Montenegro Cristian, Irarrázaval Matías, González Josefa, Thomas Felicity, Urrutia Jorge
Wellcome Centre for Cultures and Environments of Health, University of Exeter, Exeter, UK.
Millennium Institute for Research in Depression and Personality, Santiago, Chile.
Glob Ment Health (Camb). 2023 May 4;10:e29. doi: 10.1017/gmh.2023.18. eCollection 2023.
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.
精神科去机构化（PDI）进程旨在通过关闭或缩减精神病院、重新分配床位以及为患有严重且持续性心理健康问题的个体建立全面的社区服务来转变长期精神科护理。本范围综述探讨了关于PDI的大量文献，这些文献跨越数十年、多个地区、不同社会政治背景和学科，以确定PDI实施的障碍和促进因素，为研究人员和政策制定者提供这些因素的分类。为了确定障碍和促进因素，检索了三个电子数据库（Medline、CINAHL和社会学文摘），共获得2250条参考文献。经过筛选和评审，最终分析纳入了52项研究。采用主题综合法对确定的因素进行分类，以回应综述问题。分析表明，PDI的障碍包括规划不足、资金不足、领导力欠缺、知识有限、利益冲突、基于社区的替代方案不足以及来自工作人员、社区和家庭/照顾者的抵制。相比之下，促进因素包括精心规划、资金筹集与协调、现有研究和证据、强有力且持续的宣传、全面的社区服务以及参与该过程的训练有素的工作人员。冲突和人道主义灾难等外部因素在PDI进程中也可能发挥作用。实施PDI需要多方面的策略、强有力的领导、不同利益相关者的参与以及长期的政治和财政支持。了解当地需求和力量至关重要，研究PDI需要方法上的灵活性以及对背景差异的敏感性。同时，基于综述本身的发展，我们确定了文献中的四个局限性，涉及“时间”“地点”“重点”和“声音”。我们呼吁围绕当代全球精神卫生政策这一被忽视的方面制定新的研究和宣传议程。
