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Despite decades of de-institutionalization and the best efforts of community mental health services, individuals with schizophrenia living outside the hospital may be described as in the community but not of the community, and remain in a very real sense socially excluded. To determine the relationship between social integration and quality of life among patients with schizophrenia attending the outpatient clinic of the Neuropsychiatric Hospital Abeokuta in Nigeria. One hundred and fifty-one patients were recruited. Sociodemographic questionnaire, MINI-PLUS, WHOQOL-BREF, Social Integration Scale and PANSS were administered. Multivariable regression analyses were performed to identify the determinants of quality of life and the relationship with social integration. The mean (± SD) age of the respondents was 40.00 (± 10.23), 56.3% were males, 37.1% were single. Independent predictors of lower quality of life were: (1) more severe psychopathology for the domains of general health (p = 0.003), social relationship (p = 0.019) and environment (p = 0.008); (2) longer duration of illness for the social relationship (p = 0.028) and environment (p = 0.015) domains; and (3) negative symptoms (p = 0.034) for the physical domain. There is a need to pay closer attention to social outcome measures such as quality of life and level of social integration among patients with schizophrenia who come in contact with psychiatry services, and not just on symptom remission only.

From Crime to Care Many clinicians are working on the front lines of decarceration, supporting and treating patients who might once have been incarcerated. Models for decarceration involving proble...

Zablotskiy A. R. Characteristics of alternative forms of state care for orphan children and children deprived of parental care. Journal of Education, Health and Sport. 2020;10(11):373-381. eISSN 2391-8306. DOI http://dx.doi.org/10.12775/JEHS.2020.10.11.037 https://apcz.umk.pl/czasopisma/index.php/JEHS/article/view/JEHS.2020.10.11.037 https://zenodo.org/record/5484134 The journal has had 5 points in Ministry of Science and Higher Education parametric evaluation. § 8. 2) and § 12. 1. 2) 22.02.2019. © The Authors 2020; This article is published with open access at Licensee Open Journal Systems of Nicolaus Copernicus University in Torun, Poland Open Access. This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author (s) and source are credited. This is an open access article licensed under the terms of the Creative Commons Attribution Non commercial license Share alike. (http://creativecommons.org/licenses/by-nc-sa/4.0/) which permits unrestricted, non commercial use, distribution and reproduction in any medium, provided the work is properly cited. The authors declare that there is no conflict of interests regarding the publication of this paper. Received: 16.10.2020. Revised: 30.10.2020. Accepted: 30.11.2020. CHARACTERISTICS OF ALTERNATIVE FORMS OF STATE CARE FOR ORPHAN CHILDREN AND CHILDREN DEPRIVED OF PARENTAL CARE A. R. Zablotskiy Kremenets Regional Humanitarian and Pedagogical Academy named after Taras Shevchenko, Kremenets, Ukraine Department of Pedagogy and Psychology, teacher Abstract Problem statement and purpose. Modern domestic society is characterized by a number of negative phenomena –impoverishment, unemployment, rising crime, mass labor migration both abroad and internally, related to the occupation of Crimea and hostilities in eastern Ukraine. All of them, directly or indirectly, cause disruption of the structure and functioning of the family, which, in turn, leads to an increase in the number of people such as orphans and children deprived of parental care. The system of social assistance and protection of this category of children combines both traditional and alternative forms of state care. Unfortunately, the reform of this system is too slow due to various reasons of social and economic, social and political and psychological and pedagogical nature. It is also worth noting that nowadays only the scientific basis for its functioning is being formed.Thus, Bader S., Bevz H., Vodyana O., Borysova V., Volynets L., Kobzar B., Komarova N., Ivanova I., Petrochko J., Kalibaba O., Makiychuk T., Orzhekhovska V., Pesh I., Piren M., Polyanychko A., Trubavina I. Turchyn O., Fedorova N., Kharkhan G., Chervonyy Yu. and others,studied the technologies of creation and organization of life of adoption and foster families, as well as children's homes (as alternative forms of state care), various aspects of stay and upbringing of children in such families.The content of social and pedagogical work in protection institutions and families where children are under protection is reflected in the works of domestic scientists: Bezpalko O., Hykava G., Zavgorodna T., Evdakh K., Ivanova A., Kapska A., Kurlyak I., Maksymova N., Naumenko T., Oleksyuk N., Pesh I., Sydorenko O., Chenbay I., Yurchenko T., Yaskal L., Yashchenko N. and others.Despite the wide and multifaceted scientific interest in this problem, the peculiarities of the formation and operation of alternative forms of care still remain unresolved. That is why the purpose of our study is to characterize the features of the functioning of alternative forms of care for orphans and children deprived of parental care and to determine the possibilities of their development. Research methods: to achieve this goal we used a set of methods: theoretical (conceptual and comparative analysis of philosophical, sociological, psychological and pedagogical, scientific and methodological and reference encyclopedic literature, regulatory and program documentation on research topics to clarify the content of basic concepts and study of the state of development of the researched problem in theory and practice); empirical (content analysis, questionnaires, pedagogical observation, study and generalization of independent characteristics and pedagogical experience, survey). Results. Based on the analysis of the scientific literature, the essence of the concepts "adoption", "custodianship/ care", "foster family", "family-type orphanage", "family patronage", "small group home", "deinstitutionalization" and "alternative care"is specified. Alternative forms of state protection of children as a social phenomenon are characterized, the relevance of deinstitutionalization and transformation of services for children is substantiated. Keywords: orphans; adoption; custodianship/care; foster family; family-type orphanage; family foster care; small group home; deinstitutionalization; alternative care; alternative forms of public upbringing.

The mental health system in Portugal evolved from an institutional-centred system to a community-based system, a process which began in 1998 and has gathered pace since 2006. The approval and implementation of the Portuguese Mental Health Law and the Portuguese National Mental Health Care Plan has contributed to the implementation of institutions and regulations aimed at decentralized, local and less restrictive models of care. The implementation and evolution process has been steady and gradual, introducing many of the envisioned changes whilst adapting existing mental health institutions and services. The current article describes this transition process, attempting to identify the strengths and weaknesses of the Portuguese Mental Health System from a community-centred perspective.

A busca pela garantia dos direitos civis e sociais como direitos indissociáveis foi crescente a partir dos anos 1970, influenciando a reorganização dos modelos assistenciais à saúde diante do reconhecimento de novos sujeitos de direitos. Um dos aspectos mais evidentes desse cenário no Brasil foi a visibilidade da Reforma Psiquiátrica como parte estruturante da Reforma Sanitária Brasileira que acompanhou o movimento dos direitos humanos. Este estudo tem como elemento central contribuir com a qualificação do processo de monitoramento da política de saúde mental pelo Ministério Público Estadual a partir da observância dos principais aspectos debatidos academicamente em relação ao processo de desinstitucionalização de pessoas. Trata-se de uma pesquisa qualitativa constituída de busca sistemática de evidências nas literaturas técnica (normativas, portarias, leis, resoluções) e científica, a partir de dados eletrônicos da Biblioteca Virtual em Saúde e que utilizou como descritores: “desinstitucionalização” AND “saúde mental” OR “hospitais psiquiátricos”. Destaca-se que o Ministério Público é uma instituição permanente e essencial do Estado de Direito, incumbido por obrigação constitucional de atuar na defesa dos interesses sociais, da ordem jurídica e do regime democrático. The guarantee civil and social rights as inseparable rights has been increasingly sought for since the 1970s and has influenced the reorganization of health care models in face of the recognition of new subjects of right. In Brazil, one of the most evident aspects of this scenario was the visibility of the Psychiatric Reform as a structuring part of the Brazilian Health Reform that treaded along the human rights movement. This study aims to contribute to the qualification of the mental health policy monitoring process by the State Prosecutor’s Office, based on the compliance with the main points of academic debates on process of deinstitutionalization of people. This is a qualitative research study consisting of a systematic search for evidence in technical (norms, ordinances, laws, resolutions) and scientific literature, based on electronic data from the Biblioteca Virtual em Saúde and using the descriptors: “deinstitutionalization” AND “mental health” OR “psychiatric hospitals”. It should be noted that the Brazilian Public Prosecution Service is a permanent and essential institution of the rule of law, entrusted with the constitutional obligation of acting in defense of social interests, the legal system and the democratic regime.

Expenditures on mental health care in the Czech Republic are not being published regularly, yet they are indispensable for evaluation of the ongoing reform of Czech mental health care. The main objective of this study is to estimate the size of these expenditures in 2015 and make a comparison with the last available figures from the year 2006. The estimation is based on an OECD methodology of health accounts, which structures health care expenditures according to health care functions, provider industries, and payers. The expenditures are further decomposed according to diagnoses, and inputs used in service production. The amount spent on mental health care in 2015 reached more than 13.7 billion Czech korunas (EUR 501.6 million), which represented 4.08% of the total health care expenditures. This ratio is almost identical with the 2006 share (4.14%). There are no significant changes in the relative expenditures on mental health care and in the structure of service provision. The Czech mental health care system remains largely hospital based with most of all mental health care expenditures being spent on inpatient care. Future developments in the expenditures will indicate the success of the current effort to deinstitutionalise mental health care. Electronic supplementary material The online version of this article (10.1007/s11126-019-09688-3) contains supplementary material, which is available to authorized users.

In the wake of COVID-19, non-profit organizations that focus on providing social support services in Russia consolidated their efforts to take proactive measures to change internaty 1, the system of institutions for people with physical, mental, and intellectual disabilities. As a result of advocacy efforts by the non-profit organizations, 26 people from these institutions were evacuated and provided with temporary assisted housing. The decision to act proactively to prevent the spread of the virus among the residents of the institutions is indicative of the galvanized efforts of the non-profit sector to advocate for deinstitutionalization and assisted living. COVID-19 served as an opportunity for the non-profit organizations to emphasize the need for expediting deinstitutionalization reform. Drawing on media sources, the literature on disability and advocacy in Russia, and the conceptual framework of citizenship, this paper will provide an overview of the internaty system, analyze the legislative context of disability and COVID-19, and discuss the context of deinstitutionalization advocacy in Russia.

Objective.We aimed to systematically review risk factors for criminal recidivism in individuals given community sentences.Methods.We searched seven bibliographic databases and additionally conducted targeted searches for studies that investigated risk factors for any repeat offending in individuals who had received community (non-custodial) sentences. We included investigations that reported data on at least one risk factor and allowed calculations of odds ratios (ORs). If a similar risk factor was reported in three or more primary studies, they were grouped into domains, and pooled ORs were calculated.Results.We identified 15 studies from 5 countries, which reported data on 14 independent samples and 246,608 individuals. We found that several dynamic (modifiable) risk factors were associated with criminal recidivism in community-sentenced populations, including mental health needs (OR = 1.4, 95% confidence interval (CI): 1.2–1.6), substance misuse (OR = 2.3, 95% CI: 1.1–4.9), association with antisocial peers (OR = 2.2, 95% CI: 1.3–3.7), employment problems (OR = 1.8, 95% CI: 1.3–2.5), marital status (OR = 1.6, 95%: 1.4–1.8), and low income (OR = 2.0, 95% CI: 1.1–3.4). The strength of these associations was comparable to that of static (non-modifiable) risk factors, such as age, gender, and criminal history.Conclusion.Assessing dynamic (modifiable) risk factors should be considered in all individuals given community sentences. The further integration of mental health, substance misuse, and criminal justice services may reduce reoffending risk in community-sentenced populations.

Objectives Evidence regarding the relationships between patient, hospital, and regional factors and early unplanned readmission (short-term outcome) in patients with bipolar disorder is lacking. This study aimed to examine risk factors associated with early unplanned readmission in patients with bipolar disorder. Method We retrospectively analyzed adult bipolar patients (ICD-10; F31) between April 2012 and March 2014 in the Japanese Diagnosis Procedure Combination database. We examined factors affecting the 30-day unplanned readmission using multivariable logistic regression analysis. Results A total of 2688 patients admitted to psychiatric beds were included. Multivariate analysis showed that unchanged or exacerbation discharge outcome (adjusted odds ratio [aOR]: 1.93; 95% confidence interval [CI]: 1.06–3.51, p = 0.031), unplanned or urgent admission settings (aOR: 1.51; 95% CI: 1.00–2.26, p = 0.048), physical comorbidity (chronic pulmonary disease) (aOR: 4.74; 95% CI: 1.30–17.29, p = 0.018), presence of psychiatric acute-care beds (aOR: 1.72; 95% CI: 1.02–2.87, p = 0.040), and intermediate-level hospital psychiatric staffing (aOR: 1.82; 95% CI: 1.14–2.91, p = 0.012) were significantly associated with higher early unplanned readmission, while higher density of psychiatrists in the area (aOR: 0.50; 95% CI: 0.29–0.87, p = 0.014) was significantly associated with lower early unplanned readmission. Conclusions The results suggest that not only careful management of high-risk patients but also consideration of functional differentiation in psychiatric inpatient care, psychiatric resource allocation, and follow-up support for patients with bipolar disorder are needed for reducing the early unplanned readmission rate.

This study tests several hypotheses regarding the impact of deinstitutionalization of inpatient care on levels of psychiatric disability. It employs a secondary analysis of existing datasets from the World Health Organization's mental health program, the Global Burden of Disease study, as well as supplemental datasets on the national environments examined. The primary model accounts for 87.1% of the variation in global disability levels, but only a quarter or 28.3% of the recent changes in these levels between 1990 and 2015. One of the most important predictors of declines in mental disability is the proportion of a nation's health budget that is invested in mental health services.

Background In Italy the Law 9/2012 prescribed the total closure of forensic psychiatric hospitals (OPGs) and the conversion to a care model based on residential units in the community employing only clinical personnel (Residenze per l'Esecuzione delle Misure di Sicurezza – REMS) and fully integrated in public mental health services. The aim of this study is to report sociodemographic, clinical and criminological characteristics of patients admitted in Volterra REMS since it opened on 01/12/15 up to 31/12/17. Methods Sociodemographic and clinical information was collected from official documents (clinical files, ward reports) and from patients' personal health records. Psychiatric diagnoses were made by REMS psychiatrists according to the DSM-5 criteria. Criminological information was obtained from patients' criminal records. Results Volterra REMS patients' characteristics are similar to those of samples of OPGs patients (unmarried socially disadvantaged males with an average age of 40, no offsprings, low education, high rates of Schizophrenia Spectrum Disorders and medical comorbidity). However, the REMS model presents a very high turnover rate: during the study period 61 patients were admitted while 32 were discharged. Being assisted by public mental health services before committing the crime increased the probability of discharge. In non-EU patients long acting injectable antipsychotics were used more frequently than in community ones. Substance-Related Disorders are the main psychiatric comorbidity and resulted as being more frequent in bipolar patients than in other patients. Conclusions Due to the high patients' turnover, we expect a progressive change in sociodemographic, clinical and criminological features of the REMS population. The REMS model provides a return for mentally disordered criminals to the care of local public mental health services which are recovering after many years some of their most challenging patients ensuring their deinstitutionalization and reintegration into society.

Summary Background The COVID-19 pandemic priorities have focused on prevention, detection, and response. Beyond morbidity and mortality, pandemics carry secondary impacts, such as children orphaned or bereft of their caregivers. Such children often face adverse consequences, including poverty, abuse, and institutionalisation. We provide estimates for the magnitude of this problem resulting from COVID-19 and describe the need for resource allocation. Methods We used mortality and fertility data to model minimum estimates and rates of COVID-19-associated deaths of primary or secondary caregivers for children younger than 18 years in 21 countries. We considered parents and custodial grandparents as primary caregivers, and co-residing grandparents or older kin (aged 60–84 years) as secondary caregivers. To avoid overcounting, we adjusted for possible clustering of deaths using an estimated secondary attack rate and age-specific infection–fatality ratios for SARS-CoV-2. We used these estimates to model global extrapolations for the number of children who have experienced COVID-19-associated deaths of primary and secondary caregivers. Findings Globally, from March 1, 2020, to April 30, 2021, we estimate 1 134 000 children (95% credible interval 884 000–1 185 000) experienced the death of primary caregivers, including at least one parent or custodial grandparent. 1 562 000 children (1 299 000–1 683 000) experienced the death of at least one primary or secondary caregiver. Countries in our study set with primary caregiver death rates of at least one per 1000 children included Peru (10·2 per 1000 children), South Africa (5·1), Mexico (3·5), Brazil (2·4), Colombia (2·3), Iran (1·7), the USA (1·5), Argentina (1·1), and Russia (1·0). Numbers of children orphaned exceeded numbers of deaths among those aged 15–50 years. Between two and five times more children had deceased fathers than deceased mothers. Interpretation Orphanhood and caregiver deaths are a hidden pandemic resulting from COVID-19-associated deaths. Accelerating equitable vaccine delivery is key to prevention. Psychosocial and economic support can help families to nurture children bereft of caregivers and help to ensure that institutionalisation is avoided. These data show the need for an additional pillar of our response: prevent, detect, respond, and care for children. Funding UK Research and Innovation (Global Challenges Research Fund, Engineering and Physical Sciences Research Council, Medical Research Council), UK National Institute for Health Research, US National Institutes of Health, and Imperial College London.

The deinstitutionalization of social care in Lithuania started in 2012 after the adoption of the strategic guidelines by the Ministry of Social Security and Labour. The goal of this reform was to improve the care conditions and introduce new community-based services for persons with disabilities. Almost ten years of the reform resulted in only five percent of persons with disabilities who moved to community settings, mainly group-living homes. The slow-motion of the reform, as well as the tensions in the communities, suggests the need for a thorough analysis of the process of deinstitutionalization and its improvement. Bronfenbrenner’s ecological theory is applied as a conceptual and methodological tool for understanding the roles of deinstitutionalization agents at different levels, including the Ministry of Social Security and Labour, municipalities, non-governmental organizations, social care institutions, and local communities. All of these agents are involved and diversely interact among themselves during the transformation process of the social care system. The ecological theory provides the necessary integrated approach to the analysis of the process of deinstitutionalization of the social care system at the micro-, meso-, exo-, and macro levels. Deinstitutionalization and the trajectories of its participants reveal resilient connections with different fields of the ecological system and show that different system components not only represent different systems but become microsystems themselves that affect all elements in the ecological system. The complexity of environmental systems constitutes the basis of ecological systems theory. It serves as a lens to guide the analysis of the transformation of a particular person’s life in the context of deinstitutionalization. Herewith, it is an appropriate tool for understanding the impact of deinstitutionalization on specific local communities.

Background A fundamental challenge for many people with severe mental illness (SMI) is how to deal with cognitive impairments. Cognitive impairments are common in this population and limit daily functioning. Moreover, neural plasticity in people with SMI appears to be reduced, a factor that might hinder newly learned cognitive skills to sustain. The objective of this pilot trial is to investigate the effects of cognitive remediation (CR) on cognitive and daily functioning in people dependent on residential settings. In addition, transcranial direct current stimulation (tDCS) is used to promote neural plasticity. It is expected that the addition of tDCS can enhance learning and will result in longer-lasting improvements in cognitive and daily functioning. Methods This is a pragmatic, triple-blinded, randomized, sham-controlled, pilot trial following a non-concurrent multiple baseline design with the participants serving as their own control. We will compare (1) CR to treatment as usual, (2) active/sham tDCS+CR to treatment as usual, and (3) active tDCS+CR to sham tDCS+CR. Clinical relevance, feasibility, and acceptability of the use of CR and tDCS will be evaluated. We will recruit 26 service users aged 18 years or older, with a SMI and dependent on residential facilities. After a 16-week waiting period (treatment as usual), which will serve as a within-subject control condition, participants will be randomized to 16 weeks of twice weekly CR combined with active (N = 13) or sham tDCS (N = 13). Cognitive, functional, and clinical outcome assessments will be performed at baseline, after the control (waiting) period, directly after treatment, and 6-months post-treatment. Discussion The addition of cognitive interventions to treatment as usual may lead to long-lasting improvements in the cognitive and daily functioning of service users dependent on residential facilities. This pilot trial will evaluate whether CR on its own or in combination with tDCS can be a clinically relevant addition to further enhance recovery. In case the results indicate that cognitive performance can be improved with CR, and whether or not tDCS will lead to additional improvement, this pilot trial will be extended to a large randomized multicenter study. Trial registration Dutch Trial Registry NL7954. Prospectively registered on August 12, 2019.

Background: The deinstitutionalization process is complex, long-term and many countries fail to achieve progress and consolidation. Informing decision-makers about appropriate strategies and changes in mental health policies can be a key factor for it. This study aimed to develop an evidence brief to summarize the best available evidence to improve care for deinstitutionalized patients with severe mental disorders in the community.Methods: We used the SUPPORT (Supporting Policy Relevant Reviews and Trials) tools to elaborate the evidence brief and to organize a policy dialogue with 24 stakeholders. A systematic search was performed in 10 electronic databases and the methodological quality of systematic reviews (SRs) was assessed by AMSTAR 2.Results: Fifteen SRs were included (comprising 378 studies and 69,736 participants), of varying methodological quality (3 high-quality SRs, 2 moderate-quality SRs, 7 low-quality SRs, 3 critically low SRs). Six strategies were identified: (i). Psychoeducation; (ii). Anti-stigma programs, (iii). Intensive case management; (iv). Community mental health teams; (v). Assisted living; and (vi). Interventions for acute psychiatric episodes. They were associated with improvements on a global status, satisfaction with the service, reduction on relapse, and hospitalization. Challenges to implementation of any of them included: stigma, the shortage of specialized human resources, limited political and budgetary support.Conclusions: These strategies could guide future actions and policymaking to improve mental health outcomes.

Vaccination plus Decarceration With the rollout of Covid vaccines, public debate regarding health in jails and prisons has increasingly shifted from decarceration toward vaccination of incarcerated...

Purpose While the number of forensic beds and the duration of psychiatric forensic psychiatric treatment have increased in several European Union (EU) states, this is not observed in others. Patient demographics, average lengths of stay and legal frameworks also differ substantially. The lack of basic epidemiological information on forensic patients and of shared indicators on forensic care within Europe is an obstacle to comparative research. The reasons for such variation are not well understood. Methods Experts from seventeen EU states submitted data on forensic bed prevalence rates, gender distributions and average length of stay in forensic in-patient facilities. Average length of stay and bed prevalence rates were examined for associations with country-level variables including Gross Domestic Product (GDP), expenditure on healthcare, prison population, general psychiatric bed prevalence rates and democracy index scores. Results The data demonstrated substantial differences between states. Average length of stay was approximately ten times greater in the Netherlands than Slovenia. In England and Wales, 18% of patients were female compared to 5% in Slovenia. There was a 17-fold difference in forensic bed rates per 100,000 between the Netherlands and Spain. Exploratory analyses suggested average length of stay was associated with GDP, expenditure on healthcare and democracy index scores. Conclusion The data presented in this study represent the most recent overview of key epidemiological data in forensic services across seventeen EU states. However, systematically collected epidemiological data of good quality remain elusive in forensic psychiatry. States need to develop common definitions and recording practices and contribute to a publicly available database of such epidemiological indicators.

A door-to-door survey was conducted on households within a one square block of a Canadian Mental Health Association Crisis Stabilization Unit (Swan River, Manitoba, Canada). This was undertaken to examine the opinions and attitudes of the members of the surveyed households regarding the neighboring community mental health residence, as well as their general attitudes toward mentally ill individuals. The survey utilized preliminary questions to obtain personal characteristics of the respondents, which were followed by 11 short questions regarding attitudes towards mental illness and the neighborhood facility. The findings of this study agree with previous research suggesting a general receptiveness on the part of community residents to deinstitutionalization and to having community mental health residents as neighbors. The personal characteristic with the greatest positive influence on attitudes was previous personal contact with mentally ill individuals. However, it was found that a segment of the population holds negative attitudes towards the CSU. The author suggests that education of the community regarding the mental health facility and mentally ill persons may improve acceptance to a greater extent.

Deinstitutionalization in psychiatry led to a decrease in hospital beds, short hospital admissions focussed on symptoms reduction, and the development of ambulatory care. However, the needs of patients who despite symptoms reduction do not display the minimal competencies to live alone or in a sheltered accommodation, are not met in such a context. They usually go through long admissions and fail to improve. In 2016, we implemented a new inpatient program focused on fostering the development of the competencies needed to adapt to living outside the hospital; the aim of this study was to evaluate if it lead to the resolution of these situations or in contrary if it turned into a long stay unit. 116 patients admitted to the program between 2016 and 2018 were included in the study. They were psychiatric inpatients who had no home, did not find a place in a sheltered accommodation and couldn't be discharged. In the majority of cases, the situation was resolved within 180 days and the majority of patients was referred to a sheltered accommodation. Functional and symptom levels improved significantly over time. A specific focus on restoring competencies to live outside of hospital allows complex patients to improve their functional level and to find a place to live in the community within a relatively short time. While deinstitutionalization has been beneficial to the vast majority of patients, denying the specific needs of a minority of patients leads to unnecessary long and inefficient hospital admissions.

Background: This study assessed the hypothesis that violent behavior prior to admission prolongs psychiatric hospitalization and evaluated the likelihood of hospital discharge to a community care setting based on demographic and clinical factors, with an emphasis on violent behavior.Methods: We retrospectively selected 362 patients who were involuntarily admitted to a psychiatric hospital in Japan from December 1, 2015 to November 30, 2017, stayed longer than planned, and underwent review by a multidisciplinary team. We assessed (a) education and marital status and history of substance abuse, (b) the presence/absence and type of violent behavior that led to hospital admission, and (c) the discharge criteria. We divided the subjects into groups according to whether they had demonstrated violent behavior prior to admission and compared demographic and clinical variables between the groups using bivariate analysis. We also analyzed data using the Cox proportional hazard model, defining discharge to the community as the outcome. Age, sex, and variables that were significant at a level of P < 0.05 based on Cox univariate analysis were included in the multivariate models using the forced entry method.Results: The Violent group included 94 patients (26%). There were no significant between-group differences in age, sex, educational background, marital history, career history, or the history of substance abuse. However, hospitalization was significantly longer in the Non-violent group. The Cox proportional multivariate hazard ratios revealed that violent behavior prior to admission resulted in a higher probability of hospital discharge.Conclusion: Violent behavior prior to admission did not significantly contribute to prolonged hospitalization in patients who deviated from the treatment plan and had exceeded the planned hospitalization duration. Our findings recommend caution when using violence and impulsiveness observed during the acute stage to predict the difficulty of long-term treatment.

Background Care policies emphasize deinstitutionalization and aging in place in response to demographic changes. Different eHealth technologies are one way to achieve this aim. However, there is a need to better understand older adults’ needs for eHealth services, and thus, these health solutions require further exploration. Objective The purpose of this systematic literature review is to appraise, synthesize, and summarize the literature on older adults’ (aged ≥60 years) eHealth learning and use in real home settings, particularly in rural and remote areas, with a focus on the social and cultural context. Methods A systematic search was conducted in January 2020 using 4 academic databases. The studies by means of qualitative thematic analysis to identify the barriers, enablers, and support practices involved in the domestication process were examined. In addition, we identified the various meanings attached to eHealth technologies for older adults living in rural and remote areas. Results In total, 31 empirical studies published between 2010 and 2020 were included in this review. A total of 17 articles included participants from rural and remote areas. The most regularly reported barriers related to older adults’ learning to use and use of eHealth were health-related difficulties, such as cognitive impairment or impaired hearing. The most reported enabler was the support provided for older adults in learning and use of eHealth. Support mainly comprised older adults’ own digital competences, which were distributed with their social network. It was found that eHealth technology is needed for rural and remote areas to facilitate access and reduce logistical barriers to health care services. Conclusions The literature review provided information and practical implications for designers, health care providers, and policy makers. On the basis of these findings, eHealth technologies should be easy to use, and adequate support should be provided to older adults for use.

Introduction: There are large differences in the development of mental health systems of the West and the countries of the former Eastern Bloc. The latter is characterized by a more biological approach to mental health and reliance on psychiatric hospitals. In 2018, Uzbekistan authorities showed interest in reforming mental health care of the country. The policy report provides an overview of progress towards the provision of community mental health (CMH) care across Eastern Europe and recommendations for this transition within Uzbekistan.Methods: A literature search on mental health care in Uzbekistan was conducted to understand its strengths and weaknesses. Progress towards the provision of CMH care across Eastern Europe was assessed using data on the number of psychiatric beds and availability of mental health services in community settings reported within the published literature. Countries identified as making the greatest progress towards CMH care were reviewed in detail to better understand the process of reform assets and barriers.Results: Mental health care in Uzbekistan is highly institutionalized, underfunded and understaffed. Social care services are poorly developed. However, current leadership has kindled the promise of mental health reform. Georgia, Lithuania and Poland have made the most progress in terms of CMH care availability. However, due to various obstacles such as dual financial burden, high stigma and lack of political will, their programs lack social integration and/or uniform availability and underfunding along with scarcity of mental health specialists are common. On the other hand, research and evaluation, involvement of service users into service planning and cooperation with donors facilitated reform implementation.Conclusion: Uzbekistan may develop into a modern mental health system and avoid the setbacks encountered by other countries in the region, through careful financial planning, stigma reduction, improving mental health literacy, human resources strategic development and civil society engagement.

Background Despite the fact that the overwhelming majority of mental health services are delivered in outpatient settings, the effect of changes in non-hospital-based mental health care on increased suicide rates is largely unknown. This study examines the association between changes in community mental health center (CMHC) supply and suicide mortality in the United States. Methods Retrospective analysis was performed using data from National Mental Health Services Survey (N-MHSS) and the Centers for Disease Control and Prevention (CDC) Wide-Ranging Online Data for Epidemiologic Research (WONDER) (2014–2017). Population-weighted multiple linear regressions were used to examine within-state associations between CMHCs per capita and suicide mortality. Models controlled for state-level characteristics (i.e., number of hospital psychiatric units per capita, number of mental health professionals per capita, age, race, and percent low-income), year and state. Results From 2014 to 2017, the number of CMHCs decreased by 14% nationally (from 3406 to 2920). Suicide increased by 9.7% (from 15.4 to 16.9 per 100,000) in the same time period. We find a small but negative association between the number of CMHCs and suicide deaths (− 0.52, 95% CI − 1.08 to 0.03; p = 0.066). Declines in the number of CMHCs from 2014 to 2017 may be associated with approximately 6% of the national increase in suicide, representing 263 additional suicide deaths. Conclusions State governments should avoid the declining number of CMHCs and the services these facilities provide, which may be an important component of suicide prevention efforts.

Background: Knowledge Translation (KT) is an effective strategy that uses the best available research evidence to bring stakeholders together to develop solutions and improve public health policy-making. Despite progress, the process of deinstitutionalisation in Brazil is still undergoing consolidation, and the changes and challenges that are involved in this process are complex and necessitate evidence-informed decision-making. Accordingly, this study used KT tools to support efforts that aim to improve the care that is available to deinstitutionalised people with severe mental disorders in Brazil. Methods: We used the Supporting Policy relevant Reviews and Trials (SUPPORT) Tools for evidence-informed health Policymaking (STP) and followed eight steps: 1) capacity building; 2) identification of a priority policy issue within a Brazilian public health system; 3) meetings with policy-makers, researchers and stakeholders; 4) development of an evidence brief (EB) that addresses the problem of deinstitutionalisation; 5) facilitating policy dialogue (PD); 6) the evaluation of the EB and PD; 7) post-dialogue mini-interviews; and 8) dissemination of the findings. Results: Capacity building and meetings with key informants promoted awareness about the gap between research and practice. Local findings were used to define the problem and develop the EB. Twenty-four individuals (policy-makers, stakeholders, researchers, representatives of the civil society and public defence) participated in the PD. They received the EB to subsidise their deliberations during the PD, which in turn were used to validate and improve the EB. The PD achieved the objective of promoting an exhaustive discussion about the problem and proposed options and improved communication and interaction among those who are involved in mental health care. The features of both the EB and PD were considered to be favourable and helpful. Conclusions: The KT strategy helped participants understand different perspectives and values, the interpersonal tensions that exist among those who are involved in the field of mental health, and the strategies that can bridge the gap between research and policy-making. The present findings suggest that policy dialogues can influence practice by promoting greater engagement among stakeholders who formulate or revise mental health policies.

Objective: to analyze the process of deinstitutionalization resulting from a psychiatric hospital shut down, and know the fate of users after dehospitalization. Method: a descriptive, qualitative study based on the critical-analytical perspective, which had as its setting the Hospital Colônia de Rio Bonito. Institutional documents and narratives of five managers who participated in the deinstitutionalization process were analyzed. Results: Hospital Colônia deinstitutionalization lasted longer than expected. For this to happen, a tripartite intervention was necessary, and especially the mobilization of networks and implementation of Psychosocial Care Networks by the cities. Regarding destination of users, most were referred to therapeutic or transinstitutionalized residences. Final considerations: Hospital Colônia deinstitutionalization led to the establishment of connections between services and people. This was a powerful device for the implementation of Psychosocial Care Networks at municipal level. RESUMEN Objetivo: analizar el proceso de desinstitucionalización resultante del cierre de un hospital psiquiátrico, y conocer el destino de los usuarios después de salir del hospital. Método: Estudio descriptivo, cualitativo, que tuvo como escenario el Hospital Colônia de Rio Bonito. Se analizaron documentos institucionales y narrativas de cinco gestores que participaron del proceso de desinstitucionalización. Resultados: el proceso de desinstitucionalización del Hospital Colônia duró un tiempo mayor que lo esperado. Para que se concretizara, fue necesaria una intervención tripartita y, especialmente, la movilización e implementación de las Redes de Atención Psicosocial por los municipios que internaban. Cuanto al destino de los usuarios, la mayor parte fue encaminada para residencias terapéuticas o transinstitucionalizadas. Consideracion finales: el proceso de desinstitucionalización del Hospital Colônia provocó el estabelecimiento de conexiones entre los servicios y las personas, deduciéndose que este fue un dispositivo potente para implementar las Redes de Atención Psicosocial en el ámbito municipal. RESUMO Objetivo: analisar o processo de desinstitucionalização resultante do fechamento de um hospital psiquiátrico, e conhecer o destino dos usuários após a desospitalização. Método: estudo descritivo, qualitativo, fundamentado na perspectiva crítico-analítica, que teve como cenário o Hospital Colônia de Rio Bonito. Foram analisados documentos institucionais e narrativas de cinco gestores que participaram do processo de desinstitucionalização. Resultados: o processo de desinstitucionalização do Hospital Colônia durou um tempo maior que o esperado. Para que se concretizasse, foi necessária uma intervenção tripartite e, especial, a mobilização das redes e implementação das Redes de Atenção Psicossocial pelos municípios internantes. Quanto ao destino dos usuários, a maior parte foi encaminhada para residências terapêuticas ou transinstitucionalizada. Considerações finais: o processo de desinstitucionalização do Hospital Colônia provocou o estabelecimento de conexões entre serviços e pessoas, inferindo-se que este foi um dispositivo potente para a implementação das Redes de Atenção Psicossocial em âmbito municipal.

There are significant barriers to the development of a ‘balanced model’ of mental health in low-income countries. These include gaps in the evidence base on effective responses to severe mental health issues and what works in the transition from hospital to home, and a low public investment in primary and community care. These limitations were the drivers for the formation of the non-government organization, YouBelong Uganda (YBU), which works to contribute to the implementation of a community-based model of mental health care in Uganda. This paper overviews an intervention protocol developed by YBU, which is a combined model of parallel engagement with the national mental hospital in Kampala, Uganda, movement of ‘ready for discharge’ patients back to their families and communities, and community development. The YBU programme is theoretically underpinned by a capabilities approach together with practical application of a concept of ‘belonging’. It is an experiment in implementation with hopes that it may be a positive step towards the development of an effective model in Uganda, which may be applicable in other countries. Finally, we discuss the value in joining ideas from social work, sociology, philosophy, public health and psychiatry into a community mental health ‘belonging framework’.

Resumo: Passados quase vinte anos de implantação da reforma psiquiátrica no Brasil, o país conta com uma assistência à saúde mental híbrida, na qual os serviços asilares são parte da própria rede que deveria substituí-los. Este estudo buscou analisar criticamente a oferta dos serviços de assistência à saúde mental no país, no intuito de identificar se efetivamente decorre um processo de substituição dos serviços de ênfase asilar pelos comunitários. Para alcançar o objetivo, foi realizado um estudo longitudinal retrospectivo da oferta de serviços de assistência à saúde mental no Brasil, no período de 2008 a 2017, com a elaboração de uma base de dados única com informações dos 5.570 municípios. Como ferramenta auxiliar da análise crítica da reforma psiquiátrica, foi construído o Índice de Cobertura Assistencial da Rede de Atenção Psicossocial (iRAPS), considerando-se a parametrização legal dos serviços. Foi verificado o avanço da oferta dos serviços comunitários e a redução dos asilares. Porém, com o iRAPS identificou-se que 77% da população brasileira habitam localidades com cobertura de serviços comunitários baixa ou inexistente. As pequenas cidades, que concentram 16% da população nacional, foram as que mais impulsionaram o avanço do iRAPS em nível nacional. Apenas 439 cidades, 7,9% do total, apresentam cobertura assistencial total da Rede de Atenção Psicossocial (RAPS), expressando apenas 6,69% da populacional nacional. As metrópoles, que concentrarem 46% da população brasileira, não apresentaram avanço na cobertura de serviços comunitários. A análise da oferta de serviços de saúde mental com base no iRAPS permiti-nos afirmar que o avanço dos serviços comunitários ocorreu de forma não homogênea entre as localidades. Abstract: Nearly 20 years after the implementation of Brazil’s psychiatric reform, the country has a hybrid model of mental health care, in which asylum services are part of the network that should replace them. This study aimed to critically analyze the supply of mental health services in Brazil in order to verify whether there is actually a replacement of asylum-based services by community-based services. A retrospective longitudinal study was performed on the supply of mental health services in Brazil from 2008 to 2017, building a single database on 5,570 municipalities (counties). As an ancillary tool for critical analysis of the psychiatric reform, we developed the Health Coverage Index for the Psychosocial Care Network (iRAPS, in Portuguese), considering the services legal parametrization. The results showed an increase in the supply of community-based services and a reduction in asylum services. However, the iRAPS tool found that 77% of the Brazilian population lives in areas with low or nonexistent coverage of community services. Small towns, with 16% of the Brazilian population, were those with the greatest increase in iRAPS. Only 439 cities, 7.9% of the total, showed total coverage by the Psychosocial Care Network (RAPS, in Portuguese), expressing only 6.69% of the national population. The metropolises, with 46% of the Brazilian population, did not show an increase in community services. The analysis of the supply of mental health services based on the iRAPS tool showed that the increase in community services did not occur homogeneously across the country. Resumen: Transcurridos casi veinte años desde la implantación de la reforma psiquiátrica en Brasil, el país cuenta con una asistencia a la salud mental híbrida, en la que los servicios de acogida a enfermos mentales son parte de la propia red que debería substituirlos. Este estudio buscó analizar críticamente la oferta de los servicios de asistencia a la salud mental del país, con el fin de identificar si, efectivamente, deriva en un proceso de sustitución de los servicios de acogida por parte de los comunitarios. Para alcanzar el objetivo, se realizó un estudio longitudinal retrospectivo de la oferta de servicios de asistencia a la salud mental en Brasil, durante el período de 2008 a 2017, con la elaboración de una base de datos única con información de los 5.570 municipios. Como herramienta auxiliar del análisis-crítico de la reforma psiquiátrica, se creó el Índice de Cobertura Asistencial de la Red de Atención Psicosocial (iRAPS), considerando la parametrización legal de los servicios. Se verificó el avance de la oferta de los servicios comunitarios y la reducción de los de acogida. No obstante, con el iRAPS se identificó que un 77% de la población brasileña vive en localidades con cobertura de servicios comunitarios baja o inexistente. Las ciudades pequeñas, que concentran a un 16% de la población nacional, fueron las que más impulsaron el avance del iRAPS a nivel nacional. Apenas 439 ciudades, 7,9% del total, presentan cobertura asistencial total de la Red de Atención Psicosocial (RAPS), suponiendo solamente un 6,69% de la poblacional nacional. Las metrópolis, que concentraron un 46% de la población brasileña, no presentaron un avance en la cobertura de los servicios comunitarios. El análisis de la oferta de servicios de salud mental a partir del iRAPS nos permitió afirmar que el avance de los servicios comunitarios se produjo de forma no homogénea entre las localidades.

Background Take-home naloxone (THN) programmes are an evidence-based opioid overdose prevention initiative. Elevated opioid overdose risk following prison release means release from custody provides an ideal opportunity for THN initiatives. However, whether Australian prisoners would utilise such programmes is unknown. We examined the acceptability of THN in a cohort of male prisoners with histories of regular injecting drug use (IDU) in Victoria, Australia. Methods The sample comprised 380 men from the Prison and Transition Health (PATH) Cohort Study; all of whom reported regular IDU in the 6 months prior to incarceration. We asked four questions regarding THN during the pre-release baseline interview, including whether participants would be willing to participate in prison-based THN. We describe responses to these questions along with relationships between before- and during-incarceration factors and willingness to participate in THN training prior to release from prison. Results Most participants (81%) reported willingness to undertake THN training prior to release. Most were willing to resuscitate a friend using THN if they were trained (94%) and to be revived by a trained peer (91%) using THN. More than 10 years since first injection (adjusted odds ratio [AOR] 2.22, 95%CI 1.03–4.77), having witnessed an opioid overdose in the last 5 years (AOR 2.53, 95%CI 1.32–4.82), having ever received alcohol or other drug treatment in prison (AOR 2.41, 95%CI 1.14–5.07) and injecting drugs during the current prison sentence (AOR 4.45, 95%CI 1.73–11.43) were significantly associated with increased odds of willingness to participate in a prison THN programme. Not specifying whether they had injected during their prison sentence (AOR 0.37, 95%CI 0.18–0.77) was associated with decreased odds of willingness to participate in a prison THN training. Conclusion Our findings suggest that male prisoners in Victoria with a history of regular IDU are overwhelmingly willing to participate in THN training prior to release. Factors associated with willingness to participate in prison THN programmes offer insights to help support the implementation and uptake of THN programmes to reduce opioid-overdose deaths in the post-release period.

OBJECTIVE The objective of this study was to evaluate the impact of Minnesota's Return to Community Initiative (RTCI) on postdischarge outcomes for nursing home residents transitioned through the program. DATA SOURCES Secondary data were from the Minimum Data Set and RTCI staff (January 2015 to December 2016), state Medicaid eligibility files and death records. The sample consisted of 29,201 nursing home discharges in Minnesota occurring in 2015. RESEARCH DESIGN Cox proportional hazard models were used to compare 1-year postdischarge outcomes of nursing home readmission, mortality, and Medicaid conversion for RTCI assisted community discharges and a propensity-matched sample of unassisted community discharges. RESULTS The majority (60%) of RTCI assisted discharges remained alive, in the community and not having converted at Medicaid at 1 year after discharge. Time to mortality was significantly lower for the assisted group than the unassisted group, but time to readmission and Medicaid conversion were similar. CONCLUSION The RTCI assisted residents fared well postdischarge in their time to mortality, nursing home readmission, and Medicaid conversion; they lived longer than a propensity-matched sample of their peers.

In Circles of Support and Accountability (CoSA), trained volunteers support an individual convicted for sexual offenses to reintegrate safely into the community. Developed in Canada, CoSA has been established in many jurisdictions with a growing number of volunteers; however, little is known about whether the training and support provided meets volunteer needs. Using a mixed-methods approach, the aim of the present research was to explore New Zealand CoSA volunteer experiences of the training and support they received and their perceptions about what contributed to the effective operation of a circle. In total, 18 volunteers took part in an interview and 23 volunteers completed a questionnaire. The findings found a mixed response to the training and support received, whereby some volunteers thought the training and support was adequate, whereas other felt the training support they received was inadequate. Findings also illustrate that adequate training, having access to a circle coordinator, selecting the right volunteers and core member, clear communication, and setting up boundaries were important factors in maintaining an effective circle. Findings are discussed in terms of implications for the training and support offered to current and future volunteers, as well as for maintaining the effectiveness of future circles.

Deinstitutionalisation in Ireland began following the impetus of the successful transfer of psychiatric patients into the community in other countries. This study sought to evaluate the quality of life (QoL) and social functioning (SF) of former long-stay institutionalised patients with severe and enduring mental illness who had been relocated into local community settings and followed up 10 years later. One month prior to hospital closure, 87 former long-stay psychiatric patients, the majority of whom had a diagnosis of schizophrenia, were assessed on a range of QoL and SF measures. Patients were followed-up 10 years later in the community, to evaluate baseline predictors of quality of life and social functioning. Study completers (n = 35) improved significantly on a range of QoL and SF measures over the 10 year period. Specific improvements were noted in domestic skills (t = − 2.8, p

Direct support workers play an important role in the social integration process of people with intellectual disabilities. However, time restrictions and client-worker ratios may make improvements to even physical integration difficult, and in some cases almost impossible. This research, conducted in the Netherlands, investigated the role of volunteers in enhancing the physical integration of people with intellectual disabilities, as the first step towards social integration. Study 1 involved an exploratory inventory of volunteer tasks in a large disability service organisation; in Study 2, support workers completed a questionnaire in which they rated the tasks suitable for volunteers to undertake. Most volunteers performed activities that enabled people with intellectual disabilities to be physically integrated in the community. The most frequent of these was "assisting with group activities." Most support workers believed that supporting community-based activities was not a suitable task for volunteers. Although volunteers already play a role in the social integration of people with intellectual disabilities, support workers did not acknowledge or were unaware of this role and the associated current and future possibilities for supporting people with intellectual disabilities.

Aim.Italy pioneered deinstitutionalisation over the past 60 years and enforced a famous mental health (MH) reform law in 1978. Deinstitutionalisation has been completed with the very closure of all psychiatric hospitals over two decades.Methods.After 40 years of implementation, this article presents the main achievements and challenges of the Italian MH reform law, including its long-term effect and impact in Italy and abroad.Results.The Legislation of 1978 was based on the discovery of rights as a key tool in mental healthcare. At the climax of crisis of psychiatric hospitals as total institutions in this country, through the new community-based system of care, it has fostered the lowest rate of involuntary care and gave back the full citizenship to people with MH disorders. This act was also part of a social movement for expanding civil and social rights, and a promise of a true paradigm shift not only in psychiatry, but also in the way of providing an adequate welfare community for all citizens. According to the WHO, the Italian city of Trieste, together with its region, is a practical example of how the Italian movement achieved deinstitutionalisation, intended as a complex process resulting in the gradual relocation of the economic and human resources and subsequent creation of 24 h services together with the development of social inclusion programmes.Conclusions.Even if the great principles of the Italian reform law were anticipatory (e.g., the UN Convention on Rights of Persons with Disabilities – CRPD), the law application has been poorly provided with resources and did not follow those avant-garde experiences as models. Limitations are evident today especially at the organisational levels, such as services capable to take up the challenge and transforming the field, left free from the imprint of total institutions. These endemic critical aspects concerning to implementation policies, together with the financial crisis of the Italian healthcare system, must be taken into consideration for a re-launch of this historical law. The rights-based approach opened by the Law 180 should now take into consideration the new legal situation caused by the CRPD worldwide in the area of individuals’ human rights, especially about the issue of legal capacity and related involuntary care.

The U.S. government has a long tradition of providing direct care services to many of its most vulnerable citizens through market-based solutions and subsidized private entities. The privatized welfare state has led to the continued displacement of some of our most disenfranchised groups in need of long-term care. Situated after the U.S. deinstitutionalization era, this is the first study to examine how immigrant Filipino women emerged as owners of de facto mental health care facilities that cater to the displaced, impoverished, severely mentally ill population. These immigrant women–owned businesses serve as welfare state replacements, overseeing the health and illness of these individuals by providing housing, custodial care, and medical services after the massive closure of state mental hospitals that occurred between 1955 and 1980. This study explains the onset of these businesses and the challenges that one immigrant group faces as owners, the meanings of care associated with their de facto mental health care enterprises, and the conditions under which they have operated for more than 40 years.

OBJECTIVE: This study assessed the contribution of a form of outpatient commitment—community treatment orders (CTOs)—to mortality risk and quality of life of patients with severe mental illness. METHODS: Data (2000–2012) were obtained from the Australian National Death Index, Victoria Department of Health, Victoria police records, and National Outcomes and CaseMix Collection quality-of-life records for patients in the Victorian Psychiatric Case Register/RAPID with a history of psychiatric hospitalization: CTO cohort, N=11,424; non-CTO cohort, N=16,161. The contribution of CTOs to mortality risk associated with CTO facilitation of access to general medical care and prevention of criminal involvement was assessed with logistic regression models. Cohort differences in quality of life were also examined. RESULTS: A total of 2,727 patients (10%) in the overall sample died, and the sample had a higher mortality risk than the general population. Probability of death by any cause was 9% lower in the CTO cohort than in the non-CTO cohort. Facilitation of access to medical care accounted for a 20% reduction in risk of non–injury-related deaths in the CTO cohort, compared with the non-CTO cohort. Risk of death by self-harm was 32% higher, compared with the non-CTO cohort. CTO placement appeared to lead to a gain of 3.8 years of life among men and 2.4 years among women, compared with the non-CTO cohort. Quality-of-life scores were modestly less favorable for the non-CTO cohort. CONCLUSIONS: CTO placement was associated with lower mortality risk via facilitated access to medical care and with modest enhancement of quality of life.

Objective This study was performed to examine the changes in psychiatric hospitalization in Korea after the mental health law revision of 2017 with consideration of the COVID-19 pandemic. Methods The data were obtained from National Health Insurance and Medical Aid statistical yearbooks of 2011–2020. The changes in the inpatient and outpatient utilization for schizophrenia from 2011 to 2020 were compared with those for other psychiatric disorders and the general population. With difference-in-differences analysis, the changes in utilization of inpatient and outpatient care for schizophrenia after the law revision of 2017 were analyzed with two comparison groups. Results While the number of inpatients and inpatient days for schizophrenia decreased between 2017 and 2019, the number of outpatients and outpatient visits for schizophrenia increased during the period. Inpatient care utilization in two comparison groups increased during the same period. Whereas the COVID-19 pandemic of 2020 led to a general decrease in health care use among the population including inpatient care for schizophrenia, the number of outpatients for schizophrenia increased slightly after the pandemic. Difference-in-differences analysis showed that the law revision was associated with the decrease in the use of inpatient care for schizophrenia after adjustment for the effect of the COVID-19 pandemic. Conclusions The mental health law revision in Korea led to a significant decrease in hospitalization for schizophrenia. However, the limited effect of revision on the Medical Aid beneficiaries suggests that the revision was not followed by the provision of the proper alternatives which can replace hospitalization of the most vulnerable population.

Suicide is an increasingly serious public health care concern worldwide. The impact of decreased in-house psychiatric resources on emergency care for suicidal patients has not been thoroughly examined. We evaluated the effects of closing an in-hospital psychiatric ward on the prehospital and emergency ward length of stay (LOS) and disposition location in patients who attempted suicide. This was a retrospective before-and-after study at a community emergency department (ED) in Japan. On March 31, 2014, the hospital closed its 50 psychiatric ward beds and outpatient consultation days were decreased from 5 to 2 days per week. Electronic health record data of suicidal patients who were brought to the ED were collected for 5 years before the decrease in in-hospital psychiatric services (April 1, 2009–March 31, 2014) and 5 years after the decrease (April 1, 2014–March 31, 2019). One-to-one propensity score matching was performed to compare prehospital and emergency ward LOS, and discharge location between the 2 groups. Of the 1083 eligible patients, 449 (41.5%) were brought to the ED after the closure of the psychiatric ward. Patients with older age, burns, and higher comorbidity index values, and those requiring endotracheal intubation, surgery, and emergency ward admission, were more likely to receive ED care after the psychiatric ward closure. In the propensity matched analysis with 418 pairs, the after-closure group showed a significant increase in median prehospital LOS (44.0 minutes vs 51.0 minutes, P

How things are perceived from a distance may help better understand their nature. Perceptions at home are likely to shape perceptions abroad. The mutual cross-references between local and distant perspectives on the Italian Mental Health Law 180 may help understand the process which preceded and resulted in the reform. This editorial argues that Law 180 came about at a unique – enabling – time in history. It argues that the run-up to and passing of Law 180 constituted a great accomplishment by professionals, the wider public and politicians/administrators. This editorial goes on to argue that the profession managed to cope with (many) adverse effects of the reform. The attention that Law 180 has received internationally should be devoted to other national (or regional) mental health reform processes as this may help us to understand how mental health care systems evolve and what defines ‘windows of (operative) opportunity’ or ‘moments for (public) action’.

Global consensus and national policies have emphasized deinstitutionalization, or a shift in providing mental health care from institutional to community settings. Yet, psychiatric hospitals and asylums receive the majority of mental health funding in many countries, at odds with research evidence that suggests that services should be delivered in the community. Our aim is to investigate the norms, actors, and strategies that influence the uptake of deinstitutionalization internationally. Our study is informed by prior literature on management and implementation science. The success and failure of mental health care operations depend on identifying and overcoming challenges related to implementing innovations within national contexts. We surveyed 78 experts spanning 42 countries on their knowledge and experiences in expanding community-based mental health care and/or downsizing institution-based care. We also asked them about the contexts in which said methods were implemented in a country. We found that mental health care, whether it is provided in institutions or in the community, does not seem to be standardized across countries. Our analysis also showed that moving deinstitutionalization forward requires meaningful engagement of three types of actors: government officials, health care professionals, and local experts. Progress toward deinstitutionalization depends on the partnerships formed among these actors and with diverse stakeholders, which have the potential to garner resources and to scale-up pilot projects. In conclusion, different countries have adapted deinstitutionalization in ways to meet idiosyncratic situations and population needs. More attention should be given to the management and implementation strategies that are used to augment treatment and preventive services.

BackgroundThe process of deinstitutionalization (community-based care) has been shown to be associated with better quality of life for those with longer-term mental health problems compared to long stay hospitals. This project aimed to investigate the relationship between national progress towards deinstitutionalization and (1) quality of longer-term mental health care (2) service users’ ratings of that care in nine European countries.MethodsQuality of care was assessed in 193 longer-term hospital- and community-based facilities in Bulgaria, Germany, Greece, Italy, the Netherlands, Poland, Portugal, Spain and the UK. Data on users’ ratings of care were collected from 1579 users of these services. Country level variables were compiled from publicly available data. Multilevel models were fit to assess associations with quality of care and service user experiences of care.ResultsSignificant positive associations were found between deinstitutionalization and (1) five of seven quality of care domains; and (2) service user autonomy. A 10% increase in expenditure was associated with projected clinically important improvements in quality of care.ConclusionsGreater deinstitutionalization of mental health mental health services is associated with higher quality of care and better service user autonomy.

This article analyzes spending on mental health by the Brazilian Ministry of Health between 2001 and 2014. It is documental research of the Brazilian Ministry of Health's databases. It analyzes the data using descriptive statistical analysis. Total spending on mental health for the period 2001 to 2014 shows a percentage increase in resources destined for outpatient care, but this increase is a reallocation from hospital services to community-based services and total resources for the mental health program remain at an average of 2.54% of the total health budget. Within outpatient expenditure, spending on medications remains high. Professionals committed to psychiatric reform fight to guarantee that a small fraction of the surplus appropriated by the state is directed towards social policies.

Aim The aim of this paper is to analyse the main issues and obstacles to optimizing the organization of mental healthcare and the strategies that should be applied by presenting the examples from practice. Results Outcomes of mental healthcare are in relation with ‘improved legislation’ and the introduction of up-to-date management and economic concepts including continuous treatment model, in addition to the advantages and disadvantages in the provision of mental healthcare within primary and secondary inpatient and outpatient healthcare. Some of these lessons are learned from reforms implemented in Serbia.

Over the past 50 years, deinstitutionalization changed the face of psychiatry. However, outpatient treatment in the community does not always fit the needs of those who left institutions and sometimes leads to frequent re-hospitalizations, a mechanism known as the “revolving door” phenomenon. The study aim was to identify different typologies of hospitalization trajectories. Records of 892 inpatients from the Department of Psychiatry of Lausanne University Hospital were analyzed over a 3-year period with discrete sequential-state analysis. Trajectories could be split between atypical users (4.9% of patients totalling 30.6% of hospital days) and regular users. Within the atypical users group, three categories were identified: “Permanent stays” (3 patients totalling 6.3% of hospital days), “long stays” (1.7% patients/8.6% hospital days) and “revolving door” stays (2.9% patients/15.8% hospital days). The remaining 95.1% of the patients were classified into “unique episodes” (70.0% patients/24.5% hospital days) and “repeated episodes” (25.0% patients/44.9% hospital days). Diagnoses of schizophrenia were overrepresented among heavy users. Most patients went through a unique or low number of brief hospital admissions over the 3 years of the study. While the shift of previously institutionalized individuals towards high users of psychiatric hospital seems limited, this phenomenon should not be neglected since 4.9% of patients use about a third of hospital beds. Early identification of problematic profiles could allow the implementation of relapse prevention strategies and facilitate the development of alternatives to hospitalization such as assertive community treatment or housing first programs.

Background : Over the past few decades, there has been an emphasis on the de-institutionalisation of psychiatric care with a focus on community care. With Quality of Life (QoL) as an outcome measure, this study compared the QoL of patients with schizophrenia attending a psychiatric hospital and a community psychiatric centre. Design : This was a cross-sectional study in two psychiatric facilities Methods : Data were obtained through a socio-demographic and clinical questionnaire; the QoL was assessed with the WHOQOL-BREF and patient satisfaction with care with CPOSS. Total and domain scores of WHOQOL-BREF for each group were calculated and compared with each other and other group characteristics. Diagnosis of schizophrenia was based on ICD-10. Results : Participants from the two centres did not differ significantly on any of the socio-demographic characteristics measured. Similarly, there was no significant difference in their overall mean WHOQOL-BREF scores as well as the mean WHOQOL-BREF of domain scores. However, the married and females from both centres significantly had higher mean WHOQOL-BREF scores than their male counterparts. Patients in remission for more than two years or those on a single type of medication (either oral or depot preparation) from both centres significantly had higher mean WHOQOL-BREF score compared with those who had less than two years of remission or on both oral and depot preparations. Conclusion : Overall QoL of patients managed at the two centres was comparable, with similar socio-demographic as well as clinical variables influencing QoL. This suggests that patients with schizophrenia can be well managed at community psychiatric centres. Keywords : schizophrenia, quality of life, community psychiatric care, psychiatric hospital, patient satisfaction, treatment outcomes F unding : None declared

ObjectiveTo review systematically the evidence on how deinstitutionalisation affects quality of life (QoL) for adults with intellectual disabilities.DesignSystematic review.PopulationAdults (aged 18 years and over) with intellectual disabilities.InterventionsA move from residential to community setting.Primary and secondary outcome measuresStudies were eligible if evaluating effect on QoL or life quality, as defined by study authors.SearchWe searched MEDLINE, PsycINFO, CENTRAL, CINAHL, EconLit, Embase and Scopus to September 2017 and supplemented this with grey literature searches. We assessed study quality using the Critical Appraisal Skills Programme suite of tools, excluding those judged to be of poor methodological quality.ResultsThirteen studies were included; eight quantitative studies, two qualitative, two mixed methods studies and one case study. There was substantial agreement across quantitative and qualitative studies that a move to community living was associated with improved QoL. QoL for people with any level of intellectual disabilities who move from any type of institutional setting to any type of community setting was increased at up to 1 year postmove (standardised mean difference [SMD] 2.03; 95% CI [1.21 to 2.85], five studies, 246 participants) and beyond 1 year postmove (SMD 2.34. 95% CI [0.49 to 4.20], three studies, 160 participants), with total QoL change scores higher at 24 months comparative to 12 months, regardless of QoL measure used.ConclusionOur systematic review demonstrated a consistent pattern that moving to the community was associated with improved QoL compared with the institution. It is recommended that gaps in the evidence base, for example, with regard to growing populations of older people with intellectual disability and complex needs are addressed.PROSPERO registration numberCRD42018077406.

PurposeEngland and Italy are considered pioneers in the development of community mental health services. Both have implemented supported accommodation services for those with more complex needs, which can be broadly categorized into three main types with a similar specifications. The aim of this study was to compare the characteristics of these services and their users in England and Italy. MethodsData from two cross-sectional surveys of supported accommodation services undertaken across England and in Verona, Italy (England—619 service users from 87 services; Verona—167 service users from 25 services) were compared. ResultsService users in the two samples had similar socio-demographic and clinical characteristics; most were male, unmarried, and unemployed, with a primary diagnosis of schizophrenia or other psychosis and over 15years of contact with mental health services. Supported accommodation occupancy was high in both samples. The actual length of stay was greater than the expected length of stay for all three service types but overall turnover was similar between countries (p=0.070). Across services, total needs and quality of life were higher for Italian compared to English service users (p ConclusionsEngland and Italy have similar mental health supported accommodation pathways to assist those with more complex needs to gain skills for community living, but individuals tend to require longer than expected at each stage. &nbsp

Of 9.8 million U.S. adults with serious mental illness, an estimated 40% receive no treatment in any given year, often with dire consequences. But the structural impediments to care can’t be addressed without reconciling the conflicting ideals underlying them.

Deinstitutionalization has not been pursued in the post-communist Europe until recently. The population of psychiatric patients institutionalized in the regional mental hospitals is, however, largely understudied. The aim of this study is to assess discharges of long-term inpatients with schizophrenia from Czech psychiatric hospitals and to analyse re-hospitalizations within this group. The nationwide register of all-cause inpatient hospitalizations was merged with the nationwide register of all-cause deaths on an individual level basis. Descriptive statistics, survival analysis and logistic regression were performed. 3601 patients with schizophrenia previously hospitalized for more than a year were discharged from Czech mental hospitals between 1998 and 2012. This included 260 patients hospitalized for > 20 years. Nearly one fifth (n = 707) of the long-term patients died during the hospitalization; and discharges of 19.36% (n =697) were only administrative in their nature. Out of 2197 truly discharged patients, 14.88% (n = 327) were re-hospitalized within 2 weeks after the discharge. The highest odds of rehospitalization were associated with being discharged against medical advice (OR 5.27, CI: 3.77–7.35, p < 0.001). These data are important for the ongoing mental health care reforms in the Czech Republic and other countries in the Central and Eastern Europe.

A total of 149 children, who spent an average of 13.8 months in Russian institutions, were transferred to Russian families of relatives and nonrelatives at an average age of 24.7 months. After residing in these families for at least 1 year (average = 43.2 months), parents reported on their attachment, indiscriminately friendly behavior, social–emotional competencies, problem behaviors, and effortful control when they were 1.5–10.7 years of age. They were compared to a sample of 83 Russian parents of noninstitutionalized children, whom they had reared from birth. Generally, institutionalized children were rated similarly to parent-reared children on most measures, consistent with substantial catch-up growth typically displayed by children after transitioning to families. However, institutionalized children were rated more poorly than parent-reared children on certain competencies in early childhood and some attentional skills. There were relatively few systematic differences associated with age at family placement or whether the families were relatives or nonrelatives. Russian parent-reared children were rated as having more problem behaviors than the US standardization sample, which raises cautions about using standards cross-culturally.