The mental health system in Trieste, a city of 240,000 in northern Italy , is famous . Allen Frances, former chair of the Department of Psychiatry at Duke University School of Medicine has visited it five times and called it “ the place I would most want to be if I had a severe mental illness”
It has been the site of a collaborating centre of the World Health Organization for over four decades with the goal of disseminating its practices across the world and receives 1000 visitors a year .
Initiated by Franco Basaglia, pioneer of deinstitutionalisation and community alternatives to hospitalization between 1971 and 1980, this system is based on four CMHC,s and and did not have a separate crisis service. Instead , crisis management was integrated into these CMHC’s which are located in large houses and are open 24 hrs a day.
Compulsory treatments were very rare and by 2005, only 15 people were treated compulsorily, representing seven compulsory treatment episodes per 100,000 inhabitants -the lowest in Italy ( national figure was 25 per 100,000 ) The Barcola CMHC in particular , had used no involuntary treatment over three years
Despite the limited number of hospitalizations, the Trieste system felt the need to reduce these even further , and , to that end, in October 2017 formed the “ Homecare Crisis Attention Team “ based on the Crisis Resolution Home Treatment model
After one year, compulsory admission rates were reduced by 78.8 %; 93 % of patients showed significant improvement in symptoms and 81 % showed significant improvement in overall functioning according to this 2020 report in a Brazilian journal : Saude Soc. Sao Paulo , v29, n3 , one of the authors of which is based in Trieste
This result is remarkable and a testament to the effectiveness of Intensive Home Treatment ( IHT) programs . The Trieste system’s avoidance of coercion of patients includes an approach described as “ relentless negotiation “ which can take hours, involves the patient’s clinicians , the family, and anybody else in the social system who might have some influence. So, it would be reasonable to assume that the patients who were diverted from compulsory admission by IHT were particularly acute and difficult to engage .
This is is a simple naturalistic study comparing practice before and after the introduction of IHT. It is surprising there are not more of these studies as avoidance of involuntary admission is a very important goal and percentage reduction, an important metric
A 2003 study in County Monaghan, a rural area of Ireland showed involuntary admission rates were more than halved and were one third of the average national rate after the introduction of IHT
These results are consistent with my experience in IHT and are not surprising; just because a patient refuses to be admitted does not necessarily mean that they will not accept treatment or cannot be persuaded to with skillful management .
I have encountered numerous patients who would have been eligible for involuntary admission had IHT not been available .