Infusion therapy in the Day-Center to treat anxiety and depression

Interview with Professor Stefano Pallanti

Associated Professor of Psychiatry at the University of Florence, Doctor in Neurophysiopathology
Head of the clinical and scientific activities and programs of the Neurosciences Institute

Being treated in the Day-Center: Professor Pallanti, what does this mean?

Very simply, the Day-Center is a way of integrating different types of therapeutic expertise within the same space and revolving around a comprehensive project for the treatment of each patient. It is not only a place, it also becomes a therapeutic procedure having the treatment of a suffering patient at its core and each individual person is considered in his/her way of experimenting in their relationship to others.
The way in which we operate aims at combining respect for each individual person and the use of all the techniques and technologies that can be useful during the crucial diagnostic phase as well as during the treatment.

This is no easy task, since all the different technical instruments available to provide diagnoses and therapies must in some way be integrated, even in the patient’s mind, otherwise they tend to be seen as a form of mechanical intrusions.

Harmonizing the technique and the treatment requires time and a relationship that takes into account the obvious perplexities of a person that feels ill and perceives that the therapeutic method proposed to him/her is detached from his/her suffering.

The option of treating disorders like anxiety or depression by administering medications through the infusion therapy is not very well-known. Why?

As it has always happened in the history of medicine, therapeutic innovations are immediately seen as a threat to the therapeutic relationship.

For example, over a century ago, the stethoscope was initially rejected because it distanced the patient and deprived him/her of the physical contact that had always been necessary to perform medical check-ups. Placing the instrument on the patient’s chest eliminated that kind of embrace and contact between the face of the auscultating doctor and the bare chest of the patient undergoing the auscultation.

Nowadays, people are still very prejudiced against the use of medications for the treatment of the so-called "afflctions of the soul", but since science has now determined that there is a relationship between these afflictions and biochemical alterations of the nervous system, which are well documented and widely divulged, the prejudices will slowly be overcome.

Certainly, the option of an intravenous administration to treat the subject’s melancholy or the burden of obsessions and compulsions might appear as a magical or miraculous method to most people while, on the contrary, some might see it as an evil and sadistic method.

It is necessary to work on the relationship with the patient and his/her own world, in order to eliminate such positive or negative idealizations. These should be replaced by a more realistic view that puts this simple yet quintessentially medical procedure back in its rightful place: the dimension of curing and taking care of a person.

This integration also requires a physical space.

A space that is as open and accessible as possible but also capable of ensuring one’s "privacy".

To sum up, my impression is that you are referring to the need to integrate medical treatment and psychological treatment.

At our Day-Center, the diagnostic-therapeutic intervention is the result of a system that combines different types of expertise, both specialized and not specialized.

This is our challenge, that of combining state-of-the-art technique with respect for the individual.

The final result is similar to what is known as "Intensive care", but with more space and autonomy for the patient, who actively participates in the treatment by regularly visiting the Day-Center.

Integrating several different types of expertise into the DH’s time and space unity is the most complex and expensive method and yet the most effective.

On the other hand, if we speak in metaphorical terms about the chemistry of therapeutic interaction, the product that derives from the integration of the people providing the cure among each other and with the person being cured is not simply a more complex compound. What is being produced is a true change of state; it is as if the treatment moved from a solid to a volatile state.

The French have long been talking about the concept of "milieu", i.e. of the therapeutic environment, but it would be appropriate, in an even more nonmaterial sense, to talk about therapeutic environment.

Besides the need for a physical environment, the treatment can be provided through interaction mechanisms among different professional figures and types of expertise, which are only partially structured by means of formal meetings; for the rest, the integration is ensured by the organization of the work itself, carried out side by side and often together by different operators.

What are the needs the Day-Center can meet?

Nowadays, the aspect of the effectiveness of the treatment cannot be overlooked and historically the DH was created on the basis of two precise needs: leaving the person who is suffering within his/her social and family environment and curing the person by preserving the highest possible level of social activity, guaranteeing at the same time therapeutic programs with daily check-ups by specialists, individually tailor-made programs, and programs that can be immediately initiated both from a pharmacological and a psychological point of view, alongside psychoeducational activities and support to the patients and their families.

One of the most effective medical methods we adopt at the Day Center is the use of the infusion therapy.

This act has deep psychological significance and it is connected to a mythology of medicine in which the alliance between the doctor and the patient is sanctioned through an act reminiscent of the Holy Communion.

Anyhow, way beyond these meaningful suggestions, which however should not be disregarded, the treatment technique is particularly suited in case of psychic disorders such as depression, obsessive-compulsive disorders, disorders related to anxiety, and cognitive disorders. The infusion therapy offers several advantages both in terms of effectiveness and of quick action and reduced side effects.

Tell us about your experience in Florence

The Day-Center of the Neurosciences Institute in Florence has been operating for over 16 years and it is continuously evolving, because it is not only a treatment center but also a research center specializing in the cure of psychiatric disorders, which is constantly updated according to the most recent international guidelines.

Our experience began by devoting the greatest care to the choice of the location and of the characteristics of the building in which the activities of the Day-Center would be carried out.

In the psychiatric tradition, places devoted to the treatment of mental illnesses have mostly been located outside of urban environments, with the consequence of removing patients, even though temporarily, from the social contest and from city life, according to the old principle of protecting the sane from the mad.

The destiny of places where psychiatric treatments were administered often overlapped with that of penitentiaries, sanatoriums, and cemeteries. This unfortunately contributed to accentuate the social stigma, the shame, and the feeling of isolation, which can nowadays still be traced in individuals who have suffered from depression or disorders related to anxiety.

Even the building we are in right now does not look at all like a hospital.

Actually, the small villa in which the Neurosciences Institute is located does not look at all like a hospital.

But the Day-Center in particular is not a closed facility, it is always open.

During opening hours (from 8.30 a.m. to 8.00 p.m.), the door to access the Institute is always open and one can freely walk in or out.

This aspect is also very important, because the idea of a closed environment where mental illnesses are cured is largely connected to the social stigma associated to mental disorders, to the inhibition related to being treated, and to the shame felt in asking for help for psychic problems.

Therefore, the environment of the Day-Center does not look very much like a medical or psychiatric facility, but it actually provides all the services a patient might need from a modern medical and psychiatric point of view. The environment must therefore be socially reassuring and integrated and not at all discrediting.

From this point of view, the private scope, in which our experience has developed, immediately seemed particularly suitable to the success of a Day-Center project.

In fact, bureaucratization is reduced to a minimum, since it is the cause of much therapeutic discontinuity.

Moreover, the presence of two specialized doctors at the Day-Center allows for constantly available direct telephone contact to anyone in need.

Additionally, the Center can always be contacted by telephone also by general practitioners, who wish to put forward one of their clinical cases, in order to ask for consultancies or simply for therapeutic suggestions.

Which are the principles on the basis of which you operate to treat psychic disorders?

First of all, the Day-Center is anti-institutional and pursues evolutional projects for the patient.

The Day-Center offers therapeutic pharmacologic and non-pharmacologic programs with their own time definition. In other words, the philosophy of day-hospital is anti-institutional and aims at handing back the highest degree of autonomy to individuals who suffer or have been suffering from psychic disorders.

In order to achieve that, it is necessary that the pharmacological or non-pharmacological therapy is undertaken when requested, focusing on a precise diagnosis, and that the techniques are the most effective and quickest available to relieve the patient from his/her suffering.

A high degree of accessibility and timely acknowledgement of requests for help are the prerequisites for the development of a greater and more dignified awareness of one’s illness. After having involuntarily created time and space obstacles to the cure, it is actually very difficult to reinforce the belief that a cure is necessary and that it must be constant in order to prevent relapses.

But this could also be a reason to induce addiction in the patient if tailor-made programs do not provide the patient and his/her family members with all the necessary guidelines for prevention and for the early detection of any sign of relapse.

In this way, thanks to the instruments available, all the people involved benefit from an increase in their autonomy and self-competence.

Are there clinical advantages for patients being treated in day-hospital?

We know that the administration of medications by means of the intravenous infusion therapy involves a reduced amount of side effects, is often more effective, and it acts faster in comparison to simple medications prescribed for the patient in the consultation room.

The use of information material and psychoeducational group programs with audiovisual support are an integral part of the day hospital philosophy, because they help the patients to get to know the disorder they are suffering from and to regain their autonomy and integration as fast as possible.

Another very important aspect is that the "meeting" between a suffering patient and "psychotropic drugs" occurs under the supervision of professional health personnel.

Patients are no longer left by themselves; even though it is nowadays known that modern medications are for the most part very easy to tolerate, the stigma that goes with all the things related to a psychiatric treatment still makes the beginning of the cure an unsettling moment.

Therefore, we believe that all the treatments, at least in our field, should always be begun by using the day-hospital system, even when the medications are well-known and administered orally.

So the tolerability of the treatment is a very important aspect.

Certainly. Day-hospital treatment means caring for the quality of life and for behavioral toxicity.

The quality of life is nowadays one of the most important parameters in the assessment of therapy effectiveness, particularly in the case of psychic disorders. It is believed that avoiding hospitalization as much as possible without renouncing an effective treatment is extremely helpful to the patient’s quality of life.

This commitment also involves the greatest attention to the therapy’s side effects that can have a negative influence on the patient’s behavioral functions in his/her daily life.

Sedation, for example, is not a desirable effect and the personnel prescribing the treatment should always keep up-to-date in order to provide effective therapies involving as few limitations as possible to the patient’s normal activities and working life as well as social life.

How many people know about the opportunity to treat depression and panic disorders at the Day-Center?

Unfortunately, they are still but a few, including doctors. They do not know that psychic disorders can be effectively treated at the Day-Center.

Still today, psychiatric hospitals are health institutions that people talk about with a sense of unease and also the media take them into consideration only when reporting scandals or talking about cases of poor health service and malpractice.

We try to promote our Day-Center as much as possible, because we believe it necessary to improve the treatment of those suffering from psychic problems.

In 1999, the staff of the Institute presented the Day-Center to the troupe of the RAI2 TV channel, live from the Institute, during a popular television program.

Some of the patients who were being treated at the Day-Center at that moment said they were willing to be interviewed as "experts" on depression.

Quite often, after having recovered, some of our patients come back to the Center not for check-ups but simply for courtesy calls and many of them send us postcards with greetings and good luck wishes from holiday resorts.

The relationship between the person that received the treatment and the Institute changes, becoming a normal relationship based on "friendship" between two subjects. It is very nice when that happens.