Rethinking hospital psychiatry in Italy in light of COVID-19 experience

Abstract

BACKGROUND Italy retains a distinctive organization of mental health services according to a community-based model of care with a multidisciplinary team serving a well-defined catchment area under the coordination of the local department of mental health. The coronavirus disease 2019 (COVID-19) pandemic is forcing Italian mental health services to develop new organizational strategies at all levels of care in order to face the associated challenges. AIM To explore factors associated with changes in psychiatric admissions to an inpatient psychiatric unit located in Lombardia Region, Italy. METHODS All hospital admissions ( n = 44) were recorded to an inpatient psychiatric unit during a three month national lockdown in Italy in 2020 and compared with those occurring over the same time period in 2019 ( n = 71). For each admission, a 20-item checklist was completed to identify factors leading to admission. Statistical analyses were performed using Statistical Package for Social Sciences for Windows, release 11.0. Chi-square test (or Fisher’s exact test) and Mann-Whitney U-test were applied, where appropriate. RESULTS Hospital admissions dropped by 38% during the COVID-19 pandemic. No significant differences were found in demographics, clinical variables associated with hospital admissions and length of stay between 2019 and 2020. Compared with 2019, a significantly greater proportion of hospital admissions in 2020 were related to difficulties in organizing care programs outside the hospital (chi-square = 4.91, df 1, one-way P = 0.035) and in patients’ family contexts (chi-square = 3.71, df 1, one-way P = 0.049). On the other hand, logistic and communication difficulties pertaining to residential facilities and programs were significantly more common in 2019 than in 2020 (chi-square = 4.38, df 1, one-way P = 0.032). CONCLUSION Admissions to the inpatient psychiatric unit dropped significantly during the COVID-19 pandemic in 2020, with difficulties in organizing care programs outside the hospital and in patients’ family contexts occurring more frequently compared with 2019.

The Impact of COVID-19 Pandemic on Psychiatric Emergencies in Two Different Settings: Emergency Room and Community Mental Health Service

“…This last data could indicate a potential marginalization of immigrant groups who have less access to care, as reported by some authors ( 69 ). Our regression model highlighted the outcomes more frequently associated with UPCs during COVID-19 period: referral to outpatient service from UPC in ER and home care from UPC in CMHS, neither indicating hospitalization, which was drastically reduced during the first months after pandemic outbreak ( 70 ). In any case, as observed by an author ( 71 ), we will appreciate the real impact and consequences of the COVID-19 pandemic on mental health of the general population only in future.…”

Psychiatric ward admissions during the COVID-19 pandemic in Canton of Ticino (Swiss Confederation) and the province of Como (Italy): a comparison between two different systems of care and outbreak response strategies

“…The improvement in coping strategy of severe psychiatric patients in critical periods 31,32 and more similar condition to the general populations could improve the mental health of the more severe patients, along with the increase of patients and family's support. 18 Moreover, the reduction of Emergency Room (ER) admissions for psychiatric disorders 3,4,33 in the lockdown period attributable to the fear of the contagion, 34 especially in older people, 35 could also delay the diagnosis of new onset psychiatric disorders. A multicen-ter study carried out in Italian ERs, 35 in line with this hypothesis, found a 50% reduction of admissions also for non psychiatric patients, especially for less severe reasons (white and green codes) while no changes were found for the most severe reasons (red codes).…”

“…Thirteen percent of psychiatric ward in Lombardy (that in Italy are positioned in the general hospitals) were temporary converted in intensive and nonintensive non psychiatric care COVID unit. 6,13,18 More specifically, in the province of Como, the psychiatric ward in the Hospital of Cantù was temporary closed, with reduction of the beds in the entire province, and consequently, along with the fear of the contagion, a reduction of availability for new admissions. 12 In fact, in line with other studies carried out in Italy; 6,15,17 we found a significant reduction in voluntary admissions while the number of compulsory admissions remained stable; that mean an "increased threshold" for inpatient admissions and only the more severe patients keep being admitted to the psychiatric wards.…”

“…9,10 However, to evaluate the more severe burden of pandemic and lockdown on mental health status, the investigation of psychiatric hospitalizations is an essential index, since it is well known that patients with psychiatric comorbidity are linked with longer hospitalization also in internal medicine wards. 11 Surveys carried out during the first wave of the pandemic 3,6,[12][13][14][15][16][17][18][19] showed a reduction in the overall number of psychiatric ward admissions, but not for compulsory admissions 3,6,[12][13][14][15]17,20 and in high acuity units; 16 by contrast, in a survey carried out in Sweden (where lockdown measures were lighter), 21 In studies investigating the post-lockdown period and the following waves of the pandemic (with the consequent of new restrictions), the number of admissions either reached (without exceeding) the numbers of pre-pandemic period, 6,15,17,21,22 or remained slightly lower. 19,20,23 However, none of these studies compared data from two or more different countries.…”

Involuntary Psychiatric Treatment during the Covid-19 Pandemic. An international qualitative study.

“…One wonders whether intervening in these cases necessarily corresponds to a forced hospitalization in a psychiatric facility or if it was possible to carry out other types of treatment, for example by carrying out a home intervention over a medium-short period (days or a few weeks). The forced hospitalization is a tool experienced in a violent way by those who are subjected to it, and often the patient's rehabilitation measures do not allow the patient to nd a home in his or her family that can accommodate them once hospitalization is over [39,40,41] The hope for the future would be to be able to nourish and nurture a global model of community mental health intervention [42] by training professional staff in a holistic conception of mental distress and educating society to request and integrate psychiatric interventions [43] with support from the third sector, ascertaining the continuity of care in the family and community after discharge from hospitals.…”