Why Mad in Italy?

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!