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Bisphenol-A is an emerging pollutant that is widespread in the environment, and to which live beings are continuously and inadvertently exposed. It is a substance with an endocrine-disrupting capacity, causing alterations in the reproductive, immunological, and neurological systems, among others, as well as metabolic alterations. Our study aimed to assess its clinical signs, and effects on the most relevant blood biochemical parameters, and to evaluate pituitary and gonadal histology after a chronic exposure of adult mice to different BPA doses (0.5, 2, 4, 50 and 100 µg/kg BW/day) through their drinking water. The biochemical results showed that a marked significant reduction (p < 0.05) was produced in the levels of serum glucose, hypoproteinaemia and hypoalbuminemia in the groups exposed to the highest doses, whereas in the group exposed to 50 µg/kg BW/day the glucose and total protein levels dropped, and the animals exposed to 100 µg/kg BW/day experienced a diminution in albumin levels. In the case of the group exposed to 50 µg/kg BW/day, however, hypertriglyceridemia and hypercholesterolemia were determined, and the blood parameters indicating kidney alterations such as urea and creatinine experienced a significant increase (p < 0.05) with respect to the controls. Regarding the pituitary and gonads, none of the animals exposed presented histological alterations at the doses tested, giving similar images to those of the control group. These results suggest that continuous exposure to low BPA doses could trigger an inhibition of hepatic gluconeogenesis, which would result in a hypoglycaemic state, together with an induction of the enzymes responsible for lipidic synthesis, a mechanism by which the increase in the lipid and serum cholesterol levels could be explained. Likewise, the decline in the protein and albumin levels would be indicative of a possible hepatic alteration, and the increase in urea and creatinine would point to a possible renal perturbation, derived from continuous exposure to this xenobiotic. Based on our results, it could be said that chronic exposure to low BPA doses would not produce any clinical signs or histological pituitary-gonadal effects, but it could cause modifications in some blood biochemical parameters, that could initially indicate a possible hepatic and renal effect.

Ensuring adequate quality of care to patients with severe mental disorders remains a challenge. The implementation of clinical indicators aimed at assessing the quality of health care pathways delivered is crucial for the improvement of mental health services (MHS). This study aims to evaluate the quality of care delivered to patients who are taken-into-care with depressive disorders by MHS. Thirty-four clinical indicators concerning accessibility, appropriateness, continuity, and safety were estimated using health care utilization databases from four Italian regions (Lombardy, Emilia-Romagna, Lazio, Sicily). A total of 78,924 prevalent patients treated for depressive disorders in 2015 were identified, of whom 15,234 were newly engaged by MHS. During the year of follow-up, access to psychotherapeutic interventions was low, while the intensity was adequate; 5.1% of prevalent patients received at least one hospitalization in a psychiatric ward (GHPW), and 3.3% in the cohort of newly engaged in services. Five-out-of-10 patients had contact with community services within 14 days after GHPW discharge, but less than half of patients were persistent to antidepressant drug therapy. Furthermore, prevalent patients showed an excess of mortality compared to the general population (SMR = 1.35; IC 95%: 1.26–1.44). In conclusion, the quality of health care is not delivered in accordance with evidence-based mental health standards. Evaluation of health interventions are fundamental strategies for improving the quality and equity of health care.

The BLUES project: implementing innovative practices in screening and home care for women with perinatal depression Introduction Perinatal depression is frequent (1 woman out of 10 during the perinatal period), nonetheless to this day the screening is incomplete and the treatment gap is high. Materials and methods The BLUES project was financed by the Italian Ministry of Health and implemented in 10 Local Health Units of Lombardy Region. It had the goals of improving screening and implementing home visiting for women with perinatal depression. As far as the first goal, a smartphone app searchable by authorized professionals has been developed for transmitting screening tools (Edinburgh Postnatal Depression Scale - EPDS - and Whooley questions) to a cloud database; the app was also connected to a free website informing on mental health during the perinatal period. As far as the second goal, a home visiting programme was implemented according to the WHO Thinking Healthy method. A total of 110 professionals (most midwives), working in the family care centers, attended a structured training course in the Thinking Healthy approach and then applied the intervention to women during the perinatal period. The effectiveness and feasibility of the intervention were assessed at its completion (pre-post comparisons). Results The smartphone app and the related website were successfully activated in family care centers in the Province of Lecco (Lombardy, Italy). 39 women responding to selection criteria (EPDS ≥ 10 and a diagnosis of depression) were recruited for the home visiting intervention: 31 of them have completed the Thinking Healthy program. A clinically significant reduction of the EPDS scores was assessed in 80% of the women with moderate depressive symptoms (EPDS score ≥ 12). Both women and professionals evaluated the intervention useful and acceptable. Conclusions The BLUES project improved the screening using e-tools and implemented home visiting following the Thinking Healthy method. The process of task shifting from mental health sector to midwives was successful, while professionals met difficulties in balancing home visiting activities and routine activities.

Aims To evaluate the quality of mental health care delivered to patients with schizophrenia and related disorders taken-in-care by mental health services in four Italian regions (Lombardy, Emilia-Romagna, Lazio, Sicily). Methods Thirty-one clinical indicators concerning accessibility, appropriateness, continuity and safety were defined and estimated using healthcare utilisation (HCU) databases, containing data on mental health treatments, hospital admissions, outpatient interventions, lab tests and drug prescriptions. Results A total of 70 586 prevalent patients with schizophrenia and related disorders treated in 2015 were identified, of whom 1752 were newly taken-in-care by the facilities of regional mental health services. For most patients community care was accessible and moderately intensive. However, care pathways were not implemented based on a structured assessment and only half of the patients received psychosocial treatments. One patient out of ten had access to psychological interventions and psychoeducation. Activities specifically addressed to families involved a third of prevalent patients and less than half of new patients. One patient out of six was admitted to a community residential facility, and one out of ten to a General Hospital Psychiatric Ward (GHPW); higher values were identified in new cases. In general hospitals, few patients had a length of stay (LoS) of more than 30 days, while one-fifth of the admissions were followed by readmission within 30 days of discharge. For two-thirds of patients, continuity of community care was met, and six times out of ten a discharge from a GHPW was followed by an outpatient contact within 2 weeks. For cases newly taken-in-care, the continuity of community care was uncommon, while the readiness of outpatient contacts after discharge was slightly more frequent. Most of the patients received antipsychotic medication, but their adherence to long-term treatment was low. Antipsychotic polytherapy was frequent and the control of metabolic side effects was poor. The variability between regions was high and consistent in all the quality domains. Conclusions The Italian mental health system could be improved by increasing the accessibility to psychosocial interventions, improving the quality of care for newly taken-in-care patients, focusing on somatic health and mortality, and reducing regional variability. Clinical indicators demonstrate the strengths and weaknesses of the mental health system in these regions, and, as HCU databases, they could be useful tools in the routine assessment of mental healthcare quality at regional and national levels.

Defective insight is a hallmark of schizophrenia. Less is known about insight in emerging psychosis. In this study a widely used measure of cognitive insight, the Beck Cognitive Insight Scale (BCIS), has been applied to a sample including patients with first-episode psychosis (FEP), at ultra-high risk (UHR) for psychosis, and help-seeking youths without psychotic symptoms.The Comprehensive Assessment of At-Risk Mental State (CAARMS) interview was used to classify patients. Enrolled patients were assessed with the General Health Questionnaire-12 (GHQ-12), the Prodromal Questionnaire-16 (PQ-16), the Social and Occupational Functioning Assessment Scale (SOFAS), and the BCIS.The sample included 212 participants (58%) with non-psychotic mental distress, 131 participants (36%) were UHR, and 22 (6%) were with FEP. Males and females were in equal proportion, mean age was 19.2 ± 2.6 years old (range: 15-25 years). Reliability (Cronbach's alpha) was good for clinical scales (0.7) and acceptable (around 0.6) for the two BCIS subscales. The self-certainty subscale of the BCIS was more reproducible in factor analysis than the self-reflectiveness scale. Youths devoid of psychotic symptoms scored lower than UHR and FEP participants on the GHQ-12 and the PQ-16 and had better psychosocial functioning as measured by the SOFAS. Levels of cognitive insight did not differ between groups.People in the early stages of psychosis may be still accessible to self-reflectiveness and more hesitant about the certainty of their beliefs than patients at more advanced stages of the illness, as those with fully displayed schizophrenia.

In experimental procedures inevitably leading to the sacrifice of animals, suitable measures should be taken to minimise their pain and suffering as much as possible, as well as to prevent any modification or masking in the experimental results obtained. An overdose of anaesthetic is the method of euthanasia most employed in fish, since it is effective and easy to apply. Our objectives were to compare the efficacy of eugenol and of tricaine methanesulfonate (MS-222) as euthanasia agents in zebrafish, and to make a histological evaluation of the possible effects derived from their application. The concentrations established for eugenol were 0.25 and 0.35 mg/mL, and those for MS-222 were 0.25 and 0.50 mg/mL, for both the buffered solution and the non-buffered one. Eugenol turned out to be a stronger euthanasia agent than MS-222 in zebrafish, presenting with significantly shorter euthanasia times. However, the exposure of the fish to euthanasia doses of eugenol triggered branchial alterations, in addition to serious lesions and changes in their nerve tissue. The results obtained with MS-222 also revealed a marked branchial alteration derived from its use. In this respect, the addition of a buffer to the MS-222 solution enhanced the effectiveness of the drug, with significantly shorter euthanasia times being achieved than with the non-buffered solution, and diminished the severity of the lesions described. We therefore determined that the buffered MS-222 solution is the most effective, reliable and safest method of euthanasia for use in research on zebrafish.

Background and aims To validate a set of indicators for monitoring the quality of care of patients with diabetes in ‘real-life’ practice through its relationship with measurable clinical outcomes and healthcare costs. Methods and results A population-based cohort study was carried out by including the 20,635 patients, residents in the Lombardy Region (Italy), who in the year 2012 were newly taken-in-care for diabetes. Adherence with clinical recommendations (i.e., controls for glycated haemoglobin, lipid profile, urine albumin excretion and serum creatinine) was recorded during the first year after the patient was taken-in-care, and categorized according whether he/she complied with none or almost none (0 or 1), just some (2) or all or almost all (3 or 4) the recommendations, respectively denoted as poor, intermediate and high adherence. Short- and long-term complications of diabetes, and healthcare cost incurred by the National Health Service, were assessed during follow-up. Compared with patients with poor adherence, those with intermediate and high adherence respectively showed (i) a delay in outcome occurrence of 13 days (95% CI, -2 to 27) and 23 days (9 to 38), and (ii) a lower healthcare cost of 54 € and 77 €. In average, a gain of 18 Euros and 15 Euros for each day free from diabetic complication by increasing adherence respectively from poor to intermediate and from poor to high were observed. Conclusion Close control of patients with diabetes through regular clinical examinations must be considered the cornerstone of national guidance, national audits, and quality improvement incentive schemes.

Purpose To measure indicators of timeliness and continuity of treatments on patients with schizophrenic disorder in ‘real-life’ practice, and to validate them through their relationship with relapse occurrences. Methods The target population was from four Italian regions overall covering 22 million beneficiaries of the NHS (37% of the entire Italian population). The cohort included 12,054 patients newly taken into care for schizophrenic disorder between January 2015 and June 2016. The self-controlled case series (SCCS) design was used to estimate the incidence rate ratio of relapse occurrences according to mental healthcare coverage. Results Poor timeliness (82% and 33% of cohort members had not yet started treatment with psychosocial interventions and antipsychotic drug therapy within the first year after they were taken into care) and continuity (27% and 23% of patients were persistent with psychosocial interventions, and antipsychotic drug therapy within the first 2 years after starting the specific treatment) were observed. According to SCCS design, 4794 relapses occurred during 9430 PY (with incidence rate of 50.8 every 100 PY). Compared with periods not covered by mental healthcare, those covered by psychosocial intervention alone, antipsychotic drugs alone and by psychosocial intervention and antipsychotic drugs together were, respectively, associated with relapse rate reductions of 28% (95% CI 4–46%), 24% (17–30%) and 44% (32–53%). Conclusion Healthcare administrative data may contribute to monitor and to assess the effectiveness of a mental health system. Persistent use of both psychosocial intervention and antipsychotic drugs reduces risk of severe relapse.

Background One critical barrier to the uptake of mental health programmes is the so-called physical healthcare gap, a concern raised by the unattended physical comorbidity and early mortality of persons with severe mental illness. Aims To evaluate the extension of physical healthcare gap among persons with severe mental illness under chronic drug therapies. Method A population-based cohort study was carried out, using Lombardy healthcare utilisation databases. Prevalent patients treated with blood pressure-, lipid- or glucose-lowering agents were identified in January 2017. Among these, those who were receiving care for depression, schizophrenia, bipolar disorder or personality disorder formed the study cohort. A reference cohort was randomly selected from prevalent patients treated with chronic therapies without signs of severe mental disorders, to be matched with study cohort members for gender, age and number of previous contacts with the National Health System. One-year adherence to healthcare was measured through the proportion of days covered (drug adherence), and exposure to selected recommendations (clinical control adherence). Results The 55 162 patients with severe mental illness were less likely to have high adherence to blood pressure-lowering, lipid-lowering or antidiabetic agents than the reference cohort by −24% (95% CI −26 to −22%), −10% (95% CI −14 to −6%) and −25% (95% CI −29 to −21%), respectively. The 9250 patients with diabetes and severe mental illness had −18% (95% CI −22% to −13%) reduced likelihood to meet recommendations for the clinical management of diabetes, compared with the reference cohort. Conclusions Adherence to chronic drug therapies was sensibly worse among patients living with mental illness than those without signs of mental disorders.

Aim Early Intervention in Psychosis (EIP) is a well-established approach with the intention of early detection and treatment of psychotic disorders. Its clinical and economic benefits are well documented. This paper presents basic aspects of EIP services, discusses challenges to their implementation and presents ideas and strategies to overcome some of these obstacles. Methods This paper is a narrative review about the evidence supporting EIP, with examples of successful implementation of EIP and of cases where major obstacles still need to be overcome. Results Experience from successfully implemented EIP services into the mental healthcare system have generated evidence, concepts and specific strategies that might serve as guidance or inspiration in other countries or systems where EIP is less well developed or not developed at all. Previous experience has made clear that evidence of clinical benefits alone is not enough to promote implementation, as economic arguments and political and social pressure have shown to be important elements in efforts to achieve implementation. Conclusions Users’ narratives, close collaboration with community organisations and support from policy-makers and known people within the community championing EI services are just a few of the approaches that should be considered in campaigns for implementation of EI services. Fast progress in implementation is possible.

Background Multimorbidity is a growing concern for healthcare systems, with many countries experiencing demographic transition to older population profiles. A simple multisource comorbidity score (MCS) has been recently developed and validated. A very large real-world investigation was conducted with the aim of measuring inequalities in the MCS distribution across Italy. Methods Beneficiaries of the Italian National Health Service aged 50–85 years who in 2018 were resident in one of the 10 participant regions formed the study population (15.7 million of the 24.9 million overall resident in Italy). MCS was assigned to each beneficiary by categorizing the individual sum of the comorbid values (i.e. the weights corresponding to the comorbid conditions of which the individual suffered) into one of the six categories denoting a progressive worsening comorbidity status. MCS distributions in women and men across geographic partitions were compared. Results Compared with beneficiaries from northern Italy, those from centre and south showed worse comorbidity profile for both women and men. MCS median age (i.e. the age above which half of the beneficiaries suffered at least one comorbidity) ranged from 60 (centre and south) to 68 years (north) in women and from 63 (centre and south) to 68 years (north) in men. The percentage of comorbid population was lower than 50% for northern population, whereas it was around 60% for central and southern ones. Conclusion MCS allowed of capturing geographic variability of multimorbidity prevalence, thus showing up its value for addressing health policy in order to guide national health planning.

Objective: To assess the quality of mental healthcare provided to patients with schizophrenic disorders in the Italian region of Lombardy. Design: Forty-one clinical indicators were applied to Lombardy's healthcare databases containing data on mental health treatments, hospital admissions, somatic health treatments and pharmaceutical prescriptions. Setting: All public departments of mental health and private residential facilities in Lombardy. Participants: All 28 227 patients with schizophrenic disorders that were under the care of Lombardy mental health services in 2009. Interventions: N/A. Main outcome measures: N/A. Results: The care that was delivered to patients and family members was more frequent for firstepisode cases than for prevalent ones. Seven out of ten patients made use of continuing care and, after hospitalization, more than half of the discharged patients received a follow-up visit by community mental health centre staff within 2 weeks of their discharge. Psychotherapeutic and psychoeducative treatments, such as employment and independent living support, were not widespread among these discharged patients. Antipsychotic drug dosage was usually within the recommended range. The adherence of first-episode patients to antipsychotic treatment was lower than that of prevalent patients, and the monitoring of metabolic side effects was not always consistent. Inappropriateness of hospital care, in terms of longer admission, readmission, compulsory admission and restraint, was limited. Mortality during the period was significant. Conclusions: Clinical indicators demonstrate the strengths and weaknesses of the mental health system in Lombardy and they can be useful tools in the routine assessment of mental healthcare quality.

To analyze the differences in mental health service utilization by immigrant and native populations of Lombardy, an Italian region that hosts one-fourth of the immigrants living in Italy. The data are drawn from the regional mental health information system (based on the case register model), which supplies information on the users and mental health activities of the Departments of Mental Health, Lombardy, a region of about 10 million people; 139,775 adult users were treated in mental health services in 2010. Mental health services are used by 11.3 immigrant users out of 1,000 immigrants (with marked differences depending on country of origin) compared with 17.0 native users. Acute mental health services are used more frequently by immigrant patients; the types of intervention provided to immigrants differ from those provided to the native population (mainly as far as psychotherapeutic interventions is concerned), while gender differences are substantial. The number of immigrant users using mental health services has increased notably in recent years, and in Lombardy it has been observed that the use of such services differs from service unit to service unit. This raises the problem of how to increase the cultural awareness of mental health professionals dealing with the mental health needs of the immigrant population. On the whole, immigrants use community mental health services less than the native population; however, immigrants tend to be more frequently admitted to general hospital psychiatric units during acute phases and both the utilization rates and gender differ greatly, depending on the country of origin.

International audience; We study the stability of the origin for a class of linear time-varying systems with a drift that may be divided in two parts. Under the action of the first, a function of the trajectories is guaranteed to converge to zero; under the action of the second, the solutions are restricted to a periodic orbit. Hence, by assumption, the system's trajectories are bounded. Our main results focus on two generic case studies that are motivated by common nonlinear control problems: model-reference adaptive control, control of nonholonomic systems, tracking control problems, to name a few. Then, based on the standing assumption that the system's dynamics is persistently excited, we construct a time-dependent Lyapunov function that has a negative definite derivative. Our main statements may be regarded as off-the-shelf tools of analysis for linear and nonlinear time-varying systems.

Aims.To determine the prevalence of women of childbearing age with schizophrenia and bipolar disorder exposed to antipsychotic (AP) drugs and mood stabilizers (MS) in Lombardy, a European region of 10 million inhabitants and 1 752 285 women of childbearing age.Methods.The data concerning psychiatric care, drug treatments and pregnancy outcomes were retrieved from local administrative databases during a 12-month census period.Results.During a 12-month census period, 2893 women of childbearing age with schizophrenia (74.8% of all women of childbearing age with schizophrenia) and 918 with bipolar disorder (80.1% of all women of childbearing age with bipolar disorder) were exposed to AP drugs or MS, yielding a prevalence of exposure for women with schizophrenia of 1.65 (95% confidence interval (CI) 1.59–1.71) per 1000 female inhabitants, and for women with bipolar disorder of 0.52 (95% CI 0.49–0.55) per 1000 female inhabitants. Persistent exposure to potentially teratogenic medications accounted for one in every 1000 women of childbearing age. Of the 57 pregnancies in women with schizophrenia, normal delivery was recorded in 23 (40%) cases; of the 26 pregnancies in women with bipolar disorder, normal delivery was recorded in 10 (38%) cases.Conclusions.In women of childbearing age with severe mental disorders, exposure to psychotropic drugs is substantial, which suggests that the issue of reproductive health is epidemiologically relevant and a major public health concern.

Aims.Information is crucial in mental healthcare, yet it remains undervalued by stakeholders. Its absence undermines rationality in planning, makes it difficult to monitor service quality improvement, impedes accountability and human rights monitoring. For international organizations (e.g., WHO, OECD), information is indispensable for achieving better outcomes in mental health policies, services and programs. This article reviews the importance of developing system level information with reference to inputs, processes and outputs, analyzes available tools for collecting and summarizing information, highlights the various goals of information gathering, discusses implementation issues and charts the way forward.Methods.Relevant publications and research were consulted, including WHO studies that purport to promote the use of information systems to upgrade mental health care in high- and low-middle income countries.Results.Studies have shown that once information has been collected by relevant systems and analyzed through indicator schemes, it can be put to many uses. Monitoring mental health services, represents a first step in using information. In addition, studies have noted that information is a prime resource in many other areas such as evaluation of quality of care against evidence based standards of care. Services data may support health services research where it is possible to link mental health data with other health and non-health databases. Information systems are required to carefully monitor involuntary admissions, restrain and seclusion, to reduce human rights violations in care facilities. Information has been also found useful for policy makers, to monitor the implementation of policies, to evaluate their impact, to rationally allocate funding and to create new financing models.Conclusions.Despite its manifold applications, Information systems currently face many problems such as incomplete recording, poor data quality, lack of timely reporting and feedback, and limited application of information. Corrective action is needed to upgrade data collection in outpatient facilities, to improve data quality, to establish clear rules and norms, to access adequate information technology equipment and to train health care personnel in data collection. Moreover, it is necessary to shift from mere administrative data collection to analysis, dissemination and use by relevant stakeholders and to develop a “culture of information” to dismantle the culture of intuition and mere tradition. Clinical directors, mental health managers, patient and family representatives, as well as politicians should be educated to operate with information and not just intuition.

This study assessed whether patients being treated for schizophrenia spectrum and affective disorders in Lombardy receive adequate treatment and sought predictors of adequate treatment.Patients were aged ≥ 18, were residents of Italy's Lombardy region, and were treated in 2007 for schizophrenia spectrum and affective disorders (N = 44,462). The patients were assessed as part of a retrospective analysis of pharmaceutical and mental health services databases. Adequacy of 12-month treatment from the first psychiatric contact in 2007 was assessed at the patient level. A hierarchical log-binomial regression model was fitted to estimate relative risk and 95% confidence intervals for association between patients, characteristics of the departments of mental health (DMH), and receipt of minimally adequate treatment.About half the patients with serious mental disorders did not receive adequate care; 45.5% of patients with depressive disorders, 55.7% of those with bipolar disorders, and 49.3% of those with schizophrenia spectrum disorders received minimally adequate treatment. Diagnosis of a schizophrenia spectrum disorder or bipolar disorder and male gender predicted adequate treatment, whereas employment and high comorbidity predicted inadequate treatment. Patients who received mental health services in the past year were significantly more likely to receive adequate treatment compared with those who had received services in the past five years or new patients.Minimally adequate treatment is a useful indicator to monitor quality of care in Italy's regional mental health system. These data should be used at regional and local levels to implement clinical audits, to create benchmark measures, and to define new quality-improvement projects to meet specific DMH needs.

Objective: The aims were to assess the feasibility of routinely collecting outcome data in everyday mental health services across Italy and to evaluate clinical change in a cohort of patients stratified by illness duration. Method: A prevalence sample of patients attending nine Italian community mental health services (CMHS) was assessed over one year with the Health of the Nation Outcome Scales (HoNOS). The patients were classified on the basis of the duration of their contact with services. Clinical outcome was evaluated taking into account parameters of reliable and clinically significant change (RCSC). Predictors of change included clinical and socio-demographic characteristics at first assessment and six month reliable improvement. Results: 2059 patients were evaluated with only 3% attrition at follow up; 22% of first time and about 7% of longer term users achieved reliable improvement at one year. First contacts had a better outcome than longer term users and significant differences were seen at both group and individual level. Reliable improvement at six months was the best predictor of clinical improvement at one year for the whole cohort. Conclusion: The study demonstrated the feasibility of routine outcome assessment and gave an expected and realistic picture of the one-year outcome of a representative sample of patients attending a group of Italian CMHS. RCSC showed potential utility as a means of communicating with clinicians and decision makers.

Background: Little is known about the treated prevalence and services received by children and adolescents in low- and middle-income countries (LAMICs). The purpose of this study is to describe the characteristics and capacity of mental health services for children and adolescents in 42 LAMICs. Methods: The World Health Organization Assessment Instrument for Mental Health Systems (WHO-AIMS), a 155-indicator instrument developed to assess key components of mental health service systems, was used to describe mental health services in 13 low, 24 lower-middle, and 5 upper-middle-income countries. Child and adolescent service indicators used in the analysis were drawn from Domains 2 (mental health services), 4 (human resources), and 5 (links with other sectors) of the WHO-AIMS instrument. Results: The median one-year treated prevalence for children and adolescents is 159 per 100,000 population compared to a treated prevalence of 664 per 100,000 for the adult population. Children and adolescents make up 12% of the patient population in mental health outpatient facilities and less than 6% in all other types of mental health facilities. Less than 1% of beds in inpatient facilities are reserved for children and adolescents. Training provided for mental health professionals on child and adolescent mental health is minimal, with less than 1% receiving refresher training. Most countries (76%) organize educational campaigns on child and adolescent mental health. Conclusions: Mental health services for children and adolescents in low- and middle-income countries are extremely scarce and greatly limit access to appropriate care. Scaling up of services resources will be necessary in order to meet the objectives of the WHO Mental Health Gap Action (mhGAP) program which identifies increased services for the treatment of child mental disorders as a priority.

Background: Several guidelines consider psychosocial treatments an essential component of clinical management of bipolar disorders in addition to drug therapy. However, to what extent such interventions are available in everyday practice to the average patient attending mental health services is not known. Aims: This study aims to investigate access of people with bipolar disorders to psychosocial treatments in a community-based care system. Method: Information on care delivery and service utilization were retrieved from the psychiatric database of Lombardy, Italy, covering a population of 9,743,000, for all adults who had at least one contact in 2009 with psychiatric services. Rates of patients with a diagnosis of bipolar disorder who had access to individual psychotherapy, couple/family therapy, group psychotherapy and family interventions were calculated and compared to patients with schizophrenia and depression. Results: A total of 8,899 subjects with bipolar disorder had been in contact with psychiatric services, corresponding to a treated annual prevalence rate of 1.1‰. More than 80% of patients were treated in community settings. Rates of patients receiving structured psychosocial treatments ranged from 0.7% for couple/family therapy to 6.1% for individual psychotherapy. No differences with patients with schizophrenia and depression were found. Patients with schizophrenia received more interventions labeled as rehabilitation. Conclusion: Few people with bipolar disorders had access to psychosocial treatments. Even in a well-developed system of community care, offer of psychosocial interventions for bipolar disorders is inadequate. This issue should be a target for future research on dissemination and implementation strategies.

Aims: Routinely collected data can be used to monitor the performance and improve the quality of mental healthcare systems. Data-based and system-level Quality Monitoring Programmes in Mental Health Care (QMP-MHC) are increasingly being implemented in EU countries. They are believed to be indispensable for the sustainable improvement of the quality of mental healthcare. However, there is a paucity of comparative research on national strategies in quality monitoring. This study explores the status of system-level Quality Monitoring Programmes in Mental Health Care (QMP-MHC) in EU countries. It aims to provide a descriptive overview, which is intended to be the first step for comparative research in this field. Methods: Case studies of system-level QMP-MHCs were gathered from eight EU countries. Experts from each country were asked to describe their approach using a template. These experts were all members of a Europe-wide network of researchers and members of public institutions involved in quality assessment and performance monitoring of mental healthcare. Results: Country profiles were gathered from England, Denmark, France, Germany, Italy, the Netherlands, Portugal, and Sweden. All these countries have or are in the process of implementing system-level QMP-MHCs. Implementation seems to be facilitated when a national performance monitoring programme for general healthcare is already in place, although in the Netherlands, a QMP-MHC was established without being attached to a general monitoring programme. All the monitoring programmes described use various quality and performance indicators; some systems enhance this methodology with the addition of qualitative assessment methods such as peer reviews linked to accreditation processes. Research is needed to better understand the historical, political and technical backgrounds of the different national cases and to explore the effectiveness of different improvement mechanisms on the actual quality of healthcare. Policy makers and those designing performance measurement programmes are recommended to look across the borders of their own healthcare systems as there are many ways to assess performance and many ways to feedback results to service providers. No evidence is available whether one of these methods is superior to the others in improving the quality of mental healthcare. (C) 2016 Elsevier Ireland Ltd. All rights reserved.

Although many countries' policies give Severe Mental Illness (SMI) priority inside Mental Health Services, researches assessing the prevalence of SMI in Mental Health Services according to operational criteria are still few. The aim of this is paper is to define annual SMI treated prevalence, describing socio-demographic and clinical characteristics, patterns of care and treatment costs of SMI and non-SMI patients. SMI prevalence in 10 Departments of Mental Health of the Lombardy Region (Italy) was assessed in 2000 by applying criteria concerning both severity, measured through HoNOS (Health of the Nation Outcome Scales), and utilisation patterns in the previous year. Annual SMI prevalence was equal to 3.1 cases per 1,000 inhabitants aged over 14; SMI patients' costs were 5.5 times higher than those of non-SMI patients ($5,183 versus $939 per year) and patterns of care were different. The variables predicting the SMI status were diagnosis, presence of paid employment, duration of service contact, care packages delivered in 2000 and severity of some HoNOS items (self harm, drug abuse, cognitive problems, delusions, other symptoms, relationships, activities of daily living and housing). The use of the combined criteria of severity and intensity of contact with mental health services in the previous year seems to be able to define severely ill patients adequately.

Objective Little is known about the practice of predicting community-based care effectiveness of patients affected by schizophrenic disorders. We assessed predictors of treatment failure in a large sample of young people affected by schizophrenia. Methods A cohort of 556 patients aged 18–35 years who were originally diagnosed with schizophrenia during 2005–2009 in a Mental Health Service (MHS) of the Italian Lombardy Region was identified. Intensity of mental healthcare received during the first year after index visit (exposure) was measured by patients’ regularity in MHS attendance and the length of time covered with antipsychotic drug therapy. Patients were followed from index visit until 2012 for identifying hospital admission for mental disorder (outcome). A proportional hazards model was fitted to estimate the HR and 95% CIs for the exposure-outcome association, after adjusting for several covariates. A set of sensitivity analyses were performed in order to account for sources of systematic uncertainty. Results During follow-up, 144 cohort members experienced the outcome. Compared with patients on low coverage with antipsychotic drugs (≤4 months), those on intermediate (5–8 months) and high (≥9 months) coverage, had HRs (95% CI) of 0.94 (0.64 to 1.40) and 0.69 (0.48 to 0.98), respectively. There was no evidence that regular attendance at the MHS affected the outcome. Conclusions Patients in the early phase of schizophrenia and their families should be cautioned about the possible consequences of poor antipsychotic adherence. Physicians and decision makers should increase their contribution towards improving mental healthcare.

A public mental health indicator scheme may be defined as a systematic collection of brief proxy measures that represent summary information on variables that are potentially influenced by or relevant to mental health systems, programmes and services. Existing public mental health indicator schemes have been developed in or for high-income countries.The paper describes and compares four existing high-income country public mental health indicator schemes and highlights key observations.The range of indicators and subclasses of indicators covered by the four existing schemes is large. There was only one item (indicator) that was covered by more than one scheme.The variety of possibilities in indicators and types of indicators suggests a lack of consensus in the essential contents of an indicator scheme. There is a need for a public mental health indicator scheme that is applicable in resource-poor countries.

Objective: Many authors recommended that reliable and clinically significant change (RCSC) should be calculated when reporting results of interventions. To test the reliability of the Health of the Nation Outcome Scales (HoNOS) in identifying RCSC, we applied the Jacobson and Truax model to two HoNOS assessments in a large group of people evaluated in 10 community mental health services in Lombardy, Italy, in 2000. Method: The HoNOS was administered to 9817 patients; of these, 4759 (48%) were re-assessed. Reliable change (RC) was calculated using Cronbach's alpha ( α), as a parameter of the reliability of the measure. Clinical significance cut-offs were calculated using a classification of severity based on HoNOS items. Results: In the whole sample, the clinical improvement cut-off was 11 and the remission cut-off was 5. Considering the severe patients, the clinical improvement cut-off was 12. The RC index calculated on the whole group and on the subgroup of severe patients indicated that eight-point and seven-point changes, respectively, were needed to be confident that a real change had occurred. Longitudinal changes were depicted on two-dimensional graphs as examples of reporting RCSC on HoNOS total scores in a routine data collection: 91.6% of the whole sample (4361) was stable, 5.6% (269) improved and 1.8% (129) worsened. Conclusion: Our study proposes a methodological framework for computing RCSC normative data on a widely used outcome scale and for identifying different degrees of clinical change.

SummaryAims — Evaluation of community residential facilities effectiveness in the Department of Mental Health of Desio (Milan). Method — Outcomes in symptoms, disability, family burden and quality of life were evaluated during one year through a longitudinal study, using a pre—test and post test design without control group. Results — Residential care is effective in reducing disability and symptoms, while it is not effective towards family burden. Quality of life is improved in some domains, but not in others (e.g. social and family relationships). Conclusions — Outcome assessment is feasible in residential facilities, following a multiaxial and multifactorial model. We need to clarify the goals of residential care, focussing on active components of the residential treatment.Declaration of Interestthe research project was funded by Department of Health of Regione Lombardia (DGR n. 37596 del 24.7.1998).