Research report: Perceived satisfaction with care, service atmosphere and mood fluctuations among patients with schizophrenia spectrum disorder in Italian mental health supported accommodations: a multicenter study

People living with schizophrenia spectrum disorders who reside in Italy’s supported accommodations report better momentary mood when they hold more positive perceptions of their care environment, according to a multicenter study published in BMC Psychiatry. The finding emerged from a structural equation model in which a latent construct combining service satisfaction and perceived ward atmosphere was the only statistically significant predictor of momentary mood, outperforming demographic and clinical variables such as age, sex, illness duration, symptom severity and functioning.

The research formed part of the DiAPAson project, a national initiative titled “DAily time use, Physical Activity, quality of care and interpersonal relationships in patients with Schizophrenia spectrum disorders.” The project involved 20 Departments of Mental Health and 17 private supported accommodations situated across various regions of Italy. Between October 2020 and October 2021, the parent project enrolled 340 residents with schizophrenia spectrum disorders from 98 supported accommodations, an average of 12.8 residents per facility. Because of logistical and financial constraints, the ecological Experience Sampling Method component could be conducted only in a subset of 30 facilities that had the human resources to manage this specific research activity, and 68 residents, or 21.7 percent of those assessed in these settings, took part in the current study.

Participants were aged between 20 and 55 years, held a DSM-5 diagnosis of a schizophrenia spectrum disorder, and were proficient in Italian. Severe cognitive impairment, inability to provide informed consent, a recent substance use disorder diagnosis, cerebrovascular or neurological disease, and a history of clinically significant head injury were exclusion criteria. The final sample comprised 20 women and 48 men, with a mean age of 42.8 years. Most participants were single, and 79.4 percent were unemployed. The average duration of illness was 19.2 years, and more than half of the participants had spent between one and five years in psychiatric facilities over their lifetime, while 45.6 percent had been hospitalized for more than five years.

Clinical assessments indicated moderate symptom severity and functioning. The mean score on the 24-item Brief Psychiatric Rating Scale was 47.3, and the Brief Negative Symptom Scale yielded a mean of 23.3. Psychosocial functioning, measured with the Specific Levels of Functioning Scale, averaged 175.7, and disability assessed with the WHO Disability Assessment Schedule 2.0 averaged 33.3. Service satisfaction, measured with the Verona Service Satisfaction Scale (VSSS-32), produced a total mean score of 3.8 on its five-point scale, while perceived ward atmosphere, measured with the patient version of the Ward Atmosphere Scale (WAS-P), averaged 56.8.

The distinctive methodological feature of the study was its use of the Experience Sampling Method, or ESM, which collects real-time data on emotions, thoughts and activities in natural settings. Before starting the monitoring phase, participants completed questionnaires covering psychopathology, functioning, ward atmosphere and service satisfaction, and attended a 30-minute briefing session delivered by research assistants. Over a seven-day period, each participant received semi-randomised notifications on a smartphone application developed for the project, sent across eight time slots running from 8 a.m. to midnight, with a reminder after 15 minutes and a maximum of 30 minutes to reply. Mood was assessed with the question “Right now, I feel …”, with answer options including happy, sad, tired, relaxed, nervous, quiet and full of energy.

The structural equation model treated environmental perception as a latent variable, called Env-Perc, inferred from two observable self-report indicators: the VSSS-32 total score and the WAS-P total score. Both indicators loaded strongly on the construct, with the WAS-P total score showing a standardized loading of 0.779 and the VSSS-32 total, fixed at 1.00 for model identification, showing a standardized loading of 0.709. The model fit indices indicated an excellent fit to the data, with a non-significant chi-square test, a Comparative Fit Index of 1.000, a Root Mean Square Error of Approximation of 0.000 and a Standardized Root Mean Square Residual of 0.060. Given the small sample size and minimal departures from normality, the researchers used non-parametric bootstrap standard errors to ensure robust estimation.

Among all the predictors examined, only Env-Perc was significantly associated with mood, with a standardized coefficient of 0.344, a 95 percent confidence interval of 0.084 to 0.954 and a p-value of 0.033. This suggests that individuals who reported more positive perceptions of their environment tended to experience better momentary mood states. In contrast, demographic variables and clinical scales, including age, sex, illness duration, symptom severity and social functioning, showed no significant relationship with mood. The authors note, however, that the model explained only 14 percent of the variance in mood, indicating that while the perceived environment plays a role, other elements not addressed in this study, such as trauma history, stigma, cognitive distortions or neurobiological variables, likely contribute to emotional well-being.

The study sits within a distinctive national context. Supported accommodations are a central component of Italy’s long-term mental health care system, providing combinations of housing, clinical support and rehabilitative interventions with varying levels of staffing intensity. Italian national guidelines classify these services into five main types based on rehabilitation and care intensity, ranging from high-support facilities with 24-hour staff presence to lower-support or supported housing solutions. The system traces its origins to the psychiatric reform of 1978, when Law 180, known as the Basaglia Law, mandated the gradual closure of psychiatric hospitals and the shift to a community-oriented mental health system. The services are managed by both non-profit and for-profit private providers, with accommodation and care costs fully covered by the Italian National Health Service.

The concept of ward atmosphere refers to the social climate of a care setting, encompassing its emotional and physical qualities, and is commonly measured with the Ward Atmosphere Scale developed by Moos and Houts in 1968. The scale covers three higher-order dimensions of relationship, personal growth and system maintenance, with ten subscales including involvement, support, spontaneity, autonomy, practical orientation, personal problem orientation, anger and aggression, order and organization, program clarity and staff control. Prior literature cited by the authors indicates that satisfaction with care and therapeutic ward atmosphere are closely tied to mood and psychological well-being in people with schizophrenia spectrum disorders, that higher satisfaction is associated with better quality of life, and that discrepancies between staff and resident perceptions of needs, with staff often overestimating met needs, may contribute to dissatisfaction and negative mood.

The authors identify several limitations. The findings may not generalize to individuals with diagnoses other than schizophrenia spectrum disorders, to those with significant cognitive impairment, or to settings other than supported accommodations. Data were collected during the SARS-CoV-2 pandemic, a period marked by significant disruptions to daily routines, which may have influenced participants’ mood and environmental perceptions. The study also lacked complete information regarding the specific type of supported accommodation where participants lived, preventing more detailed characterization of residential settings. Because the researchers wanted to examine the relationship between global patients’ perception of ward atmosphere and momentary mood, only the average WAS-P total score was used, an approach that may have missed potentially meaningful patterns across different dimensions of ward climate. The authors conclude that interventions targeting ward atmosphere and service satisfaction, such as fostering supportive staff-patient relationships, addressing unmet needs and providing structured daily activities, may improve mood outcomes, and they call for future research incorporating a broader range of psychosocial and clinical factors to build more comprehensive predictive models.

Subject of Research: Associations between perceived ward atmosphere, care satisfaction and momentary mood among residents with schizophrenia spectrum disorders in Italian supported accommodations

Article Title: Perceived satisfaction with care, service atmosphere and mood fluctuations among patients with schizophrenia spectrum disorder in Italian mental health supported accommodations: a multicenter study

Article References: Martinelli, A., Toffol, E., Martella, D., Carnevale, M., Calza, S., & de Girolamo, G. (2026). Perceived satisfaction with care, service atmosphere and mood fluctuations among patients with schizophrenia spectrum disorder in Italian mental health supported accommodations: a multicenter study. BMC Psychiatry, 26(1), Article 816. https://doi.org/10.1186/s12888-026-08365-7

Image Credits: AI Generated

DOI: 10.1186/s12888-026-08365-7

Keywords: schizophrenia spectrum disorders, supported accommodations, ward atmosphere, service satisfaction, Experience Sampling Method, momentary mood, structural equation modeling, community mental health care, Italy, DiAPAson project, psychiatric rehabilitation, Ward Atmosphere Scale