key: cord-0717642-qi6houl6
authors: Pelizza, Lorenzo; Pupo, Simona
title: The COVID-19 Pandemic and Italian Public Mental Health Services: Experience and Future Directions
date: 2020-10-21
journal: J Patient Exp
DOI: 10.1177/2374373520956857
sha: 706da28e9c301e459dc95d42a2f784b6a6c34e20
doc_id: 717642
cord_uid: qi6houl6

The COVID-19 pandemic has crosses every health care area (from primary care to specialist ones), leading to a review of all public health policies. The use of smart working allows important technological innovations, but it must be accompanied by a review of hospital and residential programs and locations. Since many institution are talking about economic investments for mental health (a crucial area for a full recovery of the society), specific funds are needed in mental health professionals (eg, psychologists), skills, and innovation of locations and technology, such as the conversion of psychiatric wards to community services that carefully must consider the patient experience and clinician’s point of view. Some considerations on the COVID-19 experience in Italy are reported, and suggestions on future directions for public mental health service organization are hypothesized.

In the time of COVID-19, a transitioning from face-to-face to online treatments has been designed to enforce the social distancing (1) . This is an important topic, especially considering the relevance of psychotherapy and rehabilitation interventions in public services and the little space dedicated in the literature to patients with severe mental illness usually receiving community support (2) . In this respect, some considerations based on public mental health service experience in Italy during the epidemic are reported.

As of June 25, 239 410 confirmed cases and 34 705 deaths due to the COVID-19 infection make Italy one of the most affected countries in the world (3) . Italian public mental health services are traditionally organized according to a community-based model of care, in which multidisciplinary teams (ie, psychologists, psychiatrists, professional educator, nurses, psychiatric rehabilitation therapist, social workers) provide a wide range of interventions from long-term rehabilitation to acute emergency treatment (4). Since February 21, clinical activities of the Italian psychiatric services have been significantly changed by the pandemic. After 4 months, suggestions from the Italian experience could be useful for planning post-COVID-19 interventions on public mental health service organization, also based upon patient and clinician experiences.

To date the emergency has prevailed, although with greater attention to the community in recent weeks. Indeed, while in the first phase, the need to cope with the wave of hospitalizations has required an extraordinary effort focusing to increase dedicated beds in intensive care units, the community medicine (called into question since the greater part of infected patients was at home) has shown to play a crucial role in the early intervention against the infection (5).

Physical distancing have required a change in public mental health activities, especially in outpatient and day services, which have been suspended or, where remodeled, have largely passed toward the person's home. For psychiatric services in Italy, this (ie, "the individual as a community resource"-as repeatedly suggested by an influential Italian colleague) (6) is a central point that the pandemic has relaunched. However, to be successful, it is crucial to combine the individual responsibility with that of the caring community, passing by family members and local social agencies. It is necessary to build a dynamic link between a "patient-centered" and a "community-centered" system. In this respect, although a "patient-centered care" model places greater emphasis on the patients' involvement in determining the goals of treatment that are meaningful to them (eg, quality of life, functioning, sense of hope, and self-efficacy), community-based mental health services enables people with psychiatric disorders to maintain family relations, friendships, and jobs while receiving treatment, avoiding isolation and social stigma. This important challenge requires a transition that passes from an institutional system ("hospital-centered" or "outpatient-centered") to a postinstitutional one, based on people and communities connected by a complex set of relationships. The invitation to stay at home may be an opportunity for a new "proximity welfare," in which the person's home is a nonisolated but connected house (eg, via Internet), not abandoned but supported also with innovative rehabilitation interventions (such as Personal Health Budget, Individual Placement and Support) (7) . In this regard, several patients taken in charge in the Parma Department of Mental Health with in-home interventions and virtual treatments during the initial months of the COVID-19 pandemic have definitely appreciated these new therapy approaches ("I'm pleased to have my mental health service so close during the social distancing," "videocalls alleviate my loneliness," "It's nice do treatments at home") (6) .

The public mental health system should be completely rethought, avoiding an irrational "total institution" model and providing citizens with a range of places where mental disorders can be treated without reaching a high care density. To date, it is a very viable model, which can use technological innovations for remote work and in-home health care (eg, new computer technologies, apps), although reinforced in terms of nursing, educational, and psychological staff, also for coping with the current community complexity (with the idea that when possible, the patient should only be admitted as long as necessary for the most important acute treatments). Based on the "Chronic Care Model" (8), psychiatric wards must be considered as integrated parts of the community system. To avoid unnecessary hospitalizations, it is a matter of reaching effective risk stratification without segregating solutions, but better analyzing every single case with its psychopathological, family, socioeconomic, and legal complexity. The COVID-19 pandemic reaffirms that the most important place for recovery and rehabilitation remains the person's home, making explicit the relevance of the support and the connection with the community (4,6).

For access in Community Mental Health Centers (CMHCs), outpatient teams should carefully asses mental health problems and needs of people who are not in charge, while maintaining the centrality of the consultation with General Practitioners (GPs; also by a phone triage and dedicated times), so implementing a "stepped care" approach (ie, from GPs' referrals to specialist outpatient services) (8) . Indeed, in the pandemic, smart working has shown the appropriateness of conducting clinical interviews via internet or by telephone, especially for younger and more distant individuals (4) . In this respect, adolescents and young adults taken in charge in the Parma child/adolescent or adult mental health services have particularly appreciated the "online-visit model," because more faster, practical, and friendly ("in line with our usual interpersonal communication") (6) .

For patients under treatment, remote interventions (making clear programming, intensity [ie, daily, weekly, monthly], mode [by phone, video, or email], and purpose) may be very useful, promoting a sort of "home hospitalization" and extending specialist support into the native community where the patient lives. It is also necessary to rethink specific mental health care pathways to favor online treatments (eg, for early psychosis or eating disorders), online nursing interventions (eg, for metabolic syndrome, healthy lifestyles), and to expand self-help activities (also using peer support and patient experiences) (9) . Psychosocial intervention may be structured remotely or by integrating remote procedures with activities in real situations. This requires a transition to services combining remote activity with the "de visu" one (within mixed "real" and "virtual" CMHCs). Some of the more frequent "key obstacles" that must be often addressed when attempting to have more in-home treatment and/or virtual care (even for serious mental illness) are represented by the lack of supporting infrastructure, the user's preference in outpatient or hospital-based care and clinician concerns (eg, home care visits take longer time) (10) . Overcoming these obstacles means that patient-centered care opportunities could be available for the broader population.

The COVID-19 pandemic has crosses every health care area (from primary care to specialist ones), leading to a review of public health policies (eg, strengthening of in-home treatments instead of hospital-centered care). Since several governments and prestigious international health institutions (eg, World Health Organization, World Psychiatric Association) have proposed economic investments for mental health (a crucial area for a full recovery of the society), specific public funds are needed in mental health professionals, skills, and innovation of locations and technology, such as the remodeling of inpatients units to community sites that must carefully consider the patient experience and clinicians' point of view.

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Lorenzo Pelizza https://orcid.org/0000-0003-4746-2061

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Parmaearly psychosis" program: general description and process analysis after 5 years of clinical activity. Early Interv Psychiatry

Evidence on school closure and children's social contact: useful for coronavirus disease (COVID-19)?

Transizione al dopo coronavirus: spunti per la salute mentale. Conferenza Nazionale per la Salute Mentale

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Evidence on the chronic care model in the new millennium. Health Aff (Millwood)

The "Parma-early psychosis" programme: characterization of help-seekers with first episode psychosis

Five obstacles to home-based health care and how to overcome them. Innovation

Lorenzo Pelizza is a director of the Mental Health Service in the Parma Penitentiary Institutes and currently working as psychiatrist in the Parma Department of Mental Health and Pathological Addictions.Simona Pupo is a medical doctor working in the Anesthesia and Resuscitation Service of the Parma University Hospital. She had experience and currently working in COVID-19 inpatient units.