In April 2008, the Italian government approved a major reform of mental health care for mentally ill offenders. Up until then the six Ospedales Psichiatrici Giudiziari (OPG; Forensic Psychiatric Hospitals) fell completely under the responsibility of the Ministry of Justice and policy, regulations, staff management, careers, budget, etc. were completely organised at a national level. A census on 31 January 2012 showed that 1.264 mentally ill offenders resided in the six OPGs (Reggio Emilia, Montelupo Fiorentino, Naples, Aversa, Castiglione delle Stiviere and Barcellona Pozzo di Gotto). Apart from Castiglione delle Stiviere, the OPGs are described as obsolete 19th-century institutions, with heavy use of custodial staff. Many user associations, psychiatric societies, associations of psychiatrists working in OPGs, and also political parties demanded radical reform of the sector. However, it was not until 2006, when the Italian government received a warning of the council of Europe for violation of human rights because of the poor quality of care and living conditions, that an Italian Parliamentary Commission unanimously recommended that (except Castiglione delle Stiviere) these OPGs should be rapidly closed down.
In 2008 all resources and responsibilities for general and mental health care both in prisons and OPGs was transferred to the National Health Service (NHS), to be delivered by Regional Health Systems (RHSs). In 2012, as a consequence of another Law (9/2012), which aimed to reduce the number of prison inmates, extra financial support was given for a rapid closure of the OPGs. These changes occurred without any changes in the Criminal Code, simply stipulating that security measures be set up in ordinary psychiatric NHS settings or in newly established Residenze per la Esecuzione della Misura di Sicurezza (REMS; high-security small-size residential facilities). The REMS have been developed to better meet the needs of providing intensive and high quality mental healthcare under proper secure conditions. The REMS (for no more than 20 patients) are intended to replace admissions to OPGs. The implementation of the laws has been unsatisfactory, and in May 2014 Law 81/2014 set deadlines and operational procedures2 . Although the deadline for the final dismantlement of the OPGs was March 2015 in many regions the forensic services are currently still in the transformation phase.
As stated above the REMS are (being) developed to offer better high secure mental health care. A concept that is increasingly being used to assess (the outcome of) mental health care is quality of life (QoL). Although there is a lack of consensus about the exact definition, QoL as whole refers to an overall “sense of well-being and satisfaction experienced by people under their current life conditions”. QoL or better said the optimization of QoL could also be considered as a facilitator for forensic psychiatric treatment, as it might influence the patient’s readiness for treatment and the patient’s preparation for reintegration into society (Good Lives Model4 ). Besides, QoL also serves to monitor if patient’s basic human rights of good quality of care and living conditions are being met with the creation of new facilities.
To conceptualize QoL different approaches can be used. A first approach would be a generic conceptualization of QoL; based on research in the general population the most determining aspects of QoL are being assessed. Some of these aspects are not necessarily directly affected by the fact that patients are receiving mental health care e.g. functional status, access to resources and opportunities. These instruments are especially of value to compare QoL between different populations. A second approach is a disease-specific conceptualization of QoL; the main focus is on the aspects that are being affected by the (mental) health condition. These instruments are especially valuable when evaluating pharmaceutical interventions; e.g. medication might reduce symptoms but the side effects of the medication might actually worsen QoL.
The choice for the approach or conceptualization of QoL should be guided by the goals of the evaluation or the topic of interest that is being studied. QoL-assessment can be useful in determining needs, developing intervention strategies, and evaluating the outcomes of interventions at both the service and the individual patient level. At service level, QoL can provide an ongoing feedback from service users about the outcomes of services and thus influence further development of service and resource allocation. At the individual patient level, QoL assessment can be used to determine needs and to monitor the impact treatment interventions and services. Besides, QoL assessment can be used to guide treatment planning in (newly developed) forensic psychiatric services.
Based on the above, the Italian forensic services would be served by a more generic QoL approach in order to compare QoL in different facilities. A well-known generic QoL instrument is the World Health Organisation Quality of Life assessment and its´ abbreviated version the WHOQoL-Bref. Although the WHOQoL is health related, it is not sufficiently disease-specific and assesses a broad range of aspects related with QoL. However, what is lacking in the WHOQoL is to take into account liberty deprivation and a restrictive context, as is the case in forensic mental health services. In forensic services QoL is being influenced by generic, disease-specific and context-specific aspects. These three aspects come together in the Forensic Psychiatric inpatient Quality of Life questionnaire (FQL) and its abbreviated version the FQL-SV. The FQL has been developed as a tool for every day practice, containing life domains that can be of guidance for (individual) treatment in forensic psychiatric services. Therefore, also the FQL could be of additional value in the reorganisation of forensic psychiatric services in Italy.
The first aim of the STSM was to gain insight in the conceptualization of QoL for assessment in forensic psychiatric services in Europe. This was done by further exploring the concept of QoL against the background of newly developed forensic psychiatric services in Italy.
A secondary aim was to increase the knowledge of QoL as an outcome measure for service evaluation and (individual) treatment planning in the host institutions of the STSM. This was among others done by providing a seminar for staff about QoL within a forensic psychiatric context.