Objective – Epidemiological and clinical studies indicate that 10–50% of primary care patients suffering from clinically relevant psychiatric distress are not diagnosed by their physician and only a minority of them receive an appropriate treatment. The improvement of physicians' ability to detect mental distress and psychiatric disorder, in their routine clinical activity, represents a crucial point to reduce the social impact of mental illnesses, prevent their worsening and chronicity and, eventually, relieve mental health services of an excessive burden of care and costs. The aim of this article is to examine a number of factors which intervene in the process of detection of mental distress by the physician. Then, we will examine factors related to the management of psychiatric disorders most commonly co-occurring with physical illness in general health care sector. Method – The method used for this review was essentially a recension of the literature concerning detection and treatment of psychiatric disorders in primary care settings, having in view to see the factors connected with these processes. Results – Among factors intervening in the process of identification of mental distress in primary care settings, both the characteristics of the physician and the characteristics of the patient should be taken into account. Primary care physicians and psychiatrists are being asked to work together more frequently in this era of community care. The principal aim of such invoked collaboration is the amelioration of quality of care and reduction of costs for mentally ill patients. An important issue within this collaboration is the referral by primary care physicians to specialist services.

Nature and nurture stand in reciprocity, not opposition. Offspring inherit, along with their parents' genes, their parents, their peers, and the places they inhabit. The ontogenetic niche is a crucial link between parents and offspring, an envelope of life chances. Development is at one and the same time a social and a psychological and a biological process. If we psychiatrists allow ourselves to become mere pill pushers — or psychotherapists who fit all patients into one Procrustean bed — each as the exclusive road to mental health, we will have abandoned the duty we owe our patients and our integrity as physicians.

Objective - In recent years an extensive literature has grown up around the concepts of subthreshold, subsyndromal, minor and brief recurrent affective disorder and their applications in population-based research. The aim of this short review is to examine the definitions and current status of these proposed categories with special reference to depression, and to assess their potential contribution to psychiatric epidemiology. Method - A Medline search was carried out for the period 1965-1999, based on the above four terms. Relevant references found in all identified publications were also followed up. Results - In great measure these constructs have been developed as a reponse to deficiencies in the DSM classification system and to a lesser extent in the ICD. The groups are all defined by having fewer criterial symptoms, or a shorter duration of symptoms, than the ‘official’ diagnostic categories. Use of these definitions has resulted in widely varying prevalence estimates. Conclusion - Improved methods are badly needed for classifying all those persons in the wider community who are in need of medical treatment and help for psychological disorder, but do not satisfy operational criteria laid down in the official guidelines. This cannot, however, be achieved simply by lowering operational thresholds in these systems. Further research on clinical and psycho-social characteristics of the common mental disorders is called for, and in many societies a favourable setting is that of primary health care, where a move towards pragmatic, comprehensive classification of community health problems is already under way.

Objective – Starting from research on environmental factors that influence schizophrenia, the author speculates on innovations that could reduce the occurrence of the illness, improve its course and enhance the quality of life of sufferers and their relatives. Results – Ranging from education about obstetric risks to a stigma-reducing campaign, the suggestions could be of interest, not only to clinicians, but also to advocates, policy-makers and communications specialists. Conclusions – Several of the suggestions, which would be innovative in the United States, are already established features of Italian mental health care. These features include social enterprises, family support payments and a disability pension system without severe disincentives to work.

Objective - Following the introduction of guidelines of rational drug use, the pharmacoepidemiology of psychotropic drugs was investigated in a sample of long-stay patients living in a Italian psychiatric hospital. Design - Aprospective, longitudinal two-year follow-up study was carried out. Information about sociodemographic and clinical characteristics of the inpatientpopulation, and about medications prescribed, was collected at baseline and after one and two years of follow-up. Setting - Three wards of the psychiatric hospital of Milan. Main outcome measures - Number of patients taking psychotropic drugs, number of patients taking more than one neuroleptic or benzodiazepine, mean neuroleptic dose, psychopatological status according to the Brief Psychiatric Rating Scale (BPRS). Results 70 patients were recruited and followed for two years. At follow-up a reduction in the number of patients taking neuroleptic drugs was recorded, together with a 50% decrease in the number of patients taking more than one neuoleptic. A reduction in the use of depot formulations was in addition shown. Patients taking benzodiazepines decreased of 50%. According to the BPRS, no psychopatological changes were observed during the study. Conclusions - These data suggest that education in psychopharmacology may guide towards a more rational use of drugs; longitudinal clinical audits should be implemented to monitor everyday practice.

An evaluation is currently underway concerning the changes which have taken place in Italy in the twenty years following the reform law. The qualitative and quantitative changes are being analyzed based on a possible shared definition of the processes of deinstitutionalization. This theme is generally the object of misundestandings and cliches. The need for change in clinical and istitutional psychiatry is the indispensable premise for the development of community psychiatry and the growth of a culture of public psychiatry in general. In this framework, an attempt is being made to define the meaning of change through the growth of the active participation of persona affected with mental disorders and their families in treatment, the participation of ordinary citizens, the spread of services in the community and the quantitative increase of the number of personnel involved in public community services. Emblematic of this change is the increase in the number of psychiatrists working in the public sector, from 700 to 7,000, over this twenty year period. The changes which must take place in psychiatric practice must also be emphasized: the heirarchies, the relationships, the search for non-health resources and enhancing the value of operators as subjects outside of their institutional role. The various forms of resistence which have retarded, and continue to retard, the process of change are also considered: the persistence of clinical cultural models, administrative inertia, the defense of acquired privileges by medical and nursing lobbies, the interests of the private, commercial and religious sectors and political manipulation. In any case, the beginning of a process of change which contains all the potential of a real project for prevention is judged positively.

Objective – The study of the relation between treatment costs and disability of psychiatric patient groups. Design – Perspective assessment of costs and disability of 1371 adult psychiatric patients in charge at two Operative Psychiatric Units (OPU), followed during an average period of 9 months. Data are related to all OPU's psychiatric services, including ambulatory, full or half-residential and psychiatric departments of acute hospital services. Setting — OPUs of Magenta (MI) and Desio (MI). Methods – The disability level has been measured by Health of the Nation Outcome Scales (HoNOS) filled in at the inclusion of the patient in the study and every three—months on average thereafter. Besides other HoNOSs have been filled in both at admission and discharge from psychiatric departments of acute hospitals, Residential Centres of psychiatric Therapies and Rehabilitation and Guarded Communities. All patients have been grouped using the main psychiatric diagnosis (first digit ICD—10) and the maximum disability level shown in the whole period of the study. Direct costs of publicly financed psychiatric services have only been considered. Their attribution to each patient has been made applying standard costs or tariffs (diagnostic procedures) to the data perspectively collected by the regional Register and a purposely designed protocol. Results – Total cost of 1371 patients has been 9771.1 million lire with a cost per patient of 7127000 lire (sd 19499000) and a cost per «day in charge» of 27172 lire (sd 68358). The cost per day has been found unrelated with the length of observed time frame. At the inclusion the mean level of disability has been 4.26 points (sd 3.73) and 3.19 points (sd 3.26) at the end of the study. Its value, measured at maximum level shown by each problem in the whole period of study, has been 6.00 points (sd 4.64). Disability and treatment cost of each patient did result directly related (r = 0.626, p = 0.0001). All patients have been grouped in 12 classes with a significant (p = 0,0001) overall difference on both their disability level and treatment cost. Conclusion – All adult psychiatric patients could be grouped in disability related classes which sometimes have also a different treatment cost. A study on a greater number of patients is needed to confirm these results. It may also provide a more reliable basis for a new financing system of psychiatric services.