Aims – To obtain a new, well-balanced mental health funding system, through the creation of i) a list of psychiatric interventions provided by Italian Community-based Psychiatric Services (CPS), and associated costs; ii) a new prospective funding system for patients with a high use of resources, based on packages of care. Methods – Five Italian Community-based Psychiatric Services collected data from 1250 patients during October 2002. Socio-demographical and clinical characteristics and GAF scores were collected at baseline. All psychiatric contacts during the following six months were registered and categorised into 24 service contact types. Using elasticity equation and contact characteristics, we estimate the costs of care. Cluster analysis techniques identified packages of care. Logistic regression defined predictive variables of high use patients. Multinomial Logistic Model assigned each patient to a package of care. Results – The sample's socio-demographic characteristics are similar, but variations exist between the different CPS. Patients were then divided into two groups, and the group with the highest use of resources was divided into three smaller groups, based on number and type of services provided. Conclusions – Our findings show how is possible to develop a cost predictive model to assign patients with a high use of resources to a group that can provide the right level of care. For these patients it might be possible to apply a prospective per-capita funding system based on packages of care.

Declaration of Interest: None

Aim – To develop predictive models to allocate patients into frequent and low service users groups within the Italian Community-based Mental Health Services (CMHSs). To allocate frequent users to different packages of care, identifing the costs of these packages. Methods – Socio-demographic and clinical data and GAF scores at baseline were collected for 1250 users attending five CMHSs. All psychiatric contacts made by these patients during six months were recorded. A logistic regression identified frequent service users predictive variables. Multinomial logistic regression identified variables able to predict the most appropriate package of care. A cost function was utilised to estimate costs. Results – Frequent service users were 49%, using nearly 90% of all contacts. The model classified correctly 80% of users in the frequent and low users groups. Three packages of care were identified: Basic Community Treatment (4,133 Euro per six months); Intensive Community Treatment (6,180 Euro) and Rehabilitative Community Treatment (11,984 Euro) for 83%, 6% and 11% of frequent service users respectively. The model was found to be accurate for 85% of users. Conclusion – It is possible to develop predictive models to identify frequent service users and to assign them to pre-defined packages of care, and to use these models to inform the funding of psychiatric care.

Objective – The study aims to identify the predicting factors of hospitalization in patients who come in Emergency Room with psychiatric symptoms. Method – Cross-sectional study using data collected by E.R. of S.Gerardo Hospital in Monza from 1st of June 1995 to 31 May 1997. Inclusion criteria were age older than 18 and the need for psychiatric evaluation. The influence on disposition decision of demographic, clinical and service variables were assessed. Main outcome measures – Data were collected by a questionnaire designed for the study and administered by a trained psychiatrist. Statistical analysis was performed by univariate analysis and logistic regression. Results – 2076 cases were evaluated. Univariate analysis yielded higher odds of hospitalization for patients between 39 and 48 years of age, unmarried, unemployed, affected by schizophrenia, mood disorders or personality disorders. A linear trend was reported between hospitalization and severity of illness, siucide risk and aggressivness. While anxiety proved to be a protective factor, hallucination, delusion, lack of insight, psychomotor inhibition, agitation, confusion, destructive behaviour, odd behaviour, abnormal consciousness and previous hospitalization increase inpatient disposition. On Monday and Friday higher frequency of hospitalization was observed. Logistic regression confirm the role of age, symptoms, aggressive behaviour, severity of illness, suicide risk, and, among services variables, days of the week. Conclusion – Clinical variables proved to be the main predictors of hospitalization, and an important role is played by the availability of outpatients services: hospitalization was more frequent in the days closer the week-end, when the outpatient services are closed.

Objective – Two forms of early intervention in psychosis are currently being proposed — intervention before the onset of illness with at-risk individuals and intervention after the onset of psychosis. Method – The risks and potential benefits associated with these two approaches were examined using published data and Bayes probability theorem. Results -Claims for benefits from early intervention in established psychosis go back more than two hundred years to the nineteenth-century advocates for asylum construction. Theoretical support for early intervention in psychosis rests on data suggesting that a longer duration of untreated psychosis (DUP) is associated with poor outcome. The association of DUP with outcome, however, appears to be inseparable from the confounding influence of the good outcome expected in recent-onset psychosis. Although some researchers advocate treating people with premorbid features of psychosis or other high-risk indicators, adequate screening measures and effective interventions are not yet available. The most promising current screening measure, if applied to the general population, would be accurate only two percent of the time. The accuracy of these measures can be improved by screening only those patients who are referred to a clinic, but this strategy will result in many cases in the population-at-large being overlooked. Discussion – The risks and potential benefits associated with the two early intervention approaches are very different. The provision of optimal treatment early in psychosis could produce benefits, but people with brief, good-prognosis psychotic episodes are likely to receive unnecessary treatment. Screening the general population or patients referred to a clinic will have little public health impact on the incidence of schizophrenia. There is likely to be considerable negative impact on those who are inaccurately labeled as being at imminent risk of psychosis and are treated accordingly.

Objective – The analysis aims to study the packages of care in the public Departments of Mental Health by diagnosis and service utilisation intensity. Design – Data on community, hospital and residential contacts were provided by the Regional Psychiatric Information System. The sample has been composed by 55518 patients residents in Lombardy and treated in public Departments of Mental Health. Setting – The public Departments of Mental Health in Lombardy. Main outcome measures – Fifteen packages of care were defined according to researchers' experience; the package “community care only” has been divided in five sub–packages; for every package the care weight has been attached. Results – Four packages of care (“community care only”, “hospital care plus community care”, “hospital care only” “community care plus day centre care”) represented 95% of the patients. Three quarter of the patients were treated only in the community setting, without hospital, residential and day centre contacts in the year. Heavier patients (patients with more than 5000 care weight) represent only 4%. Residential care is the heavier setting (36% of the total weight), while schizophrenia is the diagnosis with mayor impact on the community services (59% of the total weight). Of the patients treated only in the community setting one third receives only psychological and psychiatric visits, while two thirds integrated community care. Conclusions in community care the mixed packages represent the exception not the rule. More complex or heavier packages are addressed to severe mental illness patients.

Objective - After a review of recent developments in the economic evaluation of mental health care, the study described in this paper suggests a methodology for the measurement and evaluation of costs in the Italian psychiatric system. Method and results - To conduct such an evaluation it is necessary to identify all relevant services, collect data on patients' receipt or utilization of health services (direct costs) and other services and resources within the socio- economic system (indirect costs), and to attach monetary values for the costs. A detailed unit cost list (LICU) was constructed for facilities available at South-Verona Community Psychiatric Service (CPS), as well as in many other community-based psychiatric services in Italy. This list covers psychiatric services, other public and private health services, criminal justice services, voluntary organisations and self-help groups. The procedure for calculating costs in three of these facilities (hospital inpatient service, psychiatric outpatient service and rehabilitation groups) are described in this paper in detail. A new instrument (ICAP) was developed to collect the data required to calculate the costs of community care for individual patients. In order to check the applicability and comprehensibility of the instrument, and the time ne- eded for its administration, the ICAP was tested with five patients. Conclusions - It will be interesting to utilise ICAP and LICU in a larger sample. The methodology described here would provide the basis for epidemiologically-based studies, as well as exploration of the factors which predict cost differences (such as socio-demographic characteristics, diagnosis, psychiatric history, ecc). It is important to emphasise the insights for policy and practice which can flow for the merged examination of costs, needs and outcomes. This research is presently in progress in South-Verona.

Aims – It used to be thought that the problems of psychosis were qualitatively difference from those of other disorders and therefore unamenable to psychological interventions. However more recent evidence will be summarised which suggests otherwise. Methods – A cognitive model of the positive symptoms of psychosis (Garety et al, 2001; Kuipers et al.,2006) is described which builds on work on the dimensions of symptoms of psychosis, the continuum between non-clinical and clinical populations, and the contribution of emotional processes, cognitive reasoning biases and social factors. Results – Evidence from both epidemiological and empirical studies from our research group and others, support some of the pathways of symptom formation and maintenance proposed by the model. Specifically there is evidence for the role of trauma, social adversity and stress. These may trigger emotional responses and unusual experiences and together with reasoning biases lead to appraisals that can be defined as positive symptoms such as delusions and hallucinations. Similar processes interact to maintain symptoms. Conclusions – Cognitive models of psychosis have led to the development of cognitive behavioural treatments for delusions and hallucinations, which show some evidence of efficacy. Such treatments need to be refined in the light of recent research.

Declaration of Interest: none

Aggressive or antisocial behaviours with violations of social rules are the main features of disruptive behaviour disorders (DBDs), which are developmental diseases and include conduct disorder and oppositional defiant disorder. In the last decade, several efforts have been made to shed light on the biological underpinnings of DBDs. In this context, the main findings of functional magnetic resonance imaging studies in DBD are reported here. There are indications of neural dysfunctions in response to affective stimuli, especially regarding medial and orbitofrontal prefrontal cortex and connected subcortical structures.

There has been recent debate regarding the efficacy of electroconvulsive therapy in the treatment of depression. This has been based on narrative reviews that contradict existing systematic reviews and meta-analyses. In this special article, we highlight the mistakes that occur when interpreting evidence using narrative reviews, as opposed to conventional systematic reviews and meta-analyses.

Randomized controlled trials (RCTs), typically, randomize participants to one of two intervention groups. It has been shown, however, that about 25% of RCTs published in the scientific literature randomize participants to three or more treatment groups. These studies are called ‘multi-arm’ trials: there may be, for instance, two or more experimental intervention groups with a common control group, or two control intervention groups such as a placebo group and a standard treatment group. A special case of multi-arm studies are factorial trials, which address two or more intervention comparisons carried out simultaneously, using four or more intervention groups.

Aims — This study had two objectives: 1) to design and develop a computer-based tool, called Multi-Objective Evolutionary Algorithm/Hot-Spots (MOEA/HS), to identify and geographically locate highly autocorrelated zones or hot-spots and which merges different methods, and 2) to carry out a demonstration study in a geographical area where previous information about the distribution of schizophrenia prevalence is available and which can therefore be compared. Methods — Local Indicators of Spatial Aggregation (LISA) models as well as the Bayesian Conditional Autoregressive Model (CAR) were used as objectives in a multicriteria framework when highly autocorrelated zones (hot-spots) need to be identified and geographically located. A Multi-Objective Evolutionary Algorithm (MOEA) model was designed and used to identify highly autocorrelated areas of the prevalence of schizophrenia in Andalusia. Hot-spots were statistically identified using exponential-based QQ-Plots (statistics of extremes). Results — Efficient solutions (Pareto set) from MOEA/HS were analysed statistically and one main hot-spot was identified and spatially located. Our model can be used to identify and locate geographical hot-spots of schizophrenia prevalence in a large and complicated region. Conclusions — MOEA/HS enables a compromise to be achieved between different econometric methods by highlighting very special zones in complex areas where schizophrenia shows a high autocorrelation.

Declaration of Interest: This study was partly supported by the Andalusian Government, P05-TIC-00531, PAI:P06-CTS-01765, CTS-587, PI-338/2008]; the Ministry of Education and Science [TIN2005–08386-C05–02] and the Ministry of Health [PI08/90752]. No additional financial sources have been received. No involvements are in conflict with this paper.

It has been argued that gene-by-environment interactions (G × E) research is unlikely to progress knowledge about psychiatric disorders, in contrast to genome-wide association (GWA) studies. However, G × E approaches are not alternatives for gene-hunting but a way to identify genetic and biological mechanisms within subgroups of patients exposed to a similar aetiological (environmental) factor via a process of ‘aetiological stratification’. This is important as diagnostic categories targeted by GWA studies are inherently heterogeneous and lack biological validity. Aetiological stratification builds on examining possible phenotypic and/or molecular specificity associated with exposure to the environmental factor across multiple potentially relevant disorders, combined with efforts to identify an underlying biological substrate. G × E hypotheses within this framework investigate (1) which genes influence the degree to which individuals develop identified biological alterations that link environmental exposure to specific phenotypic and/or molecular characteristics within or across psychiatric disorders and (2) which genes are implicated in determining the development of psychopathology once this biological alteration has been brought about. As gene-hunting is not a goal in itself, the examination of pathway and/or polygenic risk scores may be more informative than the examination of individual markers, at the same time reducing multiple testing and the associated risk of spurious findings.

Aims – Assessment of the efficacy of the rehabilitation approach that is recommended by the manual VADO (AAOS in English: Abilities Assessment and Objectives Setting) in schizophrenic syndromes. Methods – Controlled trial, partly with individual randomisation. Centres were invited to recruit 10 patients who in most centres were randomly allocated either to the VADO approach or to usual rehabilitation practice. At least two professionals for each centre attended a brief intensive training course. Patients were assessed at baseline and six months later with a) the FPS scale, which is an improvement on the DSMIV SOFAS; b) the BPRS 4.0; c) AR, a clinical tool that is contained in VADO. Results – 55 patients received the experimental interventions and 40 the control one. Six months later greater significant improvements were observed in the experimental group, both in social functioning and in psychopathology. Conclusions – The dissemination of structured rehabilitation approaches that are based on personalized definition of objective, intensive progress monitoring, patient's therapeutic education and validated strategies and do not imply additional costs, may be warranted. A longer follow–up is under way.

Declaration of Interest: this work was partly funded by the National Mental Health Project (PNSM) of the Istituto Superiore della Sanita.

How things are perceived from a distance may help better understand their nature. Perceptions at home are likely to shape perceptions abroad. The mutual cross-references between local and distant perspectives on the Italian Mental Health Law 180 may help understand the process which preceded and resulted in the reform. This editorial argues that Law 180 came about at a unique – enabling – time in history. It argues that the run-up to and passing of Law 180 constituted a great accomplishment by professionals, the wider public and politicians/administrators. This editorial goes on to argue that the profession managed to cope with (many) adverse effects of the reform. The attention that Law 180 has received internationally should be devoted to other national (or regional) mental health reform processes as this may help us to understand how mental health care systems evolve and what defines ‘windows of (operative) opportunity’ or ‘moments for (public) action’.