needless to say, I am referring to the huge role played by the social, cultural, economic, ideological, and political contexts in the development and persistence of emotional distress.23 In this framework, we will emphasize the role of “lived experience” and the testimony of people who live and face daily the reality of emotional distress as a valid and reliable form of practice-based knowledge.24

In conclusion, while understanding that solving the issues of any mental health system is a monumental task, we see the role of MAD IN ITALY as part of constructive dialogue helping the reader to address the experience of emotional distress contextually and, hopefully, to generate debates and initiatives which can stimulate real change. In this perspective, we will welcome posts, articles, blogs, feedback and criticism relevant to the functioning and/or malfunctioning of the Italian mental health system.

THANKS!

Show 24 footnotes

  1. Dr. Breggin’s best overview Critique of psychiatric drugs – Peter Breggin https://breggin.com/dr-breggins-best-overview-critique-of-psychiatric-drugs/
  2. Joanna Moncrieff, The Myth of the Chemical Cure: A Critique of Psychiatric Drug Treatment, 2007, Springer, New York.
  3. Kinderman P, Read J, Moncrieff J, (2013); Drop the language of disorder. Evidence-Based Mental Health; 16:2-3.
  4. The Conversation, How neoliberalism is damaging your mental health, January 30, 2018 (https://theconversation.com/how-neoliberalism-is-damaging-your-mental-health-90565)
  5. Heath I. Commentary, (1999); There must be limits to the medicalisation of human distress. BMJ.; 318:439
  6. P. Thangadurai and K. S. Jacob; (2014) Medicalizing Distress, Ignoring Public Health Strategies Indian J Psychol Med. Oct-Dec; 36(4): 351–354.
  7. Psicopillole. Per un uso etico e strategico dei farmaci (2017) di A. Caputo e R. Milanese Recensione del libro https://www.stateofmind.it/2018/05/psicopillole-caputo-milanese/
  8.  Barbui, C., Papola, D., & Saraceno, B. (2018); Forty years without mental hospitals in Italy. International journal of mental health systems, 12, 43. doi:10.1186/s13033-018-0223-1
  9. Come posso prendermi cura della mia Salute Mentale – AIRInforma, http://informa.airicerca.org/it/2018/04/23/prendermi-cura-salute-mentale/
  10.  SIEP Salute Mentale in Italia La Mappa delle Disuguaglianze http://www.condicio.it/allegati/353/Salute_mentale_Italia_2_2018.PDF
  11.  AIFA homepage http://www.aifa.gov.it/content/trend-consumo-psicofarmaci-italia-2015-2017
  12. Psicofarmaci e minori – Istituto Mario Negri, http://www.marionegri.it/media/sezione_media/rassegna_stampa/rassegna_2015/rs_Psicofarmaci_e_minori.pdf
  13. Cosa ci dicono i dati sul consumo di psicofarmaci in Italia – VICE https://www.vice.com/it/article/neg9dd/dati-sul-consumo-di-psicofarmaci-in-italia
  14. Procedura TSO, legge Basaglia e abusi | Estreme Conseguenze; https://estremeconseguenze.it/2018/12/17/cose-da-pazzi/
  15. Interview with Prof. Maurizio Pompili, In Italia 4000 suicidi l’anno, la metà evitabili – Repubblica.it https://www.repubblica.it/salute/2018/09/10/news/in_italia_4000_suicidi_l_anno_la_meta_evitabili-206050272/
  16. Gisella Trincas su Salute Mentale, OPG e Diritti Umani | Unasam; http://www.unasam.it/gisella-trincas-su-salute-mentale-opg-e-diritti-umani/
  17.  What’s Recovery? SAMHSA’s Working Definition. https://store.samhsa.gov/product/SAMHSA-s-Working-Definition-of-Recovery/PEP12-RECDEF
  18. Peers; https://www.samhsa.gov/brss-tacs/recovery-support-tools/peers
  19. Luigi Basso, Ileana Boggian, Paola Carozza, Dario Lamonaca & Alessandro Svettini (2016) Recovery in Italy: An Update, International Journal of Mental Health, 45:1, 71-88, DOI: 10.1080/00207411.2016.1159891
  20.  Peer working. L’orientatore esperto in supporto fra pari in salute mentale;
    https://www.ausl.re.it/comunicazione/congressi/xiii-settimana-della-salute-mentale-20-settembre-1-ottobre-2018
    .
  21. Raffaella Pocobello, Marcello Macario, Giuseppe Tibaldi (2016) Open Dialogue UK Conference “Towards openness and democracy in mental health services. Open Dialogue and related approaches in the UK and internationally” 2nd February 2016 — Friends House, Euston, London.
  22. Hellerstein D. J. (2008). Practice-based evidence rather than evidence-based practice in psychiatry. Medscape journal of medicine, 10(6), 141.
  23. WHO and the Calouste Gulbenkian Foundation (2014), Social determinants of mental health.
    https://www.who.int/mental_health/publications/gulbenkian_paper_social_determinants_of_mental_health/en/
  24. Louise Byrne, Brenda Happell & Kerry Reid-Searl (2015) Recovery as a Lived Experience Discipline: A Grounded Theory Study, Issues in Mental Health Nursing, 36:12, 935-943, DOI: 10.3109/01612840.2015.1076548

51 COMMENTS

  1. “Our core team members, in alphabetic order, are: Francesca Bagaglia, psychologist; Laura Guerra, pharmacologist; Marcello Maviglia, psychiatrist and specialist in addiction medicine.”

    Not exactly a paradigm shift.

    “I am referring to the huge role played by the social, cultural, economic, ideological, and political contexts in the development and persistence of emotional distress.”

    So am I.

    • Not sure what you’re getting at, Alex? Did you look into their bios? https://mad-in-italy.com/category/chi-siamo/

      “He completed a Master’s Degree in Public Health at the University of New Mexico, and has worked for decades in the mental health sector with a strong interest in cultural aspects and social determinants of health…His main areas of interest are: mental health problems as part of the ‘recovery’ model, research on historical trauma, integration of culturally effective approaches, social determinants of health, coordination and integration of mental and physical health assistance, teaching and supervision of Native American students at the ‘Center for Native American Health’ (University of New Mexico, Albuquerque).”

      “She edited the Italian edition of Peter Breggin’s book ‘Psychiatric drug withdrawal – a manual for prescribers, therapists, patients and their families.'”

      “She carried out an internship at the ASL of Grosseto following a joint project to support victims of violence…She has lectured extensively on issues relating to violence from a psychosocial, family and legal perspective.”

      (from above) “We will emphasize the role of ‘lived experience’ and the testimony of people who live and face daily the reality of emotional distress as a valid and reliable form of practice-based knowledge.”

      • I don’t see anything new in this, it has been claimed repeatedly with absolutely no shift in perspective or power dynamics.

        People with lived experience can “emphasize” themselves and play any role they choose in life. I would not recommend playing a role assigned by mh clinicians in any arena whatsoever because that is inhernently a disempowering and marginalizing role, one way or another, where people tend to get used and sucked dry. There is no need to continue giving away one’s energy and power for the agenda of professionals, unless of course that is a person’s choice and perhaps they don’t see it that way. That is possible, but still, I believe my perspective here is reasonable and well-founded.

        “They” can do what they want and perhaps some good will come for some people who need this support. That’s fine, but I believe it is limited at best without the basic shift in the systemic professional vs. client paradigm–and re “client,” that includes those who are no longer clients but have the lived experience of going through all the crap of psych drugs and withdrawal, along with escaping and healing from systemic abuse and oppression from these very same power dynamics.

        Otherwise, I don’t see how a profesisonal can even begin to match the wisdom or depth of knowledge which one acquires living this, unless of course they have had these very experiences and has processed through them to at least some degree. They are unique kinds of trauma that have to be lived in order to be understood, I’m absolutely certain of this. The truth comes from the FEELING experience of life, not from observing it from the outside. That’s just pure projection. Truth is within, not outside of us, ALWAYS.

        Despite anything, as I said in my original post, this is not a paradigm shift in the slightest, and I don’t see it even as a move in that direction. To me, this is status quo, despite this often stated pledge to “emphasize the role of lived experience.”

        That is not change because the role of the person with “lived experience” still depends on how the clinical team chooses to perceive it. That’s a limiting social program, and not at all the freedom to grow and evolve past the systemic dynamic artificially created and skewed toward the professionals’ interests, at the expense of those with “lived experience.”

        That is a power issue, plain and simple, and is exactly what has been going on and which continues to be problematic in the mh industry.

        The “role” of lived experience is flexible in a community, including the potential for leadership and teacher. That’s where true core change will occur, when lived experience stops being a “role” assigned by a system made up of a group of clinicians, and this community allows people with lived experience to own their wisdom from that experience and create for themselves/ourselves from that very powerful energy, rather than to continue to give their life force away to professional opportunists. That is exactly status quo and where the core problem is as I’ve experienced and seen it over the years.

        So where’s the change here? That’s what I was getting at.

  2. Marcello Maviglia, would you agree that neuroleptics fall under the category of “addictive medicine”? In the sense that it’s extremely difficult to get off them. And, that taking them is not in any way beneficial? Have you ever tried them yourself, to get a first-hand understanding?

  3. Benvenuti nella famiglia MiA, così felice che il popolo italiano sarà in grado di accedere a informazioni veritiere sugli psicofarmaci.

    Laura e Marcello, siete entrambi a conoscenza del fatto che gli antipsicotici / neurolettici, e altri farmaci anticolinergici come gli antidepressivi, possono creare sia i sintomi negativi che quelli positivi della “schizofrenia”?

    I sintomi negativi della “schizofrenia” possono essere creati attraverso la sindrome da deficit neurolettico indotto. E i sintomi positivi, come la psicosi e le allucinazioni, possono essere creati attraverso il toxidrome anticolinergico indotto antipsicotico.

    https://en.wikipedia.org/wiki/Neuroleptic-induced_deficit_syndrome
    https://en.wikipedia.org/wiki/Toxidrome

    Gotta love Google translate, it allows us so called “rude Americans” to try to be polite, as long as it properly translated what I wanted to say. Hopefully it did. Nonetheless, welcome.

    E sono contento di vedere che siete lavoratori della “salute mentale” che sono preoccupati per i sopravvissuti al trauma. Perché qui negli Stati Uniti, i nostri lavoratori della “salute mentale” sembrano essere determinati ad avvelenare tutti i sopravvissuti di abusi sui minori e le loro famiglie, per le nostre religioni non etiche. Per non parlare dell’olocausto psichiatrico di tutti i nostri anziani, con le droghe psichiatriche.

    https://www.youtube.com/watch?v=GNpGe5r0jI0

    You do have to work with Google translate, sometimes it translates things into the opposite of what you’re trying to say. It’s certainly not perfect. Hopefully, that translated properly. Welcome Mad in Italy, the entire world needs to fight against psychiatry’s modern day “reign of error and terror,” and our modern day, all Western civilization, psychiatric “holocaust” of innocents.

    https://www.naturalnews.com/049860_psych_drugs_medical_holocaust_Big_Pharma.html

  4. The Moral Improvement Model is what is being put forward to sustain the Mental Health System, so that survivors will still be oppressed and abused. It is being promoted as the replacement for the Biomedical Model.

    It amounts to Psychiatrists and Psychotherapists duking it out to see who will win the power and prestige, and who will be able to abuse the most survivors.

    The Moral Improvement Model is the underly8ing doctrine behind Psychotherapy.

    The idea is to convince patients that their pains and struggles are all over things which happened long ago, and that this is the only real form of abuse. They are not supposed to see how unfair our world is, how much it depends on lies and denial, and that they are being abused continually, even by the therapist sitting in the arm chair across the office from them.

    The therapist wants them to see their own life affirming anger as the real problem, and of course they are the ones responsible for this.

    We should be putting as many psychotherapists out of business as possible, and we should be severely restricting their access to doing sessions with children.

  5. Marcello all you are doing is saying that survivors are responsible for their own distress. This really is not true.

    “Everybody needs Recovery” is just that mantra of the Evangelical Rick Warren, it is the new version of Original Sin.

    And going back to Freud, Psychoanalysis has worked like this too.

  6. “MAD IN ITALY now joins the “MAD Family” to contribute to the diffusion of a critical and constructive approach to mental health, which highlights the often-neglected principles of recovery and psychosocial context contributing to good emotional wellbeing and good quality of life. ”

    I hope we can marshal all necessary resources and put an end to this “constructive approach to mental health” and the propagation of this idea of “recovery”.

  7. So when you emerge from your therapist’s office, nothing has changed. You are still living with a voided biography, living without honor, because you have not done anything to restore your honor.

    The only way of restoring your honor is to engage with worthy foes and vanquish them. This is how it works in the Parceval Myth. He is always redressing wrongs and vanquishing foes. Even maidens who had been rude, get a suitable rebuke.