A Thirty-Year Forensic Case Report of Chronic Psychosis: Systemic Implications for Italian Forensic Psychiatry.

Background: Italy's forensic psychiatric system has undergone major reforms over recent decades, shifting from custodial institutions to a right-based, community-oriented model. While internationally praised for its commitment to dignity, recovery, and social reintegration, this framework presupposes a degree of clinical recoverability that is not always achievable. Individuals with chronic, treatment-resistant disorders-particularly those who remain socially dangerous-pose complex challenges that strain the system. Methods: We report a thirty-year longitudinal case of G.D.M.: a man initially diagnosed with schizophrenia and later with chronic delusional disorder. Clinical data, forensic assessments, institutional records, and community-based rehabilitation reports were reviewed to reconstruct his clinical, criminological, and forensic trajectory. Results: The patient committed a femicide in early adulthood and, decades later, engaged in stalking behavior toward the victim's family. Despite prolonged institutionalization, pharmacological treatment, multiple forensic evaluations, and rehabilitation programs, his psychopathology remained substantially unchanged. He persisted with fixed delusional ideation, exhibited minimal insight, and maintained a high level of social dangerousness. Conclusions: This case exemplifies structural gaps in Italy's forensic psychiatric system, particularly the absence of stratified security levels, long-stay therapeutic facilities, and post-custodial continuity of care for individuals who do not recover. It also highlights the increasing burden placed on the Dipartimenti di Salute Mentale (DSM, Italian Mental Health Departments), which must manage both general psychiatric and high-complexity forensic cases, often without adequate resources or training. Targeted reforms-including secure long-term care pathways, systematic outcome monitoring, and clearer forensic mandates-are needed to ensure proportionate, ethical, and effective management of such cases.