COVID-19 Impact on the Italian Community-based System of Mental Health Care: Reflections and Lessons Learned for the Future

Italy, the first European country hit by COVID-19, instituted a national lockdown from March 9 to May 3, 2020. The regionalized national health system led to variable responses, with hospitals rapidly overwhelmed and insufficient integration with primary/community care in some regions. Confinement measures increased loneliness, hopelessness, and stress in the general population, especially among vulnerable groups. A national cross-sectional study reported that the prevalence of depressive and anxiety symptoms doubled to affect over one third of adults, psychotropic drug use increased by 20% (mostly anxiolytics/benzodiazepines), and hopelessness was more common in women and increased with age. Since Law 180/1978, Italy shifted from asylum-based care to a community-based system centered on Community Mental Health Centers (CMHCs), psychiatric wards in general hospitals, and residential facilities. CMHCs aim to keep patients in their families/communities, providing essential care and rehabilitation. During lockdown, unlike hospital services that drastically reduced activity, CMHCs maintained continuity of care (albeit with reduced hours/activities), prioritizing severe cases, medication administration, and limited urgent home interventions. From summer 2020, activities largely returned to pre-pandemic levels. The study aims to summarize available evidence on COVID-19’s impact on the Italian community-based mental health system and reflect on lessons learned for future organization and policy.

COVID-19 impact on CMHC organization and activities: Surveys and regional reports showed substantial reorganization. An Italian Society of Psychiatry survey (over 50% department response rate) found 25% of CMHCs reduced hours, 13% closed; day hospital activity decreased by ~80% and day centers by ~85%; residential care facilities remained mostly operational with admission/discharge restrictions; teleconsultation and mobile counseling were widely implemented; home interventions limited to urgent cases. In Friuli Venezia Giulia, services complied with national recommendations, increased telepsychiatry, and conducted group rehabilitative activities remotely. An early intervention service in Milan reported young patients felt supported by remote individual and group interventions and many wished to retain some remote services post-emergency. Provider attitudes toward tele-mental health were initially skeptical in some reports, though later surveys (e.g., Liguria) indicated general satisfaction with adapted therapeutic settings in the post-lockdown phase. COVID-19 impact on CMHC patients: In Milan CMHC outpatients, 34% reported mild, 32% moderate, and 26% severe distress on IES-R; nearly 60% screened positive on SRQ-20 (more frequent in women, ages 45–65, and employed individuals with lifestyle disruption); higher SRQ-20 scores associated with affective and personality disorders. In Lazio residential care facilities, patients reported lower stress than healthy controls but higher anxiety, perceived infection risk, and worry; greater staff/peer support and maintenance of usual care likely mitigated stress. COVID-19 impact on CMHC workers: In Trieste’s Mental Health Department (Feb–Mar 2021), over 90% of professionals increased telephone contact with users, ~70% revised pharmacological plans to meet new needs, ~80% balanced user needs with safety procedures, many reported strengthened collegial support and discovery of users’ resources, and 60% identified positive aspects arising from the pandemic experience.

Narrative review and expert reflection. The authors synthesized findings from published studies and regional/national surveys on Italian community-based mental health services during COVID-19, complemented by insights from daily clinical practice. Evidence included: (a) five studies/surveys on CMHC/Mental Health Department reorganization and telepsychiatry adoption during lockdown and post-lockdown phases; (b) two observational studies on patient outcomes (CMHC outpatients and residents in psychiatric rehabilitation communities); and (c) one survey of mental health professionals regarding perceived positive changes after one year of the pandemic. No systematic search strategy or meta-analytic methods were reported; the review collates key data points and contextualizes them within Italy’s community-based mental health model and policy framework (Law 180/1978).

- Service reorganization during lockdown: 25% of CMHCs reduced opening hours; 13% closed (national survey). Day hospital activities decreased by ~80%; day centers by ~85%. Residential care facilities remained mostly operational with restrictions on admissions/discharges. Teleconsultation/mobile counseling was established for the general population and healthcare workers; video calls used with over two-thirds of patients; home interventions provided only for urgent needs. - Regional implementations: Friuli Venezia Giulia services complied with national recommendations, increased telepsychiatry, and delivered remote group rehabilitation. - Patient perspectives: Young patients in an early intervention program (Milan) felt supported by remote individual and group care; most wished to retain some remote services post-pandemic. - Provider perspectives: Initial skepticism toward tele-mental health reported in some provider surveys, but post-lockdown assessments (e.g., Liguria) showed general satisfaction with adapted therapeutic settings. In Trieste, >90% of staff increased phone contact; ~70% revised medication plans; ~80% balanced user needs and safety; 60% reported positive takeaways from the pandemic. - Patient outcomes: Among CMHC outpatients (Milan): IES-R distress levels were 34% mild, 32% moderate, 26% severe; ~60% screened positive on SRQ-20 (notably women, ages 45–65, employed); higher SRQ-20 scores associated with affective and personality disorders. Among residents of psychiatric rehabilitation communities (Lazio): lower stress than healthy controls but higher anxiety and perceived infection risk; greater continuity of care and peer/staff support likely mitigated stress. - Public mental health context: In a representative national adult sample, prevalence of depressive and anxiety symptoms doubled during lockdown to affect over one third of the population; use of at least one psychotropic medication increased by 20% (mostly anxiolytics/benzodiazepines); hopelessness was more common in women and increased with age. - Continuity of care and teleconsultation were associated with reduced psychopathological decompensation and lower hospitalization needs, with satisfaction among patients and providers.

The review indicates that Italy’s community-based mental health system (CMHC-centered) maintained essential services during COVID-19 despite hospital service restrictions, providing continuity of care through reduced but ongoing in-person services and rapid expansion of telepsychiatry. This continuity supported at-risk populations during quarantine and self-isolation, mitigating psychopathological decompensation and reducing hospital pressure. Patient and provider experiences suggest remote care was acceptable and often preferred to remain in hybrid models post-pandemic, although initial provider skepticism existed. Patient data highlight substantial psychological distress among CMHC outpatients during lockdown, with specific vulnerability among women and individuals aged 45–65, especially those experiencing major lifestyle disruptions; residents in psychiatric communities benefited from sustained support and stable care routines but experienced heightened anxiety about infection risk. The findings reinforce the importance of resilient, integrated community-based services capable of rapid adaptation (telehealth, re-prioritization) and collaboration across sectors. They underscore system-level needs: robust territorial epidemiology to map needs and guide resource allocation; increased mental health funding to align with European peers; structured primary care–mental health collaboration to manage common mental disorders in primary care while focusing CMHCs on severe cases; youth services bridging CAMHS and adult CMHCs for the high-risk 12–25 age group; and strengthened psychosocial rehabilitation via day centers and employment-oriented programs to support recovery and social inclusion.

Italy’s community-based mental health system withstood the COVID-19 shock by preserving continuity of care and leveraging teleconsultation, thereby lowering risks of decompensation and hospitalization. Lessons for future improvement include: (1) establishing territorial epidemiology to make mental health needs visible and inform workforce planning; (2) increasing mental health resources to levels comparable with other European high-income countries; (3) formalizing collaborative models between primary care and mental health services, enabling primary care management of milder conditions and allowing CMHCs to focus on severe cases; (4) creating youth mental health services that bridge CAMHS and adult CMHCs with multidimensional, multidisciplinary, family-inclusive approaches; and (5) promoting day centers and employment-focused rehabilitation as recovery-oriented models. These priorities align with Italy’s reform ethos (Law 180/1978) and should be integrated within national strategies, including the National Recovery and Resilience Plan (PNRR).

The review is narrative and based on a limited number of studies, many region-specific, with heterogeneous designs and measures. No systematic search strategy or quality appraisal is reported. National statistics lack shared operational definitions, limiting comparability and interpretation of service data. Comprehensive, up-to-date, nationwide epidemiological studies on mental health prevalence and service use in both adults and adolescents are lacking, constraining generalizability.