Management of mental disorders in Italy: what are ASOs and TSOs, and how do responders act?

By Cristiano Antonino On Sep 18, 2021

Mental disorders in Italy, what are ASO and TSO? Very often the two acronyms ASO and TSO are used without really knowing what they are and how they work. Respectively they stand for Compulsory Sanitary Assessment and Compulsory Sanitary Treatment

According to Article 32 of the Italian Constitution, the Republic protects health as a fundamental right of the individual and in the interest of the community, and guarantees care for the indigent.

No one may be obliged to undergo health treatment except by provision of law (Law 180/1978; Law 833/1978).

The good of life, health and physical and psychic integrity are the subject of personal rights; essential and absolute natural rights that cannot be renounced, are not transmissible and cannot be expropriated.

If no one can be compelled, we are talking about consent.In fact, health treatments and checks are based on consent, which in turn requires a meeting based on the individual’s will and active participation, so as to produce informed consent, i.e. a shared decision within a doctor-patient relationship based on trust.

Mental disorders in Italy: ASO, the compulsory health assessment

What is meant by an ASO (compulsory health assessment).

First of all, it is possible to request an ASO when there is a well-founded suspicion of the presence of psychic alterations such as to require an urgent, non-deferrable intervention, when the person does not accept the necessary diagnostic tests.

This intervention must always be preceded by a search for consent.

The compulsory health assessment is requested by a doctor in respect of a person for whom there is a well-founded suspicion of psychic alterations that make therapeutic intervention urgent, but which the person concerned refuses to accept.

The ASO order is issued by the Mayor as the local health authority, on a reasoned proposal by the requesting doctor.

The outcome of the ASO must also be sent to the mayor.

WHERE AN ASO IS CARRIED OUT

An ASO can be carried out at the person’s home, or as an in-patient at an out-patient facility, the emergency department (PS), and the mental health centre (CSM).

The place of the assessment must be indicated in the order issued.

After a compulsory health assessment, if the conditions are met and the person refuses to undergo the necessary treatment, compulsory health treatment (TSO) may be ordered.

It should be noted that this service is free of charge.

TSO, compulsory health treatment in in the patient with mental disorders

There are, however, variables.

Some mental disorders may result in a mere lack of awareness of illness to the extent that the person may refuse extremely urgent and necessary medical interventions.

In such circumstances, so-called compulsory measures such as TSO (compulsory health treatment, for a renewable period of seven days) can be implemented with respect for the person’s dignity.

TSO thus becomes an extreme means of enforcing the right to health of a person with a serious mental pathology of which he or she is not aware.

The TSO can be carried out without resorting to hospitalisation, at the Mental Health Centre (MHC), the outpatient clinic, the patient’s home, the emergency department (ED).

If hospitalisation is necessary, TSO can only be carried out at the psychiatric diagnostic and treatment service of the health authority.

The TSO is ordered by order of the mayor, validated by the tutelary judge, on the motivated proposal of a doctor, preferably approved by a doctor from the Mental Health Department or another doctor from the public facility.

The reference point for the person and his/her family is the Mental Health Centre of the Azienda Usl.

The Mental Health Centre (MHC) is present in every District and in almost all cases is open for 12 hours on weekdays.

The CSM collaborates with the family doctor of the person concerned and represents the point of reference for the assisted person and his/her family.

In order to protect the person, the TSO cannot exceed seven days.

If it is to be prolonged, the validation of the Tutelary Judge must be obtained again (by the Psychiatric Diagnosis and Treatment Service).

If, as is generally the case, the patient accepts treatment during in-patient stay, the TSO is converted into voluntary admission.

It is always advisable to contact the Mental Health Centre; during the Mental Health Centre’s closing hours, contact the Emergency Department, where psychiatric counselling is available, or the Medical Guard Service.

The CSM is the point of reference for any problems. It should be noted that this service is totally free of charge.

WHEN COMPULSORY HEALTH TREATMENT IS NOT REQUIRED

TSO is not required in cases of impaired consciousness due to intoxication, drunkenness, trauma, delirium or dementia.

In fact, people cannot be forced to undergo diagnostic examinations or to take drug therapies for pathologies other than psychiatric ones.

These cases mentioned above are further considered complex cases and consequently under the jurisdiction of the Judiciary.

TSO AND MINORS

Another particular case of TSO request is reserved for minors in need of urgent care.

It all revolves around the consent or otherwise of the minor and the consent or otherwise of one and/or both parents. In any case there will be the information or the report to the Juvenile Court (art. 403 CC).

Article written by Dr. Letizia Ciabattoni

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