THE ITALIAN NATIONAL MENTAL HEALTH LAW
Short description and comments
The Italian mental health law reform consists of a set of laws: one national law on the principles and 20 regional laws on policies, according to the Italian Constitution who give a high autonomy to the Regions in the planning, management and administration of health services.
意大利精神卫生法改革法案包括以下法案律：一部有关原则的全国性法律和二十部有关政策的地区性法律。根据意大利宪法，各省对卫生机构在计划、管理和行政方面享有高度自治。 The national law was firstly approved the 13th of May 1978 with number 180. Six month later, the 31 of December 1978, it was included, with minor modifications, within the General Health Law no. 833.
该全国性法律在1978年5月13日得到180票赞成通过。6个月后，在1978年12月31日，该法经过少量修改后被收录并入第833号普通健康法第833条中（General Health Law no.833）。
Therefore the Italian mental health law now consists of four articles ( 33, 34, 35 and 64) of the Law no. 833.
During the reform’s twenty-five years of existence, the national law has never been changed whereas there have been many revisions to all the regional laws.
1. The pillars of the national law
Three are the pillars of the national law :
A ban on building new mental hospitals and on admitting new patients to the existing ones, which had to be gradually phased out and used for other purposes.
The principle that the prevention, treatment and rehabilitation of the mentally ill normally be carried out in community services. The law also establishes the creation of Services or Stations for Psychiatric Diagnosis and Treatment within the General Hospitals, which can have a maximum of 15 beds each.
The establishment of Involuntary Health Treatment ( IHT)
2. The Involuntary Health Treatment
As in the case of involuntary treatment for other illnesses provided for in the same article of the law, IHT for mental illness must be implemented respecting people’s dignity and their civil and political rights. It must be accompanied by initiatives to ensure the consent and participation of the person receiving involuntary treatment.
Involuntary treatment is requested by two physicians. One must be a psychiatrist from the public mental health department.
The IHT is ordered by the mayor or by a delegate and it is authorised by the tutelary judge who is entrusted with the jurisdictional safeguard of such treatment.
Involuntary treatment can be done in the General Hospital Psychiatric Stations and also in the Mental Health Centres.
If involuntary treatment exceeds 7 days, and in cases of further extensions, the psychiatrist must follow the above mentioned procedure ( mayor + judge) and give a written explanation for any such extension.
3. Comments on IHT
The reason for involuntary treatment is no longer that the patient is dangerous but that the patient needs help.
In the words of the law, involuntary treatment must be provided if and when “mental condition of the person requires urgent treatment that the person does not accept”.
That has some important consequences:
the fact that a mentally ill person does not accept treatment is no longer an indication that he or she is socially dangerous;
the psychiatrist is no longer obliged to control and repress social dangerousness;
obliging mentally ill persons to receive treatment is a way of protecting their rights not reducing them. That make acceptable an involuntary treatment provided by community services: it is not anymore a police measure.
Most of the legislations, even the ones stating the respect of human rights, give social dangerousness as the reason for involuntary treatment, keep the existence of mental hospitals and the legitimacy of seclusion for the mentally ill citizens.
Those legislations protect the rights of the mental patient by limiting and controlling the psychiatrists’ work – for example, by making distinctions between compulsory treatment and the compulsory administration of drugs, by supervising seclusion and some specific treatment etc.
The Italian legislator considered that those forms of control cannot be fully effective in protecting the rights of patients as soon as mental illness continue to have a “special statute” among illnesses and the psychiatrist continues to be responsible for controlling and repressing social dangerousness.
As a result, under Italian law, this last responsibility is entirely given to the police and to the other institutions of the criminal justice system.
Psychiatric services and police can or must do act together, in case of need, each on its own specific responsibility.
4.The movement for reform
This reform have had a very long period of preparation.
The movement for reform has started in Italy in the in the late sixties, leaded by the work of the psychiatrist Franco Basaglia and pushed by a network of “de-institutionalisation” practices which have started up to create community services already before the reform, with the resources no longer needed once the hospital wards were closed.
In 1968 Italy has had a first partial law reform, the law n.431, and ten years later the parliament approved the present law in the framework of the general health law reform.
THE ARTICLES OF THE ITALIAN NATIONAL MENTAL HEALTH LAW
Norms for voluntary and involuntary health assessments and treatments
Health assessments and treatments are normally voluntary. In cases provided for by the present law and in cases expressly provided for by other laws, the health authorities may order involuntary health assessments and treatments in accordance with Article 32 of the Constitution. Such care shall be given in full respect for the dignity and civil and political rights of the person including, to the extent possible, the right to freely chose the physician and place of care. The mayor, as local health authority, shall order the involuntary health assessments and treatments by a special provision, based on a request by a physician which shall also include the reasons for such request. The involuntary health medical assessments and treatments shall be carried out by the public community health care services and centres and any required hospitalisation shall take place in public hospital facilities or in those which are under contract with the public health system. Involuntary assessments and treatments must be joined with initiatives to obtain the consent and participation of the person obliged. The local health care agencies shall operate in such a manner as to reduce the recourse to the aforesaid involuntary health assessments and treatments by means of initiatives aimed at health prevention and education and the development of structured relationships between the health care services and the local community.
During an involuntary health assessments and treatments, patients have the right to communicate with whomever they wish.
Anyone may petition the mayor to annul or modify the provision by which the involuntary health assessments and treatments have been ordered or prolonged.
In the event of such a petition, the mayor shall decide within 10 days. The provision to annul or modify such care shall be adopted following the same procedure as the provision being annulled or modified.
Voluntary and involuntary health assessments and treatments for mental illnesses
The departmental services and structures for mental health prevention, care and rehabilitation shall be established by Regional law, within the context of the local health care agencies and the overall general services for health protection.
The measures described in paragraph 2 of the preceding article may also be applied to persons suffering from mental illness.
The activities for the prevention, care and rehabilitation of mental illnesses shall normally be carried out by the extramural community services and centres described in paragraph 1.[z1]
Involuntary health assessments and treatments for persons suffering from mental illnesses shall be carried out in conditions of hospitalisation only if the mental alterations are such as to require urgent therapeutic measures, if the patient does not accept the aforesaid assessments and treatment or if it is not possible to adopt timely and appropriate health care measures without hospitalisation. The involuntary treatment in conditions of hospitalisation must be validated beforehand by a physician of the local health care agency (as per paragraph 3 of Art. 33), and must be justified according the present paragraph.
In the cases described in the preceding paragraph, hospitalisation must take place within a general hospital, in specific psychiatric stations for diagnosis and treatment within the mental health department that must also include extramural centres and services, in order to guarantee the therapeutic continuity. The number of beds in the hospital services described in the present paragraph shall be determined by the Regional Health Care Plan.
Procedures relating to involuntary health assessments and treatments for mental illnesses in conditions of hospitalisation and jurisdictional safeguard
The mayor’s provision ordering involuntary health assessments and treatments in conditions of hospitalisation, which shall be issued within 48 hours after validation as per Art. 34, paragraph 4, and which shall contain the request by a physician and the reasons for the request, as per Art. 33, paragraph 3, as well as the aforesaid validation, must be notified by the town-hall usher to the competent tutelary judge with jurisdiction for the area in which the city or municipality is located, within 48 hours of hospitalisation.
The tutelary judge, having acquired the information and provided for any verifications, shall validate or invalidate, within 48 hours, the involuntary treatment by means of a decree which shall contain the reasons for the decision and shall notify the mayor. If the provision is not validated, the mayor shall order the termination of the involuntary treatment in conditions of hospitalisation.
If the provision described in paragraph 1 of the present article is ordered by the mayor of a city or municipality different from the patient’s place of legal residence, the mayor of this latter city or municipality shall be notified, as well as the competent tutelary judge with jurisdiction for the city or municipality of residence. If the provision described in paragraph 1 of the present article is adopted for foreign nationals or persons without any nationality, the Ministry of the Interior and competent consulate shall be notified by the Prefect.
If the involuntary treatment needs to be prolonged beyond the 7th day, and for any additional extensions of such treatment, the medical director of the psychiatric service of the local health care agency shall, in a timely manner, request an extension from the mayor who has ordered the hospitalisation, stating the reasons for this request. The mayor shall then notify the tutelary judge, following the procedures described in paragraphs 1 and 2 of the present article, indicating the presumed duration of the extension of the involuntary treatment.
The aforesaid medical director shall notify the mayor, both in the case of the release of the hospitalised person or his continued hospitalisation, of the termination of the conditions which required the involuntary treatment. [z2] The aforesaid medical director shall also notify the mayor if involuntary treatment cannot be continued. The mayor shall then notify the tutelary judge within 48 hours of being notified by the medical director.
If necessary, the tutelary judge shall adopt the urgent provisions required in order to preserve and administer the patient’s finances and property.
The failure to notify, as per paragraphs 1, 4 and 5 of the present article, shall result in the termination of all of the provision’s effects and such failure shall constitute the criminal omission of an official act, if some more serious criminal act is not involved.
The person receiving involuntary treatment, or any other interested party, may appeal the provision validated by the tutelary judge in the competent tribunal.
Within 30 days, beginning from the term set by paragraph 2 of the present article, the mayor may also make such an appeal by not validating the provision ordering the involuntary treatment.
At the time of the hearing, the parties may appear before the Tribunal without legal representation and may be represented by a person or persons provided with a written mandate included in the appeal, or in a separate legal deed. The appeal may be submitted to the Tribunal by means of certified post with notification of receipt.
The president of the Tribunal shall set the date of the hearing of the parties by means of a decree attached to the appeal, which shall by notified by the Clerk of the Court to the respective parties and to the Public Prosecutor.
The president of the Tribunal, after having acquired the provision ordering the involuntary treatment and consulted with the Public Prosecutor, may suspend the involuntary treatment even prior to the first appearance of the parties before the Tribunal.
The president of the Tribunal shall decide on the request for suspension within ten days.
The Tribunal shall deliberate in its chambers, after having heard the Public Prosecutor and acquired any necessary information and evidence through its office or at the request of the parties.
The appeals and all subsequent procedures are exempt from stamp tax. The sentence of the tribunal is not subject to registration.
如收到第一款的非自愿性诊断和治疗的人是外国人或无国籍人，需要由当地政府首脑通知国务部部长（ministry of the interior）和相应大使馆。
庭审时，控辩双方均可不派法律代表出庭（legal representation)，也可以委派一人或多人携书面委托书或代理合同出庭。上诉应该随同（by means of certified post with notification of receipt. ）证明文件及通知收据提交法庭。
以上上诉及其所致所有程序均免除印花税。此庭审判决可以不登记（is not subject to registration.）。
Title III – Transitory and final norms
Transitory and final norms for psychiatric care
The Regions, within the general provisions of the regional health care plans, shall regulate the gradual phasing out of the psychiatric or neuro-psychiatric hospitals as soon they are not in use. The Region shall also establish the date when the temporary extension for the voluntary hospitalisation of persons who were hospitalised before May 16, 1978 and who require psychiatric care with hospitalisation, shall end. However, this derogation cannot be extended beyond December 31, 1980.
By this same date, and without the possibility of any further extensions, the public agencies must terminate their contracts and agreements with private institutions that provide exclusively psychiatric care.
In any case, it is prohibited to build any new psychiatric hospitals, to use those already existing as specialised psychiatric divisions of general hospitals, to establish in general hospitals psychiatric divisions or departments, and to use as such psychiatric divisions or departments, or neurological or neuro-psychiatric departments.
The Region will also regulate, pursuant to the norms contained in Articles 66 and 68, the assignation to local health care agencies of the assets and personnel of the public care and welfare institutions (IPAB) and of the other public agencies which at the time of the present law going into effect, on behalf of or under contract with the provincial administrations, provide for the hospitalisation and care of mentally ill persons, as well as the distribution of the assets and personnel of the provincial administrations assigned to the facilities and services for psychiatric care and mental hygiene. When such facilities and services involve more than one Region, the Regions involved shall proceed in agreement among themselves.
Beginning January 1, 1979, the Region shall establish psychiatric services as per Article 35, utilising the personnel of the public psychiatric services. In the event that there are no public psychiatric structures in the provincial territory, the Region, within the general provisions of the regional health care plan and for the purpose of establishing mental health centres within the local health care agencies, shall regulate the assignation of such personnel of the private psychiatric structures as shall make a specific request (and which structures at the time of the present law going into effect have contracts for providing care), and shall authorise, where necessary, the hiring by a public competition of the other personnel indispensable for the functioning of such centres.第64条
Until such time as the regional health care plans are adopted, as per the first paragraph of Article 34, the services as per paragraph 5 of Article 34 shall be established and structured as provided for by the Presidential Decree of March 27, 1969, n. 128, in order to guarantee the continuity of health care for the protection of mental health, and those services shall have a maximum of 15 beds each. Until the adoption of the delegated provisions as per Article 47, the health care functions of the director, chief psychiatrist, assistant psychiatrists and attendants of the psychiatric hospitals shall be those established, respectively, by Articles 4 and 5 and Article 7 of the Presidential Decree of March 27, 1969, n. 128.
Until the adoption of the Regional health care plans as per paragraph 1, the prohibitions contained in Article 6 of the Legislative Decree of July 8, 1974, n. 264, which was converted, with amendments, into Italian Law n. 386 of August 17, 1974, are extended to psychiatric and neuro-psychiatric hospitals which are under the control of the IPAB or other public agencies or provincial administrations. Any competitions for the hiring of staff shall continue to be carried out in accordance with the procedures applied by each agency or body before the present Law entered into effect.
Included among the health care professionals described at sub-paragraph i) of Article 27 of the Presidential Decree of July 24, 1977, n. 616, are nurses as per Article 24 of the Regulation approved by the Royal Decree of August 16, 1909, n. 615. Taking into account what is provided for by sub-paragraph q) of Article 6 of the present Law, the Region shall provide for the re-skilling and re-training of nursing personnel, in view of （鉴于）the phasing out of psychiatric hospitals and the new functions of such personnel in the mental health services within the local health care agencies.
The norms contained in Article 7, last paragraph of the Italian Law of May 13, 1978, n. 180 shall continue to remain in effect.这些地区性健康计划批准时，于第34条第1款、34条第5款所述的服务设施应该根据1969年3月27日的第128号总统政令设立和建筑，以保证精神健康治疗的持续；每所服务设施的床位均不可多于15张。直到如第47条的授权性法令生效时，领导、主任精神科医生、助理精神科医生和精神病医院工作人员应分别根据1969年3月27日的128号总统政令中第4、5、7条实现其健康促进功能。
Translation by Eric Schneider for the Mental Health Department of Trieste Local Health Agency
Revision and comments by Maria Grazia Giannichedda
由Maria Grazia Giannichedda改写及评论
Health care plan 健康发展计划
Specific Psychiatric Service / Station 精神专科医院
 From Maria Grazia Giannichedda Evaluation of the Mental Health Law Reform in Italy. Lessons learned presentation for the Second WHO International Training Forum on Mental Health, Human Rights and Legislation, Geneva, 10-12 November 2003
 Source: ordinary supplement to the ‘Official Gazette’, n. 360, December 28, 1978