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This study examines the initial impact of a broadly participatory planning process in the Czech Republic during 2016–2017, aimed at both reducing inpatient care and expanding community mental health systems, on policy and programmatic decision making. A central focus of the study involves the trade-offs between and efforts to integrate shared decision making with evidence-based planning methods within the context of a national psychiatric reform strategy, particularly one involving a former Soviet bloc state. Given the uniqueness of the Czech experience, an exploratory case study methodology is used, one involving ten interviews with key informants and examination of a wide variety of documents. Results include the development of broad new decision and oversight structures, and the initial implementation of community mental health services. The nation faces some of the same trade-offs found elsewhere, such as in the United States, between an inclusive participatory process, and one that systematically incorporates empirical rational and evidence and best practices within bounded parameters. Implications for new psychiatric deinstitutionalization initiatives are identified, including development of a national mental health authority, a professional workforce, new funding strategies, multi-level service coordination, mechanisms to assure transparency, among others.