IMAGINE if you could dramatically cut suicide rates and mental health relapses, get hundreds of previously sick people into work, and achieve all this with a fraction of the budget, beds, psychiatric drug prescriptions, and involuntary treatment relied on by traditional mental health models.
It may sound too good to be true, but this is the evidence accumulated over decades in Trieste, Italy - hailed by experts as "the best place in the world to be a patient with a mental disorder".
And talks are now underway which could pave the way to a pilot of the Trieste model in Inverness, in a first for Scotland.
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The initiative is being driven by former Herald writer, Mark Smith, who co-founded charity the Joshi Project with his wife Cath as a lasting tribute to their late daughter, Joshi, who succumbed to a fatal overdose aged 24 in 2020 following a 20-year battle with anxiety, depression, self-harm and obsessive compulsive disorder.
Described by her father as "the smartest person I knew" with "truly astonishing analytical abilities" and a flair for language from an early age, Joshi spent years in NHS counselling and cognitive behavioural therapy from the age of 11 without any improvement.
"I have a haunting memory of the head psychiatrist throwing his arms in the air and saying: 'We have nothing left in our armoury for her'," said Smith.
"A phonecall a couple of weeks later confirmed that she was 'no longer in the system'.
"Thinking back, that meeting was the beginning of my daughter’s end."
As the paralysis of grief gave way to anger and frustration, Smith was determined to find a solution that would avoid other families enduring the same fate.
"I became desperate to know if anything could have been done to save our daughter," said Smith.
"Too late, I discovered the Trieste model."
The brainchild of pioneering psychiatrist Franco Basaglia, Trieste's approach is based on the mantra that "freedom is therapeutic".
There was a time when the patients at the city's psychiatric hospital were locked in cages, tied in straitjackets and subjected to freezing water baths, electroshock and lobotomies.
But when the institution finally closed in 1980 it ushered in a new vision for mental health based around community hubs with an "open door" policy, both in terms of access and discharge: patients are free to leave and friends and family are welcome.
The result is earlier treatment, and far less stigma.
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"People can just walk in," said Dr Roberto Mezzina, the former director for mental health in Trieste and adviser to the World Health Organisation on the Trieste model.
"There is a welcoming attitude. People are encouraged to contact the service as soon as possible in the early stage of their problems.
"There's no requirement for referral by a general practitioner.
"We don't have any form of restraint, including seclusion, so all the services are organised around the principle of the open door.
"This means the person can leave the service but we try to negotiate - we're always ready to re-discuss their care plan. Flexibility is one of the most important features of the approach."
Each Community Mental Health Centre (CMHC) is open 24/7, serving a local population of around 50-60,000, with just six to eight overnight "crisis" beds. Remarkably, however, this is usually enough to prevent any acute hospital admissions.
The holistic approach is based on an appreciation that good mental health is down to social factors, as well as clinical, and a "whole-life response".
Everything from housing problems to family conflicts and unemployment will be mediated, with personalised plans developed with - not for - the patient.
Social cooperatives are involved to provide work placements and job training, while the centres can even sponsor parties, trips, exercise, art and theatre workshops.
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Mezzina said: "I can’t say we don’t use medication, but research has shown that compared to other services across Italy – particularly acute care – we have about half the average use of medication.
"The work opportunities are very important - these are key to getting out of the psychiatric network and to feel yourself more of a citizen than a patient.
"These services can be the catalyst to recovery - of reintegration and inclusion. We have quite dramatically seen these kinds of outcomes for many people.
"We have demonstrated that after the first crisis, we have less and less need to have people in crisis beds.
"Relapses, when they occur, can be supported quite easily because of knowledge the team has of this person and the reciprocal trust that has been developed between them."
The model was credited with cutting Trieste's suicide rate by 40% in its first 15 years, even as real-terms spending on the city's mental healthcare roughly halved between 1971 and 2001.
Sashi Sashidharan, a professor of psychiatry at Glasgow University who has helped set up Trieste-based models around the world, said: "If somebody in Italy or America or anywhere else finds a different way of treating cancer, and people are getting better - they are getting happier, they don't have the same relapses, they don't die to the same extent - people would be rushing to find ways to do it here.
"The question is not whether the model will work in Scotland or not - of course it will - but why we are waiting to do it?"
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Versions of the Trieste model are already operating in 30 countries around the world, including Wales.
It is also being adopted by at least six NHS trusts in England, but is yet to find a foothold in Scotland.
Smith hopes to change that by setting up an inaugural 'Joshi hub' in Inverness, emulating Trieste's approaches, with a view to a nationwide rollout in future.
He is in preliminary discussions with mental health leaders at NHS Highland, which has some of the highest suicide rates in Scotland in its rural communities.
Smith said: "It is far and away the most effective model for recovery from pretty much any form of mental illness in the world.
"When I first spoke to Dr Mezzina, I mentioned that Joshi had been a lover of poetry and Shakespeare. His response shook me to the core.
"It was immediately clear that this was no ordinary psychiatry model.
"He said: 'One of the first things we would have done to help Joshi would have been to bring in a Shakespeare expert or even a poet to talk to her. This is what we mean by community outreach and working with people’s life aspirations. It might have helped.'
"I knew this approach would have inspired Joshi and help give her life purpose.
"I continue to believe that had she had access to the Trieste model, it would have saved her life."
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