Psychiatric Register, Economics & Geography of Mental Health

By Francesco Amaddeo

A psychiatric case register (PCR) was started on 31 December 1978 and is used for clinical, administrative and research purposes. For research, the PCR is used for: longitudinal analyses of patterns of care; studies on incidence and prevalence and related factors; services utilisation; comparisons with other case-register areas; and costs of care and outcome. The PCR has facilitated the detailed observation of changes in Italian mental health care since the Italian psychiatric reform. The Unit has been conducted a series of studies in prevalence and incidence samples to explore the relationships between the socio-demographic and clinical characteristics of patients and the costs of community-based mental health care and to assess the association between Socio-Economic Status (SES), services utilisation and costs. Lately the Unit has developed researches regarding the mortality of psychiatric patients, analyzing in detail the general mortality, the avoidable mortality, and the mortality for cancer. Data on mortality of psychiatric patients will also be compared with those of a psychiatric Service in Tromso, Norway. The Unit is conducting a comparison between this Psychiatric Service in Tromso and the Psychiatric Service of Verona Sud.
Recently, the Unit has participated to a national study (funded by the Ministry of Health) that has permitted to develop a new funding system for community-based Mental Health Services. The Unit is the coordinating Centre for a National study on "Socio-economic status, urbanisation and mental health" that use a health geography approach. The Unit collaborated with the WHO centres based in Geneva and Copenhagen on a research project consisting in an evaluation of the psychiatric assistance in Ukraine, Georgia and Moldova.


Francesco Amaddeo, MD, Professor
Alberto Rossi, Clinical Psychologist, PhD
Laura Grigoletti, Clinical Psychologist, PhD, research grant
Valeria Donisi, Psychologist, PhD, research grant
Laura Rabbi, Social Worker
Riccardo Pertile, Statistician, PhD, research grant
Damiano Salazzari, Geographical Information System (GIS) Expert, Master, research grant
Cristina Pighi, PCR Data Manager, part time
Sabrina Zuliani, PCR Data Entry Operator, research grant, part time
Lorena Libanti, PCR Data Entry Operator, research grant, part time
Gianluca Rambaldelli, IT manager, PhD, part time
Mario Ballarin, IT technician, research grant, part time



DRGs and other patient-, service- and area- level factors influencing Length of Stay in acute psychiatric wards
R Pertile, V Donisi, L Grigoletti, A Angelozzi, G Zamengo, G Zulian, F Amaddeo
This study aims to identify services-related and area-based measures together with socio-demographic factors that could improve Diagnosis Related Groups in explaining length of stay variability in general hospital psychiatric units in Veneto region (North East of Italy). Data are collected from the regional hospital discharge records database. A hierarchical multiple regression model with only Diagnosis Related Groups as predictors of length of stay has to be compared with a second model in which patient-, service- and area-level variables are included.

Continuity of care and clinical outcome in a community based mental health Service
V Vailati Venturi, L Grigoletti, A Rossi, F Amaddeo
This study aims to examine the relationship between indicators of continuity and intensity of care and the Global Assessment of Functioning (GAF) scale used as an outcome measure, in a community-based mental health service. All South-Verona patients who had more than one contact with the Community Mental Health Service (CMHS) and at least two GAF evaluations in the period between the 1st of February 2006 and the 15th of September 2006 are included. 176 patients are involved in the study. Each diagnosis and each setting are considered.

Comparison of quality and quantity of psychiatric services in Verona (IT) and Tromso (NO)
D Pucci, F Amaddeo, R Olstad, G Rezvy, A Rossi, M Tansella, V Hansen
The aim of this study is (a) to compare the use of services of two mental health care systems, in Verona catchment area (northern Italy) and in northern Norway and to verify any differences in the service provision (and outcomes of mental health care), (b) to classify and to describe, in a standardized way, mental health services in two areas, using the European Service Mapping Schedule (ESMS) and the International Classification of Mental Health Care (ICMHC) and (c) to report the experience of ESMS use to describe service provision.


Cancer mortality among psychiatric patients treated in a community-based system of care: a 25-year case register study
G Perini, B Hanife, L Grigoletti, A Biggeri, M Tansella, F Amaddeo
Mortality data allow to assess the quality of care provided to targeted population. This study explores the risk of death by single tumour site of a psychiatric population treated in a community-based psychiatric service. Data are drawn from South Verona Psychiatric Case Register for all patients with an ICD-10 psychiatric diagnosis in 1982-2006 (25 years). Mortality and cause of death are ascertained using different procedures and sources. Standardised Mortality Ratios are used to compare the observed number of deaths with the expected number using reference population of Veneto Region.

Comparing direct mortality rate ratios: an Italian case vs. a Norwegian one
F Amaddeo, A Biggeri, L Grigoletti, R Pertile, G Perini, L Grisotto
The aim of this study is to compare the mortality of psychiatric patients in two mental health care systems, in Verona catchment area (northern Italy) and in northern Norway, using age and gender specific rates. The sample will be grouped by age, gender and population census. Differences between the two Services and the mortality in the two sites will be analysed.

Cancer incidence among psychiatric patients in a community-based mental health service
L Grigoletti, R Pertile, G Perini, L Grisotto, A Biggeri, B. Hanife, F Amaddeo
This study explores the cancer incidence by single tumor site of a psychiatric population treated in a community-based psychiatric service. Data are drawn from South Verona Psychiatric Case Register for all patients with an ICD-10 psychiatric diagnosis and from the Veneto Tumour Registry.


How are caseload and service utilisation of psychiatric services influenced by distance? A geographical approach to the study of community-based mental health services
G Zulian, V Donisi, G Secco, R Pertile, M Tansella, F Amaddeo
The aim of this study is to assess how the caseload and the utilisation of mental health services vary according to travel distance and to socio-economic characteristics. Spatial and statistical analyses are carried out on a sample of 12,347 patients, with ICD-10 psychiatric diagnosis, who had at least one contact with psychiatric services between 2000 and 2006.
For assessing distance and modelling accessibility, sites of mental health services and patients domicile have to be geo-coded, and data have to be organised in a spatial database. In order to calculate the distances, patients' and facilities' locations are connected to the road network. Accessibility is modelled by using the Network Analyst Service Area Function and 13 Service Areas are created around any facility location, by measuring distances along the street network. For performing epidemiological analyses patients and census block centroids are linked to the service areas by using spatial join techniques.

Can previous psychiatric history and socio-economic status predict the costs of patients' care?
R Pertile, J Jones, V Donisi, G Zulian, L Grigoletti, F Amaddeo
The aim of this study is to estimate the costs of patients' care and to evaluate the performance of various regression models to predict costs. All patients who had at least one contact with the Verona Mental Health Service in 2002 are included in the study. They are divided into four groups on the basis of their previous service utilisation. The costs of care are calculated by merging service contact data with unit cost estimates, derived from a unit cost list. A regression model will be estimated for each group and for all patients involved. The independent variables in the regression analysis are demographic, clinical and services' utilization (derived from the Verona Psychiatric Case Register) and the Verona socio-economic status index (SES), calculated using the 2001 census data.

Socio-economic Status, urbanisation and mental health

V Donisi, R Pertile, D Salazzari, L Grigoletti, A Fiorillo, M Percudani, F Amaddeo
The main aim of this project is to evaluate the effect of socio-economic and accessibility inequality on the utilization of different psychiatric services, considering also the socio-demographic and clinical individual characteristics of patients and the services' characteristics. The study linked the information concerning the local environment (social, economic and spatial conditions) with the psychiatric services utilization combining data from the Mental Health Information System (MHIS) with data from other sources. It is a multicenter study, involving three catchment areas characterized by different socio-demographic, economic and geo-morphological patterns: the South Verona Community Mental Health Service (Verona), the Psychiatric District of Bollate (Milan); the Psychiatric Districts of Sant'Angelo dei Lombardi (Avellino).

Psychiatric Services Atlas
D Salazzari, G Zulian, L Grigoletti, C Pighi, F Amaddeo
The Psychiatric Services Atlas gives an overview of the demographic, socio-economics and of mental health services utilisation characteristics in the ULSS 20 area. It is formed by indicators that characterize the area regarding the demographical and socio-economics most important aspects for mental health and by information about the contacts of the structures of the different services and about diagnosis. For each indicator there are six maps, in order to represent the whole ULSS 20 area, each Service's area of reference, and the Verona Municipality. It was possible to calculate the indicators and to realize the theme cartography thanks to the Psychiatric Departmental Geographical Informative System, created in the Department of Medicine and Public Health, Section of Psychiatry and Clinical Psychology, of the University of Verona.

How distance from the clinic may influence patients' decision to return for treatment?
A Rossi, D Salazzari, R Pertile, F Amaddeo
The goals of community-based mental health services are to identify people suffering from psychiatric problems and to provide them with appropriate care for as long as required. Therefore, the number of patients who do return after the first visit could be considered as a key outcome indicator in this setting. This study aims to understand how distance from the clinic may influence patients' decision to return for treatment. A 33-month cohort of new episodes of care was already followed up to identify patients who dropped out after the first contact, patients who were low users and patients who were high users of the clinic in the 90 days after the first contact. Geographical Information System (GIS) will be used to geographically map the place of residence of each of these patients in order to evaluate the distance from the clinic. A set of ecological variables will also be collected at census-block level and place of residence. Multilevel analyses will be performed at individual and ecological level to understand how distance from the clinic is associated with these different types of service utilization. Socio-demographic, contact characteristics and clinical information of these patients will be taken into account as confounding factors.


Is the implementation of assertive community treatment in a low-income country feasible? The experience of Tbilisi, Georgia
N Zavradashvili, V Donisi, L Grigoletti, R Pertile, K Gelashvili, M Eliashvili, F Amaddeo
In Georgia, difficult socioeconomic conditions have resulted in a drastic decrease in government financing for the health sector. State mental hospitals continue to be the main solution for the mentally ill, due to the severe lack of community-based services, and mental health services are inadequate to meet the needs of patients. An experimental intervention of assertive community care was implemented with the aim to engage socially isolated patients who lacked contact with outpatient services and to answer their different social and psychological needs. The intervention lasted 10 months and consisted of outpatient visits, visits at home, meetings outside, and telephone calls to the services' facilities; all services were provided by a multidisciplinary team. The intervention was conducted in a psychiatric dispensary in a district of Tbilisi, Georgia. This pilot study showed the economic sustainability of community care and its effectiveness to facilitate continuity of care and to improve clinical and social outcomes.

A predictive model to allocate frequent service users of community-based Mental Health Services to different packages of care
L Grigoletti, F Amaddeo, A Grassi, M Boldrini, M Chiappelli, M Percudani, F Catapano, A Fiorillo, F Perris, M Bacigalupi, P Albanese, S Simonetti, P De Agostini, M Tansella and the I-psycost group
The aim of this study is to develop predictive models to allocate patients into frequent and low service users groups within the Italian Community-based Mental Health Services (CMHSs). Moreover, it want to allocate frequent users to different packages of care, identifying the costs of these packages. Socio-demographic and clinical data and GAF scores at baseline are collected for 1250 users attending five CMHSs. All psychiatric contacts made by these patients during six months are recorded. A logistic regression will identify frequent service users predictive variables, while multinomial logistic regressions will identify variables able to predict the most appropriate package of care. Costs are estimated with a cost function.

A model to allocate patients living in Residential Facilities to a clinically and economically appropriate package of care
L Grigoletti, L Rabbi, A Barichello, F Amaddeo
The aim of this study is to verify the cost of different individual interventions dedicated to patients in charge to the Mental Health Department of Verona, living in a Residential Facility. Furthermore, the study wants to identify patients' characteristics that lead to the allocation to a different rehabilitative-residential project, and to verify the reliability and the cross-validation of a previously proposed decision-making tree to the placement and to the evaluation of the care cost. We will use data about all patients living in Residential Facilities that are followed by the Mental Health Department of Verona, including four Mental Health Services, dislocated in Verona North-West, Center and East, South and in the city of Soave.

Drug prescription in five Italian Community-based Psychiatric Services (CPS)
A Grassi, M Boldrini, M Chiappelli, P De Agostini, F Amaddeo, L Grigoletti, P Albanese, A Fiorillo, M Percudani, M Tansella and the I-psycost group
The aim of this study is to investigate, in a sample of Italian out-patients (N=1250), the prescription of psychotropic drugs as well as related variables, prescribing patterns, polypharmacy and the appropriate use of psychotropic drugs. It is based on a drug-utilization survey conducted within the framework of a multicenter Italian study (I-psycost study), involving five Community-based Psychiatric Services (CPS): Avellino, Bologna, Legnano (Mi), Roma and Verona. For each patient recruited comprehensive information about socio-demographic and clinical status and about pharmacological regime were collected during October 2002, in order to verify the current prescribing practice in a sample of Italian CMS.

The costs of psychiatric in-patient facilities for acute psychiatric disorders
F Amaddeo, M Percudani, L Grigoletti, G de Girolamo, S Calì
Legislation in 1978 led to the gradual replacement of mental hospitals in Italy with a full range of community-based services, including facilities for acute in-patient care. The aim of the PROGRES-Acute study was to survey the main characteristics of Italian public and private in-patient facilities for acute psychiatric disorders. The aims of this part of the study are to estimate the costs of these facilities and to evaluate which factors affect their cost and the cost of their patients.


Extending web-based medical records system to deal with spatial data: an application in the psychiatric domain
S Migliorini, C Combi, A Belussi, G Zulian, L Grigoletti, G Rambaldelli, M Ballarin, C Pighi, F Amaddeo
The aim of this study is to develop a web-based application for the Health District of Verona, in order to support the Verona Psychiatric Case Registry (PCR) that collect information about medical records and patient's contacts with the Community-Based Psychiatric Services (CPSs). The structure of the database where the PCR data are stored will be described, highlighting the main refactor activities performed during the web-application development. The additional spatial information that has to be connected to the database for performing clinical-spatial analyses will be analysed. Finally, the architecture of the web-based application and the technologies used, in particular respect to the security issues, will be described.


Compassion fatigue in the Verona Mental Health Department
A Rossi, L Grigoletti, V Donisi, L Rabbi, C Curtolo, F Amaddeo
Compassion fatigue (CF) is the "cost of caring" for others in emotional pain that may lead helping professionals to abandon their work with patients. In contrast to burnout, the clinician with compassion fatigue can still care and be involved, albeit in a compromised way. Compassion fatigue may lead to burnout. A self-test to measure CF is available in many languages including Italian.
The aim of this study is to assess the level of CF in the Verona Mental Health Department, that involves four psychiatric services. Professionals involved in the clinical activities are psychiatrists, psychiatrists in training, psychologists, social workers, psychiatric nurses and educators. The total number of professionals of the four psychiatric services is about 250 persons. They will be asked to fill the questionnaire making it clear that their answers will remain anonymous. Statistical analyses on these data will be conducted to understand the extent of the CF problem in this Mental Health Department, and how different sort of professionals are affected by this problem.

Norway version of the Diagnostic Interview for psychoses (DIP)
A Rossi, V Hansen, F Amaddeo
An ongoing collaboration with the University of Northern-Norway aim to verify the validity, reliability and applications of the Diagnostic Interview for Psychosis (DIP) - Norwegian Version. The interview will be translated into Norwegian and its content validity tested by back translation. Sixty Norwegian patients will be included in the study. Each patient will be first assessed independently by two raters, one of whom will conduct the interview, while the other will assume the role of observer. Subsequently, some of these patients will be re-interviewed by a third rater, who will made an independent assessment. Diagnostic validity will be assessed using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) as 'gold standard'.