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

Abstract

AbstractPsychiatric deinstitutionalisation (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 2250 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.Impact StatementThe transition from a mental health system centred on long-term psychiatric hospital care to one centred on community-based services is complex, usually prolonged and requires adequate planning, sustained support and careful intersectoral coordination. The literature documenting and discussing psychiatric Deinstitutionalisation (PDI) processes is vast, running across different time periods, regions, socio-political circumstances, and disciplines, and involving diverse models of institutionalisation and community-based care. This scoping review maps this literature, identifying barriers and facilitators for PDI processes, developing a categorization that can help researchers and policymakers approach the various sources of complexity involved in this policy process.Based on the review, we propose five key areas of consideration for policymakers involved in PDI efforts: 1) Needs assessment, design and scaling up; 2) Financing the transition. 3) Workforce attitudes and development; 4) PDI Implementation and 5) Monitoring and quality assurance.We call for a multifaceted transition strategy that includes clear and strong leadership, participation from diverse stakeholders and long-term political and financial commitment. Countries going through the transition and those who are starting the process need a detailed understanding of their specific needs and contextual features at the legal, institutional, and political levels.