RESUMEN
Considering teratogenic risk, recent data suggest that selective serotonin reuptake inhibitors (SSRIs) can be prescribed during pregnancy, even though some SSRIs are to be considered as a second choice. In any case, antidepressive treatment during pregnancy must be carefully tailored to the pregnant woman, considering absolute risk/benefit ratio of SSRIs, but also availability of other effective treatments, as well as woman's preferences.
Asunto(s)
Antidepresivos de Segunda Generación/uso terapéutico , Depresión/tratamiento farmacológico , Inhibidores Selectivos de la Recaptación de Serotonina/uso terapéutico , Anomalías Inducidas por Medicamentos/prevención & control , Adulto , Antidepresivos de Segunda Generación/administración & dosificación , Antidepresivos de Segunda Generación/efectos adversos , Depresión/epidemiología , Relación Dosis-Respuesta a Droga , Femenino , Humanos , Italia/epidemiología , Embarazo , Efectos Tardíos de la Exposición Prenatal/prevención & control , Prevalencia , Medición de Riesgo , Inhibidores Selectivos de la Recaptación de Serotonina/administración & dosificación , Inhibidores Selectivos de la Recaptación de Serotonina/efectos adversos , Resultado del TratamientoRESUMEN
OBJECTIVE: Benzodiazepines (BDZs) safety profiles in pregnancy suggest that the risk of major malformations (MMs) cannot be considered simply as a "class effect". The aim of this paper was to review and update the available literature on the risks of MMs in women exposed to BDZs in the first trimester of pregnancy. METHODS: PubMed was searched for English-language articles, from January 2001 to November 2011, introducing as keywords "teratogens", " major malformation", "foetus", "infant", "newborn", "pregnancy", in conjunction with "benzodiazepines" as a keyword or BDZ generic name as text words. RESULTS: Twelve studies were selected for the review. BDZ exposure during the first trimester of pregnancy seems not to be associated with an increasing risk of congenital MMs. Diazepam and chlordiazepoxide should be considered drugs of first choice. CONCLUSIONS: Data published in the last 10 years did not indicate an absolute contraindication in prescribing BDZs during the first gestational trimester. In any case, studies analyzed suffer from a number of methodological limitations such as lack of careful report of BDZ patterns of use in pregnancy, possible influences of recall bias, lack of controlling for confounding factors and lack of data concerning possible MMs in aborted fetuses.
Asunto(s)
Anomalías Inducidas por Medicamentos/etiología , Benzodiazepinas/efectos adversos , Primer Trimestre del Embarazo , Teratógenos , Aborto Espontáneo/etiología , Femenino , Humanos , Recién Nacido , Embarazo , RiesgoRESUMEN
INTRODUCTION: The paper represents a systematic review on the efficacy, tolerability and safety of paliperidone, an antipsychotic drug recently approved in Italy for the treatment of schizophrenia and of schizoaffective disorder. METHODS: A comprehensive PubMed search using the term "paliperidone" was performed from January 1980 to February 2011. Papers reporting data on efficacy in the treatment of schizophrenia and of schizoaffective disorder were included, also if published as abstracts and all retrieved articles were manually searched for other references of interest. RESULTS: Paliperidone was found to be effective in short and long-term treatment of schizophrenia, as well as in the treatment of schizoaffective disorder. For both disorders, paliperidone showed to be effective in improving psychotic and affective symptoms. In the studies analyzed it was well tolerated and the most frequent reported adverse events were mild extrapyramidal symptoms and an increase in serum prolactin levels. CONCLUSIONS: Paliperidone has been shown to be an effective and safe medication for the treatment of schizophrenia and schizoaffective disorder. Further controlled clinical trials are needed to confirm this clinical profile in the long-term treatment, as well as for specific conditions such as schizophrenic patients with medical comorbidities.
Asunto(s)
Antipsicóticos/uso terapéutico , Isoxazoles/uso terapéutico , Trastornos Psicóticos/tratamiento farmacológico , Pirimidinas/uso terapéutico , Esquizofrenia/tratamiento farmacológico , Antipsicóticos/efectos adversos , Humanos , Isoxazoles/efectos adversos , Palmitato de Paliperidona , Pirimidinas/efectos adversos , Resultado del TratamientoRESUMEN
PURPOSE: The present study investigated: (i) the rate of prescription of antipsychotic (AP) polypharmacy (APP) in a large, representative sample of psychiatric inpatients; and (ii) the relationship between APP prescription and the characteristics of patients and facilities. METHODS: The sample included 1022 psychiatric patients scheduled to be discharged from acute inpatient facilities with drug therapies including AP. Demographic and clinical data were obtained from the treating physician or retrieved from patients' records through a standardized Patient Form. Patients were administered the 24-item Brief Psychiatric Rating Scale. Three indicators were used to describe the process of care in the facilities: a Restrictiveness score, a Standardization score, and a Treatment score. A multilevel mixed-effect logistic regression was used to predict APP using patient and facility as the variables. RESULTS: APP was prescribed to 333 (32.5%) patients, the most common patterns being a first-generation and a second-generation AP (n = 178, 17.6%) or of two first-generation APs (n = 80, 7.8%). Patients with a diagnosis of schizophrenia and poorer insight into illness at admission were significantly more likely to receive APP. The availability of more complex therapeutic interventions in the facility was also associated with APP. CONCLUSIONS: In our nationwide sample of psychiatric inpatients, APP was frequently prescribed to treat the more severe patients. However, it was also associated with process of care characteristics such as delivery of more complex therapeutic interventions, and was therefore not used only to control patient behavior.
Asunto(s)
Antipsicóticos/administración & dosificación , Prescripciones de Medicamentos/estadística & datos numéricos , Encuestas de Atención de la Salud , Hospitales Psiquiátricos/estadística & datos numéricos , Polifarmacia , Adulto , Antipsicóticos/uso terapéutico , Utilización de Medicamentos/normas , Utilización de Medicamentos/estadística & datos numéricos , Humanos , Italia , Masculino , Trastornos Mentales/tratamiento farmacológico , Pautas de la Práctica en Medicina/normas , Pautas de la Práctica en Medicina/estadística & datos numéricos , Factores SocioeconómicosRESUMEN
BACKGROUND: Information on outcomes of acute inpatient care in routine psychiatric practice is scant. In particular, it is uncertain to what extent short hospitalization can produce clinically meaningful changes. AIM: Our aim was to estimate the symptomatic outcome in a representative sample of patients admitted for short treatment to general hospital psychiatric units in Italy. METHODS: Patients were assessed at admission and discharge using 24-item Brief Psychiatric Rating Scale (BPRS). Reliable change index was calculated to estimate the proportion of change attributable to measurement error and a cut-off score of 38 was adopted to identify the patients who showed clinically significant change. RESULTS: Average length of stay was 5.7 days. Mean BPRS score dropped from 53.2 on admission to 41.5 at discharge, showing statistically significant improvement with an effect size of 0.80. However, reliable change was achieved by 24.7% of patients and clinically meaningful change by 13.6%. CONCLUSIONS: Reliance on statistical significance and effect size overestimates treatment effects, whereas reliable and clinically significant change index provides a conservative way to assess outcome. Few patients showed relevant improvement after a brief admission.
Asunto(s)
Hospitalización , Hospitales Psiquiátricos , Trastornos Mentales/terapia , Adulto , Escalas de Valoración Psiquiátrica Breve , Estudios de Cohortes , Femenino , Humanos , Italia , Tiempo de Internación , Masculino , Trastornos Mentales/psicología , Persona de Mediana Edad , Alta del Paciente , Resultado del Tratamiento , Adulto JovenRESUMEN
The aim of this study was to describe the sociodemographic, clinical and treatment-related characteristics of patients admitted to any acute psychiatric inpatient facilities in Italy for the first time in their life, and to identify reasons contributing to admission. Data from the PROGRES-Acute Project, a national survey on facilities admitting acute psychiatric patients in Italy, were used. A cluster analysis was carried out in order to identify patients' groups sharing similar sociodemographic and clinical characteristics. Among patients admitted during the index period, 337 were at their first-ever admission. Median age at admission was 40, and about 46% of patients were not receiving any treatment in the month prior to admission. Social/work functioning problems, social withdrawal and conflict with family members were the most common reasons contributing to admission. Cluster analysis yielded four patient groups: two groups of younger subjects, differentiating each other for frequency of antisocial behaviors, compulsory admissions, treatment at time of admission and family support; two groups of older subjects, with high rates of affective disorders, who showed remarkable differences with regard to their living situation and family support. Our study shows that first-ever admitted patients represent a highly heterogeneous group. Early intervention research should take this sociodemographic and clinical diversity into account, in order to better allocate resources and develop special intervention programs.
Asunto(s)
Internamiento Obligatorio del Enfermo Mental/estadística & datos numéricos , Pacientes Internos/estadística & datos numéricos , Trastornos Mentales , Admisión del Paciente/estadística & datos numéricos , Adolescente , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Análisis por Conglomerados , Servicios Comunitarios de Salud Mental , Femenino , Humanos , Italia/epidemiología , Masculino , Trastornos Mentales/diagnóstico , Trastornos Mentales/epidemiología , Trastornos Mentales/terapia , Persona de Mediana Edad , Escalas de Valoración Psiquiátrica , Factores Sexuales , Adulto JovenRESUMEN
AIM: To review studies conducted to establish the risk of spontaneous abortion (SA) in women exposed to antidepressant drugs (ADs) during early pregnancy. METHODS: By using different search terms, PubMed, Toxline, EMBASE, PsychINFO, and the Cochrane library databases were searched from January 1980 to March 2008, to identify studies assessing the risk of SA in women exposed to different classes of ADs during the first trimester of pregnancy. RESULTS: Ten studies over 21 identified were selected for the analysis. All were performed prospectively and included as control group unexposed women, or exposed to non-teratogenic drugs or to placebo. In seven studies a depressive episode was specified as the reason for which the drug was prescribed, while the time of exposure was in nine. CONCLUSIONS: Only three studies over ten selected reported a significant association between an increased rate of SAs and early pregnancy exposure to some ADs. Many methodological flaws in the study design were found in all studies considered. Given this background and a lack of strong evidence on this issue, further prospective and better designed studies are needed to assess the risk of SA in pregnant women exposed to ADs against the risk of an untreated maternal depression.
Asunto(s)
Aborto Espontáneo/inducido químicamente , Antidepresivos/efectos adversos , Femenino , Humanos , Embarazo , Primer Trimestre del Embarazo , Factores de RiesgoRESUMEN
Violence committed by acute psychiatric inpatients represents an important and challenging problem in clinical practice. Sociodemographic, clinical, and treatment information were collected for 1324 patients (677 men and 647 women) admitted to Italian public and private acute psychiatric inpatient facilities during an index period in 2004, and the sample divided into 3 groups: nonhostile patients (no episodes of violent behavior during hospitalization), hostile patients (verbal aggression or violent acts against objects), and violent patients (authors of physical assault). Ten percent (N = 129) of patients showed hostile behavior during hospitalization and 3% (N = 37) physically assaulted other patients or staff members. Variables associated with violent behavior were: male gender, <24 years of age, unmarried status, receiving a disability pension, having a secondary school degree, compulsory admission, hostile attitude at admission, and a diagnosis of schizophrenia, bipolar disorder, personality disorder, mental retardation, organic brain disorder or substance/alcohol abuse. Violent behavior during hospitalization was a predictive factor for higher Brief Psychiatric Rating Scale scores and for lower Personal and Social Performance scale scores at discharge. Despite the low percentage of violent and hostile behavior observed in Italian acute inpatient units, this study shed light on a need for the careful assessment of clinical and treatment variables, and greater effort aimed at improving specific prevention and treatment programs of violent behavior.
Asunto(s)
Hospitalización/estadística & datos numéricos , Hospitales Psiquiátricos/estadística & datos numéricos , Trastornos Mentales/psicología , Servicio de Psiquiatría en Hospital/estadística & datos numéricos , Violencia/estadística & datos numéricos , Adulto , Factores de Edad , Anciano , Agresión/psicología , Internamiento Obligatorio del Enfermo Mental/estadística & datos numéricos , Femenino , Encuestas Epidemiológicas , Hospitales Privados/estadística & datos numéricos , Hospitales Públicos/estadística & datos numéricos , Humanos , Italia/epidemiología , Masculino , Trastornos Mentales/diagnóstico , Trastornos Mentales/epidemiología , Persona de Mediana Edad , Escalas de Valoración Psiquiátrica/estadística & datos numéricos , Factores Sexuales , Violencia/psicologíaRESUMEN
BACKGROUND: The aim of the present study was to assess the characteristics of long-stay inpatients in public and private Italian acute inpatient facilities, to identify risk factors and correlates of the long duration of hospital stay in these patients, and to identify possible barriers to alternative placements. METHODS: All patients in 130 Italian public and private psychiatric inpatient units who had been hospitalized for more than 3 months during a specific index period were assessed with standardized assessment instruments and compared to patients discharged during the same index period, but staying in hospital for less than 3 months (short-stay inpatients). Assessed domains included demographic, clinical, and treatment characteristics, as well as process of care. Logistic regression analysis was used to identify specific variables predicting inpatient long-stay status. Reasons for delaying patient discharge, as reported by treatment teams, were also analyzed. RESULTS: No overall differences between long-stay and short-stay patients emerged in terms of symptom severity or diagnostic status. Admission to a private inpatient facility and display of violent behavior during hospital stay were the most powerful predictors of long-stay. Lack of housing and a shortage of community support were the reasons most commonly cited by treatment teams as barriers to discharge. CONCLUSION: Extra-clinical factors are important determinants of prolonged hospitalization in acute inpatient settings.
Asunto(s)
Administración de Instituciones de Salud , Pacientes Internos , Tiempo de Internación , Alta del Paciente , Adulto , Femenino , Humanos , Italia , Modelos Logísticos , Masculino , Persona de Mediana Edad , Factores de RiesgoRESUMEN
OBJECTIVE: To analyze the characteristics of patients scheduled for discharge from acute psychiatric inpatient facilities in Italy, and their pattern of care. METHODS: Socio-demographic and clinical characteristics, and patterns of care of 1,330 patients discharged from public and private inpatient facilities in Italy were assessed with a standardized methodology during an index period in the year 2004. RESULTS: About one half of the sample had schizophrenia or bipolar disorder. However, the case-mix differed between public and private facilities, where in-patients had more frequently mood and anxiety disorders. The use of two or more drugs was very common, involving more than 90% of patients and including typically benzodiazepines and antipsychotics. Structured psychosocial treatments were rarely initiated during the hospital stay. Increasing age, male gender, long stay in the facility (>60 days), personality disorder and type of facility were associated with a higher likelihood of being discharged to a community residential facility. Predictors of discharge to another psychiatric facility were increasing age, being single, schizophrenia, personality disorder and organic mental disorder. Families were not involved in decisions about patients' discharge in a significant proportion of cases. University psychiatric clinics and private facilities were less coordinated with the community system of care than General Hospital Psychiatric Units. Referral of patients with substance use disorder to drug addiction services occurred in just 30% of subjects. CONCLUSIONS: This study provides information on the characteristics and the pattern of care of patients discharged from inpatient facilities in a country that has closed down all its mental hospitals. This information may be relevant for those countries that are affording now the downsizing of MHs, and the expansion of community-based models of care.
Asunto(s)
Investigación sobre Servicios de Salud/estadística & datos numéricos , Hospitalización/estadística & datos numéricos , Trastornos Mentales/terapia , Alta del Paciente/estadística & datos numéricos , Servicio de Psiquiatría en Hospital/estadística & datos numéricos , Adulto , Antipsicóticos/uso terapéutico , Trastornos de Ansiedad/tratamiento farmacológico , Trastornos de Ansiedad/epidemiología , Trastornos de Ansiedad/terapia , Benzodiazepinas/uso terapéutico , Servicios Comunitarios de Salud Mental/estadística & datos numéricos , Grupos Diagnósticos Relacionados , Femenino , Encuestas de Atención de la Salud/estadística & datos numéricos , Hospitales Privados/estadística & datos numéricos , Hospitales Públicos/estadística & datos numéricos , Humanos , Italia/epidemiología , Tiempo de Internación , Masculino , Trastornos Mentales/tratamiento farmacológico , Trastornos Mentales/epidemiología , Trastornos del Humor/tratamiento farmacológico , Trastornos del Humor/epidemiología , Trastornos del Humor/terapia , Psicoterapia , Derivación y Consulta , Esquizofrenia/tratamiento farmacológico , Esquizofrenia/epidemiología , Esquizofrenia/terapiaRESUMEN
On May 8, 2003, a survey was conducted of all inpatients at 369 psychiatric facilities for adult acute patients in all Italian regions except Sicily. The estimated point prevalence rate of admissions was 18.3 per 100,000 adult population. There were 305 involuntarily admitted patients (3.8%, or .70 per 100,000 population). Large differences between public and private facilities were found in age and gender distribution: the proportion of men age under age 35 was larger in public facilities, and the proportion of women age 65 and older was larger in private facilities. In Italy, monitoring and evaluation of community services, at both the local and national levels, is essential for policy development, implementation, and evaluation.
Asunto(s)
Censos , Centros Comunitarios de Salud Mental/estadística & datos numéricos , Pacientes Internos/estadística & datos numéricos , Servicios de Salud Mental/estadística & datos numéricos , Admisión del Paciente/estadística & datos numéricos , Adulto , Anciano , Estudios Transversales , Femenino , Reforma de la Atención de Salud , Historia del Siglo XX , Capacidad de Camas en Hospitales/estadística & datos numéricos , Hospitales Privados/estadística & datos numéricos , Hospitales Psiquiátricos/estadística & datos numéricos , Humanos , Italia , Masculino , Servicios de Salud Mental/historia , Servicios de Salud Mental/legislación & jurisprudencia , Persona de Mediana Edad , Instituciones Residenciales/estadística & datos numéricos , Negativa del Paciente al Tratamiento/estadística & datos numéricosRESUMEN
Attitudes toward medication (ATM) exert an influential role on compliance. Ninety-nine inpatients with schizophrenia were administered the Rating of Medication Influences scale (ROMI). Patients were also rated using: i) the Health of the Nation Outcome Scales, ii) the Global Assessment of Functioning scale, iii) the Clinical Global Impression, Severity scale, and iv) the WHO Quality Of Life assessment, Brief Version. Seventy-seven subjects (77.8%) completed the ROMI interview. Cluster analysis identified the following four clusters: i) Ambivalence (n=17; 22%); ii) Problems with Patient, Family, Alliance (n=11; 14.3%); iii) Medication Affinity, Positive Influence from Others (n=30; 39%); and iv) Illness, Medication, Label Distress (n=19; 24.7%). Clusters did not differ in demographic or clinical variables except for depressed mood and physical well-being, which were, respectively, lower and higher in patients with mostly negative ATM. Based on rater assessment, psychotic symptoms were related to negative ATM independently of their severity, and the family played a central role in the expression of negative attitudes. ATM were relatively independent of clinical and psychosocial variables. The existence, in each cluster, of both external and inner motivations underpinning ATM suggests that therapeutic interventions must take into account both patients and their broader living contexts.
Asunto(s)
Antipsicóticos/uso terapéutico , Actitud Frente a la Salud , Hospitalización , Esquizofrenia/tratamiento farmacológico , Psicología del Esquizofrénico , Adulto , Análisis por Conglomerados , Depresión/diagnóstico , Depresión/psicología , Emoción Expresada , Relaciones Familiares , Femenino , Estado de Salud , Humanos , Masculino , Cooperación del Paciente , Satisfacción Personal , Escalas de Valoración Psiquiátrica/estadística & datos numéricos , Psicometría , Calidad de Vida , Esquizofrenia/diagnóstico , Índice de Severidad de la Enfermedad , Encuestas y CuestionariosRESUMEN
BACKGROUND: Legislation in 1978 led to the gradual replacement of mental hospitals in Italy with a full range of community-based services, including facilities for acute in-patient care. AIMS: To survey the main characteristics of Italian public and private in-patient facilities for acute psychiatric disorders. METHOD: Structured interviews were conducted with each facility's head psychiatrist in all Italian regions, with the exception of Sicily. RESULTS: Overall, Italy (except Sicily) has a total of 4108 public in-patient beds in 319 facilities, with 0.78 beds for every 10,000 inhabitants, and 4862 beds in 54 private in-patient facilities, with 0.94 beds per 10,000 inhabitants. In 2001 the rates of psychiatric admissions and admitted patients per 10,000 inhabitants were 26.7 and 17.8 respectively. In the same year the percentage of involuntary admissions was 12.9%, for a total of 114,570 hospital days. Many in-patient facilities showed significant limitations in terms of architectural and logistic characteristics. Staffing showed a great variability among facilities. CONCLUSIONS: The overall number of acute beds per 10,000 inhabitants is one of the lowest in Europe. The survey has provided evidence of two parallel systems of in-patient care, a public one and a private one, which are not fully interchangeable.
Asunto(s)
Centros Comunitarios de Salud Mental/organización & administración , Hospitales Privados/organización & administración , Trastornos Mentales/terapia , Servicios de Salud Mental/organización & administración , Instituciones Residenciales/organización & administración , Centros Comunitarios de Salud Mental/normas , Centros Comunitarios de Salud Mental/estadística & datos numéricos , Encuestas de Atención de la Salud/normas , Necesidades y Demandas de Servicios de Salud , Capacidad de Camas en Hospitales/estadística & datos numéricos , Hospitalización/estadística & datos numéricos , Hospitales Privados/normas , Hospitales Privados/estadística & datos numéricos , Humanos , Italia , Tiempo de Internación/estadística & datos numéricos , Servicios de Salud Mental/normas , Personal de Enfermería en Hospital , Instituciones Residenciales/normas , Instituciones Residenciales/estadística & datos numéricosRESUMEN
OBJECTIVE: To investigate the process of care in Italian public acute inpatient facilities. METHOD: Each facility's head psychiatrist (in all Italian regions except Sicily) completed a structured interview concerning provision of treatment and facility rules. RESULTS: Twenty-three university psychiatric clinics with 399 beds (mean=17.3 beds), 16 24 h community mental health centers with 98 beds (mean=6.1 beds), and 262 general hospital psychiatric units with 3431 beds (mean=13.1 beds) were surveyed. Mean length of stay was 18.5+/-7.1 days, 37.0+/-55.3 days and 12.0+/-3.4 days, respectively. Pharmacotherapy was ubiquitous. Approximately 80% of facilities held regular clinical evaluations, supportive talks, and counselling. Dynamic focused psychotherapy was available in 29% of the facilities; 24% provided cognitive behavioural therapy; 32% family therapy; and 39% structured rehabilitative intervention. Vocational training and activities targeted at helping patient integration into their local communities were uncommon. Most facilities did not allow the possession of cutting utensils (96%), personally possessed medication (96%), or lighters (72%), and most had locked doors (75%). Fewer facilities (37%) prohibited the use of mobile phones (32%) and metal knives during meal times (37%). Frequency of physical restraint was associated with number of internal rules. Delivery of psychotherapy was associated with nurse provision. CONCLUSIONS: The process of psychiatric inpatient care in Italy shows considerable variability. Future clinical practice guidelines should address the currently limited provision of evidence-based psychosocial intervention in these facilities. Efforts should also be devoted to improving the effectiveness of the hospital-community mental health service interface.
Asunto(s)
Hospitales Generales , Trastornos Mentales/epidemiología , Trastornos Mentales/rehabilitación , Servicios de Salud Mental/organización & administración , Servicio de Psiquiatría en Hospital/organización & administración , Adulto , Terapia Cognitivo-Conductual , Femenino , Capacidad de Camas en Hospitales/estadística & datos numéricos , Hospitalización/estadística & datos numéricos , Humanos , Italia/epidemiología , Tiempo de Internación/estadística & datos numéricos , Masculino , Trastornos Mentales/terapia , Servicios de Salud Mental/estadística & datos numéricos , Servicio de Psiquiatría en Hospital/estadística & datos numéricos , Encuestas y CuestionariosRESUMEN
After legislative changes in 1978, Italian psychiatry underwent a thorough overhaul, with the gradual closure of all Mental Hospitals. A nation-wide network of Departments of Mental Health now deliver outpatient and inpatient care, but also run semi-residential and residential facilities (the latter with 2.9 beds per 10,000 inhabitants). Hospital care is delivered through small psychiatric units (with no more than 15 beds). There are also many private inpatient facilities operating in Italy, and the number of private inpatient beds per 10,000 inhabitants exceeds the number of public beds; overall there are 1.7 acute beds per 10,000 inhabitants - one of Europe's currently lowest numbers. There is marked quanti- and qualitative variation in the provision of out- and inpatient care throughout the country, and service utilization patterns are similarly uneven. Studies examining quality of life report a fairly high degree of patient satisfaction, whereas patients' families frequently bear a heavy burden. In conclusion, the Italian reform law led to the establishment of a broad network of facilities to meet diverse care needs. Further efforts are required to improve quality of care and to develop a more effectively integrated system. Greater attention must be paid to topics such as quality of care and outcomes, public and private sector balance, and the coordination of various resources and agencies.
Asunto(s)
Servicios de Salud Mental/estadística & datos numéricos , Servicios de Salud Mental/tendencias , Psiquiatría , Calidad de la Atención de Salud , Humanos , Italia/epidemiología , Trastornos Mentales/epidemiología , Trastornos Mentales/terapiaRESUMEN
Quality of Life (QOL) is an outcome measure particularly useful to assess the effects of deinstitutionalization policies. To date no large-scale study has been conducted in residential facilities (RFs). Participants included 1492 subjects living in 174 RFs (20% of the total) randomly sampled in 15 Italian regions. Assessment instruments included the WHOQOL-Bref, the GAF, and the Physical Health Index (PHI). WHOQOL scores of residents were compared with those of healthy subjects (N = 65) and outpatients with schizophrenia (N = 162). Multivariate analyses were used to examine the relationship between selected patients' characteristics and WHOQOL scores. Mean WHOQOL scores of residents were similar to those of outpatients with schizophrenia, and substantially lower than those of healthy controls. Lower scores on WHOQOL domains were associated with schizophrenia and non-affective psychoses, unipolar depression, anxiety or somatoform disorders, shorter duration of illness, positive, negative or mood symptoms, lower GAF scores, no participation in internal activities, and PHI score. Our findings are consistent with previous studies. The present study highlights a marked difference between patients in RFs and healthy controls in the social domain. This suggests the need of well-designed rehabilitation plans, tailored to patients' needs, to foster the development of their independence and, ultimately, improve their QOL.
Asunto(s)
Pacientes Internos/psicología , Trastornos Mentales/psicología , Calidad de Vida/psicología , Adolescente , Adulto , Anciano , Estudios Transversales , Recolección de Datos , Femenino , Indicadores de Salud , Humanos , Discapacidad Intelectual/psicología , Italia , Masculino , Persona de Mediana Edad , Trastornos Neurocognitivos/psicología , Pruebas Psicológicas , Trastornos Psicóticos/psicología , Reproducibilidad de los Resultados , Instituciones ResidencialesRESUMEN
We administered structured interviews to managers and staff of a random sample of 265 Italian psychiatric Residential Facilities (RFs). Most are independent buildings, located in urban and suburban areas. The median number of residents is 10. The few RFs (5.7%) with more than 20 beds have a higher rate of drop-outs and escapes. The average indoor space per resident is 36 square meters, there is often a garden, and residents generally live in two-bed rooms. Most facilities are located within walking distance of shopping centers or recreational facilities. Three-quarters have 24-hour staff coverage. On average, each facility has about 10 full-time equivalent workers, with a staff:resident ratio of 0.92. Most of the professional input is provided by nurses and auxiliary staff. Critical issues to be considered in planning facilities include the physical environment, the size, and the staffing patterns.
Asunto(s)
Recolección de Datos , Ambiente de Instituciones de Salud , Servicios de Salud Mental/organización & administración , Admisión y Programación de Personal/estadística & datos numéricos , Instituciones Residenciales/organización & administración , Medio Social , Humanos , Italia , Trastornos Mentales/terapia , Servicios de Salud Mental/normas , Reorganización del Personal/estadística & datos numéricos , Instituciones Residenciales/normas , Recursos HumanosRESUMEN
BACKGROUND: Although residential facilities (RFs) have largely replaced mental hospitals (MHs) in most developed countries for the long-term residential care of severely impaired patients, the process of care in RFs has not been well studied. The aim of this paper is to investigate the process of care in 265 RFs, representing 19.3% of all RFs in Italy, and to devise a classification of RFs based on process characteristics. METHODS: Structured interviews were conducted with the manager and staff of each RF. Residents were evaluated using standardized rating instruments. RESULTS: Most RFs had specific admission criteria, with one third having a waiting list that averaged about 3 months. There was no formal limitation to the length of stay in three quarters of RFs, and turnover rates were very low. Although a homelike atmosphere was found in many RFs, most facilities had restrictive rules on patients' daily lives and behaviours. RFs carried out several external activities targeted at integrating patients within the local community. Standardized assessment instruments and written treatment plans were rarely used. A cluster analysis based on the levels of restrictiveness and the standardization of the process of care classified RFs into five groups that differed with respect to daily staff coverage, size, geographical distribution and proportion of former MH residents. No significant intercluster differences were associated with the current clinical and psychosocial characteristics of residents, or with several other outcome variables. CONCLUSIONS: This study provides naturalistic evidence of the heterogeneity of the process of residential care on a large scale. Future efforts should focus on developing an empirical classification of RFs, as well as on national and international standards of care and staffing to address patients' needs.
Asunto(s)
Actividades Cotidianas/clasificación , Comparación Transcultural , Trastornos Mentales/rehabilitación , Evaluación de Procesos, Atención de Salud/normas , Calidad de Vida/psicología , Instituciones Residenciales/normas , Análisis por Conglomerados , Encuestas Epidemiológicas , Humanos , Italia , Trastornos Mentales/epidemiología , Evaluación de Resultado en la Atención de Salud/estadística & datos numéricos , Admisión del Paciente/estadística & datos numéricos , Satisfacción del Paciente/estadística & datos numéricos , Garantía de la Calidad de Atención de Salud/normas , Estadística como Asunto , Listas de Espera , Recursos HumanosRESUMEN
AIMS: To investigate in a representative national sample (N=2,962) of patients living in Residential Facilities (RFs) patterns of polypharmacy as well as related variables, association between diagnoses and therapeutic patterns, and the rate of adverse events. METHODS: Structured interviews focusing on each patient were conducted by trained research assistants with the manager and staff of each RF. Patients were rated with the HoNOS and the SOFAS, and comprehensive information about their sociodemographic and clinical status, and their pharmacological regimes were collected. RESULTS: Conventional antipsychotics and second-generation antipsychotics were prescribed to 65% and 43% of the sample, respectively. Benzodiazepines were prescribed to two-thirds of the sample, while antidepressants were the least-used class of psychotropics. Polypharmacy was common: on average, each treated patient was taking 2.7 drugs (+/- 1.1); antipsychotic polypharmacy was also common. Many prescriptions were loosely related to specific diagnoses. Antiparkinsonianian drugs were prescribed to approximately 1/4 of the sample. Mild or severe adverse events in the previous month were reported for 9.9% and 1.4% of the sample, respectively. About 15% of patients suffered from tardive dyskinesia. CONCLUSIONS: Psychotropic drug prescription patterns for severe patients living in RFs are only sometimes satisfactory and offer the opportunity of improvement. Specific actions are required to improve prescription patterns for severe patients in RFs.
Asunto(s)
Prescripciones de Medicamentos/estadística & datos numéricos , Trastornos Mentales/tratamiento farmacológico , Trastornos Mentales/etnología , Psicotrópicos/uso terapéutico , Instituciones Residenciales/estadística & datos numéricos , Adolescente , Adulto , Anciano , Femenino , Humanos , Italia , Masculino , Persona de Mediana Edad , PolifarmaciaRESUMEN
BACKGROUND: In Italy, Residential Facilities (RFs) have completely replaced Mental Hospitals (MHs) for the residential care of mentally ill patients. We studied all patients resident in 265 randomly sampled Italian RFs (20% of the total). METHOD: Structured interviews focusing on each patient were conducted by trained research assistants with the manager and staff of each RF. Patients were rated with the HoNOS and the GAF, and comprehensive information about their sociodemographic and clinical status and care history were gathered. RESULTS: Of the 2962 patients living in the sampled facilities, most were males (63.2%) who had never married, more than 70% were over 40 years; 85% on a pension, most commonly because of psychiatric disability. A substantial proportion (39.8%) had never worked and very few were currently employed (2.5%); 45% of the sample was totally inactive, not even assisting with domestic activities in the facility. Two-thirds had a diagnosis of schizophrenia; co-morbid or primary substance abuse were uncommon. Twenty-one per cent had a history of severe interpersonal violence, but violent episodes in the RFs were infrequent. The managers judged almost three-quarters appropriately placed in their facilities and considered that very few had short-term prospects of discharge. CONCLUSIONS: Italian RFs cater for a large patient population of severely mentally ill requiring residential care. Discharge to independent accommodation is uncommon. Future studies should attempt to clarify how to match residential programmes with patients' disabilities.