The reform of Italian forensic psychiatric hospitals and its impact on risk assessment and management

  • Vittorio De Luca REMS Castore, ASL Roma 5 - Mental Health Department, Subiaco (RM)
  • Pieritalo Maria Pompili REMS Merope, ASL Roma 5 - Mental Health Department, Palombara Sabina (RM)
  • Giovanna Paoletti REMS Castore, ASL Roma 5 - Mental Health Department, Subiaco (RM)
  • Valeria Bianchini REMS Castore, ASL Roma 5 - Mental Health Department, Subiaco (RM)
  • Federica Franchi REMS Merope, ASL Roma 5 - Mental Health Department, Palombara Sabina (RM)
  • Marco Lombardi REMS Castore, ASL Roma 5 - Mental Health Department, Subiaco (RM)
  • Brunella Lagrotteria REMS Castore, ASL Roma 5 - Mental Health Department, Subiaco (RM)
  • Cristina Iannini REMS Castore, ASL Roma 5 - Mental Health Department, Subiaco (RM)
  • Camillo Fedele REMS Castore, ASL Roma 5 - Mental Health Department, Subiaco (RM)
  • Enrico Pompili Colleferro & Palestrina Community Center, Mental Health Department, ROMA 5
  • Giuseppe Nicolò Mental Health Department, Director, ASL ROMA 5


Italy has a consolidated history of de-institutionalization, and it was the first country to completely dismantle psychiatric hospitals, in order to create small psychiatric inwards closer to the community (i.e. in general hospitals). Nevertheless, it took the nation nearly 40 years to end the process from the beginning of de-institutionalization, definitely closing all of the forensic hospitals, which was not addressed by the first Italian psychiatric reform. This paper describes the establishment of new facilities substituting old forensic hospitals, called Residences for the Execution of Security Measures (REMS), which are a paradigm shift in terms of community-based residential home, and are mainly focused on treatment and risk assessment, rather than custodial practices. The use of modern assessment tools, such as the Aggressive Incident Scale (AIS) and the Hamilton Anatomy of Risk Management (HARM), is crucial in order to point out the focus and consistent instruments of the treatment plan. A preliminary analysis of data from the first 2 years of activity, considering severely ill patients who have been treated for more than 12 months, is then described for two REMSs in the Lazio region, close to Rome. Encouraging results suggest that further research is needed in order to assess clinical elements responsible for a better outcome, and to detect follow-up measures of violence or criminal relapse after discharge.


Pycha R, Giupponi G, Schwitzer J, Duffy D, Conca A. Italian psychiatric reform 1978: milestones for Italy and Europe in 2010? Eur Arch Psychiatry Clin Neurosci 2011;261(S2): 135-9.

Piccinelli M, Politi P, Barale F. Focus on psy-chiatry in Italy. Br J Psychiatry 2002;181(06): 538-44.

Russo G. Follow-up of 91 mentally ill crimi-nals discharged from the maximum security hospital in Barcelona P.G. Int J Law Psychiatr 1994;17(3):279-301.

Fioritti A, Melega V, Ferriani E, Rucci P, Scaramelli AR, Venco C, et al. Crime and mental illness: an investigation of three Italian forensic hospitals. J Forensic Psychi Ps 2001; 12(1):36-51.

Fioritti A, Melega V. Italian forensic psychia-try: a story still to be written. Epidemiol Psy-chiatr Sci 2000;9(04):219-26.

Chaimowitz GA, Mamak M (Eds). Companion guide to the Aggressive Incidents Scale and the Hamilton Anatomy of Risk Management. 2nd éd. Hamilton Ontario, Canada: St. Joseph’s Healthcare Hamilton;

Cook AN, Moulden HM, Mamak M, Lalani S, Messina K, Chaimowitz G. Validating the Hamilton Anatomy of Risk Management–Forensic Version and the Aggressive Inci-dents Scale. Assessments 2018;25(4):432-45

Morosini P, Roncone R, Impallomeni M, Casacchia M. Presentazione dell’adattamento italiano della Brief Psychiatric Rating Scale, versione 4.0 ampliata (BPRS 4.0). Riv Riabil Psichiatr E Psicosoc 1994;3(94):195-8.

Ventura J, Green MF, Shaner A, Liberman RP. Training and quality assurance with the Brief Psychiatric Rating Scale: « the drift busters ». Int J Methods Psychiatr Res 1993;3(4):221-44.

Hathaway S, McKinley J. MMPI-2 MInnesota Multiphasic Personality Inventory-2: addata-mento italiano. Pancheri P, Sirigatti S (Eds). Florence: Organizzazioni Speciali; 1995.

Millon T. Millon Clinical Multiaxial Inventory III: versione italiana. Zennaro A, Ferracuti S, Lang M, Sanavio E (Eds). Giunti - O.S.; 2008.

American Psychiatric Association. Scale di valutazione PID-5 ADULTI e Manuale d’uso. Fossati A, Borroni S, Somma A (Eds). Milan: Raffaello Cortina Editore; 2015.

Morosini P, Magliano L, Brambilla L. VADO Valutazione di Abilita e Definizione di Obiettivi. Trento: Erikson; 1998.

Schneider LC, Struening EL. SLOF: a behav-ioral rating scale for assessing the mentally ill. Soc Work Res Abstr 1983;19(3):9-21.

Montemagni C, Rocca P, Mucci A, Galderisi S, Maj M. Italian version of the « Specific level of fuctioning ». J Psychopathol 2015;21(3): 287-96.

Weiss L, Saklofske D, Coalson D, Raiford S. WAIS-IV Clinical use and interpretation. Bur-lington MA: Academic Press; 2010. (accessed on December 8, 2018)

Randolph C. Repeatable battery for the as-sessment of neuropsychological status: ad-datamiento italiano. Ponteri M, Pioli R, Pado-vani A, Tunesi S, de Girolamo G (Eds). Flor-ence: Giunti - O.S.; 2007.

Patton JH, Stanford MS, Barratt ES. Factor structure of the barratt impulsiveness scale. J Clin Psychol 1995;51(6):768-74.

Fossati A, Di Ceglie A, Acquarini E, Barratt ES. Psychometric properties of an Italian version of the Barratt Impulsiveness Scale-11 (BIS-11) in nonclinical subjects. J Clin Psychol 2001;57(6):815-28.

Posner K, Brown GK, Stanley B, Brent DA, Yershova KV, Oquendo MA, et al. The Co-lumbia–Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry 2011;168(12):1266-77.

Hare RD. Hare Psychopathy Checklist* Re-vised (PCL-R). 2nd éd. Toronto: Multi-Health Systems; 2003.

Douglas KS, Hart SD, Webster CD, Belfrage H. HCR-20V3: assessing risk for violence. Burnaby, British Columbia: Mental Health, Law, and Policy Institute, Simon Fraser Uni-versity; 2013.

American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5. 5th ed. Washington, DC: American Psychiatric Publ; 2013.

Kane J. Clozapine for the treatment-resistant schizophrenic: a double-blind comparison with chlorpromazine. Arch Gen Psychiatry 1988;45(9):789.

Carcione A, Nicolo G, Procacci A (Eds). Man-uale di terapia cognitiva delle psicosi. Milan: Franco Angeli; 2012.

Veltro F, Vendittelli N, Pontarelli I, Pica A, Niocchiniello I. Manuale per l’intervento psicoeducativo di gruppo per il raggiungimento di obiettivi. (INTE.G.R.O.). Rome: Alpes; 2017.

Vendittelli N, Veltro F, Oricchio I, Cappuccini M, Roncone R, Simonato P. L’intervento cog-nitivo-comportamentale di gruppo nel Servizio Psichiatrico di Diagnosi e Cura. Milano: Edi-Ermes; 2015.

Linehan M. DBT® skills training manual. 2nd ed. New York London: The Guilford Press; 2015.

Bellack AS, éditeur. Social skills training for schizophrenia: a step-by-step guide. 2nd ed. New York: Guilford Press; 2004. 337 p.

Praud N, Prat SS. HARM and AIS as risk assessment tools in forensic psychiatry: benefits and limitations of their use in France. Int J Risk Recovery 2018;1(1):32-5.

Original Article