In recent years there has been a growing interest for exploring and describing the attitude of patients towards treatments provided by professionals working in mental health services. Not only the interest has been focused on whether patients perceive drug treatments as beneficial or harmful, but also on what patients think about non-phar-macological interventions, including psychological thera-pies and rehabilitative intervention programs provided by day-care centres, self-help groups or outpatient facilities. In the present issue of Epidemiologia e Psichiatria Sociale three Editorials discuss the current state of the art on this topic, and highlight the profound implications that the subjective attitude of patients may have in determining the long-term success or failure of comprehensive and articulated treatment plans.

Over the past decades, the therapeutic goal for schizophrenia has become more and more ambitious, shifting from that of controlling violent episodes to aim of ameliorating patients' symptoms, to the extent that individuals with schizophrenia can achieve a relative degree of social and relational remission. Indeed, thanks to more recent pharmacological and psychosocial forms of intervention, once pessimistic attitudes toward long-term schizophrenia outcomes are transforming gradually into guarded optimism. Evidence of the efficacy of various forms of treatment now make it possible for researchers and clinicians to consider both the remission of severe symptoms for long periods of time and good social functioning potential goals.

Only recently, success criteria became more ambitious and include a more thorough consideration of negative symptoms and cognitive dysfunction. The most important change within the last decade is the long overdue consideration of the patient's perspective. His/her subjective well-being, often unchanged or even worsened by typical antipsychotics, was neglected for a long time. One reason was the prejudice that schizophrenic patients are not able to self-rate their quality of life. Another reason was the belief that such data are not necessary because the psychiatrists' perspective, “objective” psychopathology, includes these domains. Among other scales, a self-report instrument has been constructed to evaluate “subjective well-being under neuroleptics” (SWN). This scale was used in numerous open and controlled trials, indicating: a) patients, if no longer acutely psychotic or suffering from severe cognitive deficits, are able to reliably assess their subjective well-being, b) high SWN is correlated with high compliance, c) atypical antipsychotics increase SWN, and d) individual improvements of SWN and of PANSS are not strongly related. Moreover, several studies found that early improvement of subjective well-being is a major predictor for the chance of remission. All these data indicate that a better consideration of the patient's perspective is possible and necessary.

There has been a long-running controversy about the relative benefits of Assertive Community Treatment (ACT) compared to Case Management (CM). Several health care systems have initiated major service overhauls on the basis of published evidence. Yet this evidence has been ambiguous and supports differing interpretations. Research is examined which explores the differences in outcomes reported. It uses a range of approaches, most prominently meta-regression, to test a small range of hypotheses to explain the heterogeneity in outcomes. The main determinant of differences between ACT and CM studies is the local bed management procedures and occupancy practice. Those organizational aspects of ACT which are generally shared by CM teams are associated with reduced hospital care but the stringent staffing proposed for ACT does not affect it. ACT is a specialized form of CM, not a categorically different approach. The benefits of introducing it will depend on the nature of current local practice. Important lessons about the need to focus on treatments rather than structures seem not to have been learnt. Psychiatry's recent excessive focus on service structures may have had unintended consequences for our professional identity.

This editorial gives an overview of the different roots and forms of discrimination and stigmatisation towards people with mental illness. It explains the differences between stereotype, prejudice and discrimination. It further highlights some research foci of stigma research in the last decade. The emphasis was mostly on investigating the attitudes of the general population, but barely addressed other groups that have probably more intensive and more crucial contact with people with mental illness. Furthermore, only very few intervention programs were evaluated. This editorial concludes that other groups than the general population, e.g., mental health professionals, should be investigated about their attitudes to people with mental illness. Moreover, intervention campaigns should be additionally evaluated after a given period as it is not well known whether effects of interventions are long-lasting. It might be that anti-stigma campaigns, as every public health campaign, must be repeated if sustainability is the goal. Furthermore, the message must be carefully chosen. One option is to replace the “traditional” messages by focussing, e.g., on symptoms of mental illness, for instance anxiety, affective symptoms or suicidal ideations. Finally, a plea for more stigma-related research is given as research in stigma-related issues is also stigmatised.

The aims of the Editorial are to summarise what we know for certain from clinical trials of Intensive Case Management, and to highlight lessons for clinicians and researchers. I will upon two systematic reviews of trials of Intensive Case Management versus standard care or low intensity case management. Both incorporated a meta-regression which examined the effect of fidelity to the Assertive Community Treatment model on outcome. The effectiveness of Intensive Case Management was limited to improving patient satisfaction and reducing attrition. Intensive Case Management teams organised according to the Assertive Community Treatment model offered the additional benefit of reducing days in hospital, but only when the team's clients had been high users of hospital care over the previous 12 months. Four important lessons can be drawn: a) Changes to the process of care tend to affect process variables, not outcome variables. b) Complex interventions must be defined meticulously in clear terminology. c) Researchers must demonstrate that complex interventions have been properly implemented in clinical trials. d) It is important to remember that in a clinical trial a successful outcome is determined as much by the control group as by the intervention.

The aim of this contribution is to explore how different treatments are experienced from the perspective of individu-als with mental illnesses. We used data drawn from qualitative, narrative interviews. When asked to discuss their lives, people rarely discuss their psychiatric treatment. When asked about treatment, they describe hospitalization and medication but not out-patient care. What is described as most helpful are relationships with others, especially in 24-hour centers, clubhouses, and user-run organizations; places where they report feeling that they are accepted, understood, and cared about. Also important are experiences of “giving back” to others and employment as ways of increasing participants’ sense of self-worth and value. Participants also indicated the importance of med-ication, but described protracted processes of having to find the right prescriber, the right medication, at the right dosage, and taking the medication long enough to derive its benefits. For others, symptoms were described as being an integral part of who they were and not something they wanted to eliminate. Traditional treatments (e.g., medication), if given by a practitioner who understands the person and is willing to try to find the right medication and dosage, may serve as a foundation for instrumental experiences of being accepted, understood, valued, and being able to give back to others.

This editorial provides an overview of how far access to mental health care is limited by perceptions of stigma and anticipated discrimination. Globally over 70% of young people and adults with mental illness receive no treatment from healthcare staff. The rates of non-treatment are far higher in low income countries. Evidence from some descriptive studies and epidemiological surveys suggest that potent factors increasing the likelihood of treatment avoidance, or long delays before presenting for care include: (i) lack of knowledge about the features and treatability of mental illnesses; (ii) ignorance about how to access assessment and treatment; (iii) prejudice against people who have mental illness, and (iv) expectations of discrimination against people who have a diagnosis of mental illness. The associations between low rates of help seeking, and stigma and discrimination are as yet poorly understood and require more careful characterisation and analysis, providing the platform for more effective action to ensure that a greater proportion of people with mental illness are effectively treated in future.

The usefulness of Assertive Community Treatment (ACT) in European countries with well-developed community care systems has been disputed, despite considerable relevant literature. This paper aims to assess reasons for and against implementing ACT in such countries. ACT may not be useful where generic community mental health teams are not yet well-developed, where admission rates are already low, or where an alternative model based on close integration of a full range of types of care is in place. Good reasons for introducing ACT include listening to patients' preferences, being able to monitor a high risk group of patients more successfully, good staff satisfaction, and the potential for using ACT teams as a platform for delivering interventions for difficult to treat psychosis. The ACT model is more likely to thrive in future if a recovery orientation can be adopted.

This contribution initially describes some traditional tools that are commonly used to measure drug tolerability, including measures that take into considerations both clinicians’ and patients’ views. Subsequently, it highlights a few studies that compared the patient and clinician's perspective in the evaluation of drug tolerability, trying to understand whether health care providers and patients perceive antipsychotic tolerability in different ways, and whether these different ways may have implica-tions in terms of treatment adherence and outcome. Finally, some clinical and research implications are suggested and discussed.

This editorial describes strategies used and the lessons learned in implementing two local anti-stigma projects. The WPA Programme to Reduce Stigma and Discrimination Because of Schizophrenia established projects to fight stigma in 20 countries, using social-marketing techniques to enhance their effectiveness. First steps at each site were to establish an action committee and conduct a survey of perceived stigma. Based on survey results, the action committees selected a few homogeneous and accessible target groups, such as employers, and criminal justice personnel. Messages and media were selected, tested, and refined. Guidelines are provided for setting up a consumer (service-user) speakers' bureau and for establishing a media-watch organization, which can lobby news and entertainment media to exclude negative portrayals of people with mental illness. Improvements in knowledge about mental illness were effected in high school students and criminal justice personnel. Positive changes in attitude towards people with mental illness were achieved with high school students, but were more difficult to achieve with police officers. Local antistigma projects can be effective in reducing stigma and relatively inexpensive. The involvement of consumers is important in working with police officers. Project organizers should be on the lookout for useful changes that can become permanent.

In the study of the beneficial and adverse effects of psychotropic drugs, in addition to experimental studies (Barbui et al., 2007), epidemiological studies may provide interesting insights. A key methodological aspect in drug utilization studies is how drug consumption should be measured. Specifically, the need is to end up with a single variable that may be reliably used to indicate the overall consumption, for each patient included in a certain survey, of one specific drug (for example one antipsychotic, say haloperidol) or a specific drug class (for example second-generation antipsychotics) or a group of drugs (for example psychotropic drugs, including antipsychotics plus antidepressants plus benzodiazepines). Not only such a variable has to accommodate the problem that actual doses cannot be directly compared, but also that many patients often receive more than one drug, belonging to different or to the same pharmacological class. A methodology is therefore needed to convert each medication dosage into a standardised measure that allows to calculate, for each patient, a cumulative index of drug consumption. Standardised measures of drug consumption are also beneficial for national and international comparisons, for the evaluation of time trends in drug use, and for assessing the public health impact of specific events (for example a change in reimbursement status).