The door is always open at the psychiatric emergency department at the general hospital in Trieste.
Coercion and seclusion, techniques widely used around the world to control patients in crisis, are an unknown concept here. Friends and family are welcome visitors in the space, which, with its bright paintings and informal furniture, seems pleasant rather than clinical.
Difficult situations can sometimes be alleviated by a simple walk around the hospital yard, says Domeniko Petrara, a medical technician whose mild and relaxed attitude is accompanied by informal clothes - jeans and a sweater.
The eight-bed unit is rarely fully staffed, and most patients are quickly transferred to the care of a network of community mental health centers.
The Trieste model has fascinated mental health experts for almost five decades. It is significantly different from the practice in many other parts of the world where institutionalization is much more used in psychiatry, despite the fact that the World Health Organization discourages such an approach.
While Italy had only a few beds in psychiatric hospitals for every 2022 inhabitants in 100.000, Japan, a member of the G7, had 258 beds, according to OECD data. Japan, which still has a large network of institutions, has managed to reduce suicide rates over the past two decades.
The systems of these countries represent two extremely different poles in the decades-long debate about how best to care for people with mental illness and enable them to continue to participate in society.
During the last few decades, many governments have talked about replacing psychiatric institutions with sophisticated forms of care in the community, but rarely have they successfully implemented such a transition.
The organization "United for Global Mental Health", an international non-governmental organization, estimates that 8,6 million people today live in institutions that the WHO defines as mental hospitals.
"Countries need to radically reform mental health budgets," says Sarah Klein, chief executive of the British group. "Right now, too much money and attention is focused on locking people up for unnecessarily long periods."
Local support for mental health, through services provided in the community, brings better results, is more economical and respects the rights of patients, she points out.
Nathaniel Counts, director of policy at the Kennedy Forum, an American mental health nonprofit, thinks the situation is more complex. "Mental health is a continuum," he says, noting that people require different forms of treatment at different times in their lives.
The goal is to "ensure that people have models of care that fit their needs at all times," he adds. For many policy makers, Trieste represents the ultimate example of a community-focused care system.
This small Italian city made a big impression on the international community in thinking about how to care for people with mental illnesses, thanks in large part to Frank Basalja, who took over the management of the psychiatric hospital in Trieste in 1971.
Roberto Mecina, who retired five years ago as director of the mental health system in Trieste, worked with Basalja at the beginning of his career. He says that Basalja's basic principle was that people with mental illnesses must be respected as citizens with rights, and not treated as those who are ostracized from society because of their condition.
Basalja often talked about "putting diseases in parentheses," says Mečina. "It doesn't mean denying the disease. It means putting it aside for a moment and focusing on the person, so you can better understand the disease in the context of that person's whole life."
While many developed countries, such as the US and the UK, have also decided to close a number of large psychiatric hospitals, the result has often been a sharp reduction in the overall resources available for mental health. In Trieste, the money freed up by the closing of the 1.200-bed city hospital almost 50 years ago was redirected to strengthening services in the community.
Aleksandra Oreti, acting director of the psychiatric service that covers around 360.000 people in Trieste and the neighboring province of Gorizia, says that this was the most important element in the realization of Basalja's vision. The suicide rate fell from 25 per 100.000 people between 1990 and 1996 to 13 per 100.000 between 2005 and 2011.
There are now only 46 general mental health beds in these two Italian provinces. The special ward for mentally ill persons who have committed violent crimes currently has only two patients.
Anyone with a mental health problem can seek help at one of the community mental health centers without a doctor's referral, which means that access to treatment is easier and often allows problems to be dealt with before they escalate.
Still, Oreti, who has a large black-and-white photo of Basalja in her office, says she never feels like she is short of beds and that there is no waiting list for treatment. Anyone with a mental health problem can seek help at one of the community mental health centers without a doctor's referral, which means that access to treatment is easier and often allows problems to be dealt with before they escalate. "Removing bureaucratic hurdles is part of the reason why there is no waiting list," he adds.
This achievement is even more impressive given that Italy allocates only 3,5% of its health budget to mental health, one of the lowest percentages among high-income countries.
One admirer of the Trieste model is Keri Morrison, director of Heart Forward, a mental health charity based in Los Angeles, who has visited the city several times. "They invest everything 'upstream,' starting from the moment of diagnosis, with a strong belief in recovery," she says.
In the United States, by contrast, the focus is on "stabilization in crisis," with very little community support. "So you have crisis after crisis after crisis ... but we're not investing in the recovery that could prevent these long-term financial consequences for our system," Morrison adds.
Tomazo Bonavigo, a psychiatrist in Trieste, says that this year alone, the mental health sector hosted visitors from 16 countries. Cities and countries as diverse as Los Angeles, East London, Burkina Faso and Argentina are all trying to implement the Trieste model, he adds.
At the Madalena mental health center, located in a working-class neighborhood in Trieste, Bonavigo describes a recent intervention that exemplifies their approach. A man contacted the center, concerned that his mother, who is in her eighties and suffers from bipolar disorder, was going through a manic episode and had hardly slept for several days.
Bonavigo, accompanied by a nurse who had known the woman for years, went to her apartment and spent two hours persuading her to take her medication. They then agreed on a regime of daily home visits, while respecting her determination not to be hospitalized, as she had previously suffered a broken nose in an accidental fall during a hospital visit.
"Part of our job is to take some risk," says Bonavigo, a philosophy that often comes up in conversations with staff in the mental health system. "If I can choose between two or three options in a situation, I should try to do what the patient prefers."
Japan has historically been the opposite of the Trieste community-based approach to mental health. He managed to reduce suicide rates, but psychiatric institutions still play a significant role.
Japan's suicide problem became pronounced after the Asian financial crisis of the late 1990s, peaking in 2003 with 27 deaths per 100.000 people, according to official figures. Two decades later, that number had dropped by more than a third, to 17,6 per 100.000. However, that is still above the US rate of 14,2 per 100.000 in 2022 and 11,4 in England and Wales in 2023 - although international comparisons are complicated by factors such as differences in the reporting of causes of death.
The starting point for the changes in Japan was the introduction of the Basic Law on Measures to Suppress Suicides in 2006, which set out a three-pronged approach to suicide prevention - including, as in Trieste, a greater focus on the local level, later supported by additional funding. Since 2016, local authorities are obliged by law to adopt local suicide prevention plans.
"The data shows that measures taken by both central and local governments have yielded results," said Takashi Nishio, manager of the research and analysis department at the Japan Suicide Prevention Center.
Data analysis reveals areas with high suicide rates, which are then targeted for treatment. "Our key activities include strengthening support for local authorities and communities," says Nishio. "The most important thing is to provide them with information about suicide rates, changes and patterns."
Suicide prevention efforts have also spurred the establishment of civil society groups such as Ova, which works with 13 local authorities to help young people who are considering suicide.
Suicide among school children has risen over the past five years, according to government figures. A total of 513 students took their own lives last year, while the number of female suicides rose to 254 from 221 the previous year.
In a modest fourth-floor office, Ova founder Jiro Ito displays technological answers to the problem, such as online ads. If someone types in certain terms related to suicide, such as "I want to kill myself," a message will appear offering support and options for counseling online, by phone, or in person.
"If young people have suicidal thoughts, they may not express them on their face - but we can reach them online," says Ito.
However, despite all the innovations, Japan remains old-fashioned in the sense that psychiatric institutions still play a key role in the care system - and are the subject of numerous disputes.
Human Rights Watch, a US-based human rights group, said in its 2024 report that Japan's psychiatric care sector "requires significant reform" and uses "arbitrary detention, abusive physical restraints, and coercive treatments that violate basic rights."
Concerned psychiatrists are lobbying political parties about the financial incentives private hospitals receive to keep patients in wards, says Tsuyoshi Akiyama, president of the World Federation for Mental Health and a professor at NTT Medical Center in Tokyo.
He adds that the government reimbursement system for clinics should be changed to limit the role of money in deciding how long patients should stay in hospitals.
Akiyama also notes that psychiatric hospitals are often located in remote areas, far from general hospitals, which he says isolates patients and makes it difficult for them to access treatment for physical health problems.
"The number of beds in psychiatric hospitals should be reduced," he says. "At the same time, it is necessary to build a certain number of beds in general hospitals so that people receiving care in the community can go there". He emphasizes that general hospitals are far less stigmatizing than psychiatric institutions in rural areas.
Japan's 20-year decline in suicide rates demonstrates the effectiveness of an approach that is localized and part of a broader national strategy, experts say. However, suicide rates have started to rise again in recent years and remain above average in many rich countries. The increase in the number of suicides among young people led to the adoption of an emergency action plan last year.
"There is a lot of wisdom in the efforts that have been made, and it has definitely contributed to a lower suicide rate," said Ryoji Noritake, chairman of the Health and Global Policy Institute. "But the rate is still too high."
At Trieste General Hospital, Petrara says it's been nine years since a patient committed suicide after being discharged from the emergency department. A strong support architecture surrounds people once they have been diagnosed. Non-profit organizations, such as social cooperatives, provide housing and employment.
Even in prison, a prisoner can be visited and supported by staff from community mental health centers and, in rare cases, can be allocated a bed in the center as an alternative to house arrest.
Morrison, from Los Angeles, adds, "What you see in Trieste is incredible teamwork. They don't have the silos that we have in the US, where you have... the mental health department, then the prison, then the housing people, and they they don't talk to each other or coordinate around a person."
She notes that of the approximately 14.000 inmates in the Los Angeles County Jail system, more than 5.000 suffer from mental illness with very limited access to rehabilitation.
However, the success of the methods did not insulate Trieste from the funding pressures that affect all global health systems. One in six community mental health centers can no longer operate 24 hours a day, and the system is also facing a shortage of psychiatrists and nurses.
The election of a right-wing government in the region in 2018, combined with these cuts, has led some to question whether the Trieste model can survive in its current form.
Allen Francis, professor and chairman emeritus of the Department of Psychiatry and Behavioral Sciences at Duke University School of Medicine, wrote in the Lancet in 2021 that the model "is now threatened by a right-wing government promoting the privatization and dismantling of what it misconstrues as politically left-wing psychiatry. ".
However, Rafaela Pokobello, a researcher at the Italian National Research Council, who has been studying the Trieste system for more than 20 years, points out the opposite. She claims that "it's really hard to destroy something that is deeply rooted in ethics." Basalja's legacy "is here, it is alive", and the new generation of professionals "is doing their best to maintain it at a very high level", he adds.
"Basalja really wanted people who leave the hospital to be seen by citizens. So he organized events in public squares," says Mihele Sipala, who first encountered the system in Trieste as a patient more than 30 years ago, and now provides support other patients.
He notes that Basalja was determined not to see people with mental illness as outsiders in the wider community. "It was really important to him that the people who came out of the hospital were seen by the citizens. So he organized events in public squares."
Mihele Sipala first encountered the Trieste system as a patient more than 30 years ago; now provides support to other patients.
According to him, Basalja was determined that the wider community should not view people living with mental illnesses as outsiders. "It was really important to him that the people who came out of the hospital were seen by the citizens. That's why he organized events in public squares."
One of his fondest memories is helping organize a poetry festival, working with friends from school. He says that it helped him affirm his and other patients' right to participate in the life of the city, just as Basalja would have wanted.
When asked to summarize the value of the Trieste system for mental health, he says: "The first word that comes to mind is freedom".
Prepared by: NB
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