Major changes aimed at treating psychiatric patients in the community instead of hospital requires clear and strong leadership, as well as and long-term political and financial commitment, analysis shows.
The study has found the transition is usually prolonged and requires adequate planning, sustained support and careful coordination.
The successful implementation of these changes relies in careful financing and coordination, as well as the use of available research and evidence, strong and sustained advocacy, comprehensive community services, and a well-trained workforce engaged in the process.
The transition requires long-term political and financial support, and understanding local needs and forces is crucial to its success.
The paper, authored by Cristian Montenegro and Felicity Thomas from the University of Exeter,, Matías Irarrazaval and Jorge Urrutia-Ortizfrom the Universidad de Chile and Josefa González-Moller from the Pontificia Universidad Católica de Chile, has been published in the journal Global Mental Health. It reports the result of a scoping review that includes 52 studies on the process of de-institutionalisation.
Psychiatric deinstitutionalisation involves the closure or reduction of psychiatric hospitals, reallocation of beds, and the establishment of comprehensive community-based services for individuals with severe and persistent mental health difficulties. The study identifies barriers to success, such as inadequate planning, funding, leadership, limited knowledge, competing interests, insufficient community-based alternatives, and resistance from the workforce, community, and family/caregivers.
Countries undergoing the transition and those initiating the process need a detailed understanding of their specific needs and contextual features at the legal, institutional, and political levels.
Dr Montenegro said: "Our analysis shows that before hospitals are closed there should be an assessment of the institutionalised population. This assessment should shape existing and new community-based services on their needs and preferences. A thorough analysis of how to overcome institutional inertia is crucial.
"Comprehensive and sustainable investment is necessary, and the different aspects of the transition should be adequately costed, including new facilities, support of independent living, training, new professional roles, and the reinforcement of primary health care.
"Training, incentives and guarantees of job stability are required. Curricular changes in psychiatric training, with an increased emphasis on community-based care and recovery-oriented practices, are necessary."
The analysis shows how misconceptions can hinder efforts. One such misconception is the belief that closing psychiatric beds leads to an increase on homelessness or imprisonment among people with mental health problems. However, analysis of existing research shows that homelessness and imprisonment have occurred only sporadically. Most studies reported positive changes in social functioning, stability, improvements in psychiatric symptoms and enhanced quality of life and participant attitudes towards their environment. Instances of deterioration following deinstitutionalisation was rare. This suggests that even long-stay patients, who commonly experience functional impairment due to schizophrenia, can achieve better functioning through deinstitutionalisation.
Failure at the process level, including planning and implementation, can result in negative and even fatal outcomes for patients. In South Africa, between October 2015 and June 2016, a poorly executed attempt to relocate 1,711 highly dependent patients led to 144 deaths and 44 missing individuals. This tragedy stemmed from ethical, political, legal, administrative, and clinical errors.
Jorge Jorge Urrutia-Ortiz said: "Our work provides a framework for assessing the presence of barriers and facilitators in deinstitutionalization processes. This framework can assist stakeholders and other relevant parties in developing a comprehensive understanding of their unique context."
