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The quantification of the psychiatric revolution: a quasi-natural experiment of the suicide impact of the Basaglia Law.

ABSTRACT: BACKGROUND:The Italian 180/1978 reform abolishing asylums is one of the most contested mental health programs ever implemented. It aimed to shift care of mental illness into the community improving outcomes and reducing expenditure. It was a model for successive deinstitutionalization initiatives across Europe and North America. However, there were longstanding concerns that, without expansion of community care, it may have deprived patients with mental illness access to support, placing them at increased risk of suicide. METHODS:Regression discontinuity models were used to quantify the association between the number of suicides and the introduction of the Basaglia Law, disaggregated by age-group and gender, covering 20 Italian regions during the period 1975-84. Models were adjusted for potential socio-demographic confounding factors, region-specific fixed effects and pre-existing time-trends. RESULTS:Italian regions implemented the Basaglia Law to varying degrees over time. We observed that, after adjusting for pre-existing time trends, the implementation was associated with a consistent increase in the number of suicides for all the age-groups [incidence rate ratio, age 15-44: 1.29, 95% confidence interval (CI) 1.18-1.41; age 45-74: 1.45, 95% CI 1.37-1.54] and for both genders (males: 1.47, 95% CI 1.41-1.53; females: 1.36, 95% CI 1.25-1.47). Hospital closure appeared to be an important mediating mechanism. CONCLUSIONS:The Basaglia Law was associated with a significant increase in the number of suicides, with evidence of an association with closures of facilities, leaving those with mental illness with nowhere to go, as the envisioned community care structures failed to be developed as originally planned.

SUBMITTER: Ronchetti C

PROVIDER: S-EPMC7292351 | biostudies-literature | 2020 Jun

REPOSITORIES: biostudies-literature

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The quantification of the psychiatric revolution: a quasi-natural experiment of the suicide impact of the Basaglia Law.

Ronchetti Caterina C Toffolutti Veronica V McKee Martin M Stuckler David D

European journal of public health 20200601 3

<h4>Background</h4>The Italian 180/1978 reform abolishing asylums is one of the most contested mental health programs ever implemented. It aimed to shift care of mental illness into the community improving outcomes and reducing expenditure. It was a model for successive deinstitutionalization initiatives across Europe and North America. However, there were longstanding concerns that, without expansion of community care, it may have deprived patients with mental illness access to support, placing ...[more]

PMID: 32072160

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Project description:Robust empirical evidence supports the idea that embryonic and, more generally, intrauterine disruptions induced by the 1918-flu pandemic had long-term consequences on adult health status and other conditions. In this paper we assess the 1918-flu long-term effects not just of in utero exposure but also during infancy and early childhood. A unique set of events that took place in Puerto Rico during 1918-1919 generated conditions of a "double quasi-natural experiment". We exploit these conditions to empirically identify effects of exposure to the 1918 flu pandemic and those of the devastation left by an earthquake-tsunami that struck the island in 1918. Because the earthquake-tsunami affected mostly the Western coast of the island whereas early (in utero and postnatal) exposure to the flu was restricted to those born in the interval 1917-1920, we use geographic variation to identify the effects of the quake and timing of birth variation to identify those of the flu. We benefit from availability of information on markers of nutritional status in a nationally representative sample of individuals aged 75 and older in 2002. We make two contributions. First, unlike most fetal-origins research that singles out early nutritional status as a determinant of adult health, we hypothesize that the 1918 flu damaged the nutritional status of adult survivors who, at the time of the flu, were in utero or infants. Second, we target markers of nutritional status largely set when the adult survivors were infants and young children. Estimates of effects of the pandemic are quite large mostly among females and those who were exposed to the earthquake-tsunami. Impacts of the flu in areas less affected by the earthquake are smaller but do vary by area flu severity. These findings constitute empirical evidence supporting the conjecture that effects of the 1918 flu and/or the earthquake are associated not just with disruption experienced during the fetal period but also postnatally.

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The quantification of the psychiatric revolution: a quasi-natural experiment of the suicide impact of the Basaglia Law.

Publications

The quantification of the psychiatric revolution: a quasi-natural experiment of the suicide impact of the Basaglia Law.

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