The Basaglia law turns 45, Bondi: “We need a new project for mental health”

Social changes, changes in mental problems, new pathologies, lack of personnel, the transition from OPG to REMS and, now, above all, the problem of safety. The dramatic story of the murder of Barbara Capovania psychiatrist in Pisa, has reopened a debate on Law 180, which commits experts to look at future prospects years after the closure of asylums and, more recently, of OPGs (Judicial Psychiatric Hospitals), towards a new organization of mental health that almost all scientific societies and psychiatry practitioners wish for.

Despite the enormous difficulties of ‘constructing’ community psychiatric assistance (territorial and hospital) comparable to all healthcare, our country is an international point of reference in this field. According to the Italian Society of Psychiatry there is no going back but the successes achieved must be reconsidered today as a new starting point for a process of improvement and development that appears to be mandatory. In fact, the care needs of the population have radically changed and the requests brought by citizens to the Services and the country’s changes have also been profound.

Among other things, on these issues the Sip, in collaboration with the magazine Psychiatry Online Italia, will begin on 15 May, on the PsychiatryonlineITA1 YouTube channel, a series of daily interviews broadcast at 8.30 in the morning with the best Italian experts conducted by the psychiatrist and editor of the channel, Francesco Bollorino. The preview is on Saturday 13 May at 8.30 and will, not surprisingly, be dedicated to Law 180, with the SIP president as a guest, Emi Bondi.

The social changes

“The first change – explains the president Bondi, who also directs the mental health department of the Papa Giovanni XXIII Hospital in Bergamo – is signaled by the different users who turn to public services. Only 20-25% have psychotic and bipolar disorders or depressive and anxiety disorders, while personality disorders, from drug use, have strongly increased, to arrive at the emerging needs related to neurodevelopment disorders (ADHD and autism).All this requires inevitable updates with greater integration of treatment based on current scientific evidence, which the available data indicate as still not widespread in our country”.

Prevention

All of this requires more attention to primary, secondary and tertiary prevention by the Services, but also awareness of the need to review and strengthen welfare instruments, especially in favor of the weakest sections of the population, as well as support for families.

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The reorganisation

“The organization of the Mental Health Departments – explains Dr. Bondi – must provide flexible organizational models in which, the traditional network of services (Mental Health Centres, Day Centres, Day Hospitals, SPDCs, Residential Structures) can be flanked by even more specialist dedicated users defined for specific needs (e.g. psychotic onset, serious personality disorders, offenders, autism, eating disorders).The same is true for the role diversification of hospital facilities (e.g. with realistic forecasts of places bed for acute and post-acute cases) and residential assistance, with an effective diversification of the structures to be accredited with reference to the intensity, the types of care provided and the pathologies treated”.

Psychiatry is made up of people

This requires large and stable investments in the mental health sector, to be allocated above all to fill the increasingly evident shortage of personnel at all levels. “In psychiatry – continues the president of Sip – the therapeutic relationship is decisive, at the basis of every treatment and which therefore requires an essential investment in ‘human capital’. The shortage of personnel today is dramatic and risks bringing down the entire public system Mental health cannot remain at the rear of Italian health care and a stable adjustment of available funds is essential in an amount of no less than 8-9% of the total health fund (as in other European countries such as France). Today we are below 3%”.

The security

The problem of operator safety is also enormous. “Both within the structures, both in the phases of management of patients in acute crises within the emergency room, and in all the structures where the offenders with serious mental disorders converge – explains the president Bondi – who see today in REMS the only regulatory reference, which has already been amply saturated for years in the absence of a prison adaptation policy for subjects, albeit with mental disorders, who must and can stay there with functional and diversified internal services for clinical and social control”.

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An unfinished reform

The enormous increase in referrals of offenders to Psychiatric Services is shifting the unsolved problems of prisons to the structures that have replaced the OPGs, the so-called REMS, and to the other structures of the Department of Mental Health. “This forces psychiatry, defenseless, to deal with those who cannot abide by the rules of normal coexistence when these rules have already been shown to widely transgress them – explains President Bondi -. Services and pathways do not yet exist from the OPG reform law differentiated therapeutic-rehabilitative measures capable of guaranteeing treatment but also respect for the penalties deriving from the recognition of particularly serious crimes committed by violent persons. To guarantee all of this too, funding is needed proportionate to the new commitments that the Services must undertake and new adequately trained personnel ” .

The violence

The difficulties mentioned, if not resolved, can only have dramatic consequences. “We are talking about very serious episodes of violence – says Emi Bondi – such as those that occurred almost everywhere and which generated, by level of gravity, the murder in Pisa, with offenders who remain free for months waiting for a job in REMS and are thus entrusted to the ‘supervision’ of health facilities – such as Mental Health Centers – which do not possess the ability to control violent behavior and are constantly exposed to risk.There are hundreds of reports of violent events every day, but thousands are those not denounced for the obvious impossibility of intervention and response also by the involved bodies such as the judiciary, police and carabinieri. This creates an unlivable context despite the fact that the personnel in service, underestimated for years, are giving their best”.

A new project for mental health

For this reason, a new and stronger action to address mental health action and integration policies is required, including services for addictions and adolescents. “In this sense, the SIP – concludes Emi Bondi – believes that Italy does not need new Laws, but rather a new Objective Project on National Mental Health, which outlines the new guidelines of Mental Health Services from a of integration of knowledge and actions. We hope that the New Technical Table, set up by the Minister of Health, will address the problem with an overall, unitary and highly integrated project, which starts from prevention and which can gradually bring its principles into the promotion of health, allowing the Ministries involved, many (health, education, interior, justice, university), to talk to each other”.