No abstract

Although many countries' policies give Severe Mental Illness (SMI) priority inside Mental Health Services, researches assessing the prevalence of SMI in Mental Health Services according to operational criteria are still few. The aim of this is paper is to define annual SMI treated prevalence, describing socio-demographic and clinical characteristics, patterns of care and treatment costs of SMI and non-SMI patients. SMI prevalence in 10 Departments of Mental Health of the Lombardy Region (Italy) was assessed in 2000 by applying criteria concerning both severity, measured through HoNOS (Health of the Nation Outcome Scales), and utilisation patterns in the previous year. Annual SMI prevalence was equal to 3.1 cases per 1,000 inhabitants aged over 14; SMI patients' costs were 5.5 times higher than those of non-SMI patients ($5,183 versus $939 per year) and patterns of care were different. The variables predicting the SMI status were diagnosis, presence of paid employment, duration of service contact, care packages delivered in 2000 and severity of some HoNOS items (self harm, drug abuse, cognitive problems, delusions, other symptoms, relationships, activities of daily living and housing). The use of the combined criteria of severity and intensity of contact with mental health services in the previous year seems to be able to define severely ill patients adequately.

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.

RIASSUNTOScopo — L'obiettivo di questo studio è quello di descrivere i patterns di utilizzazione dei pazienti in contatto con 5 Unità Operative di Psichiatria lombarde secondo quattro classi: alti utilizzatori lungoassistiti, alti utilizzatori non lungoassistiti, lungoassistiti non alti utilizzatori, non alti utilizzatori non lungoassistiti. Disegno — Studio descrittivo a partire dai dati ricavati dal Sistema Informativo Psichiatrico regionale; è stata analizzata una coorte di 5.670 pazienti nell'ambito della prevalenza annua relativa all'anno 1994. Setting — 5 Unità Operative di Psichiatria della Regione Lombardia (Merate, Treviglio, Crema, Desio, Castano Primo), con una popolazione complessiva di 610.184 residenti di eta superiore ai 14 anni. Principali misure utilizzate — Sono state prese in considerazione alcune variabili sociodemografiche e cliniche relative ai pazienti; oltre un'analisi descrittiva dei quattro patterns, è stata effettuata una analisi logistica multinomiale. Risultari — Gli alti utilizzatori lungoassistiti (AU-LA), pur rappresentando solo il 5.3% del campione (4.9 casi per 10.000 residenti di età superiore ai 14 anni), consumano il 60% delle risorse espresse in SCS; solo la condizione di separato, divorziato, vedovo è predittiva per tale pattern. Gli alti utilizzatori non lungoassistiti (AU-non LA) costituiscono 1.2% del campione (1.1 casi per 10.000) ed utilizzano il 7.8% del SCS. Variabili predittrici di tale pattern sono l'eta compresa tra i 15-44 anni, l'assenza di un'attivita lavorativa e di un partner, la diagnosi di un disturbo mentale grave e la presenza di contatti con i servizi psichiatrici negli anni 1985-1989. I lungoassistiti non alti utilizzatori (LA-non AU) rappresentano il 23.4% della coorte (21.6 casi per 10.000) e vengono al secondo posto per consumo dirisorse (18.1% del SCS). Sono variabili predittive: l'età compresa tra i 15-44 anni, il vivere da solo, l'assenza di un'attività lavorativa e di un partner, la diagnosi di un disturbo mentale grave e la presenza di contatti con i servizi psichiatrici antecedenti al 1990. I pazienti non lungoassistiti non alti utilizzatori (non LA-non AU), pur rappresentando il 70.1% della coorte (64.8 casi per 10.000), consumano solo il 13.8% del SCS. Conclusioni — I dati mostrano che complessivamente l'attivita delle UOP è orientata nei confronti dei pazienti piu gravi, anche se sono rilevabili marcate differenze tra le UOP lombarde rispetto all'utilizzazione dei servizi. È confermata l'utilita di un Sistema Informativo a diffusione regionale che permetta di monitorare l'evoluzione nel tempo e nel territorio regionale dei patterns di utilizzazione.

A growing body of empirical and clinical research attests to the influence of personality features on the development, course and outcome of psychotherapy. Over the last four decades, Blatt adopted a psychoanalytic and cognitive developmental approach in developing a theoretically and empirically grounded two-configurations model of personality. The main aim of this study was to evaluate possible changes in anaclitic and introjective configurations – as measured by the Depressive Experience Questionnaire (DEQ) (Blatt, D’Afflitti, & Quinlan, 1976) – set against simultaneous changes in personality profile measured by Shedler-Westen Assessment Procedure (SWAP-200). Two young patients, a man and a woman, characterized by different personality profiles – introjective and anaclitic, respectively – were assessed for one year in the context of a psychodynamic psychotherapy. A battery of instruments – Beck Depression Inventory II (BDI-II), Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders I and II, Defense Mechanism Rating Scale, DEQ and SWAP-200 – were administered at the beginning, during the assessment process, and after one year. Both patients displayed lower BDI-II scores, along with evident clinical progress. Defence profiles and Core Conflict Relationship Themes showed interesting developments, in keeping with the evolution of the psychotherapy process. Lastly, while DEQ profiles outlined substantial stability after one year, some important changes in SWAP-200 profiles – in particular with regard to Q factors – were observed. Although these findings should be considered as preliminary, these results appear to be consistent with the description of Self-criticism and Dependency as relatively stable personality dimensions. The potential influence of profile diversity – introjective vs anaclitic – on other key variables of the psychotherapy process is also discussed.