Italy, the first European country to be severely impacted by the COVID-19 pandemic, implemented a nationwide lockdown on March 9th, 2020, confining over 60 million people for nearly three months. The regional structure of the Italian healthcare system led to varied responses to the crisis, with some regions facing overwhelming hospital pressure due to insufficient integration with primary and community care. Confinement measures resulted in widespread feelings of loneliness, hopelessness, and despair, particularly affecting vulnerable populations. A cross-sectional study revealed a doubling of depressive and anxiety symptoms in the Italian adult population, impacting over one-third of the population. Since 1978, Italy has transitioned from a hospital-based to a community-based mental health system, establishing Community Mental Health Centers (CMHCs). These centers provide essential mental healthcare, supporting individuals within their communities. While hospital services significantly reduced their activity during the lockdown, CMHCs maintained continuity of care, reducing pressure on emergency departments. This paper examines the impact of COVID-19 on the Italian community-based mental health system, focusing on CMHCs, patients, and healthcare workers, analyzing available evidence and clinical practice observations to inform future improvements.

A limited number of studies directly investigated the impact of COVID-19 on the Italian community-based mental health system during and after the lockdown. Several studies explored the pandemic's effect on CMHC organization and activities, revealing reduced opening hours or closures for some centers, significant decreases in day hospital and day center activities, and a shift towards remote consultations. Other studies focused on the mental health impact on CMHC patients, showing increased distress and anxiety symptoms among outpatients and residents in residential care facilities. One study investigated mental health professionals' experiences, indicating increased telephone contact with patients, adaptations in pharmacological treatments, and unexpected positive aspects arising from the shared challenges.

This paper employed a narrative review methodology to synthesize the available evidence on the impact of COVID-19 on the Italian community-based mental health system. The authors summarized existing literature, incorporating their observations from daily clinical practice to provide a comprehensive perspective. The literature review included studies focusing on various aspects of the pandemic's effect, such as CMHC operational changes, patient mental health, and the experiences of mental health professionals. The authors did not specify a formal search strategy but integrated relevant findings from their knowledge of the field with a focus on the Italian context. This approach provides valuable insights and contextual understanding but might be limited in its generalizability due to its reliance on a narrative review and lack of pre-defined inclusion/exclusion criteria.

The study revealed that despite the significant challenges posed by the COVID-19 pandemic, Italy's community-based mental health system, particularly CMHCs, demonstrated resilience. CMHCs maintained essential services, adapting to the pandemic by incorporating remote consultations via telepsychiatry. This reduced the risk of psychopathological decompensation and hospitalization. Studies showed that patients experienced increased distress and anxiety during the lockdown, with women and older adults being particularly vulnerable. However, patients in residential facilities reported higher levels of support from healthcare workers and peers, leading to lower stress levels compared to their non-residential counterparts. Mental health professionals also reported positive changes in their professional practice, such as increased telephone contact, treatment plan revisions, and improved staff-patient relationships. The findings highlighted both the strengths and weaknesses of the Italian mental health system, emphasizing the importance of remote consultations, but also underscoring the need for further resource allocation.

The findings highlight the adaptability and essential role of Italy's community-based mental healthcare system during the COVID-19 pandemic. The successful implementation of remote consultations demonstrates the potential of telehealth to improve access and continuity of care. However, the pandemic also exposed significant shortcomings, including insufficient mental health resources and inadequate support for vulnerable populations. The need for a national mental health epidemiological observatory, increased funding to align with other high-income European countries, and strengthened collaborations between primary care and mental health services are crucial. The lack of adequate youth mental health services was also identified as a major concern, highlighting the need for multidimensional and multidisciplinary approaches. The findings underscore the critical importance of investing in community-based mental healthcare, including day centers and employment programs, to foster recovery and social inclusion.

The COVID-19 pandemic impacted the Italian community-based mental health care system, but it also highlighted its strengths and weaknesses. The successful adaptation to remote care and the resilience shown by CMHCs demonstrated the system's potential. However, the pandemic also underlined the need for substantial improvements. These include: establishing a national mental health epidemiological observatory, increasing mental health resources, formalizing primary care-mental health cooperation, creating comprehensive youth mental health services, and expanding day centers and employment programs. Future research should focus on evaluating the long-term impacts of the pandemic, measuring the effectiveness of implemented changes, and developing strategies for enhancing the system's preparedness for future crises.

The study's limitations stem from the reliance on a narrative review, lacking a systematic search strategy and predefined inclusion/exclusion criteria. The generalizability of findings might be limited due to the focus on the Italian context. The synthesis of literature and clinical observations, although providing valuable insights, may introduce subjectivity. Further research using quantitative methods, such as meta-analyses and systematic reviews, is warranted to provide more robust evidence and broader applicability.