Schizophrenia today: Epidemiology, diagnosis, course and models of care [La schizofrenia oggi: epidemiologia, diagnosi, decorso e modelli di cura]

Schizophrenia is a serious public health problem: according to WHO it is responsible for 1.1% of total disability adjusted life years (DALYs) and absorbs 1.5-3.0% of all healthcare expenditure in developed countries. In Europe, it is estimated that there are about 5 million persons with schizophrenia, with a prevalence of 0.6-0.8%. In 98% of cases onset occurs before the age of 40 years with a slight male predominance. Several environmental factors have been implicated in the genesis of schizophrenia. Epidemiological data in Italy are less accurate than those in other Western countries. The article presents national and regional epidemiological data on the characteristics of healthcare in patients with schizophrenia. The mortality rate of schizophrenic patients is approximately double that of the general population. The main causes of death are suicide, cardiovascular disease and cancer. The DSM-5 has made important changes to the diagnostic criteria of schizophrenia compared with the previous edition, eliminating the priority assigned to first-rank symptoms as well as diagnostic subtypes, and introducing the use of psychopathological dimensions in an attempt to favour a dimensional approach to diagnosis. In order to increase the reliability of differential diagnosis of schizoaffective disorder, in the DSM-5 the diagnostic criteria for this disorder are more strictly defined. A prodromal phase of schizophrenia can be demonstrated in about 75% of patients with a first psychotic episode. This initial phase lasts an average of five years, has a pathological significance and often leads to psychosocial deficits. Only 18% of patients show an acute onset of disease with symptoms that appear within a month, while 68% have an insidious onset with early symptoms appearing for over a year before the first hospitalisation. It has been shown that the duration of untreated psychosis is negatively associated with the symptomatic and functional long-term outcomes of schizophrenia. It is therefore believed that the interventions implemented during the early stages of the disease, reducing the duration of untreated psychosis and/or addressing the functional deterioration that occurs before the first psychotic episode may help to preserve the overall functional capacity of the individual. More than 30 years after the approval of the 180/78 Law and creation of a community mental health system, the Italian network of community services for mental health care likely represents a model to be followed in other countries. In the past 10 years, numerous national and regional studies have evaluated the efficiency of the community mental health system in diagnosis and care of patients with schizophrenia. Overall, the Italian mental health system is quite efficient, but much remains to be done. In particular, a national and regional computerised information system is urgently needed, which does not exist in several regions. In addition, the willingness to implement innovative programmes integrated with routine activities of community services can improve the quality and promptness of care by reducing the duration of untreated psychosis and therefore the deterioration of social functioning of affected individuals.