Stefano Mimmi

Migrant pathways to community mental health centres in Italy

Background: Many studies indicate that migrants in western countries have limited access to and low utilization of community mental health centres (CMHCs) despite the high prevalence of mental disorders. Aims: We aimed to compare migrant pathways to care across four CMHCs located in different Italian provinces and to identify pathway to care predictors. Methods: Migrants attending the four CMHCs between 1 July 1999 and 31 December 2007 were included in the study. Data were gathered retrospectively from clinical data sets and chart review. Results: Five hundred and eleven (511) migrants attended the four CMHCs, 61% were referred by GPs or other health services and 39% followed non-medical pathways to care (self-referral or through social and voluntary organizations), with important site variations. Younger age and being married were predictors of medical pathways to care; lacking a residence permit and having a diagnosis of substance abuse were related to non-medical pathways. Conclusions: Pathways to CMHCs are complex and influenced by many factors. Non-medical pathways to care seem to be frequent among migrants in Italy. More attention should be paid to developing psychiatric consultation liaison models that also encompass the social services and voluntary organizations.

First-episode psychosis at the West Bologna Community Mental Health Centre: results of an 8-year prospective study

BACKGROUND Research mostly conducted in the UK and northern Europe has established that there are high rates of first-episode psychosis (FEP) in large cities and immigrant populations; moreover, psychosis has been found to be associated with cannabis use and early trauma. The present study aimed to evaluate the incidence rate of FEP and the distribution of several risk factors (e.g. age, ethnicity, substance abuse) in Bologna, Italy. METHOD The Bologna FEP (BoFEP) study is an 8-year prospective study. All FEP patients, 18-64 years old, consecutively referred to the West Bologna Community Mental Health Centre (CMHC) from 2002 to 2009 were evaluated. Sociodemographic information, migration history and clinical data were collected through an ad-hoc schedule. Psychiatric diagnoses were recorded using the Schedule for Clinical Assessment of Neuropsychiatry (SCAN). RESULTS The overall incidence rate (IR) in the BoFEP study was 16.4 per 100 000 person-years [95% confidence interval (CI) 13.9-18.9]. The incidence was higher in young people, men and migrants (MI). CONCLUSIONS The IR of FEP found by the Bologna study is lower than that found by other European studies. However, as in other studies, the incidence was higher in certain groups. This heterogeneity has implications for policy and mental health service development, and for understanding the aetiology of psychosis.

Integration between Primary Care and Mental Health Services in Italy: Determinants of Referral and Stepped Care

This study, carried out in the context of a collaborative care program for common mental disorders, is aimed at identifying the predictors of Primary Care Physician (PCP) referral to Community Mental Health Center (CMHC) and patterns of care. Patients with depression or anxiety disorders who had a first contact with CMHCs between January 1, 2007–December 31, 2009 were extracted from Bologna Local Health Authority database. A classification and regression tree procedure was used to determine which combination of demographic and diagnostic variables best distinguished patients referred by PCPs and to identify predictors of patterns of care (consultation, shared care, and treatment at the CMHC) for patients referred by PCPs. Of the 8570 patients, 57.4% were referred by PCPs. Those less likely to be referred by PCPs were living in the urban area, suffered from depressive disorder, and were young. As to the pattern of care, patients living in the urban area were more likely to receive shared care compared with those living in the nonurban area, while the reverse was true for consultation. Predictors of CMHC treatment were depression and young age. Prospective studies are needed to assess length, quantity, and quality of collaborative treatment for common mental disorder delivered at any step of care.

30-day in-hospital mortality after acute myocardial infarction in Tuscany (Italy): An observational study using hospital discharge data

BackgroundCoronary heart disease is the leading cause of mortality in the world. One of the outcome indicators recently used to measure hospital performance is 30-day mortality after acute myocardial infarction (AMI). This indicator has proven to be a valid and reproducible indicator of the appropriateness and effectiveness of the diagnostic and therapeutic process for AMI patients after hospital admission. The aim of this study was to examine the determinants of inter-hospital variability on 30-day in-hospital mortality after AMI in Tuscany. This indicator is a proxy of 30-day mortality that includes only deaths occurred during the index or subsequent hospitalizations.MethodsThe study population was identified from hospital discharge records (HDRs) and included all patients with primary or secondary ICD-9-CM codes of AMI (ICD-9 codes 410.xx) that were discharged between January 1, 2009 and November 30, 2009 from any hospital in Tuscany. The outcome of interest was 30-day all-cause in-hospital mortality, defined as a death occurring for any reason in the hospital within 30 days of the admission date. Because of the hierarchical structure of the data, with patients clustered into hospitals, random-effects (multilevel) logistic regression models were used. The models included patient risk factors and random intercepts for each hospital.ResultsThe study included 5,832 patients, 61.90% male, with a mean age of 72.38 years. During the study period, 7.99% of patients died within 30 days of admission. The 30-day in-hospital mortality rate was significantly higher among patients with ST segment elevation myocardial infarction (STEMI) compared with those with non-ST segment elevation myocardial infarction (NSTEMI). The multilevel analysis which included only the hospital variance showed a significant inter-hospital variation in 30-day in-hospital mortality. When patient characteristics were added to the model, the hospital variance decreased. The multilevel analysis was then carried out separately in the two strata of patients with STEMI and NSTEMI. In the STEMI group, after adjusting for patient characteristics, some residual inter-hospital variation was found, and was related to the presence of a cardiac catheterisation laboratory.ConclusionWe have shown that it is possible to use routinely collected administrative data to predict mortality risk and to highlight inter-hospital differences. The distinction between STEMI and NSTEMI proved to be useful to detect organisational characteristics, which affected only the STEMI subgroup.

Understanding psychopathology in migrants: a mixed categorical-dimensional approach.

Background: Literature on mental disorders in migrants is constantly increasing. Only a few studies describe psychopathological dimensions in migrants over their nosographic diagnoses; however, there is a growing literature about the greater utility of a categorical-dimensional approach, rather than a solely categorical approach, in the understanding of mental disorders. The aim of this paper is to describe the phenomenology of mental disorders in migrants referred to the Transcultural Psychiatric Team of Bologna (BoTPT), by analysing the psychopathological dimensions that underlie their clinical diagnoses. Methods: We recruited all migrants who attended the BoTPT between May 1999 and July 2009. The psychopathological assessment was conducted with the Association for Methodology and Documentation in Psychiatry (AMDP) and clinical diagnoses were formulated according to ICD-10. We proceeded through a two-step analysis: (1) comparing the prevalence rates of psychopathological symptoms across diagnoses; then (2) conducting a factor analysis to assess how those symptoms configure psychopathological dimensions and how these dimensions underlie clinical diagnoses. Results: As expected, we found significant associations between diagnoses and the prevalence of their core psychopathological symptoms. Factor analysis revealed a strong polymorphism of the psychopathological presentation of mental disorders and unexpectedly showed that in each diagnostic cluster, the first extracted factor was not composed of core symptoms. Conclusions: A mixed categorical-dimensional approach seems to improve the description of the psychopathology among migrants, as it adds relevant information regarding psychopathological dimensions useful to the understanding of the peculiar clinical expressivity of our patients.

Hospitalization rates and post-operative mortality for abdominal aortic aneurysm in Italy over the period 2000-2011.

Background Recent studies have reported declines in incidence, prevalence and mortality for abdominal aortic aneurysms (AAAs) in various countries, but evidence from Mediterranean countries is lacking. The aim of this study is to examine the trend of hospitalization and post-operative mortality rates for AAAs in Italy during the period 2000–2011, taking into account the introduction of endovascular aneurysm repair (EVAR) in 1990s. Methods This retrospective cohort study was carried out in Emilia-Romagna, an Italian region with 4.5 million inhabitants. A total of 19,673 patients hospitalized for AAAs between 2000 and 2011, were identified from the hospital discharge records (HDR) database. Hospitalization rates, percentage of OSR and EVAR and 30-day mortality rates were calculated for unruptured (uAAAs) and ruptured AAAs (rAAAs). Results Adjusted hospitalization rates decreased on average by 2.9% per year for uAAAs and 3.2% for rAAAs (p<0.001). The temporal trend of 30-day mortality rates remained stable for both groups. The percentage of EVAR for uAAAs increased significantly from 2006 to 2011 (42.7 versus 60.9% respectively, mean change of 3.9% per year, p<0.001). No significant difference in mortality was found between OSR and EVAR for uAAAs and rAAAs. Conclusions The incidence and trend of hospitalization rates for rAAAs and uAAAs decreased significantly in the last decade, while 30-day mortality rates in operated patients remained stable. OSR continued to be the most common surgery in rAAAs, although the gap between OSR and EVAR recently declined. The EVAR technique became the preferred surgery for uAAAs since 2008.

Clinical Validation of the INTERGROWTH-21st Standards of Fetal Abdominal Circumference for the Prediction of Small-for-Gestational-Age Neonates in Italy

Objectives: To compare the accuracy of the INTERGROWTH-21st (IG-21) with the Italian Society of Ultrasound in Obstetrics and Gynecology (SIEOG) abdominal circumference (AC) standards in the detection of small-for-gestational-age (SGA) fetuses in a high-risk population. Material and Methods: Our study included all pregnant patients with an increased risk of placental insufficiency that were seen in two Italian university hospitals between 2014 and 2015. The accuracy of IG-21 and SIEOG AC standards in the detection of SGA neonates was analyzed by means of the area under the receiver operating characteristic curve (ROC-AUC) at 4 gestational age intervals (24-27, 28-31, 32-35, >35 weeks). Results: We enrolled 428 patients (278 Italians). There was no significant difference between the ROC-AUC of AC according to IG-21 and SIEOG standards for all birthweight thresholds and gestational intervals that were considered. The diagnostic performance was similar in Italian and non-Italian patients. The accuracy was, however, limited, with values of ROC-AUC ranging between 0.80 and 0.89. Conclusions: The IG-21 and SIEOG AC standards are interchangeable for the diagnosis of SGA fetuses. The diagnostic accuracy is, however, limited. We provide figures that can be used to stratify the probability that an infant will be SGA in an obstetric population at increased risk of growth restriction.

Suicide and Other Causes of Death in the Psychiatric Patients of a Mental Health Service over a 5-year Period

Aims: 1) To compare mortality rate and causes of death between psychiatric patients of a Mental Health Department (MHD) and local population of Modena. 2) To appraise the impact of selected demographic and clinical variables on suicide. Study Design: Retrospective analysis. Place and Duration of Study: MHD of Modena between March 2009 and September 2009. Research Article International Neuropsychiatric Disease Journal, 1(1): 46-63, 2013 47 Methodology: Our psychiatric sample was composed by all psychiatric patients followed by the MHD of Modena, who died from 1-1-2004 to 31-12-2008 (n=168). We compared the standardized mortality rate and causes of death of our sample to those of the local population (n=250,000), who died during the same period of time, according to data provided by the registry of the Clinical Epidemiology Service of Modena. From computerized registration system and medical records of MHD and death certificates, we collected: demographic data, psychiatric diagnosis, death causes, time elapsed from the first consultation in MHD to death, time elapsed from the last discharge from psychiatric ward or from the last consultation in MHD to death. Our sample of psychiatric patients was further divided into two groups: the first one was composed of those who committed suicide (n=25) and the second one those that died from other causes (n=143), and all variables of each group were statistically compared to highlight the demographic and clinical features of the two groups. Results: Neoplastic and cardiovascular diseases were the two most frequent causes of death in both psychiatric and local populations and suicide represented the third leading cause of death in the psychiatric sample. Psychiatric patients who committed suicide were statistically significantly younger in comparison to others and killed themselves after 12 days (median) from the last psychiatric consultation or hospital discharge. Conclusion: Our patients presented the same high vulnerability to organic disorders and their fatal consequences as local population with higher risk of suicide which remains a fatal outcome of psychiatric diseases.

P03-287 - Suicide: 5-year follow up among the psychiatric population of an Italian mental health service

Objectives Suicide remains the most severe emergency in every psychiatric disorder. Methods After evaluating the frequency of suicide among patients followed from 1-1-2004 to 31-12-2005 by the Mental Health Service of Modena Centro, we statistically analyzed socio-demographic and clinical data of suicide patients (n=25). Results Among psychiatric population followed by our psychiatric service in the observation period, suicide occurred in the 0.15% of all patients (25/16392) and represented the third cause of death, after cardiovascular disorders and neoplasia. The median age of suicide patients was 42 years for male and 50 years for women, with a ratio male/female of 1.8:1. “Depressive Disorders” followed by “Schizophrenia and other Psychotic Disorders” represented the prevalent psychiatric diagnosis with a statistically significant correlation to suicide death cause (p Conclusions Our data confirmed the literature: suicide is more frequent in young male affected by Depressive Disorders or Schizophrenia and other Psychotic Disorders1. We have to conclude pessimistically about our preventive capacity since suicide occurred in patients already hospitalized and treated for a long period and after a short period from the last psychiatric intervention.