- Approximately 60 million inhabitants, which corresponds to a population density of 200 persons per square kilometer
- Expenditure on health 2008: EUR 110 billion (7% of the gross domestic product, and 1.800 Euro yearly per each inhabitant, less than France, Germany, UK, and more than Spain, Nederland, Greece and Portugal); this percentage is growing in the last two years
- The expenditures incurred by the NHS related directly to mental and behavioral disorders amounted to EUR 5,5 billion, a mere 5% of the whole health expenditures, covering less than 1% of the population, while more than 6% of the same population need some kind of help for mental problems; therefore, a much larger expenditure is incurred by private citizens: only 7.000 psychologists are paid by NHS, while 30.000 work privately as psychotherapists. Costs caused by depression are growing, e.g. suicides per year have rapidly grown from 3.500 to 4.000 in the last few years, now reaching road accidents as the first cause of death in adolescents.
Psychotherapy in the health care system
- Psychotherapeutic healthcare is free of charge when provided by the NHS, and totally reimbursed in the rare cases a private insurance is available (Families of particular employees), Only the full range of inpatient care (hospitals, clinics), is always covered free of charge.
- Psychotherapy is defined as a form of treatment for mental and behavioral disorders classified by the International Classification of Diseases.
- For outpatients, psychologists of the NHS are free to choose the kind of treatment to provide, without restrictions on different psychotherapeutic approaches, for individuals, families and groups.
- The Italian law regulating psychologists recognizes their competence of diagnosis. On the contrary, psychotherapy, both provided by psychologists or by medical doctors, is subject to a specific training of at least four years, provided by University specializations or by private schools recognized by the Ministry of University and research. Pending that condition, patients have free access: no restrictions even concerning indications or the duration of the treatment.
- Psychotherapy is paid for by some insurance companies after approval of an accrediting committee (see www.panelonline.com, on the basis of appropriate guidelines.
- Inpatient care for persons with mental disorder is offered by psychiatric and departments of public hospitals and rehabilitation centers. There are no restrictions regarding the use of different psychotherapeutic approaches in clinics. The average duration can be only influences by the discussion of cases within the team.
- The activity of Psychotherapy is regulated by law. Qualification includes to be graduate in Psychology or Medicine, and a further specialization of a minimum of 4 years of postgraduate training in a School approved by the Ministry of University.
- A specific Commission, established at that Ministry, acknowledges each school on the basis of fixed criteria, and also on the basis of a recognized psychotherapeutic approach (psychodynamic psychotherapy, behavioral therapy, person-centered therapy or family therapy, but many others are accepted in the years)
- The two Chambers, of Medical Doctors and of Psychologists, keep a specific Register of their associates authorized to practice as psychotherapists. There is not an autonomous Chamber for this activity, which is therefore not considered an autonomous profession.
Psychotherapy for Depression
- There is not a specific provision for psychotherapy of depression in the NHS. On the Contrary, the (few and specific) private health insurances easily reimburse the treatments of employees or of their relatives suffering for a trauma (reactive depression).
Desirable Changes to Health Policy
- The density of psychotherapeutic care differs widely across Italy, not because of limitations on licensed Psychotherapists, who are on the contrary too many, but because of public money availability. The Chambers of Psychologists and Physicians proposed law expanding the reimbursement (as by insurances) to all the population, but it did not pass because of budget limits.
- In Italy, every psychological or medical psychotherapist is a compulsory member of his/her Chamber, and also obliged to be registered in one of the two Psychotherapists’ Register. The supervision of occupational standards is among the principal responsibilities of the two Chambers. Therefore, the chambers, which are all members of the CUP, work as public corporations. They have the power to exclude a member from practicing. They also represent their members officially, with the exception of the economic issues, which are dealt by recognized Unions. The scientific societies also have a role in fixing the standers of the continuing professional development, as regulated by the Health Ministry. INPA gathers all these bodies and represents them in Europe.
Dr. Pierangelo Sardi, Psychological Psychotherapist, INPA, Italian Network of Psychologists’ Associations (Italy)
The text above is an excerpt from the paper "Psychotherapy in Europe – Disease Management Strategies for Depression. National Concepts of Psychotherapeutic Care".
You can download the paper here.
Italy update July 2021
By Alberto Zucconi
Thanks to the new Essential Levels of Care (LEA), approved with the DPCM January 12, 2017, psychological and psychotherapeutic interventions are provided for a wide range of situations.
In particular in the following areas:
1) "As part of district, home and territorial care with direct access, the National Health Service guarantees women, minors, couples and families the necessary and appropriate psychological and psychotherapeutic services, including home care"
a) "assistance to pregnant women and protection of the health of the unborn child also for the prevention of related psychological distress".
b) "Psychological support for the voluntary interruption of pregnancy".
c) "Psychological support for sterility and infertility problems and for medically assisted procreation".
d) "Psychological support and assistance for problems related to menopause".
e) "Psychological counselling and assistance for individual and couple problems".
f) "Assistance to adolescents, also in collaboration with educational institutions".
g) "Psychological support to minors in distress, in a state of abandonment or victims of abuse and maltreatment".
h) "Psychological support to families in distress".
i) "Assessment and psychological support to couples and minors for family foster care and adoption, including in the phase following the child's placement in the family unit".
in this context, "psychotherapy (individual, couple, family, group)" is envisaged for necessary cases.
2) "The National Health Service shall guarantee to minors with neuropsychiatric disorders, multidisciplinary care and the development of an individualized therapeutic program, differentiated by intensity, complexity and duration, which includes psychological and psychotherapeutic services, including those provided at home".
3) "The National Health Service guarantees people with mental disorders, , multidisciplinary care and the development of an individualized therapeutic program, differentiated by intensity, complexity and duration, which includes the services, including home care, psychological and psychotherapeutic necessary and appropriate."
4) "The National Health Service guarantees people with complex disabilities, multidisciplinary care and the development of an individualized therapeutic and rehabilitation program, differentiated by intensity, complexity and duration, which includes the services, including home care, psychological and psychotherapeutic necessary and appropriate".
5) "The National Health Service guarantees people with pathological addictions, including gambling addiction, or with pathological substance abuse behaviors, including people in prison or interned, multidisciplinary care and the development of an individualized treatment program that includes the necessary and appropriate psychological and psychotherapeutic services."
The National Chronic Disease Plan (NCCP), approved in 2016, in turn provides for psychological and psychotherapeutic interventions as part of care for people with chronic physical illnesses.
In both the LEAs and the PNC, the intervention model is developed on a proactive plan of prevention and promotion and a response plan based on
- first-level psychological treatment (counseling, support) and
- treatments of 2nd level (psychotherapy).
These indications derive from scientific evidence and international guidelines concerning both mental and physical disorders, with a view to prevention, support and treatment but also to the promotion of adaptive resources.
Considering psychotherapy in particular, the available evidence, both in terms of experimental effectiveness and real effectiveness, but also in terms of cost effectiveness, shows that for many situations, especially for most depressive and anxiety disorders, this type of treatment is the intervention of first choice.
This in particular is the reason that has led several countries, such as Great Britain, to invest substantial sums to ensure the availability of psychological/psychotherapeutic interventions in a step-by-step logic, which provides for different and incremental levels of intervention.
Italy: the situation in the field
In the National Health Service, the figures who can implement psychological interventions are psychologists with a postgraduate specialization - university or psychotherapeutic recognized under the law 56/89 - included in the "health management".
Psychotherapeutic interventions can be implemented by "specialist psychologists" and by physicians with a university specialization or recognized under Law 56/89 - classified within the "medical management".
According to the most recent statistical data of the Ministry of Health (year 2018 published in 2020) in the NHS are framed:
(a) 5,337 medical psychiatrists while there is no certain data on child neuropsychiatrists.
(b) 5,029 specialist psychologists, 10% with university specialization equivalent to psychotherapy and 90% of whom have a specialization in psychotherapy under Law 56/89.
All psychiatrists work within the Mental Health Services and Psychiatric Diagnosis and Treatment Wards.
Of the 5,029 psychologists specializing in psychotherapy, to which are added approximately 1,000 outpatient specialist psychologists, approximately 4,000 work in various services (territorial and hospital psychological services, childhood, counseling, addiction, districts, rehabilitation, ADI, etc.) and 2,037 specialist psychologists work in the Mental Health Services.
According to various analyses (Piepoli Institute 2019, CREA 2019, Cittadinanzattiva 2020), the specialist psychologists of the National Health Service are able to meet only 25% of the demand for psychological interventions and just 15% of psychotherapeutic ones. Suffice it to say that in Mental Health Services only 6.5% of interventions are represented by psychotherapy (data Mental Health Information System Year 2017 published 2020).
This situation arises from the fact that the "mission" of specialist psychologists in the NHS has increased significantly by virtue of regulations and the needs of the population, while their number has undergone a considerable decrease: from 1.4% of the health workforce in 1998 to 1.1% in 2018 (data extrapolated from the MS yearbooks). From 2013 to 2018, NHS psychotherapists decreased by approximately 20%.
The NHS figure of 8.3 psychologist-psychotherapists per 100,000 inhabitants does not match the figures of countries comparable to Italy, such as France (48.7/100,000) or Germany (49.5/100,000).
As a matter of fact, today the Italian National Health Service ( SSN) is not able to provide more than a minimal share of both psychological and psychotherapeutic activities, a situation that has been greatly exacerbated by the pandemic.
All this is not only a disconfirmation of what the State and the Regions have undertaken to guarantee to citizens, but it is also strongly discordant with the vision of public opinion.
In fact, it turns out that 75% of people seeking treatment for anxiety and depression prefer psychotherapeutic treatment (McHugh et al. 2013) and 79% of Italians believe that psychological and psychotherapeutic care should be provided by the public system (Ist. Piepoli 2020).
Today, however, the vast majority of people who need psychotherapy must pay for it completely out of their own pockets, often with enormous sacrifices, or - as is increasingly the case due to the economic situation - give up treatment.
This is a situation that affects especially the most disadvantaged people from the socio-economic point of view, increasing the degree of social inequality already present.
Covid 19 The most recent regulatory indications
The pandemic emergency has led to the recent approval of laws that should constitute a reversal of the trend with respect to the scenario described above.
We refer in particular to two laws: Law No. 126 of October 13, 2020 and Law No. 176 of December 18, 2020.
Law 126/20 poses a series of indications with reference to mental health services and more generally to psychological activities:
"In order to make mental health services operating in local communities more efficient and to guarantee individual and collective psychological well-being in view of the psycho-social crisis determined by the exceptional situation caused by the SARS-COV-2 epidemic, the Italian Ministry of Health, in agreement with the Unified Conference referred to in Article 8 of Legislative Decree 28 August 1997, no. 281, within six months from the date of entry into force of the law converting the present decree, issue guidelines aimed at the adoption, by the regions and autonomous provinces of Trento and Bolzano, of a uniform protocol throughout the national territory that defines good practices of community mental health and for the protection of psycho-social fragility". (art. 29 ter)
Law 176/20 deals with the efficiency of the activities of specialist psychologists (including, therefore, the psychotherapeutic activities they provide)
"Art. 20-bis (Provisions on the activities of psychologists). - 1. In order to ensure health and individual and collective psychological well-being in the exceptional situation caused by the epidemic from COVID-19 and to ensure psychological services, including home care, to citizens and health workers, to optimize and rationalize the professional resources of psychologists employed and contracted and to ensure the activities provided by the essential levels of care (LEA), for the purposes of the application of the Directive of the President of the Italian Council of Ministers of June 13, 2006, published in the Official Gazette no. 200 of August 29, 2006, health authorities and other bodies of the National Health Service may organize the activities of psychologists in a single company function".
In order to implement these legal indications, it appears necessary to intervene in the two areas identified by Law 126/20 in conjunction with Art. 20bis of Law 176/20. In particular:
(a) Efficient mental health services;
(b) Guaranteeing individual and collective psychological wellbeing and the protection of psycho-social fragility". (art. 29 ter Law no. 126/20).
With regard to the letter a) "efficiency of mental health services", it seems absolutely necessary also in light of what is reported in the work published in Quaderni di Epidemiologia Psichiatrica, n.7/2020. This document, in reporting the SISM data of the Italian Ministry of Health, shows how the current Mental Health services, in reality, are not structures and activities of care for Mental Health, but rather, exclusively psychiatric services. One fact for all: the Indicators used refer only to the discipline of psychiatry and, with regard to treatment, refer only to treatment with antidepressants, antipsychotics and lithium.
With regard to letter b) "guaranteeing individual and collective psychological wellbeing and for the protection of psycho-social fragility" (art. 29 ter law no. 126/20) in conjunction with art. 20 bis law no. 176/20) it is necessary to implement the cross-company coordination of the complex of activities of specialized psychological competence, so as to ensure the psychological services of the 1st level and psychotherapeutic services of the 2nd level in all areas and contexts provided for by current regulations, including the psychotherapeutic activity of the Italian Mental Health Services through an adequate presence of psychological staff able to implement psychotherapeutic interventions, even for the forms of psychiatric disorders (personality disorders, psychotic type) that have indications of literature and experience in this sense, as provided by art. 26 of the Decree LEA.
Based on the above mentioned data, even a doubling of structured psychotherapists, which appears to be a minimum objective, would still not allow us to meet the demand for psychotherapy that already exists and is now strongly accentuated by the pandemic, we believe it is necessary:
(a) Implement in emergency the provision of vouchers for short psychotherapy treatments to people in greater need and economically disadvantaged;
(b) Provide, through adequate funding, forms of agreement with associations or professionals in the field of psychotherapy for the provision of psychotherapy packages.
The Coordinamento Nazionale Scuole di Psichoterapia (CNSP) an umbrella organization that includes more than the 90% of the Italian Psychotherapy Training Schools approved by the Italian Ministry of University and Reseach that Train psychologists and medical doctors to become psychotherapists after a four years post doctoral psychotherapy training program have offered to help the Italian ministry of health and the local health agencies to better manage the their duties to offer the needed mental health services to the Italian population that before the pandemic was already severely inadequate: 75% of those diagnosed in need of psychotherapy did NOT receive the service they needed since there are not a sufficient number of psychotherapists in the Italian Public health subsystem.
Now with the Covid 19 pandemic the needs for psychological services and psychotherapy are even larger and serious harm is inflicted to the Italian people and to Italy since negating access to the prescribed mental health services - also to a serious lack of respect the Italian Constitutional Law the Italian that grants citizens the right to public health service access- the Italian families and the whole Italian society are hurt as well since people are the most valuable resource for any nation
Protecting and promoting mental health also protects and promotes physical health, social health, and prosperity. According to the WHO, mental illness is the largest cause of disability (YLD) in developed countries than any other group of diseases, including cancer and heart disease.
Mental illnesses exacerbate morbidity from chronic diseases: cardiovascular disease, diabetes, obesity, asthma, epilepsy, and cancer. Furthermore the rates for intentional injuries ( homicides and suicides) and unintentional deaths from workplace accidents etc. are two to six times higher among people with a mental illness.
Mental illnesses generate economic costs of more than 4% of European gross domestic product, some of which are direct costs of treatment, while more than a third are instead linked to lower employment rates and reduced productivity (OECD Report 2018). inflicted enough psychotherapists nation and consequently psychotherapists have a significant social and strategic role.