Objectives – The evaluation matrix recently proposed by Tansella and Thornicroft suggests that the field of social and epidemiological psychiatry has focussed more on the individual/patient level of mental health care services than the system level. Moreover, phenomena such as deinstitutionalisation have been examined more as clinical events than as social ones. The aims here are to deepen our understanding of deinstitutionalisation, particularly as regards the downsizing/closure and role of psychiatric hospitals. Methods – I begin by reviewing the manifest and latent functions of psychiatric hospitals. This is followed by a discussion of how these functions must be met by any comprehensive community-oriented system of mental health care for severely mentally ill patients. Also, in order to reframe the downsizing/closure of psychiatric hospitals as a social event for the field of social psychiatry and psychiatric epidemiology, I posit that the process of deinstitutionalisation is driven today by the same forces that were present at the outset of the movement. Results – I review four recent series of studies addressing primarily the outcomes, but also other aspects, of the downsizing/closure of psychiatric hospitals, with a view to illustrating the methods used, the results obtained and the blind angles missed in this research. Conclusions – Lessons are drawn on how to fill certain vacant cells of the matrix.

Objective – This paper reviews 28 studies on the epidemiology of homicide committed by mentally disordered people, taken from recent international academic literature. Methods – The studies included were identified as part of a wider systematic review of the epidemiology of offending combined with mental disorder. The main databases searched were Embase, Medline, HealthStar, Psyclit, Mental Health Abstracts, Applied Social Sciences Index and Abstracts, and Criminology Penology and Police Science Abstracts. A comprehensive search was made for studies published since 1990, supplemented with key studies from the 1980s identified through citation tracing and personal contacts. Results – A summary is given in tabular form of the content and quality of each study. There is then discussion of the studies in eight categories: descriptive studies, studies of trends, comparative studies amongst homicide offenders, amongst prisoners and including general populations, studies of homicide of relatives, follow-up studies, and studies of recidivism. Conclusions – There is an association of homicide with mental disorder, most particularly with certain manifestations of schizophrenia, antisocial personality disorder and drug or alcohol abuse. However, the quality of epidemiological research in this area is not adequate to answer key questions, and prediction of potential for homicide remains elusive. Further research is needed.

Objective – In Italy, mental health care is in phase of reorganisation. In this frame the measurement of users' needs may be a useftil tool in planning individualised mental health service interventions and in their evaluation. Aims of the present study are (I) to highlight the basic concepts of 'needs for care' and give a brief description of the main needs assessment tools specifically developed for psychiatric patients; (II) to review studies assessing needs for mental health services in the general population; (III) to discuss the role played by the assessment of needs in planning mental health care. Methods – Studies published in the international literature from January 1980 to June 1999 were reviewed. The studies were located through a computerised search of the databases MEDLINE and PsycLit; in addition, the reference lists of the studies located through the computerised search and the content of main international psychiatric journals were manually scanned in order to avoid possible omissions. Studies assessing needs for services and studies assessing needs on individual level were separately reviewed. Both groups of studies, in turn, were divided in studies assessing needs for mental health care in the general population and in psychiatric patients. Results – Although most studies on needs for services used indirect methodologies and employed quite heterogeneous experimental design, they provide at large overlapping results. In the general population, about 60%- 70% of patients with anxiety, depression and other neurotic disorders and 30%-40% of psychotic patients do not receive any specialist mental health care, suggesting that the majority of subjects suffering from a psychiatric disorder do not receive the mental health care they need. Conclusions – Unmet needs for services show a higher frequency in patients with neurotic and depressive disorders, indicating a shortage in services delivery that should be taken into account both by psychiatrists and mental health planners. Moreover, the finding that a large number of patients suffering from psychotic disorders do not receive any kind of mental health care is of particular relevance for planning mental health services, since these subjects are usually the most problematic and difficult to treat.