Objective — Advocacy in the mental health services field is gaining importance since the traditional role of mental health hospitals is changing, particularly in North America and in Western Europe. This review will define advocacy, its goals and fundamental principles. It will then delineate the skills and strategies needed for any intervention on behalf of a patient or a group of patients. It will also deal with the issues and approaches most frequently raised and used, and finally, with the limits of advocacy. Method — The method used for this review was mainly a recension of the literature concerning advocacy throughout North America and Europe, having in view to see emerging the principal stakes and concerns related to this process. Results — Advocacy has a significant impact patients' awareness of their rights and their capacity to exercise them. It also prevents potential abuse of patients. On the other hand, some patients have an increased opportunity to cease treatment, and this could lead to serious medical consequences. There is also the possibility of retaliation from staff, as a result of being involved with an advocate. The combination of high quality care and effective advocacy is the best guarantee that a mental health patient will get the care he wants and needs with human dignity.

Objective — To discuss the contribution of epidemiology and epidemiological methods to psychosomatic medicine. Method — Critical review of the literature, including both philosophical concepts and empirical data. Results — The adjective «psychosomatic» has been used in two different ways: in the so called «psychosomatic» or holistic approach to medicine; and in a narrower approach, referring to particular disorders in which psychological factors were considered to have a fundamental aetiological role. While the ideal of the holistic, «humanistic» or «anthropological» approach should probably be never abandoned, the practical limitations of encompassing models, including Engel's bio-psycho-social model are also obvious: they may be heuristically sterile. On the other side, in relation to the narrow psychosomatic approach, psychogenetic views in the so called «psychosomatic illnesses» have been strongly criticized on empirical grounds. The potential of epidemiological methods to study these illnesses, but also «somatopsychic» disorders is shown in a number of papers in the empirical literature. We have grouped such contributions, including our own experience, in the five categories suggested by M. Shepherd for epidemiological methods in general: 1) the completion of the spectrum of disease; 2) the establishment of outcome; 3) the actuarial assessment of morbid risk; 4) the evaluation of the efficacy of treatment; and 5) the conceptual construction of diagnosis and classification. Conclusions — The contribution of epidemiological data to areas of interest in psychosomatic medicine has been relevant in recent years. The potential of epidemiological methods in this area is very important both to increase knowledge and to improve the quality of clinical practice.

This paper concerns one of the four research projects developed during a training course in clinical epidemiology managed by the Lombardy training centers IREF. Objectives — To compare the recommandations for treatment concerning 9 vignettes derived from the Australian Quality Assurance Project. Setting — Six Mental Health Services of Regione Lombardia. Design and Participants — For each vignette, all psychiatrists working in the 6 Mental Health Services were asked to fill in a questionnaire about treatment location, psychopharmacology, psychotheraphy, priority between psychotherapy and psychopharmacology and degree of difficulty in answering. Results — 44 out of 52 target psychiatrists took part to the study. Remarkable variability for treatment location and psychotherapies; moderate variation for psychodrugs prescriptions and a good agreement for diagnoses were observed. In drugs prescription an eccess of association was observed. The most prevalent model of psychotherapy was the psychodynamic, followed by the cognitivebehavioural and the family-systemic. There was a tendency toward a flexible approach, as suggested by recommendations of different psychotherapeutic models according to the nature of the disorder. No case were judged very difficult; only in 3 cases a judgement of «somewhat difficult» was expressed by more than 20% (but less than 30%) of the psychiatrists. Conclusions — Studies of this type are very easy to carry out and give useful information for continuous training programs and Continuous Quality Improvement projects.

Introduction — Many studies have been carried out recently to investigate the relationship between health conditions and family and self characteristics. Objectives — To identify family characteristics (such as type of family, socio-economic status, parent immigration, affection for parents, parents' psychological and physical health) and self characteristics (age, drug use, satisfaction for several life circumstances, psychosomatic symptomatology) that are differently distributed by sex and levels of psychological and physical distress among teen-agers. Methods — We carried out a cross-sectional study on a sample of teen-agers attending high schools in Pavia (Italy), using a self-administered questionnaire. The students were divided in four groups having different levels of psychological and physical distress, based on GHQ-30 (psychological distress indicator), on the number of hospital admissions and consultations to a physician in the last year (the last two are physical distress indicator). Data were analysed applying the multivariate analisy of Canonical Variate. Results — 1346 students were sampled, but only 1189 questionnaire were analysed: 36.8% regarding males and 63.2% females. The Canonical Variate analysis indicated that psycosomatic symptomatology, satisfaction for several life circumstances and affection for parents are important for describing the four distress groups. Conclusions — Only affection for parents has an important role on psychological and physical distress of adolescents, while family characteristics traditionally considered associated with psychological and physical distress in teen-agers (such as living with one or without parents, low socio-economic status) are not associated.

Objective — To describe requests of admissions to eight General Hospital Psychiatric Wards (SPDC) in Lombardy, Italy, during November 1995. Design — Descriptive prospective multicenter study. Setting — SPDCs of Busto Arsizio (VA), Calcinate (BG), Desio (MI), Magenta (MI), Merate (LC), Milano San Paolo I, Pavia, Treviglio (BG). The global catchment area sums up to 11% of the whole regional area, and to 18% of the population. Main outcome measures — We used a previously developed flowchart with two major key points: who decided to go to the hospital? Did a doctor confirm this initiative? Main sociodemographic characteristics, ICD10 diagnosis and previous psychiatric admissions were collected for each admission. Results — Admissions were 315, patients 246. In 9.5% of cases patients asked for admission without any medical advice. In one third of cases the ward psychiatrist was the first doctor to visit the patient. Compulsive admissions (TSO) were 45 (14.3%), although patient's initiative lacked in 55.6% of cases. A referral from Outpatient Departments (CPS) was present in 28.2%. First-ever admitted were 63 (25.6%): 20.7% sent by CPS, 16% by GPs, 11% by other non psychiatric wards. Conclusions — Although Goldberg & Huxley's model described General Hospital Psychiatric Wards as the last level of intervention, our data show that Italian SPDCs work as «front line» services: less than one admission out of two were referred by a psychiatrist. Problems raised by «self-referred» patients are conspicuous and an evaluation of the filtering function of CPSs seems necessary. In this regard, a comparison with different modalities of Department organization could be useful.