Aims – To clarify the acceptability, reliability and factorial validity of a new Italian version of the HoNOS called HoNOS-Rome. Its main innovations are both in design and in contents. Methods – Face validity was assessed by surveying 3 focus groups. Reliability was assessed in 8 different pairs of raters on a sample of 24 patients; construct validity was analysed by factor analysis using a sample of 187 patients at 6 day centres. Acceptability was investigated by means an anonymous questionnaire filled by professionals that were using the instrument. Results – Time of completion was low (range 4–12 minutes), the tool proved very acceptable and the reliability was good (weighted kappa ≥ 0.71 for all items). Factor analysis was consistent with the division of HoNOS–Rome into four sensible factors accounting for 52% of the total variance. Conclusions – The findings indicate that HoNOS–Rome has a satisfactory degree of acceptability, construct validity and reliability, and may promote the routine evaluation of outcomes in mental health services.

Declaration of Interest: the authors declare that the study was supported by grant no. 96/Q/T41 of the Italian National Mental Health Project – Istituto Superiore di Sanità – Sub-project: Development and validation of tools for outcome evaluation of mental health services, Italy (Professor P. Morosini).

In the light of the recent publication of the DSM-5, there is renewed debate about the relative merit of categorical diagnosis, as laid down in Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD) diagnostic manuals. Issues such as validity, usefulness and acceptability of the diagnoses in this manual are increasingly debated. Several alternative possibilities have been suggested including: (i) the introduction of truly cross-cutting dimensional measures, that would facilitate dynamic multidimensional formulations of psychopathology, (ii) the Research Domain Criteria, that may facilitate biological research but move away from clinical symptoms, (iii) a system of personalized diagnosis based on psychopathology as a network of symptoms and contexts, and (iv) enhanced focus on motor alterations, other than catatonia, as a possible additional informative dimension of diagnosis in psychiatry, particularly as a possible marker of underlying neurodevelopmental alterations. We suggest that novel systems of diagnosis are likely to rely more on continuous monitoring of diagnostically relevant information in daily life, complementing retrospective symptom criteria in DSM and ICD. Patients and their families are likely to benefit from these projects, as novel models of diagnosis based on daily life information may be linked more strongly to treatment needs and prognosis.

Mental health consumers/survivors developed consumer-run services (CRSs) as alternatives to disempowering professionally run services that limited participant self-determination. The objective of the CRS is to promote recovery outcomes, not to cure or prevent mental illness. Recovery outcomes pave the way to a satisfying life as defined by the individual consumer despite repetitive episodes of disorder. Recovery is a way of life, which through empowerment, hope, self-efficacy, minimisation of self-stigma, and improved social integration, may offer a path to functional improvement that may lead to a better way to manage distress and minimise the impact of illness episodes. ‘Nothing about us without us’ is the defining objective of the process activity that defines self-help. It is the giving of agency to participants. Without such process there is a real question as to whether an organisation is a legitimate CRS or simply a non-governmental organisation run by a person who claims lived experience. In considering the effectiveness of CRSs, fidelity should be defined by the extent to which the organisation's process conveys agency. Unidirectional helping often does for people what they can do for themselves, stealing agency. The consequence of the lack of fidelity in CRSs to the origins of the self-help movement has been a general finding in multisite studies of no or little difference in outcomes attributable to the consumer service. This, from the perspective of the research summarised herein, results in the mixing of programmatic efforts, some of which enhance outcomes as they are true mutual assistance programmes and some of which degrade outcomes as they are unidirectional, hierarchical, staff-directed helping efforts making false claims to providing agency. The later CRS interventions may provoke disappointment and additional failure. The indiscriminate combining of studies produces the average: no effect.

Objective – The study of the relation between treatment costs and disability of psychiatric patient groups. Design – Perspective assessment of costs and disability of 1371 adult psychiatric patients in charge at two Operative Psychiatric Units (OPU), followed during an average period of 9 months. Data are related to all OPU's psychiatric services, including ambulatory, full or half-residential and psychiatric departments of acute hospital services. Setting — OPUs of Magenta (MI) and Desio (MI). Methods – The disability level has been measured by Health of the Nation Outcome Scales (HoNOS) filled in at the inclusion of the patient in the study and every three—months on average thereafter. Besides other HoNOSs have been filled in both at admission and discharge from psychiatric departments of acute hospitals, Residential Centres of psychiatric Therapies and Rehabilitation and Guarded Communities. All patients have been grouped using the main psychiatric diagnosis (first digit ICD—10) and the maximum disability level shown in the whole period of the study. Direct costs of publicly financed psychiatric services have only been considered. Their attribution to each patient has been made applying standard costs or tariffs (diagnostic procedures) to the data perspectively collected by the regional Register and a purposely designed protocol. Results – Total cost of 1371 patients has been 9771.1 million lire with a cost per patient of 7127000 lire (sd 19499000) and a cost per «day in charge» of 27172 lire (sd 68358). The cost per day has been found unrelated with the length of observed time frame. At the inclusion the mean level of disability has been 4.26 points (sd 3.73) and 3.19 points (sd 3.26) at the end of the study. Its value, measured at maximum level shown by each problem in the whole period of study, has been 6.00 points (sd 4.64). Disability and treatment cost of each patient did result directly related (r = 0.626, p = 0.0001). All patients have been grouped in 12 classes with a significant (p = 0,0001) overall difference on both their disability level and treatment cost. Conclusion – All adult psychiatric patients could be grouped in disability related classes which sometimes have also a different treatment cost. A study on a greater number of patients is needed to confirm these results. It may also provide a more reliable basis for a new financing system of psychiatric services.

October 2013 marks the 50th anniversary of President John F. Kennedy's message to the US Congress on the need to reform mental healthcare. Much has changed in that time. In 2006, Frank and Glied summarized these changes and the forces behind them, finding that the well-being of people with mental illness was ‘better but not well.’ They also conclude that most improvements have been due to ‘mainstreaming,’ the inclusion of those with mental illness in broad reforms such as Medicare, Medicaid and Social Security. With the gradual assimilation of mental health concerns, leadership and resources into mainstream programmes and agencies, future improvements will require that these programmes are accessible and oriented to people with mental illness. The passage of broad health reform legislation in 2010 (the Affordable Care Act) reinforces this change; several of its provisions attempt to make healthcare more relevant to the population with mental illness. In this editorial, I discuss a set of challenges which remain for the population with mental illness in the healthcare system, and the prospects for change. These challenges include: (1) improving basic mental healthcare in primary care, (2) improving mental healthcare for children, (3) earlier detection and treatment of psychotic illness, (4) disability and unemployment and (5) the challenge of sustaining an adequate, speciality public mental healthcare system under conditions of mainstreaming. In general, I conclude that the prospects for successful reform are uncertain. Establishing mental healthcare specialization in mainstream systems has not been notably successful to date.

This paper enumerates and briefly discusses WHO’s recent contributions to global mental health and the current challenges and opportunities in this area. It briefly discusses response to diversity across countries and communities, the need for innovations and global exchange of information, evidence and knowledge and raises issues like psychological interventions and human rights related to mental health.

Aims – This paper aims to describe current trends in the UK primary care management of common mental disorders and explore the appropriateness of differing management approaches in light of the course and common complications of these disorders. Methods – It highlights key findings concerning the course and comorbidity of depression to indicate that depression and associated mental illnesses may often form part of more complex patterns of ill health and that these conditions have a clear potential for chronicity. A narrative review of studies providing detail of depression prevalence in selected comorbid conditions is presented for this purpose. Conclusion – The presentation and course of common mental disorders indicate organizational changes in health service delivery, and - for a sizeable patient group – the use of chronic disease management strategies.

Declaration of Interest: None.

Depression in old age deserves special attention in view of the fact of progressive population ageing, because of the way in which depression and risk factors interact in this period of life and the particularly negative impact of late-life depression on health and quality of life. This editorial aims to provide some insight into longitudinal aspects of depression in old age. Depression may follow varying trajectories (e.g. episode emergence, recurrence) across the lifespan. Late-life depression is not an exception. A symptom-based approach is presented as an appropriate research method to study the predictors and course of affective syndromes in old age. Findings from our studies on depressive symptom trajectories in old age revealed that participants with a course of unremitting elevated symptoms showed the highest levels of loneliness across the trajectory groups and that participants with subclinical symptoms also showed higher levels of loneliness than their counterparts with a minimal-symptom course trajectory. This highlights the need to address loneliness as a way of dealing with depression in old age.

Objective – Satisfaction's measurement with Mental Health Services in patients and their relatives. Design – Satisfaction scale administration to the patients who were treated in community-based psychiatric service from 1.1.1996 to 31.3.1996 and the relatives who were primarily involved in caring for the patient. Setting – The ASL Rome «C» community-based psychiatric service. Main outcome measures – Verona Service Satisfaction Scale-54, a multidimensional instrument which measure satisfaction with community-based psychiatric service. Results – Main results (301 scales for patients, 163 scales for relatives), pointed out for patients a higher satisfaction for the technical and interpersonal skills of psychiatrists and psychologists (score of specific items >4). Lowest scores of satisfaction were towards the appearance, comfort level and physical layout of the facility (score 2.95) and towards the response of the service to emergencies during the night, weekend and Bank Holidays (score 2.87). Relatives were not particulary keen for the item regarding help to find open employement (score 2.76). Furthermore patients and their relatives gave a negative evaluation of the publicity and information offered by Mental Health Services. Dimensions's analysis reachs the same conclusions deduced items's average score. The result of this study emphasizes the patients higher degree of satisfaction than the relatives. Conclusions – The above results point out three aspects to be improved by the Menthal Health Service in order to satisfy the demands of the patients and relatives: 1. appearance, comfort level and physical layout of the facility, 2. publicity and information, 3. social actives and social skills.