Objectives - (I) To review the studies which investigated the frequency of psychiatric disorders among primary care attenders, using a standardized psychiatric interview as the case finding instrument; (II) to discuss the factors possibly explaining the different results found; (III) to highlight the central role of international multicenter collaborative studies, carried out in primary care settings. Method - the studies were reviewed, which were published in international journals between 1970 and 1993. The studies were located through a computerized search of the databases MEDLINE and Psychological Abstracts; in addition, the reference lists of the studies located in this way were examined and international journals were manually scanned in order to avoid possible omissions. Finally, the annotated bibliography, edited by Wilkinson (1985), was examined, since it included the studies having psychiatric focus, carried out in primary care and published between 1977 and 1985. Results - Thirty papers were traced, but 9 were excluded since they duplicated results or because of methodological limitations. So far, the overall frequency of psychiatric disorders among primary care attenders has been investigated using standardized procedures in 13 countries only. The frequency of psychiatric disorders ranged between approximately 10% and 50%. The possible reasons accounting for the differe- nces between the studies were discussed in the light of three factors: I) the research design and study characteristics; II) the reliability and comparability of different diagnostic categories and classificatory systems; and III) the different organization of health services across countries. Conclusions - In the light of the difficulties faced when the findings of independent studies, carried out in different countries or even in the same country, are compared, the central role of in- ternational multicenter collaborative studies conducted in this field is suggested.

— During the last three decades, we have witnessed dramatic improvements in both the psychosocial and pharmacological treatments of affective disorders. Administered in concert with the new medications advances in pharmacology have produced, disorder-specific psychosocial treatments have further improved the prognosis and course of bipolar and unipolar disorder. Methods — We review our research on unipolar and bipolar disorder and their treatment, in particular interpersonal psychotherapy (IPT) and modifications thereof. Results — We provide empirical evidence that IPT is an efficacious acute and maintenance treatment for affective disorders. Our cumulative research and clinical experience suggest that interpersonal relations and circadian and social rhythms influence affective illnesses and that psychotherapy may aid in normalizing problems in these areas for patients with affective illnesses. Conclusions — Despite the excitement generated by the recent progress in research on mental disorders and their treatment, we are yet to fulfill the promise that the explosion of knowledge about targeted pharmacotherapies or psychotherapies would seem to offer. To move our field forward, we must continue to apply scientific rigor and thought to understanding the suitability of current nomenclatures, the impact of comorbid psychiatric and medical illnesses and symptoms on the manifestation and treatment of affective disorders, and the practicality of widespread utilization of new treatments.

Objective - To survey and analyse the extent of utilization of «Non Pharmacological Interventions» (NPI) in the public mental health services of a large city. Setting - Inteview of the entire medical staff employed in 1991 in 10 Departments of Mental Health in the urban area of Naples, Italy. Main measures - A «ad hoc» questionnaire was prepared to gather informations on prevalence of use on NPI in different therapeutic settings, the selected technique according to the different diagnostic categories and the degree of professional training of the interviewed medical personnel. Result - The NPI, as the only treatment, was preferred by the large majority (86%) of the medical staff. The patients treated with NPI was double in outpatient than in inpatient. Although the medical staff did not use the same diagnostic criteria (ICD-9, DSM-III, others) anxiety (49%) and personality disorders (14,3%) were the diagnostic categories most commonly selected for NPI. At the time of the survey 24% of the patients were treated with psychotherapy. Support psychoterapy, psychoanalysis, family therapy were the most frequently employed. The support psychotherapy was mainly used in treatment of schizophrenia. Near to 50% of the medical staff reported a combined use of up to five different NPI. By and large choice of NPI was found dependent on the type of training and inversly correlated with the degree of seniority. Conclusions - The data obteined from the present survey show the large use and variability in NPI employed in public mental health services. The analysis of psycotherapy used suggests a different approach between public and private sector.

Objectives – The evaluation matrix recently proposed by Tansella and Thornicroft suggests that the field of social and epidemiological psychiatry has focussed more on the individual/patient level of mental health care services than the system level. Moreover, phenomena such as deinstitutionalisation have been examined more as clinical events than as social ones. The aims here are to deepen our understanding of deinstitutionalisation, particularly as regards the downsizing/closure and role of psychiatric hospitals. Methods – I begin by reviewing the manifest and latent functions of psychiatric hospitals. This is followed by a discussion of how these functions must be met by any comprehensive community-oriented system of mental health care for severely mentally ill patients. Also, in order to reframe the downsizing/closure of psychiatric hospitals as a social event for the field of social psychiatry and psychiatric epidemiology, I posit that the process of deinstitutionalisation is driven today by the same forces that were present at the outset of the movement. Results – I review four recent series of studies addressing primarily the outcomes, but also other aspects, of the downsizing/closure of psychiatric hospitals, with a view to illustrating the methods used, the results obtained and the blind angles missed in this research. Conclusions – Lessons are drawn on how to fill certain vacant cells of the matrix.

Objective - The analysis aims to study trends, during the period of 1983-1993, of the most relevant variables concerning equipment, staff and activity of the Lombardy Region Psychiatric Services. Setting - The study used data from all services, both hospital and community, that depend on Psychiatric Units. Data regarding Psychiatric Hospitals were not included. Design - Data were provided by the Regional Psychiatric Information System, which since 1983 has regularly collected information on equipment, staff and services supplied by the Regional Psychiatric Unit. A graphic analysis with a description of trends and the interrelation of the time series has been carried out. Main outcome measures - The analysis uses two types of variables: resources and services variables related to other community psychiatric facilities. Indexes or rates are computed to study the relations between the two sets of variables. Results - We verified a remarkable upward trend in the level of activity (both hospital and community) not entirely explained by the increase in resources. In fact, the growth of psychiatric services is linked with higher productivity and a growing demand as well. We have also seen that the growth of community activity has been stronger than that concerning hospital variables. Thus, as far as we can assess from data (not including the private sector), the use of hospitalization in psychiatric activity has decreased in the last decade. Conclusions - The analysis highlights the importance of an Information System to describe changes in service organizations and to provide data for specific studies, such as outcome studies.

The aim of the paper is to provide an overview of some of the most important issues faced by acute inpatient facilities in three Scandinavian countries, including reflections and critical remarks for discussion in this field. Information was drawn from scientific articles and official reports published in recent years, as well as the authors' own knowledge of acute facilities in their home countries. Acute inpatient facilities, including General Hospital Psychiatric Units (GHPUs), in all Scandinavian countries have several issues and problems in common, which include the organisation and capacity of acute services, the assessment of dangerousness and suicidality, the use of coercion and efforts to reduce coercion, the need to define and improve the quality of acute services, and the necessity to improve collaboration and continuity between acute services and other services. Although the emphasis some of these issues receive can vary across the three countries, Scandinavian mental health professionals (and policy makers) have begun to systematically share their experiences in developing a growing spirit of collaboration. Despite the role of welfare state and the deployment of substantial resources in Scandinavian countries, mental health practitioners are struggling to implement best practices in acute wards, to develop differentiated forms of acute services, and to reach the right balance and coordination between acute services and other services.

Aim – The widespread diffusion of sleep disorders (in particular, insomnia) in the general population and the presence of sleep complaints in many mental disorders and physical illnesses justifies an interest in their assessment and treatment, still today commonly underestimated. This study aims to describe the inexpensive and relatively easy-to-use self-report measures of sleep available in literature. Method – A literature search was conducted throughout the electronic literature database “Pubmed”, selecting the pertinent articles published up to December 2006. Results – The recovered material takes the following fields into account: aspect of sleep measured, statistical population, structure, time frame, sub-scales and psychometric properties. International literature presents somewhat heterogeneous sleep self-evaluation tools, which mainly measure sleep quality and the specific causes of sleep interference. As for the Italian context, the recovered material is somewhat modest, taking into account the number of publications. Conclusions – the critical points met in this review have led us to underline the characteristics of a hypothetical tool for sleep assessment to include in routine diagnoses.

Declaration of Interest: The authors have received no fees or other financial support potentially in conflict of interest with this scientific work.

Objectives - To present a comprehensive review of the studies assessing the frequency of PTSD in the general population, in clinical populations and among subjects at risk. Design - An extensive search was made using the Excerpta Medica Psychiatry CD-ROM 1980-1993 (October). Using post-traumatic stress disorder as a key word, a total of 1,057 papers published in this timespan were retrieved. A further search was made using the same key word with MEDLINE CD-ROM 1988-1993. A manual search was also performed for all issues of the Journal of Traumatic Stress. Results - A total of 135 studies meeting inclusion criteria were selected for this review. Almost two thirds (n = 86, 64%) of these studies were carried out in the United States; only 8 (6%) studies have been carried out in developed countries. The sample size ranges from a low of 11 subjects up to a high of 22,463 subjects. The mean sample size is 500 and the median is 108. In terms of assessment methods, in one third (n = 45, 33%) of the studies the investigators used a PTSD symptom checklist (either self- administered or administered by a clinician), based on DSM criteria, to generate a PTSD diagnosis. In more than in one third of the studies (n = 44, 33%) of the studies, a structured interview was administered (e.g., the DIS, the SCID, the SADS), while in the remaining surveys the diagnostic evaluation was based either on an un- structured clinical assessment or on the administration of other specific assessment instruments (e.g., M-PTSD, IES, SCL-90-R or others). In 77 studies (57%) the investigators based their assessment on DSM-III diagnostic criteria for PTSD, whereas in 55 studies (41 %) DSM-III-R criteria were employed. Prevalence rates are discussed separately for the different population groups. Conclusions - There has been a remarkable increase in the number and quality of epidemiological studies on PTSD over the past decade. A substantial amount of information is now available about the frequency of PTSD among different population groups and among at risk subjects, and about risk factors, common symptom patterns, and natural history of this disorder. However, a number of important limitations of these studies are to be noted and should be addressed by future research efforts.

Objective – The ‘PROGRES’ (PROGetto RESidenze' Residential Project) project has 3 aims: 1. To survey all Italian psychiatric Non-Hospital Residential Facilities (NHRF) (Phase 1); 2. To assess in detail 20% of the NHRFs and the patients living there (Phase 2); and 3. To carry on training programmes for the mental health workers of these facilities (Phase 3). We report here the results of Phase 1. Methods: – All NHRFs were surveyed using a structured interview administered to the manager of the facility. In some cases, this information was supplemented with data gathered from other mental health workers at the NHRFs. Results – On May 31, 2000, there were in Italy 1,370 NHRFs with 17,138 beds, giving an average number of beds per facility of 12.5 and a rate of 2.98 beds per 10,000 inhabitants. This rate varies greatly between regions, with a ratio of 1:10 between the two regions with the lowest and the highest bed rates. Seventy-three percent of the NHRFs have a 24-hour staff coverage; more than 50% are directly managed by the NHS Departments of Mental Health and more than three-quarters of the NHRFs are directly funded by the NHS. In the course of 1999 38% of the NHRFs discharged no patients, and another 32% discharged fewer than 3 patients. In about half of the NHRFs the most common patient age group was 40-59 years. In the Italian NHRFs there are 11,240 full-time mental health workers, plus several thousand half-time staff. The average number of full-time mental health workers in each NHRF is 8.2. In 58% of the NHRFs the operational chief is a psychiatrist; some 40% of the overall number of mental health workers in the NHRFs have no specific psychiatric training. The total number of patients resident in the NHRFs is 15,943; among them, 58% have never been admitted to a mental hospital, 40% have been admitted and a small percentage (1.6%) has been previously admitted to a forensic mental hospital. The availability of NHRF beds is negatively associated with the availability of non-hospital facilities (e.g., community mental health centres, day-centres) and positively associated with the number of beds in private psychiatric facilities in each region. Discussion – The current rate of NHRF beds is higher than the officially recommended national standard (2/10,000 inhabitants). However, there is a great variability between regions, which is related to the overall provision of different types of psychiatric facilities. Most NHRFs provide intensive care, and the continuum of residential facilities with different types of care, support, degree of autonomy, etc. recommended by several authors for the long-term treatment of severe patients with different disabilities, seem to be lacking. NHRFs have a very low patient turnover rate, and this may create problems in the future. Conclusions – The PROGRES project is the first national study ever carried out in Italy to evaluate a specific type of psychiatric facilities in the context of the new system of psychiatric care. When all the data will be available, it will be possible to assess in detail for the first time a national representative sample of severe, long-stay patients and the care they are receiving; on this basis, it will also be possible to recommend evidence-based policies aimed at improving the care of the severely mentally ill.

Several discernible trends have changed the outlook of psychiatric resources available to the general public during the last 50 years in Western countries and particularly in Italy. Among these trends, two conflicting issues are here outlined. On the one side, evidence based medicine is the core of a methodological revolution, which asks for a deeper criticism of subjective judgements in clinical matters; on the other side, the study of emotions and attitudes has stressed the outstanding importance of conscious and unconscious expectations both in patients and in caregivers. Moreover, popular psychology has altered the way mental disorder is commonly perceived and treated. A comprehensive way of taking into account these three diverse trends seems to be still lacking.