Future psychiatric services in Italy: lesson from the COVID-19 pandemic.

During the COVID-19 epidemic, home care and remote working showed important technological innovations, leading to review all public mental health policies. In this article, some considerations based on the Italian COVID-19 experience in order to plan post-COVID psychiatric interventions are reported.

As of July 7, 34 869 deaths and 241 819 confirmed cases due to the COVID-19 epidemic make Italy one of the most affected countries in Europe (1). Since 24th February, public mental health services in Italy had to significantly change their clinical activities because of the COVID-19 pandemic. After 5 months, final recommendations for a future psychiatric service reorganization cannot yet be definitively outlined, but the Italian COVID-19 experience might be helpful for planning post-COVID public mental healthcare interventions.

While in the initial infection phase the emergency prevailed and the need to face the wave of hospitalizations required considerable efforts to increase dedicated beds in intensive care units, community medicine treatments (called into question since most of the infected patients were at home) subsequently showed to play a crucial role in early intervention against the pandemic spreading (2). “Staying at home” and physical distancing brought about a critical change in public mental health routine activities (mostly in day services and outpatient centers), which were stopped or reconverted towards the patient’s home (e.g. urgent visits). For psychiatric service policy in Italy, this idea (i.e. “the person as a community resource”) (3) is still a crucial point that the COVID-19 epidemic helped to revive. In this sense, it is decisive to build a dynamic bridge between a “patient-centered” and a “community-centered” healthcare system, combining patient unmet needs together with caring community responsibility (e.g. social agencies, family members) (4). This change of perspective requires a transition from an institutional healthcare service (“hospital-centered” or “outpatient-centered”) to a post-institutional one, based on communities and individuals linked together in a complex set of relationships, i.e. a new proximity welfare in which the patient’s home is a non-isolated but connected house (e.g. telepsychiatry), also supported with modern rehabilitation models (e.g. Individual Placement and Support, Personal Health Budget) (5).

In this respect, public mental health services should be totally rethought, offering care settings in which mental illness can be treated without reaching high intervention density and the patient should only be admitted the time strictly necessary for the most acute treatments (4).

Future directions

During the COVID-19 pandemic, home care and remote interventions (with clear programming, intensity [i.e. monthly, weekly, daily], mode [by email, video or phone] and purpose) showed to be helpful for patients under treatment in Community Mental Health Centers (CMHCs), providing a “home hospitalization” with a psychiatric support directly extended into the local community. This satisfactory experience induces to rethink specific mental health care pathways, favoring online treatments (e.g. for eating disorders, early psychosis), online nursing interventions (e.g. for healthy lifestyles, metabolic syndrome) and spreading online peer-support and self-mutual-help activities. Psychosocial intervention can be structured remotely or by integrating online procedures with activities in real life within mixed “real” and “virtual” CMHCs.

For individuals who are not in charge of CMHCs, it is useful to maintain the centrality of the consultation with General Practitioners (also by a phone triage) together with the implementation of online visits that showed to be effective in conducting remote clinical consultations with patients (especially for younger and more distant subjects).

In summary, smart working may provide important technological innovations in clinical practice, especially if accompanied by a review of residential and hospital locations and programs. In an announced era of economic investments for mental health, specific funds are needed in mental health skills and professionals, as well as in innovation of technology and locations (such as the transformation of psychiatric beds into community services).