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In Italy emergency physicians are the front line of care for patients with medical conditions such as trauma, heart attacks, strokes or psychiatric disorders. Triage represents the first clinical contact with the person to determine urgency of care, and includes initial risk assessment and determination of observation level. It is necessary to undertake mental health triage for all service users on entry to the Emergency Department (ED), alongside physical health triage. The recourse to emergency services for psychiatric complaints is increasing and ED providers are often the first contact a patient will have with psychiatric care. The organization of Italian EDs is constantly evolving under the pressure of various external forces (population aging, increasing use of new substances, immigration, choices of economic policy, and technological development). The psychiatric emergency service contact represents a key to addressing the presenting problem and it is a critical link for continuity of care. The management of psychiatric disorders is an evolving issue in Italy as in other countries. Research increasingly suggests the importance of specific training for EDs teams in order to provide appropriate handling in acute settings. Psychiatrists and ED physicians can – and should – play a fundamental role in promoting a targeted and shared training for emergency services to deal with crisis according to evidence-based medicine. Service organization, legal issues, safety, training and education are not well defined and established and still imply improvisation, while they deserve attention as fundamental prerequisite to implement specific treatment guidelines. Introduction Italy experienced a radical change in mental health in 1978, with a shift to new community-based psychiatric services. The Law 180 marked a turning point in mental health care organization. It sanctioned the end of the Psychiatric Hospital as a segregating institution and the integration of psychiatric treatment into the general health service. The reform established a department model offering diversified and specialized structures within one facility, the Department of Mental Health (DMH). This basic structure is responsible for prevention, care and rehabilitation of individuals with psychiatric illnesses within a defined catchment area. It deals with the full array of mental health needs of the population and offers long-term multi-disciplinary interventions and continuity of care. Geographical variability in service provision has diminished over time: in many regions substance misuse disorders and mental disorders in children and adolescents are treated by specialist services which are part of the DMH with better integration and closer collaboration between different services. The DMH also provides emergency treatment at home and in the general hospital context, where there is a Psychiatric Diagnosis and Care Service (SPDC). The creation of psychiatric wards within general hospitals has brought psychiatry into the field of medicine at a national level for the first time in Italy. The general hospital inpatient wards respond to the needs of patients who require acute treatment, both in the case of voluntary admissions and in compulsory care (about 8% of all admissions in 2016).1 It also guarantees emergency treatment in conjunction with the hospital’s Emergency Department (ED). Psychiatrists working in hospital are usually involved in consultation-liaison programs with medical and surgical wards located in the general hospital. The Italian experience attracted international attention for its innovative aspects and helped achieve what was accomplished in other countries, but many problems remain for the implementation.2 Sadly, the reform law established some general principles and indications but did not give detailed standards for service and staff provision and the quality of care is still a matter of dispute (often inadequate drug treatments, psychotherapeutic, psycho-educational and rehabilitation interventions not being available, inpatient admissions too short with high readmission rates).3 Italian psychiatric services vary considerably from one geographic area to another. The regions are independent in the organisation of the health system and manage their services in different way. The funding of psychiatric departments in different regions varies from 2.1% to 6.5% of the region’s total health budget (total spending on mental health currently stands at 3.5% of the total health budget).4

Critical issues and opportunities of emergency psychiatry in Italian emergency departments