At the psychiatric emergency unit in Trieste’s general hospital, the door is always open.
Coercion and isolation, techniques widely deployed around the world to control patients in crisis, are alien concepts here. Friends and family are welcome visitors in a space that, with its bright pictures and casual seating, is comfortable rather than clinical.
Difficult situations can sometimes be defused with a simple walk in the hospital grounds, says Domenico Petrara, a nurse whose gentle, relaxed demeanour is matched by his informal attire of jeans and sweater.
The eight-bed unit is rarely full, the majority of patients quickly released into the care of a network of neighbourhood community mental health centres.
The Trieste model has fascinated the mental health care community for close to five decades. It contrasts starkly with many other parts of the world that make much greater use of psychiatric institutionalisation, even though such confinement is discouraged by the World Health Organization.
While Italy had only a handful of beds in psychiatric hospitals for every 100,000 people in 2022, fellow G7 member Japan had 258, according to OECD data. Japan, which still has a large network of institutions, has been successful at bringing down suicide rates over the last two decades.
The two countries’ systems represent distinct polarities in a decades-long debate about the best way to care for people living with mental illness and to ensure they can continue to play their part in society. Many governments have talked over the last few decades about replacing institutions with sophisticated care in the community, but few have made a success of the transition.
United for Global Mental Health, an international non-governmental group, estimates 8.6mn people now live in institutions defined as mental hospitals by the WHO. “Countries need to fundamentally reform their mental health budgets,” says Sarah Kline, chief executive of the UK-based group. “Right now far too much emphasis and money goes on locking people up for unnecessarily long periods.”
Mental health support provided locally, through community-based services, has better outcomes and is more cost-effective while respecting patients’ rights, she argues.
Nathaniel Counts, chief policy officer for the Kennedy Forum, a mental health non-profit in the US, suggests the situation is more nuanced. “Mental health is a continuum,” he says, with people requiring different forms of treatment at different points in their lives.
The goal is “to make sure that people have stepped models of care that address their needs at every point”, he adds.
For many policymakers, Trieste represents the ultimate achievement of community-focused care.
The small Italian city has had an outsized impact on international thinking about how to care for mentally ill people, thanks in large part to Franco Basaglia, who took over as director of its psychiatric hospital in 1971.
Roberto Mezzina, who retired as director of the Trieste system five years ago, worked with Basaglia early in his career. He says his old mentor’s guiding tenet was that people with mental health problems must be respected as citizens with rights, not people whose condition placed them beyond the social pale.
Basaglia often spoke of “putting the illness in parentheses”, says Mezzina. “That doesn’t mean deny the illness. That means put it aside for a moment and look at the person, then you can better understand the illness in the context of the person’s whole life.”
While a number of other developed countries, such as the US and the UK, also opted to close many large mental health hospitals, the result was often a sharp reduction in the overall resources available for mental health care. In Trieste, the money released by closing the city’s 1,200-bed asylum almost 50 years ago went into strengthening community services.
Alessandra Oretti, acting director of a psychiatric service whose remit covers about 360,000 people in Trieste and the neighbouring province of Gorizia, says this was the most important element in realising Basaglia’s vision. Suicides fell from 25 per 100,000 people between 1990 and 1996, to 13 in 100,000 between 2005 and 2011.
Just 46 general mental health beds now serve the two Italian provinces. A separate unit for mentally ill people who have committed violent crimes houses two people.
Yet Oretti, who has a large black and white picture of Basaglia in her office, says she never feels short of beds and there is no waiting list for treatment. Anyone experiencing a mental health problem has the right to seek help from one of the community mental health centres without a doctor’s referral, a low barrier to treatment that means problems can often be addressed before they escalate. “The elimination of bureaucratic hurdles is part of the reason for the [lack of] waiting lists,” she adds.
The feat is all the more striking because just 3.5 per cent of Italy’s healthcare budget is allocated to mental health, one of the lowest figures among high-income countries.
One admirer of the Trieste model is Kerry Morrison, head of Heart Forward, a Los Angeles-based mental health charity who has visited the city multiple times. “They do all their investment ‘upstream’, starting at the time of a diagnosis [and] having a strong belief in recovery,” she says.
In the US, in contrast, the focus is on “crisis stabilisation” and there is very little community support. “So you have crisis upon crisis upon crisis . . . but we’re not investing in recovery that would help to prevent these longer-term financial impacts on our system,” she adds.
Tommaso Bonavigo, a psychiatrist in the Trieste system, says the mental health department has hosted visitors from 16 countries this year alone. Cities and countries as diverse as Los Angeles, east London, Burkina Faso and Argentina are all attempting to implement a version of the Trieste model, he adds.
In Brazil, which began a shift away from institutionalisation following a visit by Basaglia in 1979, more than three-quarters of federal mental health funding is already invested in community-based care compared with a quarter in the early 1990s, according to the 2022 WHO global mental health report.
At the Maddalena community mental health centre in a working-class suburb of Trieste, Bonavigo describes a recent callout that typifies the approach. A man got in touch, alarmed that his mother, in her eighties and living with bipolar disorder, was in a manic state and had scarcely slept for days.
Bonavigo, accompanied by a nurse who had known the woman for many 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 that respected her determination not to be taken to hospital; she had suffered a broken nose in an accidental fall during an earlier visit.
“Part of our job is to take some risks,” Bonavigo says, a philosophy that surfaces several times in conversations with staff in the mental health system.
“If in a situation, I can choose between two or three options, I should try to do what the person prefers.”
Japan has historically offered a contrast to Trieste’s community-based approach to mental health care. It has managed to bring down its suicide rates, but psychiatric institutions still play a prominent role.
Japan’s suicide problem soared after the Asian financial crisis of the late 1990s, peaking in 2003 at 27 deaths per 100,000 people, according to official figures. Two decades later, that had fallen more than a third to 17.6 per 100,000. That is still above the equivalent US rate of 14.2 in 2022 and 11.4 in England and Wales during 2023 — although international comparisons are complicated by factors such as differences in cause of death reporting.
The starting point for change in Japan was the introduction of the Basic Act on Suicide Countermeasures in 2006, which outlined a three-pronged approach to suicide prevention — including, as in Trieste, a greater focus at a local level, backed later with extra funding. Since 2016, local authorities have been required by law to make local suicide prevention plans.
“The statistics show that what both central and local governments did has worked,” says Takashi Nishio, manager of the research and analytics department at the Japan Suicide Countermeasures Promotion Center, a research organisation.
Data analysis shows areas with high suicide numbers, which can then be targeted for extra attention. “Our key activities include an enhancement of local government and local community support,” Nishio says. “Most important is that we give them information about suicide rates, changes and patterns.”
The anti-suicide effort has also spawned civil society groups such as Ova, which works with 13 local authorities to help young people who are thinking of killing themselves.
Suicides of school students have risen over the past five years, according to government data. A total of 513 killed themselves last year, with the number of female suicides rising to 254 from 221 the previous year.
In a modest fourth-floor office, Ova’s founder, Jiro Ito, demonstrates its technological responses such as internet search ads. If someone types in certain suicide-related search terms, such as “I want to kill myself”, a message will appear offering support and options for counselling online, by phone or in person.
“If young people have suicidal ideation, they may not express it on their faces — but we can reach them on the internet,” Ito says.
But for all these innovations, Japan remains an outlier in that psychiatric institutions remain a key part of the care system — and a subject of contention.
Human Rights Watch, the US campaign group, said in its 2024 world report that Japan’s psychiatric care sector needs “major reform” and uses “arbitrary detention, abusive physical restraints and forced treatment in violation of basic rights”.
Concerned psychiatrists have been lobbying political parties about the financial incentives for private hospitals to keep patients on wards, says Tsuyoshi Akiyama, president of the World Federation for Mental Health and a professor at NTT Medical Center Tokyo.
He adds that the system of reimbursements by government to clinics should be changed to curb the role of money in decision-making over how long patients should remain in hospitals.
Akiyama also notes that psychiatric hospitals are often in remote areas away from general hospitals, which he says is isolating for patients and makes it harder for them to receive treatment for physical health problems.
“Psychiatric hospital beds should reduce in numbers,” he says. “And in turn, we need to build up some beds at the general hospitals so that when people receive care in the community they can go there.” He points out that general hospitals are far less socially stigmatising than psychiatric units in rural locations.
The 20-year historical downward trend in suicides in Japan shows the effectiveness of an approach that is both localised and part of a broader national strategy, experts say. But its rates have edged up in the past few years and are still above those of many rich country peers. The rising numbers of self-inflicted deaths among young people led to an emergency action plan last year.
“There’s a lot of wisdom in the efforts that took place and that has definitely contributed to the lower suicide rate,” says Ryoji Noritake, chair of the Health and Global Policy Institute think-tank. “But it’s still too high.”
At Trieste general hospital, Petrara says it is nine years since a patient died by suicide after being discharged from the emergency unit.
A strong architecture of support surrounds people once they have received a diagnosis. Not-for-profit organisations such as social co-operatives provide housing and jobs.
Even in prison, an inmate may be visited and supported by staff from a community mental health centre, and in rare cases may even be given a bed in a centre in lieu of home confinement.
Morrison, in Los Angeles, adds: “What you see in Trieste is this incredible teamwork. They don’t have the silos that we have in the US, where you might have . . . a mental health department, and then you’ve got the jail, and you’ve got people over here doing housing, and they don’t talk to each other, they don’t co-ordinate around the person.”
She notes that of roughly 14,000 inmates in the Los Angeles county jail system, more than 5,000 are suffering from mental illness with little access to rehabilitation.
But the success of Trieste’s methods has not insulated it from the funding pressures affecting all global health systems. One of the area’s six community mental health centres is no longer able to open 24 hours a day and it is also coping with shortages of psychiatrists and nurses.
The election in 2018 of a rightwing government in the region, combined with these cutbacks, has led some to question whether it can even survive in its present form.
Allen Frances, professor and chair emeritus of the Department of Psychiatry and Behavioral Sciences at Duke University School of Medicine, wrote in The Lancet in 2021 that it was “now threatened by a rightwing government promoting privatisation and the dismantling of what it misperceives to be politically leftwing psychiatry”.
However, Raffaella Pocobello, a researcher at the Italian National Research Council who has observed the Trieste system for more than 20 years, counters that it is “really difficult to destroy something that is very rooted in ethics”. Basaglia’s legacy “is here, it’s alive”, and a new generation of professionals is “doing their best to keep it at a very high level”, she adds.
In a statement, the Friuli Venezia Giulia health and social care department, which covers Trieste and Gorizia, said the model was “not just a historical legacy linked to the 1960s and 1970s, but a dynamic and constantly evolving system . . . in response to new emergencies and social needs”.
Despite concerns “that may arise regarding possible privatisation or deconstruction, the mental health care model continues to function according to its founding principles, and continues to be an international benchmark”, it added.
Michele Sipala first encountered the Trieste system as a patient more than 30 years ago; now he is employed as a “peer supporter” to people in a residential facility.
Basaglia, he notes, was determined that the wider community should not see those living with mental illness as outsiders. “He really needed the people who went out of the hospital [to be] seen by the citizens. So he organised events in public squares.”
One of his own most cherished memories is of helping to organise a poetry festival, working with old school friends. He says it helped affirm his and other patients’ right to participate in the life of the city, just as Basaglia would have wanted.
Asked to sum up the value of the Trieste mental health system, he says: “The first word which comes to mind is freedom.”
Data visualisation by Amy Borrett
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