引言 (Introduction)

本期专辑收录的文章于2007年9月在青岛举行的题为“殖民主义与中国近代社会”的学术研讨会上初次面世。这次国际研讨会由悉尼科技大学和青岛海洋大学共同举办，与会者来自澳大利亚、美国、英国、法国、德国、意大利、日本、新加坡、中国等众多国家，论文作者当中既有享誉世界的专家也有正在攻读博士的青年学者。正如会议代表丰富多姿的不同背景，会议论文以“殖民主义与中国近代社会”为主题，从各种不同的角度，运用不同的方法探讨了中国自1840年鸦片战争到二十世纪后期香港澳门回归长达一个多世纪里与西方列强的遭遇。


Introduction M. TANSELLA
This monograph is concerned with the evaluation of a new community-based system of care set up in South-Verona, Italy, in 1978, focusing on a series of epidemiological investigations carried out by the Servizio di Psicologia Medica at the Institute of Psychiatry of the University of Verona.
In many Western countries there has been a gradual shift from hospital-centred to community-based psychiatry. The reasons for such a trend, which is proceeding at different speeds in various countries and even within regions of a given country, are complex. They include, in particular, the advances achieved in the management of patients with psychiatric disorders by psychiatrists and other members of the psychiatric team, as well as by general practitioners and other medical specialists. At the same time there have also been general improvements in statutory and voluntary social service provision, and developments in self-help for emotionally disturbed individuals.
Tyrer (1985), quoting classical studies by Barton (1959) and Goffman (1961) stated that ' over the past 40 years the disadvantages of a psychiatric service based on hospital care have become apparent both from the ease with which successful management can be achieved outside hospital and from increasing awareness of the negative effects of institutional care' (Tyrer, 1985, p. 571). Many recent contributions have underlined the advantages of community psychiatry (see, for example, Hoult, 1986;Kiesler & Sibulkin, 1987;Lawrence et al. 1988;Mosher & Burti, 1989). Nevertheless, the number of those who continue to be unimpressed by the disadvantages of hospital-based psychiatry and by the deleterious effects of institutional care remains remarkably high. Critical accounts of community-based psychiatry still regularly appear in scientific journals as well as in the media, and it is not always the case that they are based on sound scientific evidence and can therefore be justified. A survey of the scientific literature on this topic, giving full weight to both pros and cons, was recently published by Tansella & Zimmermann-Tansella (1988).
The situation in Italy in respect to community care is unique, both with regard to the speed at which the changes toward a community-based system of psychiatric care have occurred, and also because the nature of the new psychiatric services is prescribed by law. In May 1978 the Italian Parliament passed Law 180, the main aims of which were: (1) to phase out mental hospitals gradually (closing their doors to first admissions after May 1978 and to all admissions after December 1981, without encouraging abrupt de-institutionalization); and, (2) to institute a comprehensive and integrated system of psychiatric care in each Unita Locale Socio-Sanitaria (ULSS, Local Socio-Health Unit with 100000 to 200000 inhabitants). Shortly afterwards Law 180 became part of comprehensive legislation that reformed health services and introduced the Italian National Health Service (NHS).
The major provisions of Law 180 have been extensively reported elsewhere (Tansella & Williams, 1987;Mangen, 1989;Mosher & Burti, 1989). Here I would like to outline the main elements.
(1) The model of community psychiatry proposed in Italy is designed to be alternative to, rather than to complement hospital-based services (Tansella & Zimmermann-Tansella, 1988). It follows from this that an alternative district-based community service should provide care and support to all groups of patients in the at-risk population, and to develop new patterns of treatment and management in community facilities, while decreasing the number of occupied beds in mental hospitals and gradually dismantling these and similar closed and custodial institutions.
(2) The gradual phasing out of mental hospitals, to be achieved, according to the Italian model, by means of a block on admissions, differs considerably from the American community mental health experience characterized by the relocation of chronic psychotics to private, non-psychiatric facilities such as nursing homes, boarding houses, flophouses, etc. (transinstitutionalization) while the new community Community-based psychiatry in South-Verona mental health centres, funded with public funds, were selecting new populations of patients rather than serving those discharged from state hospitals (Brown, 1985;Mechanic & Aiken, 1987).
(3) It is hospital psychiatry (which, with the passage of time, is increasingly located in general hospitals rather than in mental hospitals) which now complements community care, and not vice versa, as in most European programmes for community psychiatry.
(4) Integration is intended between the various psychiatric facilities within the district-based system of care, the same team providing domiciliary, out-patient and in-patient care, an approach which facilitates continuity of care and a longitudinal perspective of care and support.
The evaluation of such a model of care is therefore of great interest and importance, and is of relevance to the practice of psychiatry not only in Italy, but also in many other countries.
During the past 10 years our unit has been involved in an extensive series of evaluative studies, focused on patterns of psychiatric care provided to South-Verona residents. South-Verona is an area of 75000 inhabitants in northeast Italy, where since 1978 a Community Psychiatric Service (CPS) has been operating in accordance with the provisions of the Italian psychiatric reform. An important component in the design and execution of these investigations is the South-Verona Psychiatric Case Register (PCR), which started on 31 December 1978.
Against this background the main aims of the monograph are as follows.
(1) To present an evaluation of an alternative community psychiatric service.
(2) To demonstrate, by the inclusion of reports on studies based in the general practice setting, the importance of considering both general and specialist levels of care when evaluating psychiatric services.
(3) To show how a psychiatric case register can be used, as a research instrument, as a framework for wider epidemiological enquiry and for follow-up studies.