Hrev_master [page 68] [Emergency Care Journal 2023; 19:11512] Emergency Care Journal 2023; volume 19:11512 The brutal murder of 55-year-old Italian psychiatrist Barbara Capovani in April 2023, at the hands of a man she had assisted dur- ing a hospitalization four years prior, produced a wave of emotion within Italian psychiatry, with important echoes in the media. It is the death of a woman at work, a doctor, a psychiatrist, a profes- sional of the National Health Service who has been taking care of serious mental illnesses for years. She was beaten to death by the attacker at the end of her shift at the psychiatric ward of the Santa Chiara Hospital in Pisa as she was untying her bicycle to go home. The man is now in jail on premeditated murder accusations. The day before he had gone to look for her in the hospital without suc- cess; the day of the crime he returned, dressed in dark clothes, masked with a hat on his head and a backpack on his shoulders. During his arrest, officers discovered a crossbow and some bolts in his home. The backdrop to this tragedy is the Italian public health envi- ronment, which is characterized by persistent and expanding attacks on workers in an increasingly weak and overburdened national health system. Workplace violence against healthcare practitioners is a major issue with numerous health, safety, and legal ramifications. Healthcare workers in mental health and emergency rooms are par- ticularly vulnerable to workplace violence, while this problem is affecting all healthcare settings. Verbal and physical violence against healthcare professionals is increasing in a changing world: acceleration, alienation, out-of- control social media, loneliness, economic crisis, volatility, social instability, less welcoming communities, clashes of cultures and worldviews, anger, and old and new addictions. All of this implies maladjustment, both for those affected by explicit psychiatric ill- nesses and for those who maintain a healthy mental balance. The concurrent underfunding and poverty of health services as a whole raises levels of discontent among the population, particularly in areas of greatest vulnerability, and blames health professionals for poor responses to their health needs. Although in 2001 the Conference of the Presidents of the Regions had indicated in 5% of the National Health Fund (NHF) the share to be allocated to mental health, in Italy, from 2015 to 2018, the expenditure is attested on values around 3.5%-3.6%. This share is well below the European average, with further sub- stantial progressive de-financing over the subsequent years. The latest available data for 2020, in fact, indicate an expenditure of less than 3% of the NHF, in line with the current situation of low- income nations.1 Behavioural and substance addictions need addi- tional funding, given the significant and ever-increasing impact on psychiatric services and the growth of departmental organizational models that progressively include developmental age and addic- tion services. The interaction between psychiatric illness and the use of substances is complex and is known to have major harmful effects on the course of the illness, risk of violence, outcome, and physical health conditions. What is happening in Italian psychiatric services is that profes- sionals feel alone and inadequate when confronted with duties deemed superior to the capabilities of personal intervention and the organizations to which they belong. Between 2019 and 2021, as many as 21,000 doctors left Italian hospitals. About 12,645 of them have retired (including early retirement). However, the remaining 35% (equal to about 8,000 doctors) simply decided to leave their jobs.2 There are several rea- sons behind it: lack of staff, frequent aggressions, court cases, eco- nomic dissatisfaction, reduced decision-making autonomy, and work-life balance discrepancy. Forecasts for the future of Italian National Health Service are not optimistic. The sociological and cultural change is so strong that more and more young doctors aspire to specializations that can be spent in the private sector, moving away from those considered more burdensome and riskier. Healthcare providers ask to be protected and to be able to work in physical, professional and legal safety. At the same time, they are fully aware that mental illness can have a profound destructive- ness in itself causing pain and suffering to themselves and others without causing the death of anyone in the vast majority of cases. We believe mental health is a fundamental element, not only for the health of the general population, but also for civil coexistence. Safety in the workplace is a basic need of the healthcare systems, as it increases the productivity and ability of professionals to man- age patients. Involvement, accountability and awareness of users and the general population in the enhancement of human resources, requires specific attention and policies of healthcare organizations at the national and local level. Much work needs to be done in these areas. Italian mental health sector experienced a significant change when the Parliament promulgated the Law 180 (known as “Legge Basaglia”) on May 13th, 1978, thus initiating the dismantling of Correspondence: Carlo Fraticelli, Academy of Emergency Medicine and Care (AcEMC), Pavia, Italy. E-mail: carlofratic@gmail.com Key words: Italian mental health system, Law 180, mental health providers, workplace violence, forensic psychiatric treatment, REMS, judicial psychiatric hospitals, OPGs Conflict of interest: the author declares no conflict of interest, the author declares accuracy. Received for publication: 8 June 2023. Accepted for publication: 8 June 2023. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2023 Licensee PAGEPress, Italy Emergency Care Journal 2023; 19:11512 doi:10.4081/ecj.2023.11512 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. The murder of a psychiatrist in Italy raises problems for all of us Carlo Fraticelli Academy of Emergency Medicine and Care (AcEMC), Pavia, Italy No n- co mm er cia l u se on ly asylums and a radical shift to new community-based psychiatric services. The legislation established some basic principles: danger- ousness is no longer the basic criterion for hospitalization; hospi- talization is limited to therapeutic emergencies; compulsory hospi- talization must be in a general hospital ward; and asylums are abol- ished.3 The dramatic dead of a colleague is part of the shortcomings arisen with the closure of the judicial psychiatric hospitals (OPGs) in Italy. This occurred on the basis of a parliamentary investiga- tion, which confirmed the extreme degradation present in those hospital facilities which were basically regulated by the Criminal Code of 1930, and the general inefficacy of the treatments. Law No. 9, dated February 17th, 2012, established the closure of OPGs. The conversion to a model of care, based on residential facilities in a community equipped only with clinical personnel (Residence for the Execution of Security Measures, hereinafter “REMS”), is indi- cated, except for individuals who no longer pose a threat to society, who must be discharged and assisted by the local Mental Health Department.4 At the same time, the safety measure tool itself was redefined, limiting the possible application time for mentally ill offenders. The transition from the OPG system to the REMS system posed considerable difficulties. The management of dangerousness has been reintroduced in fact in public mental health services, modify- ing the meaning of Law 180/1978, without giving operators neither more resources nor the legal tools to be able to manage situations. On the one hand, there is a small and insufficient number of avail- able beds in the REMS, and on the other, problems of legitimacy are raised. In fact, the Constitutional Court in considering the dif- ficulties and shortcomings of hospitalizations in the REMS, asked the Ministry of Justice and the Ministry of Health for an explana- tory report on the matter. Currently, neither patients nor society would be adequately guaranteed with respect to both the rights of fair justice and those of adequate treatment. The shortage of places in the REMS often leads the Italian judiciary to indicate the General Hospital Psychiatric Inpatient Service (Servizio Psichiatrico di Diagnosi e Cura - SPDC) as a placement place, in the absence of alternatives. But this solution creates further serious problems. First of all, a suitable environment of management for the needs of the person affected by the provision is not guaranteed. Additionally, the risk of harm to other patients and staff, the poten- tial for self-harm, escape behaviours, and the restrictions or resource consumption required for more disturbed patients have negative impacts on the ward atmosphere, and on care capacity of the health personnel. The proposals for new and more comprehensive strategy by Mental Health Departments workers, supported by scientific soci- eties, would make it possible to create a continuum of care and to define the REMS as one of the sites of treatment and not the sub- stitute for OPGs. They can be briefly summarized as follows: no assignment to psychiatry of custody tasks for the offender patient, building and coordination of the treatment pathways among the various institutional subjects, assignment of adequate resources, revision of the penal code (diagnostic assessment, imputability, responsibility, social dangerousness, and placement of the mental- ly ill offender), better qualification of the activities of the court experts, appropriate staff training. The treatment pathways must be able to start in penal institutions through adequate health care assistance from the mental health services, possibly continue in the REMS or on the territory, in residential communities or at the patient’s home, in relation to the treatment possibilities linked to the clinical conditions and the cooperation of the patient. The placement and treatment of mentally disordered offenders are contended topics in the legal systems of western countries.5 At present, mass media are playing a very important role in influenc- ing public opinion and legislative decisions. They have a pervasive power in our lives today, influencing expectations and concerns. Their ability to direct and modify thoughts, feelings, attitudes on health and well-being issues of increasingly large audiences requires a deep reflection on the role that media play in a changing world. Therefore, the media can help to reduce or increase stigma of mental illness, but also of the professionals engaged in the field of mental health, which is subject to great media coverage, espe- cially when criminal events occur. It has a role of great responsi- bility, as important socializing agent in creation and maintenance of perceptions and behaviors. The management of mentally ill offenders by a criminal justice system is a measure of the aptitude of a community to balance pub- lic safety with advances in contemporary psychiatry, and to include basic human rights into penal and mental health practice. References 1. Patel V, Saxena S, Lund C, Thornicroft G, et al. The Lancet Commission on global mental health and sustainable develop- ment. Lancet 2018;392:1553–98. 2. Palermo C, Rivetti C, Di Silverio P, Troise C (eds). Studio ANAAO-ASSOMET. Great Resignation: la grande fuga dei medici dal SSN. Available from: https://www.anaao.it/public /aaa_2916185_studiodimissioni_21aprile2022.pdf 3. de Girolamo G, Barale F, Politi P, Fusar-Poli P. Franco Basaglia, 1924-1980. Am J Psychiatry 2008;165:968. 4. Di Mizio G, Bolcato M, Rivellini G, Di Nunzio M, et al. Protection of Prisoners with Mental Health Disorders in Italy: Lights and Shadows after the Abolition of Judicial Psychiatric Hospitals. Int J Environ Res Public Health 2022;19:9984. 5. Salize HJ, Dreßing H (eds). Placement and Treatment of Mentally Ill Offenders. Legislation and Practice in EU Member States. Final Report. Central Institute of Mental Health, Mannheim, Germany. February 15, 2005. Available from: http://www.krim.dk/undersider/straffuldbyrdelse/forvar- ing/psykisk-afvigende-indsatte-placering-europa-eu2006.pdf Editorial [Emergency Care Journal 2023; 19:11512] [page 69] No n- co mm er cia l u se on ly