Moving psychiatric deinstitutionalization forward: A scoping review of barriers and facilitators

Abstract

Psychiatric deinstitutionalization (PDI) processes aim to transform long-term psychiatric care by closing or reducing psychiatric hospitals, reallocating beds, and establishing comprehensive community-based services for individuals with severe and persistent mental health difficulties. This scoping review explores the extensive literature on PDI, spanning decades, regions, socio-political contexts, and disciplines, to identify barriers and facilitators of PDI implementation, providing researchers and policymakers with a categorization of these factors. To identify barriers and facilitators, three electronic databases (Medline, CINAHL, and Sociological Abstracts) were searched, yielding 2,250 references. After screening and reviewing, 52 studies were included in the final analysis. Thematic synthesis was utilized to categorize the identified factors, responding to the review question. The analysis revealed that barriers to PDI include inadequate planning, funding, and leadership, limited knowledge, competing interests, insufficient community-based alternatives, and resistance from the workforce, community, and family/caregivers. In contrast, facilitators encompass careful planning, financing and coordination, available research and evidence, strong and sustained advocacy, comprehensive community services, and a well-trained workforce engaged in the process. Exogenous factors, such as conflict and humanitarian disasters, can also play a role in PDI processes. Implementing PDI requires a multifaceted strategy, strong leadership, diverse stakeholder participation, and long-term political and financial support. Understanding local needs and forces is crucial, and studying PDI necessitates methodological flexibility and sensitivity to contextual variation. At the same time, based on the development of the review itself, we identify four limitations in the literature, concerning “time,” “location,” “focus,” and “voice.” We call for a renewed research and advocacy agenda around this neglected aspect of contemporary global mental health policy is needed.

Pathways to community living in practice: Local development and adaptation within an older peoples mental health service

“…Implementation of the PCLI required local adaptation for the OPMH service and RACF setting according to staff training, skills and experience, echoing international deinstitutionalisation experiences. 1 The collaborative development and adaptation of the PCLI program utilised internationally-recognised multifaceted transition strategies to community care 1 supported by government, and workforce commitment to change. 2 A clear governance framework outlined roles, responsibilities, resources and mechanisms for evaluation and review, alongside a standardised assessment process.…”

“…International approaches to transitioning from long-term hospital-based psychiatric care to community-based services have varied, with identified barriers and facilitators. 1 Common considerations include needs assessment, funding, workforce training, implementation and monitoring. 1,2 Incorporating these considerations, the Australian Pathways to Community Living Initiative (PCLI) was designed to support people with enduring, serious mental health issues who have been in hospital for extended periods or are at risk of recurrent hospitalisations or long stays, to move into community accommodation.…”

“…1 Common considerations include needs assessment, funding, workforce training, implementation and monitoring. 1,2 Incorporating these considerations, the Australian Pathways to Community Living Initiative (PCLI) was designed to support people with enduring, serious mental health issues who have been in hospital for extended periods or are at risk of recurrent hospitalisations or long stays, to move into community accommodation. 3 This cohort have complex care needs, including chronic severe mental illness, physical health comorbidities, polysubstance use, and impaired cognition and functioning.…”

“…This complexity may be addressed by ongoing specialist multidisciplinary support in the community and coordination of individualised physical and mental health and functional/social support services. 1,4…”

Moving psychiatric deinstitutionalization forward: A scoping review of barriers and facilitators – CORRIGENDUM

“…The authors apologise that upon publication of Montenegro C, et al (2023), the funding acknowledgement was omitted. This should have been included and is listed below…”