Hard routes of mental health in Portugal: what can we offer to an adolescent with serious mental illness and multiple social risk factors?

Abstract

Worldwide, millions of children and adolescents are suffering due to a lack of efficient mental healthcare. Although some progress has been made to address the mental health problems in this age group, currently, even developed countries fail in providing psychiatric patients with the best practice care. We present a case of a Portuguese adolescent with a first episode of psychosis in whom multiple social and environmental risk factors were identified as triggers to his clinical presentation, as well as fundamental determinants of prognosis in the short and long term. In this case, we demonstrate how social determinants, including poverty, family dysfunction and difficulties in accessing appropriate mental healthcare, strongly influence the development, maintenance and prognosis in early psychosis during adolescence. Furthermore, we consider the implications of an absence of community-based mental healthcare and rehabilitation services and reasons for why this may complicate the management and limit opportunities to this patient population.

Background

The global burden associated with mental health disorders is increasing worldwide,¹ and the evidence recognises that most of these disorders start to manifest at younger ages, typically during childhood and adolescence.

Despite the alarming prevalence of these disorders, the public attention and political investment in mental health (especially in the paediatric age group) remains below what it should be globally. Often, investment is targeted on interventions or models with little support in the literature, with the vast majority of countries continuing to favour traditional models focused on inpatient care.

In this context, we considered it pertinent to discuss the case of a teenage boy with a severe mental illness and multiple social risk factors, which we believe illustrates the serious consequences of the lack of appropriate mental health services for children and adolescents. Considering the prevalence of these disorders, the serious individual and social consequences, and the disproportionally small political and economic investment in their prevention and treatment, we argue that this situation constitutes a global health problem that must be addressed urgently, due to the serious impact on the health of large numbers of children and young people.

Case presentation

A teenage boy, with no history of psychosis, travelled from the foster care institution where he was placed 1 month before, towards his family residence and arrived in a significantly agitated state. He reported persecutory and homicidal delusional beliefs. The family called the police, who immediately referred him to the emergency department of the local paediatric hospital.

During the psychiatric examination, the boy exhibited disorganised speech and behaviour, reporting persecutory and mystic delusions. He also described auditory hallucinations and ideas of reference. He was admitted to the adolescent inpatient unit and later diagnosed with first-episode psychosis.

Collateral history obtained from the foster care psychologist and social workers revealed that psychotic symptoms had begun suddenly around 2 weeks after moving to the new foster placement. Strange changes in his behaviour were noted, including an apparent loss of interest in daily activities, declarations of a conspiracy against him, incongruent laughter, refusal to eat, sexual disinhibition and episodes of aggression, without an apparent trigger.

His family also recalled a gradual change in his normal behaviour in the month prior to the foster care placement with increased irritability and aggressiveness, sleep disruption and social isolation.

Medical and developmental history

There were no complications during pregnancy, delivery and the postnatal period.

Regarding his developmental milestones, he presented a mild delay in language and learning difficulties. Because of that, he was integrated into the Special Education programme of his school, thereafter, showing academic success, satisfying peer relationships and general social adjustment.

In the transition to adolescence, his behaviour started to deteriorate both at home and school. He joined peer groups with disruptive behaviour and began regularly using alcohol and drugs and was referred to psychiatric services, starting an irregular outpatient follow-up. There were not any psychotic symptoms reported during this period.

Due to social difficulties and poor therapeutic adherence, he was first temporarily removed from his family and placed in a foster care institution. After a short period, he returned home, but the behavioural problems were still an issue. This fact led to a second placement in a foster care institution, where he arrived short before the clinical presentation.

He had no other significant medical or psychiatric history.

Family psychiatric and social history

There was not known family history of psychosis.

The family struggled with economic difficulties and had a history of domestic violence. He had not been in contact with his father since early childhood.

Management during hospitalisation in the acute inpatient unit

He was transferred to the acute inpatient unit where he underwent a complete medical evaluation to exclude other aetiologies, which showed all results within normal range.

He was diagnosed with first-episode psychosis and started on oral risperidone and lorazepam.

This was quickly changed to intramuscular risperidone administration due to poor compliance. He responded positively to this treatment with positive psychotic symptoms decreasing objectively. By this time, he was no longer actively verbalising delusional ideation, he was denying hallucinations and showing more organised behaviour.

After just over a month of clinical stabilisation, social services were contacted to prepare for discharge. The foster care institution where the patient was living prior to admission informed the social services that they were not able to receive the patient again since they could not provide him with appropriate mental health care.

At the time, there was a total absence of mental health facilities for adolescents, and consequently, social services placed him in another residential foster care institution, similar to the first. In view of the significant improvement in symptoms, the maintained clinical stabilisation and the possibility of maintaining the intramuscular administration of antipsychotic medication, he was discharged under the close supervision of the institution’s carers. Medical follow-up was arranged at the hospital after discharge.

Relapse at 2 weeks after discharge

Ten days after discharge, the foster care institution brought the patient to the emergency department again, after an episode of extreme agitation. They described a very turbulent week where the patient fled several times to abuse drugs and presented gradually more agitated and aggressive.

On mental state examination, he presented with disorientation, severely disorganised behaviour including restlessness, impulsivity and hostility, with catatonic behaviours including mutism and posturing. He also presented with autonomic instability (hypertension with periods of labile blood pressure, tachycardia and diaphoresis), in the absence of fever or other organic symptoms or relevant findings on laboratory results.

Rehospitalisation and differential diagnosis

During the first days of the second admission, he was refusing oral medication and food, his sleep was disturbed with wandering episodes on the ward and visible agitation. He required always 1:1 staffing and frequent chemical restraint. His speech was poorly organised and accompanied by stereotyped facial movements and frequent grimacing. There was evidence of formal thought disorder with thought blocking. Although he remained afebrile, all physical, laboratory and radiological examinations were repeated and did not show any significant finding.

After some weeks, progressive improvement in the level of consciousness and verbal responsiveness was observed with the medication adjustment.

He fulfilled the diagnostic criteria for catatonia (at least 3 of 12 features established in the Diagnostic and statistical manual of Mental Disorders, Fifth Edition (DSM-5)² The patient also showed signs of severity according to the Bush-Francis Catatonia Rating Scale, which we used to evaluate the symptom severity.³ Catatonia was the final diagnosis, which was further corroborated by improvement after appropriate treatment.

Orientation towards rehabilitation and community-based services

The patient continued to require inpatient care for several months, with further medication adjustment as well as psychoeducation. At the start of admission, he was prescribed lorazepam at a dose of 1 mg three times per day for relief of agitation, which was gradually suspended as he started to show clinical improvements and he was maintained only the biweekly intramuscular risperidone.

Because of the acute nature of the inpatient unit, no structured psychological interventions were available. In this context, the patient benefited from individual, group and family psychoeducation, training in some behavioural strategies and occupational therapy.

After clinical stabilisation, it was clear that he could not be discharged from the acute inpatient unit to home or a regular foster care institution. It was felt that he required constant behavioural and treatment supervision, which would only be possible in a specialised mental health facility. Furthermore, after months of dysfunction, he needed psychosocial rehabilitation.

In Portugal, the child protection system is based on the placement of children in foster care institutions and, less commonly, with foster care families. Institutions usually host children or adolescents temporary removed from their families, providing them care and protection, and include the presence of psychologists and other professionals trained in child care. Social services work simultaneously with institution staff and young people’s families in order to reduce social risk factors, allowing the child to return to his/her family home as soon as possible. During this period, children continue to attend external school. These institutions are not usually equipped to provide mental health care to young people with complex psychiatric disorders. They are designed as host institutions and not as healthcare facilities.

The provision of child and adolescent mental health in Portugal is almost completely based on outpatient services, usually integrated into general psychiatric departments or mental health hospitals. There are only three acute inpatient units in the country. Day-care units are a relatively recent innovation with limited access, as are residential facilities intended to receive children and adolescents with complex mental health disorders requiring functional and psychosocial rehabilitation. These facilities are still too scarce to meet demand.

Because of the scarcity of available resources, social services were not able to find a place for our patient in one of the few institutions for continuing care and rehabilitation. Even searching in adult institutions, it was not possible to find any available vacancy when the patient was medically fit for discharge.

The patient, therefore, stayed for more than a year in acute inpatient units as the process of searching for a mental health care facility was extended, a less than ideal contingency.

Global health problem list

• Mental health disorders in children and adolescents are a serious public health problem and have dramatic individual and social consequences.

• Social and family factors have a fundamental contribution to the development, exacerbation and prognosis of psychiatric disorders.

• The treatment of psychiatric disorders becomes even more complex when considering there is a lack of rehabilitation and community-based mental health facilities, in many countries, as is the case in Portugal.

• The disparity between political investment in mental health services compared with other areas of healthcare, even in developed countries, and the lack of emphasis on community-based models limits the likelihood of patients sustaining a healthy and fulfilling life.

Global health problem analysis

Mental health disorders in children and adolescents are a serious public health problem and have dramatic individual and social consequences

The WHO defines mental health as “a state of well-being in which every individual realizes his/her potential, can cope with the normal stresses of life, can work productively and fruitfully, contributing to his/her community”.⁴ Childhood and adolescence are crucial periods for developing social and emotional skills, which will be important for mental well-being during the entire lifespan. It is critical that these problems are addressed in this age group and that tools are provided to prevent the development of serious mental health conditions.^{5 6}

Mental health disorders are common in all regions of the world, affecting every community and age group across all income countries.⁴ According to multiple epidemiological studies, mental disorders account for one of the largest and fastest growing categories of the burden of disease worldwide.⁷

Globally, mental health conditions account for 16% of the global burden of disease in young people and 15%–30% of the ‘disability-adjusted life-years’ lost during the first three decades of life.⁸ By 2030, depression alone is likely to be the single highest contributor to the burden of disease in the world—more than heart disease, stroke, road traffic accidents and HIV/AIDS.⁸ This large contribution to burden has remained constant in time across all countries, including those with high socioeconomic index,⁸ showing that even in high-income countries, the mental health needs are still unmet.⁴

Mental health disorders in children and adolescents are associated with individual and social consequences, strongly affecting their life but also the society as a whole. Individually, it can lead to school failure with consequently lower educational achievements and higher rates of unemployment in adulthood.^{6 9} Prospective studies have shown that behaviour problems at the age of 7 years are related to poorer educational attainment at 16 years and poorer labour market outcomes at both 22 and 33 years of age.¹⁰ Given that approximately one in five children suffers from a mental health condition,¹¹ up to 20% of the adult population is at risk for poor educational and employment outcomes.⁹ The highest prevalence of mental disorders was seen among girls over 13 years old and those who already belong to poorer socioeconomic groups.¹² They are also strongly correlated with worse physical, reproductive and sexual health, violence and increased mortality.⁶ Individuals with severe mental illnesses experience a shortened life expectancy, dying up to 10–20 years earlier than the general population.^{4 13 14} Children with mental disorders also face challenges related to stigma, isolation and discrimination.⁵ They may face severe restrictions on the exercise of their political and civil rights and their ability to participate in public affairs, as well as potentially reduced access to health and social services.⁹

Besides the consequences for the individual, mental illness also hurts societies and economies; the Organisation for Economic Cooperation and Development (OECD) projects that the economic burden of mental illnesses can rise to up to 4% of European Union (EU) gross domestic product, which is more than the cost of cancer, diabetes and chronic respiratory disease combined.¹⁵ The indirect costs of mental health are particularly high as they include the value of lost production due to unemployment, absence from work, presenteeism or premature mortality, and being responsible for 30%–40% of chronic sick leaves. By 2030, mental illness costs are expected to reach more than $6 trillion annually.¹⁵ In this context, the failure to address mental health problems can also be considered a serious socioeconomic issue.

This patient’s case is paradigmatic of this issue, as the severity of the disease had serious consequences on his ability to return home or to a regular foster care institution as well as his chances to finish school and to develop personal autonomy to pursue his life goals. He needed special assistance to avoid the severe individual and social consequences of mental illness, which include lack of education and professional skills, lack of autonomy, risk of engaging in violence, substance abuse and unhealthy sexual behaviours. He also faced serious difficulties with reintegration into society and arguably will struggle to live a happy, productive and fulfilling life.

Social and family factors are major contributors to the development and exacerbation of psychiatric disorders in children and adolescents

The current evidence shows mental illness as a product of biological and social factors that operate across the lifespan. Determinants of mental health include not only biological factors like genetic predisposition or individual character traits but also supportive environments in the family, at school and social community, as well as a multitude of cultural, economic, political and environmental factors.⁴ The more risk factors children and adolescents are exposed to, the higher the potential impact on mental health.⁵

There were many social and family determinants in the history of our patient that exacerbate his psychiatric situation:

Family dysfunction and violence

Violence (including abuse, neglect, bullying, as well as experiencing or witnessing domestic violence) is recognised as a contributor to mental health disorders during childhood and adolescence.⁵ In the past two decades, much evidence has demonstrated that adverse childhood experiences (ACEs) are strongly associated with a marked increase in risk for major psychiatric and medical disorders, and the more ACEs experienced, the more significant the risk of suffering from a severe mental disorder.¹⁶ A recent study observed that 94% of a sample of males with schizophrenia had experienced at least one ACE and 63% suffered from four or more disruptive childhood events, the majority of them occurring within the family group.¹⁷ There is a significant relationship between patients who suffered ACEs and the presence of auditory hallucinations.¹⁷ The quality and dynamics of their family life, as well as the continuity of care, are also important factors that contribute to mental well-being across an individual’s lifespan.^{4 5}

Although this patient was not directly a victim of physical abuse, he witnessed situations of intrafamilial abuse and household dysfunction. Furthermore, the patient’s temporary removals from the family home would have been a traumatic transition for the patient. All these life events might represent stressors that cumulatively contributed to debilitating the patient’s mental state and perhaps also served as maintenance factors after the establishment of his disorder.

Poverty and social exclusion

Socioeconomic difficulties are also recognised as contributors to mental health disorders during childhood and adolescence. Children and adolescents from poor socioeconomic backgrounds are at higher risk of developing mental health issues due to their living conditions, stigma, discrimination and lack of access to quality social and health services.⁵ These also include young people living in humanitarian and fragile settings; with chronic illnesses, intellectual disabilities or other neurological conditions; as well as orphans and minority ethnic or sexual backgrounds or other discriminated groups.⁵

In this context, our patient comes from a disadvantaged socioeconomic background, with his family repeatedly struggling financially. The economic difficulties only could be responsible for the high risk for mental health conditions, but in this case, they contributed to a series of ACEs⁹ such as the removal from the family home, more exposure to risk behaviours (such as drugs use, delinquency) related to the underprivileged neighbourhoods, a less-stimulating environment, among others.

Learning difficulties (LDs) also account for higher risk of comorbid mental health conditions, not only for pathophysiological reasons but also because it constitutes a risk factor of social exclusion. LD could lead to academic failure, higher risk of engaging in risk-taking behaviours and more peer-related adverse experiences. The literature establishes that school failure is a risk factor for most paediatric mental health disorders.¹⁸

Substance abuse and other risk-taking behaviours

Many risk-taking behaviours usually start during adolescence. Limitations in an adolescent’s ability to plan and manage their emotions, in addition to contextual factors such as poverty and exposure to violence, can increase the probability of engaging in risk-taking behaviours.¹⁹ These behaviours might be both an unhelpful coping strategy and a negative contribution to an adolescent’s mental illness.¹⁹ Harmful use of substances (such as alcohol or drugs) is a major concern in most countries. Worldwide, it was estimated that 5.6% of 15–16 years old had used cannabis at least once in the preceding year, with males more at risk.¹⁹ The literature also establishes the strong correlation between the use of cannabis and the risk of psychotic episodes in individuals with a genetic predisposition.²⁰

Our patient regularly started to use drugs at an early age. This could have contributed to putting the patient at risk of developing a psychotic episode, as well as to trigger it. Drug use also confers a considerable risk of recurrence.

Difficulties in accessing appropriate mental health facilities: the lack of rehabilitation and community-based mental health services

To reduce the burden of mental health disorders, treatment needs to include a focus on the quality of the delivered intervention. Historically, mental health service provision has been grossly divided into three periods^{21 22}:

• The rise of the asylum (from around 1880 to 1955), which was defined by the construction of large asylums that were far removed from the populations they served.

• The decline of the asylum or ‘deinstitutionalisation’ (since the second half of the 20th century), characterised by a rise in services that were closer to the populations.

• The reform of mental health services according to an evidence-based approach, balancing and integrating elements of both community and hospital services.^{21 22} According to this model, care should be provided in community settings close to the populations served, with hospital stays being reduced as far as possible, and usually located in acute wards on general hospitals.²³

Community mental health services are services that emphasise the importance of treating people in the community, in a way that maintains their connection with their families, friends and work.²⁴ The services should include both prevention and treatment.²⁵ For example, individuals could be referred to services because they have already displayed certain problematic behaviours; the services focus on treating these problematic behaviours, preventing further deterioration and promoting more positive coping strategies.²⁵

A fundamental principle supporting these values is the notion of people having equitable access to services according with the United Nations (UN) Convention on the Rights of Persons with Disability(UNCRPD)²⁶ and the UN Principles for the Protection of Persons with Mental Illness and for the Improvement of Mental Health,²⁷ which specify the right of the person to be treated without discrimination; the presumption of legal capacity unless incapacity can be clearly proven and the need to involve persons with disabilities in service development and decision-making which directly affects them.

The right to community-based services is expressly recognised in Article 19 of the UNCRPD, and it declares that: (1) all persons with disabilities have the right to live in the community, choose their place of residence and have access to residential and domiciliary services as well as other community services; (2) states should facilitate the inclusion and full participation in the community of persons with disabilities.²⁶

In this context, while recognising the fact that some people are significantly impaired by their illness, a community-based mental health service seeks to foster the individual’s self-determination and participation in community life.²⁴ They are usually closer to services such as social work, public health and education, as well as families, whose participation is fundamental, especially for children and adolescents.²⁴

The available evidence suggests that a model of care, including only hospital-based provision, will be insufficient to provide access for people facing barriers to care.²⁸ Craig et al²⁹ reported that around 14% of patients under an early intervention service made no recovery over the first 18 months, requiring longer term care. Furthermore, the 10-year follow-up to the Aetiology and Ethnicity in Schizophrenia and Other Psychoses (AESOP) study also reported that 23% of 345 patients had no remission of symptoms at 6 months or more over a 10 period and, of these patients, 46% had prominent negative symptoms.³⁰

Studies comparing community-based services with other models of care consistently show significantly better outcomes for clinical symptoms, quality of life, housing stability and vocational rehabilitation.^{31 32} Community-based services also increase accessibility,²¹ continuity of care and flexibility of services, making easier early identification and prevention of relapses as well as increased adherence to treatment.^{21 33} The community-based services also proved to be better in protecting Human Rights of people with mental disorders and preventing stigmatisation.²¹ Other studies show that, when deinstitutionalisation is correctly developed, the majority of patients have less negative symptoms, with improved socialisation skills and more satisfaction.^{34 35}

In this case report, we show how the insufficient resources of community mental health care in Portugal contributed to the clinical picture in two different ways:

• First, the social and family risk factors presented in the patient’s background were slow to be identified. Consequently, there was a delay in the referral of the patient to community Child and Adolescent Psychiatry (CAP) services as well as monitoring his adherence to therapeutic interventions and follow-up appointments.

• Second, it also helped to aggravate the prognosis: the patient had a relapse when he was integrated into an undifferentiated foster care home that did not have the adequate resources to help him manage his illness. Furthermore, after recovering from the acute phase, he needed to stay longer than necessary in an acute inpatient unit, away from his normal life and routine, which consequently, will increase the difficulty in his reintegration in the community, with restriction of attainment of his life goals.

The disparity between political investments in mental health services, even in developed countries such as Portugal, particularly the lack of emphasis on community-based models, limits the likelihood of psychiatric patients sustaining a healthy and fulfilling life

Despite the alarming personal and economic costs of mental health, average governmental spending on services varies from 0.5% of the annual health budget in low-and-middle-income countries (LMICs) to 5.1% in higher-income countries (HICs), which is still disproportionately small given the prevalence and impact of mental disorders.³⁶ Child and adolescent psychiatry is even more neglected, although investments in CAP are more cost-effective, producing higher returns in terms of prevention of disorders in adults.³⁷

As discussed above, there is also a broad consensus on the need for comprehensive community-based services. Despite evidence indicating this is a cost-effective model of management, these services are lacking globally.³⁸ The reasons for this situation are multiple and complex.

First, some barriers to the development of community services exist at a policy level, when there is a lack of adequate mental health policies and legislation, as is the case of LMICs.³⁹ Another type of barriers could be found in HICs, where policies and guidelines are established, but there are difficulties in putting them into practice. Issues include resistance in releasing resources from the large institutions and lack of integration of mental health services with the general health and social care systems.³⁹

This is the case of Portugal, which as a HIC,⁴⁰ has a relatively efficient public health and educational systems and strong social welfare, that theoretically reduces the barriers to care when compared with LMICs. The organisation of the National Health Service (NHS) defines that basic care should be provided by local mental health services located in general hospitals. The Mental Health (MH) Act (Act No. 36/1998)⁴¹ establishes in its Article 3 that “the provision of mental healthcare should be primarily undertaken at the community level, to avoid the displacement of patients from their familiar environment and facilitate their rehabilitation and social integration” and “the care of patients who require psychosocial rehabilitation, is preferably undertaken in residential structures, day centres, that are part of the community and adapted to the patient’s specific degree of autonomy”.⁴¹ Mental health has been defined as a priority in successive National Health Plans in Portugal (2004–2010; 2007–2016).^{42 43} Despite these legislative efforts, in 2011, the total MH expenditure was only about 5% of the overall health budget,⁴⁴ and the system remains essentially centred around inpatient stays and emergency consultations, which consume more than 80% of provided resources.⁴⁵ During the severe economic crises of 2011–2012, the country experienced an important cut in the investment assigned to healthcare and public services and a consequently suspension or delay of many health policies that had been mooted during the preceding years.⁴³ The difficulties in the organisation of public administration and the regional disparities within the country are also major challenges in passing the good policies from paper to practice.

At present, there is a steady increase in investment in community-based services.⁴³ Nevertheless, these services are invariably designed to provide mental healthcare to adults, and CAP services in less populated areas remain scarce.⁴³ Residential and day-care facilities are integrated into the National Network of Continuing Integrated Care (NNCIC) which was a response created within the NHS to provide care to people who are in a situation of functional dependency, providing rehabilitation and social reintegration.⁴⁶ Special NNCIC units, prepared to receive patients with severe mental illness, were created for the first time in 2017. Consequently, they were still in the probationary period during our patient’s psychotic episode.⁴⁶ Among these units, only 60 places in all country were planned to children and adolescents and only a few are actually ready to receive patients, so it is not surprising that there was no immediate place for our patient. Additionally, only a few months after its opening, all these CAP units already had waiting lists for longer than 1 year.

The underinvestment in community-based services, within the general budget assigned to mental health, is one of the major healthcare problems not only in Portugal but also across Europe. In a European survey,⁴⁷ 22 countries provided information on the proportion of the mental health budget allocated to different settings of care. Only 10 countries specified the spending on community-based services, excluding beds, which ranged from 30% in Sweden to 0% in Georgia and Moldova. The median was 9%.⁴⁷ Correcting this would require reallocation of resources that are being used for other purposes to increase funding for community-oriented care.

Second, there is a concerning lack of mental health workers specialised in children and adolescents in both LMICs and HICs. The 2017 WHO Mental Health Atlas⁴⁸ revealed that the global average number of human resources is less than one mental health worker per 10 000 people. In Portugal, the medical specialty of CAP is well defined and separated from adult psychiatry, but the average number of professionals is about the lowest in EU (1.1 child psychiatrists per 100 000 people).⁴⁹ The ratio of other professionals is not much encouraging with 2.3 psychologists, 0.6 occupational therapists and 1.1 social workers per 100 000 people.⁴⁹ Additionally, it is also essential to reallocate this scarce staff from hospital to community-based services and teach them a new set of competencies, including recovery and rehabilitation.⁴⁹

Furthermore, the distribution of human resources across Portugal is highly unequal, with a much higher concentration of mental health professionals working in the three major cities.³⁹ Being placed in a foster care institution outside one of these cities, our patient was unable to access CAP services during the first days of symptoms emerging.

Scaling up interventions requires proper coordination of multiple agencies involved, including education, social care and justice. This coordination of services requires improvement in Portugal. A common language for child mental health must be developed between professionals from various backgrounds; networking and communication between agencies must be fostered.³⁷ The lack of coordination between different services (healthcare, social care, education, justice) is especially evident in the case of our patient. The special needs he required were extremely difficult to comprehend for the social and judicial services. This situation led to the consequences which arose after the first discharge and admission to an inappropriate foster care facility, against medical advice.

In the view of all the barriers and difficulties illustrated with our patient, we recommend a reallocation of public budget designated to mental health, from hospital-centred to community-based services especially those dedicated to the prevention, early intervention and psychosocial rehabilitation. We also recommend increasing the training of new professionals prepared to work directly with deprived communities. Furthermore, we highlight the importance of better cooperation between different state, private and civil society agencies, in order to facilitate the prevention and early treatment of mental illness and simultaneously preserve the dignity and future quality of life of our patients.

Patient’s perspective.

During the long months of his stay in the inpatient unit, the patient was constantly asking about the discharge. He had the opportunity to talk with the social worker and with a legal officer, expressing his suffering for being for long months living in a small acute medical ward, away from family and friends. He verbalised “I will never get out of here”, "I feel like I am not progressing in my life" and continuously asked the medical team “Did you speak with the social worker? Did you send the papers to court? How much longer will I need to be here?” occasionally distrusting what was explained to him.

Throughout this hard process, his mother visited him daily, also showing herself mixed feelings, from "extremely concern about the disease" to “grief for the future I imagined for my son" and "extremely tiredness with the delay in solving the situation". She frequently cried and told us “I hope that what happened to my son may contribute to help other kids who suffer from this problem”.

Learning points.

• The risk factors for the development of schizophrenia, the potentially devastating psychosocial impact of this disorder and the rehabilitation-focused interventions needed to improve its prognosis, are well known and validated.

• These interventions promote better and quicker recovery, reduce the probability of relapse and increase the individual quality of life with a consequent reduction of overall disease burden.

• This patient is representative of many others worldwide with similar risk factors. Improvement of early identification and intervention coupled with improved resource allocation could lead to a substantial increase in general quality of life for many individuals, families and the wider society.

• Economic and social limitations, as well as the lack of political awareness, are real barriers to the implementation of such essential and validated measures. This carries the burden of many economic, social and emotional costs.