Lippi Matteo, Campanozzi Laura Leondina, D'Andrea Giuseppe, Morena Donato, Orsini Francesca, Damato Felice Marco, Fanelli Giuseppe, Balcioglu Yasin Hasan, Ryland Howard, Fovet Thomas, Völlm Birgit, Vicente-Alba Javier, Scott Charles L, Frati Paola, Tambone Vittoradolfo, Rinaldi Raffaella
Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, 00185 Rome, Italy.
Research Unit of Bioethics and Humanities, Campus Biomedico University of Rome, 00128 Rome, Italy.
Healthcare (Basel). 2025 Sep 20;13(18):2363. doi: 10.3390/healthcare13182363.
: This article presents an international comparative review of involuntary psychiatric care, Community Treatment Orders (CTOs), and forensic mental health services, with operational implications for Italy. Italy has a community-based model inspired by the "Basaglia Law" (Law No. 180/1978), emphasizing deinstitutionalization and continuity of care. Nevertheless, risk governance gaps persist for high-complexity patients, imposing a disproportionate legal and clinical burden on mental health professionals. This group includes individuals who refuse treatment despite meeting criteria for compulsory admission, patients at elevated risk with substantial management complexity, and offenders with a current or suspected psychiatric disorder. : We conducted a comparative legal and policy review across seven jurisdictions (Italy, England and Wales (UK), France, Germany, Spain, the United States, and Canada) to map frameworks for involuntary treatment, forensic services, CTOs (or equivalents), and community-based risk management. We also extracted procedural safeguards, duration and renewal limits, and interfaces with forensic services. : CTOs are available in five of the seven jurisdictions (England and Wales, France, Spain, the United States, and Canada) but are absent in Italy and Germany. We propose a three-pillar framework: (1) enforceable outpatient measures, including CTOs; (2) Forensic Psychiatry Units within Local Health Authorities; and (3) oversight boards with judicial, clinical, and social representatives. These components aim to redistribute responsibility, ensure continuity of care, and provide proportional oversight within a least restrictive, graduated system. : When narrowly targeted, time limited, and paired with robust safeguards and service-quality standards, CTOs can support adherence and continuity for patients who repeatedly disengage from care. For Italy, integrating this instrument within the three-pillar framework and under independent oversight could strengthen patient rights and public safety, reduce revolving-door admissions, and improve outcomes.
本文对非自愿精神科护理、社区治疗令（CTO）和法医精神健康服务进行了国际比较综述，并探讨了其对意大利的实际影响。意大利拥有受“巴萨利亚法”（第180/1978号法律）启发的社区模式，强调去机构化和护理的连续性。然而，对于高复杂性患者，风险治理差距依然存在，给精神健康专业人员带来了不成比例的法律和临床负担。这一群体包括尽管符合强制入院标准但拒绝治疗的个体、具有较高管理复杂性且风险较高的患者，以及患有当前或疑似精神疾病的罪犯。
我们对七个司法管辖区（意大利、英格兰和威尔士（英国）、法国、德国、西班牙、美国和加拿大）进行了法律和政策比较审查，以梳理非自愿治疗、法医服务、社区治疗令（或类似措施）以及基于社区的风险管理框架。我们还提取了程序保障措施、期限和续期限制，以及与法医服务的衔接情况。
七个司法管辖区中有五个（英格兰和威尔士、法国、西班牙、美国和加拿大）设有社区治疗令，但意大利和德国没有。我们提出了一个三支柱框架：（1）可执行的门诊措施，包括社区治疗令；（2）地方卫生当局内的法医精神病科；（3）由司法、临床和社会代表组成的监督委员会。这些组成部分旨在重新分配责任，确保护理的连续性，并在限制最少、分级的系统内提供适当的监督。
当目标明确、时间有限，并与强有力的保障措施和服务质量标准相结合时，社区治疗令可以支持那些反复脱离护理的患者坚持治疗并保持连续性。对于意大利而言，将这一工具纳入三支柱框架并置于独立监督之下，可以加强患者权利和公共安全，减少反复入院情况，并改善治疗效果。
