The new Italian residential forensic psychiatric system (REMS). A one-year population study

The process of deinstitutionalization of the Italian forensic psychiatric system consisted mainly of the replacement of forensic psychiatric hospitals with the Residences for the Execution of Security Measures (REMS), and with community treatment of forensic psychiatric patients. The 30 existing REMS are regional-based community residential facilities with no more than 20 patients each, designed to accomplish a preeminent therapeutic/rehabilitative purpose, with limited duration of treatment and the absence of police officers. The present study aims to describe the clinical, criminological, and treatment characteristics of the REMS patient population between June 2017 and June 2018. The health managers of the 28 participating REMS provided data through an ad-hoc form relating to N = 730 patients (80 females), with average age of 41.7 (SD 11.8) years with a mean long history of disease. The patients were mostly already in psychiatric care at crime time (82.2%), and 48.4% had previous criminal convictions. Most patients suffered from schizophrenia (33.0%), personality disorder (32.0%) and substance-related and addictive disorders (21.4%). Significant psychiatric comorbidity emerged. The crimes underlying the measure were homicide/attempted homicide (26%), personal injury/threats/harassment (24%), domestic violence (29%), property crime (12%), violence against a public official (7%), stalking (7%), sexual crimes (4%), and misdemeanors (1%). Most of the victims were family members (45%), followed by previously unknown persons (31%). The most frequently used therapeutic approach was pharmacotherapy (98%), followed by psychiatric rehabilitation (81%) and psychotherapy (57%). We found a significant degree of variability of aggressive behavior in the REMS as measured by the Modified Overt Aggression Scale, with a predominance of verbal and physical aggression, but no gender differences emerged. Among recorded critical events we found absconding (5.3%), involuntary admission to civil hospital (5.9%) and physical restraint (4.1%). The REMS-based Italian forensic psychiatric system has some criticalities that should be deepened and addressed in order to preserve aspects of the protection of patients and the community.