From the closure of the O.P.G. to the functions of the R.E.M.S.: analysis of an experience

Objective. This study analyzes the practical effects of Law 81/2014 by comparing the profiles of two patient cohorts hospitalized in Castiglione delle Stiviere (MN): one in the Judicial Psychiatric Hospital (O.P.G.) in 2013 and the other in the polymodular Residence for the Execution of Security Measures (R.E.M.S.) in 2023.

Methods. Data from 200 patients were collected from medical records and entered into a dedicated database, including socio-demographic, clinical, and legal variables.

Results. The comparison showed a decrease in the proportion of female patients, in admissions from outside the catchment area, and in mean age at admission. Transfers from other O.P.G.s declined, as did admissions for crimes against the person, whereas admissions related to minor offenses such as resisting a public official increased. Substance use disorders became more prevalent. Diagnostic distribution shifted, with schizophrenia and psychotic/delusional disorders still dominant, but a larger share of personality disorders.

Conclusions. The polymodular R.E.M.S. of Castiglione delle Stiviere appears representative of the national R.E.M.S. system. The principles of territoriality and transitoriness introduced by Law 81/2014 are largely respected, but the residual nature of custodial security measures is only partially achieved. This gap is mainly due to limited collaboration between judicial and healthcare authorities and between R.E.M.S. and community psychiatric services.

INTRODUCTION

The management of psychiatric patients who have committed criminal offenses has long been debated in Italy among both psychiatrists and jurists ¹. The system was formally established in 1876 with a dedicated ward for the “insane” in the prison of Aversa, later regulated by Royal Decree No. 260 of 1891 ², and subsequently defined by the Rocco Code, which institutionalized facilities for “dangerous” mentally ill individuals-namely, Judicial Asylums (Manicomi Giudiziari). Over time, developments in psychiatry, legal science, and public opinion led to multiple reforms aimed at prioritizing treatment and rehabilitation over custodial detention.

In 1975, Judicial Asylums were converted into Judicial Psychiatric Hospitals (Ospedali Psichiatrici Giudiziari, O.P.G.) ³. Forty years later, Law 81/2014 mandated their closure and the creation of new care settings based on the principles of territoriality, transitoriness, residuality, and prioritization of treatment. This reform enabled individuals with mental disorders who committed crimes to receive care within the Mental Health Department network, in dedicated rehabilitative facilities, or in Residences for the Execution of Security Measures (Residenze per l’Esecuzione delle Misure di Sicurezza, R.E.M.S.). The transition sparked a wide debate within Italian psychiatry, amplified by analyses of early R.E.M.S. experiences ^4-9.

In 2013, six Judicial Psychiatric Hospitals were active in Italy, hosting approximately 1,000 patients. By 2023, 31 R.E.M.S. facilities were operating nationwide, with 632 hospitalized patients and 675 individuals on the waiting list ¹⁰.

This study compares the socio-demographic, clinical, and legal characteristics of two patient cohorts hospitalized in Castiglione delle Stiviere-first as an O.P.G. in 2013 and then as a polymodular R.E.M.S. in 2023. The aim is to highlight the main changes following the enactment of Law 81/2014, to examine the challenges in its implementation at administrative, legal, and healthcare levels, and to identify emerging clinical and organizational needs.

MATERIALS AND METHODS

The Lombardy region currently operates a single facility for psychiatric patients who have committed criminal offenses, organized into eight 20-bed units. The polymodular R.E.M.S. of Castiglione delle Stiviere is the largest in Italy and plays a central role in the country’s forensic psychiatric tradition. Originally opened as a criminal asylum in the 1930s, it became a Judicial Psychiatric Hospital following the 1975 reform.

In the 1990s, it was the only Judicial Psychiatric Hospital without a judicial police presence and the only one to include a female-only ward-features that distinguished it nationally. Today, it is the only Italian facility with a polymodular structure comprising eight R.E.M.S. units: seven for men and one for women. Each unit operates independently with its own staff and patient cohort. The system is part of the Department of Mental Health of the ASST of Mantua.

For this study, a dedicated database was created including two cohorts of 100 patients each: those hospitalized on 13 July 2013 in the O.P.G. and those hospitalized on 13 July 2023 in the polymodular R.E.M.S. of Castiglione. Data were extracted from medical records and the facility’s internal databases.

Collected variables included socio-demographic characteristics, provenance, legal status, type of offense, psychiatric diagnosis, and substance use. Comparative tables were generated to analyze differences across the two time points.

RESULTS

Analysis of the socio-demographic characteristics of the two cohorts (Tab. I) shows a marked decrease in the proportion of female patients admitted to Castiglione between 2013 and 2023: from 25% in the O.P.G. sample to 10% in the R.E.M.S. sample. An even more significant shift concerns geographical provenance: on 13 July 2013, 54 out of 100 hospitalized patients were from Lombardy, while 46 were referred from other regions (20 from Piedmont, 8 from Lazio, 3 each from Campania and Veneto, 2 each from Emilia-Romagna, Liguria, Sardinia, and Sicily, and 1 each from Calabria, Friuli-Venezia Giulia, Umbria, and Aosta Valley). By 13 July 2023, however, all patients (100%) admitted to Castiglione came from Lombardy.

The mean age at admission decreased from 34 years (range 22-80) in 2013 to 28 years (range 19-80) in 2023. Patients aged 18-30 increased from 18% to 41%, while those aged 31-40 declined from 41% to 28% and those aged 41-50 from 29% to 19%. The proportion of patients over 50 remained stable at 12%.

With regard to pre-R.E.M.S. allocation (Tab. II), in both 2013 and 2023 most patients were admitted from prison: 46% and 49%, respectively. Admissions from home remained unchanged at 18%. Transfers from Psychiatric Diagnosis and Care Units increased from 17% to 24%, while referrals from residential facilities decreased from 7% to 3%. In 2013, 11 patients were transferred from other O.P.G.s, whereas in 2023 only 2 came from O.P.G.s and another 2 from other R.E.M.S. facilities. In both cohorts, 1 patient was readmitted after an escape.

Regarding criminal responsibility (Tab. III), the distribution between total and partial incapacity remained essentially stable: 63%/37% in 2013 and 66%/34% in 2023.

As for offenses committed (Tab. IV), crimes against persons were the most frequent in both cohorts but declined from 48% in 2013 to 37% in 2023. Specifically, homicide/attempted homicide decreased from 32% to 20%, sexual assault/attempted sexual assault from 4% to 5%, bodily harm from 6% to 2%, while stalking increased from 4% to 7%.

Violations of parole (limited freedom) conditions resulting in custodial measures dropped from 16% to 6%. Conversely, conversions of probation to custodial measures due to inadequate containment and non-compliance rose significantly from 5% to 20%. Offenses against property declined from 16% to 9%, mostly theft/attempted theft (6% vs. 3%) and extortion/attempted extortion (4% vs. 2%). Cases of domestic abuse rose from 8% to 13%, while resistance to public officials increased markedly from 1% to 11%.

Concerning psychiatric diagnoses (Tabb. V, VI), schizophrenia and psychotic/delusional disorders remained the most prevalent in both cohorts (64% in both 2013 and 2023). Personality disorders were diagnosed in 25% of patients in 2013 and 33% in 2023. Other diagnoses-including intellectual disability, mood disorders, and anxiety disorders-increased from 5% to 26%. In both cohorts, one patient had no recorded psychiatric diagnosis.

Substance use disorders (Tab. VII) rose sharply: from 33% in 2013 to 64% in 2023. In 2013, 5% of patients had a substance use disorder without a co-occurring psychiatric diagnosis, compared with 2% in 2023. The most frequent comorbidity was with personality disorders, present in 52% of substance-using patients in 2013 and in 82% in 2023.

DISCUSSION

The marked changes in gender distribution and geographical origin between 2013 and 2023 can largely be explained by the effects of Law 81/2014. The decline in the percentage of female patients admitted to Castiglione reflects the establishment, after 2014, of several R.E.M.S. facilities across Italy capable of accommodating women ¹¹. This development ensured compliance with the principle of territoriality, which had not been respected during the O.P.G. era. At that time, Castiglione was the only institution in the country able to house women with psychiatric disorders who had committed offenses. Indeed, in 2013, among the 25 patients admitted from outside the designated catchment area (Lombardy, Piedmont, and Aosta Valley), 23 were women who could not be accommodated in the O.P.G.s of Reggio Emilia, Montelupo Fiorentino, Aversa, or Barcellona Pozzo di Gotto.

The application of the principle of territoriality also explains why 100% of the 2023 cohort came from Lombardy. Another notable finding is the reduction in mean age at admission. This may be partly related to the increasing impact of psychoactive substance use on psychiatric diagnoses, which was far greater in the 2023 cohort than in 2013.

The 2023 Annual Report to Parliament on Drug Addiction in Italy (referring to 2022 data) highlights the growing scale of substance use, which may represent a consequence, risk factor, or even cause of psychiatric disorders. It also documents a decreasing mean age among affected individuals ¹². This helps explain both the rise in patients with substance use disorders (from 33% to 64%) and the sharp increase in admissions of individuals aged 18-30 (from 15% in 2013 to 47% in 2023). Nevertheless, further considerations are needed to account for the broader increase in patients under 30 years of age (from 18% to 41%). This trend overlaps with the rise in service access among individuals under 25, as documented in reports on Mental Health Department (DSM) activity from 2015 to 2023. Although still a minority, this age group increased its service utilization by about 50% ¹³. These patients often present particular challenges, including high comorbidity, frequent personality disorders, and poor adherence to treatment. Such factors may contribute to the difficulty of managing them in community care settings, thus increasing the likelihood of custodial measures such as R.E.M.S. admission when offenses occur.

Regarding patients’ placement prior to admission, it is noteworthy that two individuals were transferred from O.P.G.s after the official closure date of 31 March 2015. One was admitted to Castiglione on 5 May 2016 from the O.P.G. of Reggio Emilia-among the final four discharges enabling that institution’s closure (14). The other was admitted on 2 August 2022 from the O.P.G. of Barcellona Pozzo di Gotto, despite its official closure in 2017 ¹⁵.

The proportion of patients with partial criminal responsibility (diminished mental capacity) remained essentially stable at around 34%. These individuals typically committed less severe offenses. In the 2023 cohort, among the 34 patients deemed partially responsible, only two had committed homicide, attempted homicide, sexual assault, attempted sexual assault, bodily harm, or stalking. Among the 20 patients admitted in 2023 due to revocation of probation and conversion to custodial measures, 17 had been judged partially responsible at psychiatric evaluation.

In terms of offense types, crimes against persons decreased, while offenses against family members and public administration increased in 2023, along with more frequent conversions of non-custodial into custodial measures. These trends are difficult to interpret conclusively but may reflect a rise in conflictual or antisocial behavior, which is more likely to result in custodial placement.

Observations concerning psychiatric diagnoses are more complex. Beyond the quantitative shifts reported in Tables VI and VII, diagnostic classification itself changed between 2013 and 2023. In 2013, broad categories were used, such as “personality disorders,” “psychotic disorders,” “dysthymic psychoses,” “organic psychoses,” “schizophrenic and other functional psychoses,” “other psychoses,” and “substance addictions.” Since 2015, following Castiglione’s integration into the national Information System for Monitoring the Transition from O.P.G.s and Prison Healthcare Services (SMOP), diagnoses have been coded using ICD-10. This has allowed for greater specificity, especially regarding personality and psychotic/delusional disorders, which were reclassified accordingly in our tables.

The fact that totals in Table VII (2023) exceed 100 patients reflects the SMOP system’s emphasis on comorbidities, particularly dual diagnoses, which accounted for 39% of the 2023 cohort. Of these, 22 involved comorbid personality disorders. Greater attention was also given to intellectual disability, previously grouped under “other diagnoses” in 2013 but identified as a comorbid condition in 16% of patients in 2023, including 3 with concurrent substance use.

CONCLUSIONS

The polymodular R.E.M.S. of Castiglione delle Stiviere represents a unique situation within the Italian R.E.M.S. system, both because of its size and its historical development. The complexity of the organization of the various regional facilities cannot be adequately represented by a single institution, even when it belongs to the most populous region and encompasses a system of multiple units.

An important advantage, however, lies in the possibility of observing and monitoring the significant transformations that have occurred over the past decade within the same institutional setting.Strengths of this study include the relatively large sample size, the wide range of variables considered for each patient, and the grounding in direct clinical experience within the facility. A limitation, however, is the absence of detailed data on the nationality of patients in the two cohorts.

Based on the comparison of two “snapshots” taken before and after the implementation of Law 81/2014, the findings indicate that the principle of territoriality-one of the cornerstones of the law-is being upheld. Likewise, the principle of transitoriness is respected, effectively preventing, ope legis, the repeated extension of custodial security measures that once resulted in so-called “white life sentences.”

A first area of concern relates to the clinical and care profiles of admitted patients, for whom the feasibility of community-based alternatives to R.E.M.S. placement remains a critical issue. Maintaining continuity of care with local services is often difficult. Stronger interaction between judges, expert witnesses, and mental health services is needed, supported by coordinated protocols at both local and national levels.

A second critical issue involves community mental health services, which require substantial reinforcement if they are to become the central component in the management of offenders with mental disorders. This objective could be pursued by expanding the capacity of specialized residential facilities and, more importantly, by improving co-management of therapeutic and rehabilitative pathways for R.E.M.S. patients.

In ruling no. 22 of 2022, the Italian Constitutional Court ¹⁶ emphasized the urgent need for legislative reform to address persistent shortcomings. The Court noted that the practical application of current regulations reveals conflicts with constitutional principles. An estimated 670-750 individuals remain on waiting lists for R.E.M.S. admission. Placement in a R.E.M.S. remains, under Italian law, a custodial security measure ordered by the criminal court, intended not only for therapeutic purposes but also for containing individuals deemed socially dangerous after committing a crime. Due to serious operational deficiencies, however, the system risks failing to safeguard both the fundamental rights of potential victims and the right to health of mentally ill offenders, who may not receive adequate treatment or support for gradual reintegration. The Court therefore called on Parliament to enact systemic reform.

On 12 November 2024, the Joint Commission of the Italian High Council of the Judiciary released a report on the current state of the R.E.M.S. system ¹⁷. The report urged further intervention to ensure that the “definitive closure of forensic psychiatric hospitals” is not only normatively stable but also effectively realized. Proposals included: creating 700 additional R.E.M.S. beds to reduce waiting lists; establishing a national observatory for monitoring data and a registry of accredited expert witnesses; developing a dual-track system to distinguish stabilized patients (suitable for rehabilitation and reintegration) from those requiring containment (to be managed in high-security facilities in northern, central, and southern Italy); reviewing existing psychiatric structures and differentiating care settings for general patients versus mentally ill offenders; and assigning R.E.M.S. management to the Ministry of Justice.

The goal of ensuring that R.E.M.S. placements do not become the inevitable endpoint for individuals who are difficult to manage in the community, but rather serve as a phase integrated within broader rehabilitative pathways connected to local services and social support networks, has yet to be fully achieved. Reaching this goal requires not only more psychiatric resources but also a systemic evolution of care, alongside legal, social, and scientific advances in the assessment and management of dangerousness.

The experience of R.E.M.S. remains relatively recent and still requires further consolidation. Addressing the current challenges cannot be reduced merely to increasing the number of available beds; rather, it requires a clearer definition of the role of R.E.M.S. and the adoption of more consistent clinical and forensic criteria in the assessment of mental illness.

In light of the way Laws No. 9/2012 and No. 81/2014 were conceived, and considering the many issues that remained unresolved after the 1978 psychiatric reform-including the complex question of treatment without consent-it is essential to critically examine these experiences in order to identify an appropriate balance between the functions of custody and those of care.

These dimensions have historically overlapped both in the development of psychiatry and in the social mandate attributed to psychiatrists. Today, however, they must be reconsidered within a broader and more integrated framework that ensures the protection of fundamental rights-including the right to care and the right to consent-while at the same time redefining, according to updated criteria, the concept of dangerousness, which has largely remained in the background throughout the decades of psychiatric reform.

Admission issues often originate from the psychiatric expert evaluations conducted during judicial proceedings. In response, the Italian National Institute of Health (Istituto Superiore di Sanità) has recently established ¹⁸ a working group to ensure scientific rigor in the development of technical guidelines and best practices for forensic evaluations. This initiative aims to provide standardized references for expert reports, support ongoing training of professionals, and reduce inconsistencies in assessment practices.

We therefore recommend further studies to monitor the long-term outcomes of R.E.M.S. patients after discharge, as well as the evolving dynamics between R.E.M.S., community psychiatric services, and the judicial system.

Conflicts of interest statement

The authors declare that there are no conflicts of interest.

Funding

The autors did not receive funding for this study.

Authors contributions

The first author conceived and wrote the final version of the article, the second author collected the data and wrote the first version, and the third author supervised the final draft and added additions.

Ethical consideration

This observational study was conducted in accordance with the ethical standards of the institutional and national research committee and with the Declaration of Helsinki. All data were collected and analyzed anonymously/in anonymized form. According to local regulations, formal ethical approval and informed consent were waived/not required for this type of observational study based on retrospective routinely collected data.

Figures and tables

TABLE I. Socio-demographic characteristics of 100 patients admitted to the Judicial Psychiatric Hospital (O.P.G.) of Castiglione delle Stiviere on 13/07/2013 and of 100 patients admitted to the Polymodular R.E.M.S. System of Castiglione delle Stiviere on 13/07/2023.

	Number of patients (2013)	Number of patients (2023)
Lombardia	54	100
Other regions	46	0
Mean age at admission	34 y.o. (min: 22; max: 80)	28 y.o. (min: 19; max: 80)
Age at admission	Number of patients (2013)	Number of patients (2023)
18-30	18	41
31-40	41	28
41-50	29	19
51-60	8	6
> 60	4	6

TABLE II. Pre-R.E.M.S. allocation of 100 patients admitted to the Judicial Psychiatric Hospital (O.P.G.) of Castiglione delle Stiviere on 13/07/2013 and of 100 patients admitted to the Polymodular R.E.M.S. System of Castiglione delle Stiviere on 13/07/2023

Pre-R.E.M.S. allocation	Number of patients (on a total of 100) (2013)	Number of patients (on a total of 100) (2023)
Prison	46	49
Residential facilities	7	3
Home	18	18
R.E.M.S./O.P.G.	0/11	2/2
Psychiatric Diagnosis and Care Units	17	24
Readmission following an escape	1	1
Other pre-R.E.M.S. allocation	0	1

TABLE III. Degree of mental incapacity of 100 patients admitted to the Judicial Psychiatric Hospital (O.P.G.) of Castiglione delle Stiviere on 13/07/2013 and of 100 patients admitted to the Polymodular R.E.M.S. System of Castiglione delle Stiviere on 13/07/2023

Degree of mental incapacity for criminal responsibility	Number of patients (on a total of 100) (2013)	Number of patients (on a total of 100) (2023)
Total mental incapacity	63	66
Partial mental incapacity	37	34

TABLE IV. Categories of crimes committed by 100 patients admitted to the Judicial Psychiatric Hospital (O.P.G.) of Castiglione delle Stiviere on 13/07/2013 and by 100 patients admitted to the Polymodular R.E.M.S. System of Castiglione delle Stiviere on 13/07/2023.

Categories of crime	Number of patients (on a total of 100) (2013)	Number of patients (on a total of 100) (2023)
Offences against the person (artt. 575-623 ter cp)	48	37
Offences against property (artt. 624-649 bis cp)	16	9
Offences against the family (artt. 556-574 ter cp)	8	13
Offences against public safety (artt. 422-452 cp)	4	1
Breach of obligations imposed / Conversion of probation into custodial security measures (artt. 231-232 cp)	16/5	6/20
Offences against public administration (artt. 314-360 cp)	1	12
Offences against the administration of justice (artt. 361-401 cp)	1	0
Police contraventions (artt. 650-730 cp)	1	0
Offences against the State’s integrity and security (artt. 241-313 cp)	0	1
Habitual drunkenness (art. 94 cp)	0	1

TABLES V-VI. Diagnostic categories of 100 patients admitted to the Judicial Psychiatric Hospital (O.P.G.) of Castiglione delle Stiviere on 13/07/2013 and of 100 patients admitted to the Polymodular R.E.M.S. System of Castiglione delle Stiviere on 13/07/2023.

Diagnostic categories	Number of patients 2013	Of whom with psychoactive substance dependence
Personality disorders	25	13
Schizophrenia, psychotic disorders and delusional disorders	64	14
Pure substance use disorder	5	5
Other diagnoses (intellectual disability, affective disorders, anxiety disorders etc.)	5	1
No diagnosis	1	0
Diagnostic categories	Number of patients 2023	Of whom with psychoactive substance dependence
Personality disorders	33	27
Schizophrenia, psychotic disorders and delusional disorders	64	36
Pure substance use disorder	2	2
Other diagnoses (intellectual disability, affective disorders, anxiety disorders etc.)	27	16
No diagnosis	1	0

TABLE VII. Drug abuse in 100 patients admitted to the Judicial Psychiatric Hospital (O.P.G.) of Castiglione delle Stiviere on 13/07/2013 and in 100 patients admitted to the Polymodular R.E.M.S. System of Castiglione delle Stiviere on 13/07/2023.

Drug abuse	Number of patients (2013)	Number of patients 2023
Yes	33	64
No	67	36