Lessons from Italy - 48 years of care in the community

The mental health service of Trieste in north eastern Italy is justly famous as one of the pioneers of community based care. It began with the closure of the nineteenth century asylum with Law 180 of 1978, which re-opened the next week as interim supported housing.

For the nearly fifty years since then, the care of people with disabling mental illness in Italy has been delivered through a system of small scale residential facilities, rather than long-term institutional settings, a reform that encouraged support in environments that reflect everyday life, with care integrated into those settings rather than separated from them. Care is delivered through community-based settings, with 30,000 places provided within residential facilities of between 10 and 25 beds. This equates to around 46 beds per 100,000 people, higher than many comparable countries and at far lower cost than hospitals. 

The outcomes are instructive. Compulsory admissions have fallen from more than 20,000 in 1978 to fewer than 9,000 in 2015, and now account for less than 5% of all psychiatric admissions. Over the same period, suicide rates have remained broadly stable, moving from 7.1 per 100,000 people in 1978 to 6.3 in 2012, despite the near elimination of long-stay psychiatric hospital beds. All this with around half the mental health budget and workforce of Australia.

The role of housing with appropriate supports stands out. A stable home creates the conditions for care to be consistent, relationships to form, and recovery to be supported over the long term. It allows people to remain connected to their local community, rather than becoming isolated and removed.

Italy’s solution is essentially what was recommended in the 1982 Richmond Report, and is closely aligned with the work of Habilis here in Australia, where we’re creating permanent, supported housing for people living with chronic mental health conditions. When people have a home, and care that meets them there, admission to hospital is often no longer necessary. Italy has shown what that can look like at scale, and Habilis is proving what it can become here.

Reference:

Barbui, C., Papola, D., & Saraceno, B. (2018). Forty years without mental hospitals in Italy. International Journal of Mental Health Systems, 12:43. https://doi.org/10.1186/s13033-018-0223-1