Management of andrological disorders from childhood and adolescence to transition age: guidelines from the Italian Society of Andrology and Sexual Medicine (SIAMS) in collaboration with the Italian So

Within the field of mental health care, there are groups of people at risk of being overlooked by the health care system, the research community and society at large. This is particularly relevant for those experiencing severe and persistent mental illness (SPMI) (Butler & O’Brien, ; Westermair et al., ). SPMI encompasses long-term and disabling mental health conditions, such as refractory schizophrenia, treatment-resistant depression and severe bipolar disorder (Zumstein & Riese, ; Woods et al., ). This population shares the characteristic of experiencing persistent symptoms despite undergoing evidence-based treatments, resulting in significantly impaired daily functioning and reduced quality of life (Zumstein & Riese, ). Simultaneously, these people face a striking reality of reduced life expectancy, which is up to 15 years shorter than the general population, mainly due to severe co-occurring somatic disorders and limited access to timely and appropriate health care (Butler et al., ; James et al., ; Oakley et al., ; Plana-Ripoll et al., ; Woods et al., ). Traditional therapeutic interventions aimed at cure often prove ineffective for SPMI, leading caregivers to either persist with futile therapeutic approaches or in some cases discontinue care altogether. In recent years, palliative psychiatry has gained increasing scholarly and clinical attention as a new clinical approach within mental health care, developed to respond to the often unmet needs of this population (Levitt et al., ; Strand et al., ; Trachsel et al., ). Palliative psychiatry represents a paradigmatic shift from a purely cure-oriented model of care, which emphasises symptom remission and functional restoration, to an approach that places the person, their well-being and their lived experience at the centre. The focus is on alleviating suffering, minimizing harm and supporting quality of life, even when psychiatric symptoms persist (Levitt et al., ; Levitt et al., ; Westermair et al., ). Drawing on this palliative philosophy, the context-specific care model ‘Oyster Care’ was developed in Flanders (Decorte et al., ). Oyster Care adopts a holistic approach in caring for this group of people based on four pillars: physical care addresses somatic conditions, psychological care focuses on comfort and well-being, social care provides structure through activities and connections and existential care promotes a sense of meaningful living. This model focuses on creating a dynamic ‘protective shell’ around a person, one that can temporarily close when symptoms pose a risk to themselves or others, yet remains as open as possible to allow for maximum autonomy. This shell serves as a metaphor for the external environmental support required to experience quality of life, acknowledging that full recovery may not always be attainable. As in regular palliative care, it places great value on interpersonal relationships and creative, out-of-the-box thinking by caregivers to go beyond standard protocol in caring for these people to improve their sense of meaning, well-being and quality of life (Decorte et al., ). Initial feedback on the care model from both health care professionals and care users is cautiously positive. Caregivers report a heightened sense of well-being, which appears to be reflected among care users in a reduced symptom burden and an improved quality of life (Decorte et al., ; Harth, ; Van den Bosch et al., ). In recent years, the dissemination of the Oyster Care model's principles has accelerated within the Flemish residential mental health care landscape. An increasing number of mental health services are implementing the model into their care practices. This development is closely intertwined with the broader trajectory of Belgian mental health reforms, where deinstitutionalisation has long been an explicit policy goal, yet in practice the system has remained strongly hospital-centred, with a persistently high number of psychiatric beds and comparatively slow bed reduction relative to other European countries (Martens et al., ; Mistiaen et al., ). Within this context, clinical inpatient settings have continued to play a central role, and the need for context-sensitive, person-centred and long-term care models has remained acute, particularly for people experiencing SPMI who cannot be adequately supported in community-based services. The Oyster Care model emerged bottom-up from this practice reality in several Flemish psychiatric units as caregivers were confronted with a combination of limited community-based alternatives, the inadequacy of existing long-stay and rehabilitation-oriented residential programmes for a small group of highly complex SPMI patients, and the need for intensive support that prioritises quality of life over cure (Decorte et al., ). While it has been adopted by psychiatric hospitals and psychiatric nursing homes, the approach is also being explored by nursing homes for older adults with psychiatric symptoms and outpa