Focus on Mental Health Care Reforms in Europe
A One-Day Census of Acute Psychiatric
Inpatient Facilities in Italy: Findings
From the PROGRES-Acute Project
Andrea Gaddini, M.D.
Lilia Biscaglia, B.Sc.
Renata Bracco, B.Sc.
Giovanni de Girolamo, M.D.
Rossella Miglio, Ph.D.
On May 8, 2003, a survey was con-
ducted of all inpatients at 369 psy-
chiatric facilities for adult acute
patients in all Italian regions ex-
cept Sicily. The estimated point
prevalence rate of admissions was
18.3 per 100,000 adult population.
There were 305 involuntarily ad-
mitted patients (3.8%, or .70 per
100,000 population). Large differ-
ences between public and private
facilities were found in age and
gender distribution: the propor-
tion of men age under age 35 was
larger in public facilities, and the
proportion of women age 65 and
older was larger in private facili-
Dr. Gaddini is a psychiatrist and Ms.
Biscaglia is a psychologist in the Mental
Health Unit, Agency for Public Health,
Lazio Region, Via di Santa Costanza 53,
00198, Rome, Italy (e-mail: gaddini@asp
lazio.it). Ms. Bracco is a social worker and
Dr. Norcio is a psychiatrist in the Depart-
ment of Mental Health, ASL (Local Health
Trust) Triestina, Trieste, Italy. Dr. de Giro-
lamo is a psychiatrist in the Department of
Mental Health, ASL of Bologna, Bologna,
Italy. Dr. Miglio is a statistician in the Fac-
ulty of Statistics, University of Bologna,
Italy. Dr. Rossi is a psychiatrist in the De-
partment of Mental Health, ASL of Peru-
gia, Perugia, Italy. Ms. Rucci is a statisti-
cian at the Western Psychiatric Institute
and Clinic, University of Pittsburgh. Dr.
Santone is a psychiatrist at the Psychiatric
Clinic of the United Hospitals of Ancona
and at Polytechnic University of Marche,
Ancona, Italy. Matt Muijen, M.D., Ph.D.,
is editor of this column.
722
Bruno Norcio, M.D.
Elisabetta Rossi, M.D.
Paola Rucci, B.Sc.
Giovanni Santone, M.D.
ties. In Italy, monitoring and eval-
uation of community services, at
both the local and national levels,
is essential for policy develop-
ment, implementation, and evalu-
ation. (Psychiatric Services 59:
722–724, 2008)
Mental health care in
Italy after the 1978 reform
The Italian psychiatric reform law was
enacted in 1978 with a strong ground-
swell of public support. The political
and cultural climate of the time led to
severe criticism of the institution of
the outdated mental hospital, which
initiated a shift in the care of persons
with mental illness from institutional-
ization to integrated community-ori-
ented treatments (1). Specifically, the
reform law stated that beginning in
1978 no new admissions to existing
mental hospitals were allowed and that
after 1981 readmissions also had to
stop. A progressive shutdown of all
mental hospitals was completed by the
end of 1999 (2).
In the meantime, a community-
based model of mental health care
was developed. In the beginning the
reform was planned and implemented
without adequate evaluation (3). Eval-
uation was further hindered by insuf-
ficient attention to the development
and maintenance of systematic collec-
tion of data on the activities of the de-
veloping services. Furthermore, the
1978 reform law set out general prin-
ciples and guidelines for the new sys-
PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' July 2008 Vol. 59 No. 7
tem of care, but it did not provide de-
tailed standards for provision of serv-
ices and recruitment and training of
staff, nor did it allocate an adequate
budget for setting up the new servic-
es. This led to an uneven implementa-
tion of reform throughout the country
(2). During the 1990s, two national
mental health plans were launched
with the aim of reducing differences
between Italian regions in the provi-
sion of services and delivery of mental
health care (2). The national plans de-
fined the organizational model of new
community-based services and pro-
vided some quantitative standards.
Currently, community-based serv-
ices in Italy have been implemented
nationwide. Mental health care is de-
livered by 211 mental health depart-
ments that cover the entire country
(4). These departments are in charge
of the management and planning of
all medical and social resources relat-
ed to prevention, treatment, and re-
habilitation in mental health within a
defined catchment area. Within the
departments, mental health centers
are the hub of the community-based
system. They cover all activities per-
taining to adult psychiatry in outpa-
tient settings and manage therapeutic
and rehabilitation activities delivered
by day care services and nonhospital
residential facilities. Acute inpatient
care is delivered in general hospital
psychiatric units with a maximum of
15 beds, which are closely linked with
the mental health centers to ensure
continuity of care.
 A significant problem is the regional
disparity in mental health service pro-
vision (4). The disparities are particu-
larly evident for nonhospital residen-
tial facilities, for which a standard of
one bed per 10,000 inhabitants was set
(the standard is two beds per 10,000 in
areas that previously included a men-
tal hospital). In a recent national sur-
vey, these facilities accounted for 2.98
beds for every 10,000 inhabitants, with
a regional variability ranging from a
low of 1.55 to a high of 6.93 beds per
10,000 (5). Specifically, Italian regions
with more extensive provision of out-
patient and day care services were
found to have lower rates of residential
beds. A few studies that have focused
on outcomes of care have also indicat-
ed inequities in mental health care de-
livery (6,7). In particular, a recent na-
tional study found that support for
families was provided unevenly; the
level of family burden was somewhat
lower in Northern Italy as the result of
better support (7).
Since 2001 responsibility for provi-
sion and commissioning of health
services has devolved from a national
level to a regional level. This has re-
sulted in the promulgation of a range
of regional policies that might ampli-
fy local variations in health care provi-
sion and delivery. It was in this frame-
work that the PROGRES-Acute proj-
ect (PROGetto RESidenze, or Resi-
dential Care Project for Acute Pa-
tients) was conducted. It was the first
nationwide survey of acute psychiatric
inpatient facilities. The survey was
conducted from 2003 to 2005 by the
National Institute of Health and by the
Department of Mental Health of Tri-
este. Physical characteristics, staffing
arrangements, admission rules, and ac-
tivities of all public and private psychi-
atric inpatient facilities were investigat-
ed (8). Results of the PROGRES-
Acute project showed that in 2003 Italy
had a total of 1.72 psychiatric inpatient
beds per 10,000 inhabitants—.78 pub-
lic and .94 private inpatient beds.
The data that are presented in this
column are from the one-day census,
which was conducted within the larger
PROGRES-Acute project. The pur-
pose of the census was to estimate the
one-day prevalence of hospitalized pa-
tients per 100,000 inhabitants in Italy,
determine the gender and age distri-
PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' July 2008 Vol. 59 No. 7
butions of inpatients in public and pri-
vate psychiatric facilities, examine
rates and characteristics of involuntary
admissions, and determine the pres-
ence and size of waiting lists in facili-
ties operating under a planned admis-
sion policy.
The one-day inpatient census
Procedures
The one-day census was conducted in
all Italian regions except Sicily. The 20
participating regions had a population
of approximately 53 million, or 90.5%
of the Italian population. The survey,
conducted on May 8, 2003, accounted
for all inpatients in public and private
facilities on that day. Public psychiatric
inpatient facilities included 262 gener-
al hospital psychiatric units with 3,431
beds (a mean of 13.1 per unit), 23 uni-
versity psychiatric clinics with 399
beds (a mean of 17.3 per clinic), 16 24-
hour mental health centers with 98
beds located in just two regions (a
mean of 6.1 per center), and 14 med-
ical wards and crisis centers with 118
beds (a mean of 8.4 per ward or cen-
ter). Data were available for all but two
facilities surveyed.
In addition, 54 private facilities with
a total of 4,862 beds (a mean of 90 per
facility) were surveyed. The private fa-
cilities, which started operating long
before the reform law went into effect,
are unevenly distributed throughout
the country but are mostly concentrat-
ed in five regions. The National
Health System covers costs for full
medical treatment and basic accom-
modation for patients admitted to pri-
vate facilities. Involuntary admissions
are made only to public facilities.
Each region appointed a coordina-
tor to organize and supervise data col-
lection for that region. One or more
research assistants per region were
trained to complete the census forms
on the index day in collaboration with
local mental health professionals. Data
were collected on the age and gender
of inpatients in each facility on the
census day, inpatient status (involun-
tary or voluntary), the involuntary ad-
mission procedures used for each pa-
tient (for example, health professional
intervention or involvement of law en-
forcement), and the presence and
length of waiting lists.
To calculate the point prevalence of
hospitalized patients on the census
day, we used data from the most re-
cently conducted census of the resi-
dent population of Italy by the Nation-
al Institute of Statistics (January 1,
2003). Residents of Sicily were exclud-
ed from the database. All analyses
were performed using SPSS software,
version 12.0 for Windows.
Census findings
Census forms were completed for
7,984 patients—3,692 (46%) in public
facilities and 4,292 (54%) in private fa-
cilities. Only a small number of inpa-
tients under age 18 were in the facili-
ties on the census day (32 patients, or
.4% of the total sample). These pa-
tients were excluded from hospitaliza-
tion rate calculations. The hospitaliza-
tion rate per 100,000 adult population
was 18.3. This rate did not vary by
gender (18.1 for men and 18.4 for
women), but it did vary by age and
type of facility. The proportion of eld-
erly patients was larger in the private
facilities. [A table summarizing the re-
sults is available as an online supple-
ment to this column at ps.psychiatry
online.org.]
Involuntary admissions. Only 289
of the 315 public facilities admit pa-
tients involuntarily. On the census
day, 305 inpatients (8.9%) had been
involuntarily admitted. Of these, 285
were in general hospital psychiatric
units. Involuntary admissions ac-
counted for 3.8% of all admissions.
The overall prevalence of involuntary
admissions per 100,000 adult popula-
tion was .70. In 30.4% of the cases, in-
voluntary admission was overseen ex-
clusively by health professionals,
whereas another 46.8% of cases in-
volved the intervention of metropoli-
tan police. State police intervention
was required for 22.9% of all involun-
tary admissions.
Age and gender. An equal propor-
tion of men and women were found in
public facilities. Private facilities had a
slightly higher percentage of women
(54.7% compared with 45.3%). In
public facilities the largest group was
men aged 35 to 44 years. In private fa-
cilities the proportion of women in-
creased with age, peaking with the
over-65 age group.
Waiting lists. Only 64 of the public
facilities (20%) reported using admis-
723
sion waiting lists, although it was a
common procedure in 37 private facil-
ities (70%). Overall, on the census day
158 persons were on a waiting list for a
public inpatient facility, and 595 per-
sons were awaiting admission to pri-
vate facilities.
Discussion
This column presents data from the
first national one-day census of all in-
patients in Italian acute psychiatric fa-
cilities. Two notable findings concern
the one-day prevalence figures and the
data on patients in private facilities.
Specifically, the prevalence of hospi-
talized acute psychiatric patients (18.3
per 100,000 inhabitants) was found to
be quite low compared with rates in
other Western countries (9,10).
Also, the proportion of inpatients
who were involuntarily admitted—
8.5%—was below the rate of 11.4%
reported by Rittmannsberger and
colleagues (11) in a survey of 24 dif-
ferent European sites. The 1978 Ital-
ian reform law established need for
treatment as the fundamental re-
quirement for involuntary admission
(12). Unlike laws in other European
countries, the Italian law does not di-
rectly mention of risk of harm to oth-
ers or self-harm (13).
Overall, the census findings suggest
that development of a comprehensive
network of community services has
resulted in remarkably low rates of
psychiatric admissions and that the
change to community-based services
has not led to an increase in involun-
tary admissions (8,14,15).
The findings in regard to private in-
patient facilities call for a better defi-
nition of the role of the private sector
in Italy. On census day the largest
proportion of inpatients (54%) were
in private facilities, which is consis-
tent with the slightly higher number
of beds available in private settings
(54.2%). Public and private facilities
were found to host different popula-
tions. Public facilities admitted most-
ly young men, whereas one-third of
the beds in private facilities were oc-
cupied by women age 65 and older.
Major differences in the clinical char-
acteristics of these populations can
also be assumed: private facilities are
not allowed to admit patients involun-
tarily, and involuntary admission can
724
be considered a proxy of greater ill-
ness severity. Thus the differences in
the populations of public and private
facilities reflect this policy (16). Fur-
thermore, the frequent use of waiting
lists by private inpatient facilities in-
dicates that admissions to these facil-
ities are planned and are not based on
emergency needs. Currently, comple-
tion of the ongoing accreditation
process is expected to increase inte-
gration between public and private
health services in Italy. This issue is
particularly important in a communi-
ty-based mental health system, where
quality of care cannot be split from
the functioning and dynamics of the
total service system (17).
Nearly 30 years after the introduc-
tion of the 1978 reform law, which
prompted a dramatic shift from a hos-
pital-based to a community-based sys-
tem, these data provide a basic picture
of the current state of acute psychiatric
inpatient care in Italy. An issue of in-
creasing relevance is the monitoring
and evaluation of the newly imple-
mented community services, and a
data-driven approach is being recog-
nized as essential for planning and
evaluating patient-centered, cost-ef-
fective community-based mental
health services. This approach re-
quires a strong commitment of the lo-
cal mental health departments and
also calls for more standardized and
rigorous evaluative and comparative
studies carried out at the local level. At
the same time a special concern for the
provision and role of national stan-
dards and national performance indi-
cators is needed. We consider that im-
plementation of a nationwide mini-
mum data set is an essential tool. Such
an approach will provide even more
evidence of the remarkable achieve-
ments of the reform efforts in Italy.
Acknowledgments and disclosures
This study was funded by the Italian Ministry of
Health. The names of the national and regional
coordinators, consultants, and researchers in the
PROGRES-Acute group are available in an on-
line supplement to this column at ps.psychiatry
online.org.
The authors report no competing interests.
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-----------------------------------------------------------------------------------------------------------------------------
Results of a one-day census of acute psychiatric inpatient facilities in Italy, by age group, facility
type, and gendera
----------------------------------------------------------------------------------------------------------------------------
Public facilities Private facilities All facilities
(N=315) (N=54) (N=369)
---------- ------------ -------- ----------- ------- -----------
Age group Men Women Men Women Men Women
----------------------------------------------------------------------------------------------------------------------------
18–34 11.1 8.7 4.7 5.2 15.7 13.9
35–64 12.0 13.7 7.2 9.2 19.2 22.9
65 and older 5.0 5.5 7.2 11.5 12.1 17.0
All ages 10.4 10.3 6.5 8.9 16.8 19.1
----------------------------------------------------------------------------------------------------------------------------
a
Hospitalization rates per 100,000 adult population
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Psychiatr Serv 59:722-724, July 2008

© 2008 American Psychiatric Association
Focus on Mental Health Care Reforms in Europe: A One-
Day Census of Acute Psychiatric Inpatient Facilities in
Italy: Findings From the PROGRES-Acute Project
Psychiatr Serv Gaddini et al. 59: 722

PROGRES-Acute group
The PROGRES-Acute group includes the following national and
regional coordinators and consultants: Francesco Amaddeo,
M.D., Angelo Barbato, M.D., Gabriele Borsetti, M.D., Renata
Bracco, B.Sc, Rocco Canosa, M.D., Massimo Casacchia, M.D.,
Ignazia Casula, B.Sc, Pietro Ciliberti, M.D., Antonio Colotto,
M.D., Angela D?Aloise, M.D., Giovanni de Girolamo, M.D.,
Giuseppe Dell'Acqua, M.D., Marisa De Palma, M.D., Walter Di
Munzio, M.D., Andrea Gaddini, M.D., Gaddomaria Grassi,
M.D., Nevio Longhin, M.D., Maurizio Miceli, M.D., Rossella
Miglio, B.Sc., Pierluigi Morosini, M.D., Mario Nicotera, M.D.,
Maurizio Percudani, M.D., Bruno Norcio, M.D., Angelo Picardi,
M.D., Rosina Potzolu, M.D., Elisabetta Rossi, M.D., Paola
Abstract
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Zanalda, M.D. The group also includes the following
researchers: Giovanna Agostini, Filomena Basile, Francesco
Basilico, Nadia Battino, L. Bavero, Giovanna Bazzacco, Lilia
Biscaglia, Raffaella Borio, Silvia Buttacavoli, Barbara Caporali,
Francesca Cappelletti, Loredana Caserta, Lucia Cifarelli,
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