The reform of Italian forensic psychiatric hospitals and its impact on risk assessment and management

Abstract

Italy has a consolidated history of de-institutionalization, and it was the first country to completely dismantle psychiatric hospitals, in order to create small psychiatric inwards closer to the community (i.e. in general hospitals). Nevertheless, it took the nation nearly 40 years to end the process from the beginning of de-institutionalization, definitely closing all of the forensic hospitals, which was not addressed by the first Italian psychiatric reform. This paper describes the establishment of new facilities substituting old forensic hospitals, called Residences for the Execution of Security Measures (REMS), which are a paradigm shift in terms of community-based residential home, and are mainly focused on treatment and risk assessment, rather than custodial practices. The use of modern assessment tools, such as the Aggressive Incident Scale (AIS) and the Hamilton Anatomy of Risk Management (HARM), is crucial in order to point out the focus and consistent instruments of the treatment plan. A preliminary analysis of data from the first 2 years of activity, considering severely ill patients who have been treated for more than 12 months, is then described for two REMSs in the Lazio region, close to Rome. Encouraging results suggest that further research is needed in order to assess clinical elements responsible for a better outcome, and to detect follow-up measures of violence or criminal relapse after discharge.