First steps towards the deinstitutionalization of older adults: A protocol for the implementation of a complex intervention / Primeros pasos en la desinstitucionalización de adultos mayores: protocolo para la implementación de una intervención compleja

Background: Nursing homes are becoming increasingly important as end-of-life care facilities. However, many older adults want to stay in their homes as they age. Objective: To assess the feasibility of a deinstitutionalization process on selected institutionalized older adults who are willing to initiate the process. Methods: This study, divided into two phases, will be carried out over 15 months on 241 residents living in two nursing homes in Navarra (Spain). The first phase has a cross-sectional design. We will identify the factors and covariates associated with feasibility and willingness to participate in a deinstitutionalization process by bivariate analysis, essential resources for the process and residents to participate in the process. The second phase has a complex interventional design to implement a deinstitutionalization process. An exploratory descriptive and comparative analysis will be carried out to characterize the participants, prescribed services and the impact deinstitutionalization intervention will have over time (quality of life will be the main outcome; secondary variables will be health, psychosocial, and resource use variables). This study will be accompanied by a pseudo-qualitative and emergent sub-study to identify barriers and facilitators concerning the implementation of this process and understand how intervention components and context influence the outcomes of the main study. Intervention components and the way the intervention is implemented will be of great relevance in the analysis. Discussion: Alternatives to institutionalization with adapted accommodation and community support can allow people who wish to return to the community.(AU)

Introducción: Las residencias de personas mayores cobran cada vez más importancia como centros de atención al final de la vida. Sin embargo, muchos adultos mayores desean permanecer en sus casas mientras envejecen. Objetivo: Se pretende evaluar la viabilidad de un proceso de desinstitucionalización en adultos mayores seleccionados que viven en las residencias y que expresen la voluntad para iniciar el proceso. Métodos: Este estudio, dividido en dos fases, se llevará a cabo durante 15 meses en 241 sujetos que viven en dos residencias de personas mayores en Navarra (España). La primera fase tiene un diseño transversal en donde se identificarán los factores y covariables asociadas a la viabilidad y voluntad para participar en un proceso de desinstitucionalización a través de un análisis bivariante, los recursos imprescindibles para el proceso y los residentes que quieran participar en él. La segunda fase tiene un diseño de intervención compleja en la que se implementa un proceso de desinstitucionalización. Se realizará un análisis exploratorio descriptivo y comparativo para caracterizar a los participantes, los servicios prescritos y el efecto de la intervención de desinstitucionalización a lo largo del tiempo (la calidad de vida será la variable principal; las secundarias serán las referentes a la salud, las psicosociales y de uso de recursos). Este estudio irá acompañado de un subestudio pseudocualitativo y emergente para identificar las barreras y los elementos facilitadores relativos a la implementación de este proceso y comprender cómo los componentes de la intervención y el contexto influyen en los resultados del estudio principal. Los componentes de la intervención y su ejecución serán de gran relevancia en el análisis. Discusión: Las alternativas a la institucionalización con viviendas adaptadas y apoyos comunitarios pueden permitir a las personas que así lo desean el retorno a la comunidad.(AU)

Uncertainty Work: Dealing with a Psychiatric Crisis in Two European Community Mental Health Teams.

The quest for how to deal with a crisis in a community setting, with the aim of deinstitutionalizing mental health care, and reducing hospitalization and coercion, is important. In this article, we argue that to understand how this can be done, we need to shift the attention from acute moments to daily uncertainty work conducted in community mental health teams. By drawing on an empirical ethics approach, we contrast the modes of caring of two teams in Utrecht and Trieste. Our analysis shows how temporality structures, such as watchful waiting, are important in dealing with the uncertainty of a crisis.

La Reforma Psiquiátrica en Andalucía. Cuatro décadas de transformaciones en los servicios públicos de salud mental / The Psychiatric Reform in Andalusia (Spain) Four Decades of Transformations in Public Mental Health Services

El artículo pretende presentar de manera resumida las características más destacadas del proceso de transformación de las estructuras públicas de atención a problemas de salud mental, iniciada oficialmente en Andalucía en junio de 1984, con la aprobación por el Parlamento de una ley específica sobre el tema. A lo largo de estos ya casi 40 años, la arcaica estructura de servicios que caracterizaba la asistencia psiquiátrica se ha transformado en una red compleja de base y orientación comunitaria, superadora de los Hospitales Psiquiátricos y con un sector sanitario integrado en el Sistema Sanitario Público y otro intersectorial dependiente de la Fundación pública FAISEM. El texto presenta las características previas, las líneas de trabajo desarrolladas y los principales resultados obtenidos, con una valoración positiva en relación con la situación de partida, pero también con importantes aspectos no adecuadamente resueltos y que necesitan desarrollos posteriores que, sin embargo, no se están abordando hoy por hoy. (AU)

The article aims to present in a summarized way the most outstanding characteristics of the process of transformation of public structures of attention to mental health problems, officially initiated in Andalusia in June 1984, with the approval by Parliament of law on the subject. Throughout these almost 40 years the archaic structure of services that characterized psychiatric care has been transformed into a complex network of community orientation, surpassing the Psychiatric Hospitals and with a health sector integrated into the Public Health System and another intersectoral dependent on the FAISEM public Foundation. The text presents the previous characteristics, the lines of work developed, and the main results obtained, with a positive assessment in relation to the initial situation, but also with important aspects not adequately resolved and that need subsequent developments that, however, are not being addressed today. (AU)

La Reforma Psiquiátrica en Andalucía. Cuatro décadas de transformaciones en los servicios públicos de salud mental / The Psychiatric Reform in Andalusia (Spain) Four Decades of Transformations in Public Mental Health Services

El artículo pretende presentar de manera resumida las características más destacadas del proceso de transformación de las estructuras públicas de atención a problemas de salud mental, iniciada oficialmente en Andalucía en junio de 1984, con la aprobación por el Parlamento de una ley específica sobre el tema. A lo largo de estos ya casi 40 años, la arcaica estructura de servicios que caracterizaba la asistencia psiquiátrica se ha transformado en una red compleja de base y orientación comunitaria, superadora de los Hospitales Psiquiátricos y con un sector sanitario integrado en el Sistema Sanitario Público y otro intersectorial dependiente de la Fundación pública FAISEM. El texto presenta las características previas, las líneas de trabajo desarrolladas y los principales resultados obtenidos, con una valoración positiva en relación con la situación de partida, pero también con importantes aspectos no adecuadamente resueltos y que necesitan desarrollos posteriores que, sin embargo, no se están abordando hoy por hoy. (AU)

The article aims to present in a summarized way the most outstanding characteristics of the process of transformation of public structures of attention to mental health problems, officially initiated in Andalusia in June 1984, with the approval by Parliament of law on the subject. Throughout these almost 40 years the archaic structure of services that characterized psychiatric care has been transformed into a complex network of community orientation, surpassing the Psychiatric Hospitals and with a health sector integrated into the Public Health System and another intersectoral dependent on the FAISEM public Foundation. The text presents the previous characteristics, the lines of work developed, and the main results obtained, with a positive assessment in relation to the initial situation, but also with important aspects not adequately resolved and that need subsequent developments that, however, are not being addressed today. (AU)

The deinstitutionalization of children and adolescents in El Salvador's child protection system.

BACKGROUND: In 2010, El Salvador introduced legislation aimed at reforming the country's Child Protective System (CPS), with a focus on promoting deinstitutionalization. OBJECTIVE: The study aim was to explore the impact of deinstitutionalization on the Salvadoran CPS. PARTICIPANTS AND SETTING: The study was conducted in El Salvador, granting authors unique access to key informants with extensive experience in the country's CPS. Unlike the United States, which is divided into states, El Salvador is divided into departments, and CPS providers were recruited from all 14 departments. Focus groups were facilitated in the East, West, and Central zones to ensure representation from all regions. METHODS: Qualitative semi-structured interviews (n = 26) were conducted in June/July of 2019, which were then followed by focus groups (n = 4) in August 2019. The analysis of the data employed a combination of deductive and inductive thematic coding methods. RESULTS: CPS providers offered valuable insights, categorized into five main themes: (1) Strengths of El Salvador's CPS, (2) Deinstitutionalization policy encompassing socioenvironmental contextual factors, (3) Challenges in the deinstitutionalization process, including insufficient follow-up on deinstitutionalized children, (4) Recommendations from participants, highlighting the importance of enhancing stakeholder coordination/collaboration, and (5) The necessity for a paradigm shift, emphasizing the need to redefine the social contract on protecting children from child maltreatment. CONCLUSIONS: The Salvadoran CPS requires substantial systemic changes. Encouragingly, key informants have demonstrated a commitment to reform not only the deinstitutionalization process but also the broader CPS system in El Salvador including case management and quality of care in institutional settings.

First steps towards the deinstitutionalization of older adults: A protocol for the implementation of a complex intervention.

BACKGROUND: Nursing homes are becoming increasingly important as end-of-life care facilities. However, many older adults want to stay in their homes as they age. OBJECTIVE: To assess the feasibility of a deinstitutionalization process on selected institutionalized older adults who are willing to initiate the process. METHODS: This study, divided into two phases, will be carried out over 15 months on 241 residents living in two nursing homes in Navarra (Spain). The first phase has a cross-sectional design. We will identify the factors and covariates associated with feasibility and willingness to participate in a deinstitutionalization process by bivariate analysis, essential resources for the process and residents to participate in the process. The second phase has a complex interventional design to implement a deinstitutionalization process. An exploratory descriptive and comparative analysis will be carried out to characterize the participants, prescribed services and the impact deinstitutionalization intervention will have over time (quality of life will be the main outcome; secondary variables will be health, psychosocial, and resource use variables). This study will be accompanied by a pseudo-qualitative and emergent sub-study to identify barriers and facilitators concerning the implementation of this process and understand how intervention components and context influence the outcomes of the main study. Intervention components and the way the intervention is implemented will be of great relevance in the analysis. DISCUSSION: Alternatives to institutionalization with adapted accommodation and community support can allow people who wish to return to the community. TRIAL REGISTRATION: NCT05605392.

Los desafíos del acompañamiento universitario a emprendimientos de gestión colectiva en procesos de desmanicomialización en Uruguay

Nos proponemos compartir resultados de una investigación que tuvo como objetivo estudiar los procesos de gestión colectiva en dos emprendimientos laborales autogestivos de Uruguay, que trabajan desde la perspectiva de la desmanicomialización. Se trató de una investigación cualitativa, situada y experiencial a partir del despliegue de una etnografía. En este artículo abordaremos los resultados de dos objetivos específicos, uno sobre las estrategias y metodologías universitarias vinculadas a los procesos de conformación y sostén de dichas experiencias y otro sobre las estrategias desplegadas para acompañar el padecimiento de lxs integrantes. Compartiremos algunos resultados en relación a las preguntas: ¿para qué y por qué se acompaña? ¿qué es lo que se acompaña? ¿cómo se acompaña?. Identificamos que ambos proyectos se llevan adelante desde la extensión universitaria, a partir de un proceso de incubación de emprendimientos cooperativos integrado solo por personas usuarias de servicios de salud mental, que denominamos: autogestión-solo-de-ellos. Este proceso implicó acompañar y sostener un doble pasaje, o sea generar ruptura con la lógica manicomial y con la lógica salarial para configurar y consolidar un emprendimiento de gestión colectiva. Esto significó para los equipos universitarios acompañar y desplegar distintas estrategias en relación a la triada: trabajo-acogida-vida. Destacamos tres componentes transversales del acompañamiento que fueron: no sustituir (hacer con), sostener otras temporalidades y abordaje interdisciplinario y en red.Durante el proceso de incubación se produce una metamorfosis a partir de que egresadxs universitarixs deciden integrar las experiencias como socixs/cooperativistas e inician un proceso que definimos como: autogestión-de-un-nosotrxs.

Propomos compartilhar resultados de uma pesquisa que teve como objetivo estudar os processos de gestão coletiva em duas empresas trabalhistas autogeridas no Uruguai, que funcionam na perspectiva da desmanicomalização. Tratou-se de uma investigação qualitativa, situada e experiencial baseada no desdobramento de uma etnografia. Neste artigo abordaremos os resultados de dois objetivos específicos, um sobre as estratégias e metodologias universitárias vinculadas aos processos de formação e sustentação dessas experiências e outro sobre as estratégias utilizadas para acompanhar o sofrimento dos membros. Compartilharemos alguns resultados em relação às questões: para que e por que é acompanhado? O que é acompanhado? E como é acompanhado? Identificamos que ambos os projetos são realizados pela extensão universitária, a partir de um processo de incubação de empreendimentos cooperativos formados apenas por usuários de serviços de saúde mental, o que denominamos: autogestão-só-deles. Este processo envolveu acompanhar e sustentar uma dupla passagem, ou seja, gerar uma ruptura com a lógica asilar e com a lógica salarial para configurar e consolidar um empreendimento de gestão coletiva. Isso significou que as equipes universitárias acompanhassem e implantassem diferentes estratégias em relação à tríade: trabalho-acolhimento-vida. Destacamos três componentes transversais do apoio, que foram: não substituir (fazer com), apoiar outras temporalidades e uma abordagem interdisciplinar e em rede. Durante o processo de incubação, ocorre uma metamorfose quando os graduados universitários decidem integrar as experiências como parceiros/cooperativistas e iniciam um processo que definimos como: autogestão-de-um-nós.

We propose to share results of a research that aimed to study the collective management processes in two self-managed labor enterprises in Uruguay, which work from the perspective of demanicomalization. It was a qualitative, situated and experiential investigation based on the deployment of an ethnography. In this article, we will address the results of two specific objectives, one on the university strategies and methodologies linked to the processes of formation and support of these experiences and another on the strategies deployed to accompany the suffering of the members. We will share some results in relation to the questions: why and what for is it accompanied? What is accompanied? And how is it accompanied? We identified that both projects are carried out by the university extension, based on an incubation process of cooperative ventures made up only of users of mental health services, which we call: self-management-only-of-them. This process involved accompanying and sustaining a double passage; that is, generating a break with the asylum logic and with the salary logic to configure and consolidate a collective management undertaking. This meant for the university teams to accompany and deploy different strategies in relation to the triad: work-welcome-life. We highlighted three transversal components of support, which were not substituting (doing with), supporting other temporalities, and an interdisciplinary and network approach. During the incubation process, a metamorphosis occurs when university graduates decide to integrate the experiences as partners/cooperativists and begin a process that we define as: self-management-of-an-us.

Castilla del Pino: un faro indispensable para navegantes de lo mental / Castilla del Pino: An Essential Lighthouse for Navigators of the Mental

Castilla del Pino ejerció un indudable liderazgo intelectual sobre varias generacio-nes de españoles en el último tercio del siglo XX, y de forma particular ejerció su función de intelectual aplicado a la práctica clínica de lo mental. Esta tarea constituyó un verdadero ma-gisterio para los profesionales interesados en prácticas clínicas rigurosas, respetuosas con la dignidad y los derechos de los pacientes. En este trabajo se revisan algunas de sus principa-les aportaciones como intelectual a la práctica psiquiátrica y la psicoterapia. Específicamen-te, se abordan sus contribuciones al estudio de la influencia de la ideología en la psicoterapia y la ideología de la locura y su impacto en la práctica psiquiátrica en contexto hospitalario. Sus observaciones y recomendaciones significan una magnífica guía para el ejercicio de la observación rigurosa, la reflexión y el pensamiento crítico frente al dogmatismo. (AU)

Castilla del Pino was an undoubted intellectual leader over several generations of Spaniards in the last third of the 20th century. He specifically played this role as an intellectual in the field of the mental health practice. This task constituted a true teaching for professionals interested in rigorous clinical practices, respectful of the dignity and rights of patients. This paper reviews some of his main contributions as an intellectual to psychiatric practice and psychotherapy. It specifically addresses his contributions to the study of the influence of ideology in psychotherapy, as well as the ideology of madness and its impact on psychiatric practice in a hospital context. His observations and recom-mendations are an excellent guide to the exercise of rigorous observation, reflection and critical thinking facing any dogmatism. (AU)

Global priority for the care of orphans and other vulnerable children: transcending problem definition challenges.

BACKGROUND: Tens of millions of children lack adequate care, many having been separated from or lost one or both parents. Despite the problem's severity and its impact on a child's lifelong health and wellbeing, the care of vulnerable children-which includes strengthening the care of children within families, preventing unnecessary family separation, and ensuring quality care alternatives when reunification with the biological parents is not possible or appropriate-is a low global priority. This analysis investigates factors shaping the inadequate global prioritization of the care of vulnerable children. Specifically, the analysis focuses on factors internal to the global policy community addressing children's care, including how they understand, govern, and communicate the problem. METHODS: Drawing on agenda setting scholarship, we triangulated among several sources of data, including 32 interviews with experts, as well as documents including peer-reviewed literature and organizational reports. We undertook a thematic analysis of the data, using these to create a historical narrative on efforts to address children's care, and specifically childcare reform. RESULTS: Divisive disagreements on the definition and legitimacy of deinstitutionalization-a care reform strategy that replaces institution-based care with family-based care-may be hindering priority for children's care. Multiple factors have shaped these disagreements: a contradictory evidence base on the scope of the problem and solutions, divergent experiences between former Soviet bloc and other countries, socio-cultural and legal challenges in introducing formal alternative care arrangements, commercial interests that perpetuate support for residential facilities, as well as the sometimes conflicting views of impacted children, families, and the disability community. These disagreements have led to considerable governance and positioning difficulties, which have complicated efforts to coordinate initiatives, precluded the emergence of leadership that proponents universally trust, hampered the engagement of potential allies, and challenged efforts to secure funding and convince policymakers to act. CONCLUSION: In order to potentially become a more potent force for advancing global priority, children's care proponents within international organizations, donor agencies, and non-governmental agencies working across countries will need to better manage their disagreements around deinstitutionalization as a care reform strategy.

The psychopathic hospital.

A new psychiatric institution emerged in the late nineteenth and early twentieth centuries: the psychopathic hospital. This institution represented a significant development in the history of psychiatry, as it marked the profession's reorientation from asylum-based to hospital-based care, and in this way presaged the deinstitutionalization movement that would begin half a century later. Psychopathic hospitals were also an important marker of psychiatry's efforts to redefine its professional boundaries and respond to its vociferous critics. This entailed both a rapprochement with general medicine in an effort to assert its scientific bona fides and a redefinition of its scope of practice to absorb non-certifiable 'borderland' cases in order both to emphasize non-coercive treatment and to enlarge the profession's boundaries.

Deinstitutionalization, community-based care and incarceration of people with severe mental illness: Out of sight, out of mind?

Although the international literature points to a number of benefits from deinstitutionalization, such as limiting coercion, more cost-effectiveness of care systems, and better use of community care, it may be helpful to take a broader perspective on where coercion and institutionalization of people with severe mental illnesses (SMI) and/or substance use disorders frequently occur: in prisons and jails. In this comment, we propose to move beyond the inpatient/outpatient dichotomy.

Saúde mental na atenção básica: metassíntese da produção do cuidado no território brasileiro / Mental health in primary care: meta-synthesis of care production in the brazilian territory / Salud mental en la atención primaria: metasíntesis de la producción del cuidado en el territorio brasileño

Este estudo objetivou compreender as concepções que guiam a produção do cuidado em saúde mental na atenção básica (AB) por meio de uma metassíntese da literatura. Por meio das bases de dados e bibliotecas virtuais Scopus, LILACS, BDENF, SciELO, BVS e PubMed e utilizando os Descritores em Ciências da Saúde (DeCS), buscaram-se textos qualitativos em português, inglês e espanhol, publicados no Brasil entre 2010 e 2020, que abordassem como a produção do cuidado em saúde mental está sendo desenvolvida na AB do país; cujos objetivos se referissem a atos e saberes desenvolvidos em saúde mental na AB; que abordassem o conceito de integralidade do cuidado em saúde mental desenvolvido na AB do Brasil; e que tratassem do entendimento quanto à mudança da prática profissional a partir dessas iniciativas. Foram selecionados 66 trabalhos, a partir dos quais se identificou que a saúde mental ainda sofre com as consequências herdadas do modelo hospitalocêntrico e asilar de produção do cuidado. Além disso, evidenciaram-se impactos das questões e experiências pessoais na saúde mental dos sujeitos, negligência e visão restrita do cuidado psicossocial, predomínio de práticas biomédicas, centralização nas ações intramuros e psiquiatrização das práticas de saúde mental na AB, os quais constituem barreiras ao processo de desinstitucionalização e integralidade do cuidado em saúde mental. Assim, é importante reconhecer a legitimidade dos saberes e repensar práticas menos cristalizadas, a fim de enfrentar e problematizar modelos hegemônicos, para que se avance na produção do cuidado em saúde mental na AB.

This study aimed to understand the concepts that guide the production of mental health care developed in Primary Care (PC), with a meta-synthesis of the literature. From the databases and virtual libraries Scopus, LILACS, BDENF, SciELO, VHL, and PubMed and using Descriptors in Health Sciences (DeCS), qualitative texts in Portuguese, English, and Spanish, published in Brazil between 2010 and 2020 were sought., which addressed how the production of mental health care is being developed in PC in the country; works whose objectives refer to acts and knowledge developed in mental health in PC; works that address the concept of comprehensive mental health care developed in PC in Brazil; and works on understanding the change in professional practice based on these initiatives. A total of 66 papers were selected, from which it was identified that mental health still suffers from the consequences inherited from the hospital-centered and asylum model of care production. In addition, the impacts of personal issues and experiences on the subjects' mental health, negligence and restricted view of psychosocial care, predominance of biomedical practices, centralization in intramural actions, and psychiatrization of mental health practices in PC were evidenced, which constitute barriers to process of deinstitutionalization and integrality of mental health care. Thus, it is important to recognize the legitimacy of knowledge and rethink less crystallized practices, to face and problematize hegemonic models, so that the production of mental health care in PC can advance.

Este estudio tuvo como objetivo comprender los conceptos que orientan la producción del cuidado en salud mental en la atención primaria (AP), mediante una metasíntesis de la literatura. Desde las bases de datos y bibliotecas virtuales Scopus, LILACS, BDENF, SciELO, BVS y PubMed, y utilizando los Descriptores en Ciencias de la Salud (DeCS), se buscaron textos cualitativos en portugués, inglés y español, publicados en Brasil entre 2010 y 2020, que abordaron cómo la producción de atención a la salud mental se desarrolla en AP en el país; trabajos cuyos objetivos se refieran a actos y saberes desarrollados en salud mental en AP; los que abordaron el concepto de atención integral a la salud mental desarrollado en AP en Brasil; y aquellos que trataron de la comprensión del cambio en la práctica profesional a partir de estas iniciativas. Se seleccionaron 66 artículos, y se identificó que la salud mental aún sufre las consecuencias heredadas del modelo hospitalario y el aislamiento de la producción del cuidado. Además, los impactos de los problemas y experiencias personales en la salud mental de los sujetos, la negligencia y la visión restringida de la atención psicosocial, el predominio de las prácticas biomédicas, la centralización en las acciones intramuros y la psiquiatrización de las prácticas de salud mental en AP constituyen barreras para el proceso de desinstitucionalización e integralidad de la atención en salud mental. Así, es importante reconocer la legitimidad de los saberes y repensar las prácticas menos cristalizadas para enfrentar modelos hegemónicos y problematizarlos para que la producción de cuidados en salud mental en AP pueda avanzar.

Psychiatric Hospital of Leros: a portrayal of the current situation.

The purpose of this study was to describe the demographic and clinical features of the inpatients currently residing at the Psychiatric Hospital of Leros. The present systematic documentation and presentation aimed to demonstrate the standard of living and healthcare conditions provided today, after the implementation of the State's "Psychargos" program; this is the main Greek Psychiatric reform program, adhering to the principles of deinstitutionalization and community psychiatry, in accordance with the current international guidelines. In addition, we discussed the current relationship between the psychiatric departments of the hospital and the other departments and clinics in terms of providing healthcare services to chronic psychiatric inpatients in full compliance with the biopsychosocial model and its application to the unique case of Leros. The implemented patient profiles incorporated both subjective and objective factors, such as compliance with rules and treatment, self-injury, and harm to others. Furthermore, we quantified and categorized the level of care required for each patient in terms of personnel-reported activities. This parameter was assessed through the Greek version of Katz's Index of Independence in Activities of Daily Living. Simultaneously, the fundamental actions provided to inpatients by the social care and support services of the hospital were also depicted and categorized, in terms of connection to State social services, communication with the patient's families, and cooperation between the families and the hospital for the patient's healthcare needs. Furthermore, we analyzed and presented all statistically significant correlations found in our patients' characteristics. Briefly, the main results of our study show that the mean age of the 212 patients was 62.4 years old (with a standard deviation of ±13.6 years and the longest hospitalization of 62 consecutive years) including patients from the institution's asylum period. Since 1989, the year when the psychiatric reform began in our hospital, 87 new patients were admitted, 85.1% of whom were from the southern Aegean, thus following the principle of naiveness. Intellectual disabilities and psychotic spectrum disorders were the most common disorders among the total number of hospitalized patients, accounting for 40% in each category. Regarding the 87 patients hospitalized after 1989, psychotic spectrum disorders were diagnosed in the vast majority (58 patients, 66.7%) followed by organic mental disorders (10 patients, 11.5%). The rest were diagnosed with other disorders. Somatic comorbidity and the need for care and services, especially for patients with intellectual disabilities, demonstrate how the Institution now mainly offers psychogeriatric healthcare services. In conclusion, the purpose of this study was to highlight the Psychiatric Hospital of Leros as it stands today, in stark contrast to the long-established, stereotypical depiction of asylums in the scientific and public communities.

An Innovative Approach to the Dismantlement of a Forensic Psychiatric Hospital in Italy: A Ten-year Impact Evaluation.

Aims: This study aimed to evaluate the impacts of a pilot project concerning the closure of a Forensic Psychiatric Hospital (FPH) inspired by Human Development Theory and the Capability Approach. Background: The dismantlement of the FPH of Barcellona Pozzo di Gotto (Sicily Region in Italy) began in 2010 with the pilot project Luce é Libertà and ended in 2017. With the closure of six FPHs, Italy officially became the first country worldwide to close such institutions. After the closure of FPHs, some critical issues emerged, and the debate shifted to developing small-scale facilities and residences for the execution of security measures (RESM). However, few studies have provided results on the cohort of patients discharged from FPHs. Objective: Following are the objectives of this study: a) Assessing the effectiveness of the pilot project in terms of better functioning accordingly to the Classification of Functioning of Disability and Health (ICF) framework, social and labour insertion, health conditions, level of dangerousness to other, rate of readmission in forensic services, b) cost analysis, and c) describing how the CA has been applied and translated into methodological and administrative devices and concrete intervention strategies. Methods: A pre-post evaluation design was performed with a comparison between the intervention and the control group for the healthcare cost analysis. Data were collected from 2010 to 2019 at three points: T0) as a baseline, T1 and T2) for the follow-up. The instruments are a structured questionnaire, the Scale HoNOS Secure, 4 sub-scales of ICF (Activity and participation dimensions: sociality, culture, and knowledge, daily life, income, and work) (Cronbach's Alpha from 0.76 to 0.94), and n.20 interviews with key stakeholders and beneficiaries. Results: Main results include a) the discharge of 55 patients through the use of a person-centered approach and the Personal Capability Budget (PCB), b) the expansion of substantial freedom of choice and the improvement of ICF score (t-test Sig. <, 02), c) the reduction of the risk for others and themselves (Mean Diff. -2,15 Sig. .000), d) at T2 42% of beneficiaries achieved a job placement and 36% were living in one's own home, e) at T2 the need of security measures has reduced from the initial 70% to 6.8%, and f) reduction of the healthcare costs from the fourth year onwards. Conclusion: Indications emerge to support processes of deinstitutionalisation and capabilities expansion through innovative models, a person-centered approach supported by PCBs, social finance, and social impact investments.

Gaps in the Dynamics and Performance of the Psychiatric Care Deinstitutionalization.

This study objective to verify the existence of gaps in the dynamics and performance of fulfillment of the deinstitutionalization of psychiatric care in the Czech Republic (CZ) and the Slovak Republic (SR) in the period between 2010 and 2020. The introduction of this the study is a search for expert knowledge in the field of deinstitutionalization of psychiatric care. The study uses the method of multi-criteria comparison of TOPSIS variants and a cluster analysis. The results 22 variants range from (ci 0.6716-0.2571) and confirm that there are large differences between CZ and SR in performance gaps (fulfillment) of deinstitutionalization goals. The SR variants are clearly better than the CZ variants, although during the years studied, the CZ variants are improving, and the size of the gap compared to the SR variants is decreasing. In the first year of the evaluated period (2010), the performance gap was 56% and in the last year (2020), the performance gap was only 31%. The conclusion of the study confirms that the measures associated with the deinstitutionalization of psychiatric care are linked to the time they were introduced and the overall implementation period of the reform.

Current services and outcomes of formerly institutionalised and never-institutionalised US adults with intellectual and developmental disabilities: A propensity score matching analysis.

BACKGROUND: Deinstitutionalization research shows better services and outcomes relative to institutional life but has not compared formerly institutionalised and never-institutionalised service users. METHODS: We used propensity score matching (PSM) to match formerly institutionalised and never-institutionalised participants on six personal characteristics. Data came from the 2018 to 2019 National Core Indicators In-Person Survey. We excluded current institution residents, and states with 25% + of missing data on former institutionalisation. RESULTS: Overall, 15.5% of participants in the 29-state full sample had lived in an institution for 1 year or more. Findings from the PSM sample showed that former-institution residents were more likely to use congregate living arrangements and less likely to live with family. They experienced more loneliness, less support-related choice, and had a consistent pattern of disability service-focused social connections. CONCLUSIONS: Many former institution residents remain disadvantaged relative to matched peers. There is a need to identify factors to enhance services and outcomes following deinstitutionalization.

The impact of the Mental Health Act revision for deinstitutionalization in Korea on the crime rate of people with schizophrenia.

This study examined changes in the crime rates of people with schizophrenia in Korea in comparison with the general population after the Mental Health Act revision for deinstitutionalization in 2017. The crime rates of people with schizophrenia and the general population were calculated from 2012 to 2021 using the Korean National Police Agency crime statistics. The effects of the law revision in 2017 on the crime rates were assessed using the interrupted time series and difference-in-difference analyses. The crime rates of people with schizophrenia tended to be lower than the general population except for murder and arson, which were 5.3 and 11.4 times, respectively, that of the general population. While no significant effect of the revision was found in the interrupted times series analysis, the difference-in-differences analysis indicated that the total crime rates and the rates of violence and public order crime increased among people with schizophrenia compared with the general population. The revision of the Mental Health Act for deinstitutionalization did not lead to an increase in the murder rate of people with schizophrenia as is commonly thought. However, the increases in overall crime and violence rates of people with schizophrenia suggest that the deinstitutionalized patients may not have been successfully relocated into the community. The increase in crime after the revision should be interpreted as a call for well-resourced community care rather than the reason for re-transfer of patients to hospitals.

Relapse among MHCUs after a Short-Term Admission in an Acute Psychiatric Unit: Primary Caregivers' Perspective.

South Africa has taken initiative to strengthen its mental health system, by improving the Mental Health Care Act 17 of 2002 which proclaims that mental healthcare users (MHCUs) can be treated in communities and homes. Due to short-term hospitalisations for acute MHCUs and advocacy for community-based care, families play a significant role in providing care to severe mental healthcare users. The objective of the study was to explore primary caregivers' perspective regarding the relapse of MHCUs following a short-term admission in acute psychiatric units. A qualitative explorative design was used. In-depth individual interviews were conducted with 18 primary caregivers whose family members were readmitted to four hospitals with units designated for acute MHCUs in Limpopo. NVivo computer software version 11 was used to analyse data. The findings are that MHCUs deny the mental health condition. Mental illness is considered a short illness that can be cured, which shows misconceptions about self-mental health conditions. Refusal of direct observed treatment support also emerged; hence, it is difficult for caregivers to identify if the patient is taking the correct doses or not taking the medication at all. Perceived wrong beliefs about mental illness can affect the patient's desire to seek proper management and it can be damaging in many ways. Drugs and alcohol abuse makes MHCUs display disruptive behaviours and contribute to treatment non-adherence resulting in caregivers becoming reluctant to be around them. In conclusion, mixing traditional and faith-based mental healthcare practices as reported by primary caregivers can mean that tailor-fabricated culture-specific mental healthcare is required.

Moving home: Community transition supports for people with intellectual and developmental disabilities.

BACKGROUND: In recognition of the important role housing plays in people's health and quality of life, Medicaid Home- and Community-Based Services (HCBS) programs are more frequently working to promote the housing security of Medicaid beneficiaries. One mechanism states use to promote housing security of people with intellectual and developmental disabilities (IDD) is to offer community transition services in their HCBS programs. Community transition services help with transition by assisting with securing housing and leases, obtaining basic furnishings, paying for utility setup, funding moving expenses, and making accessibility adaptations. OBJECTIVE: The aim of this study was to examine if and how states provided community transition services in their HCBS waiver programs for people with IDD. METHODS: We analyzed 107 fiscal year (FY) 2021 HCBS 1915(c) waivers for people with IDD from across the United States. We analyzed the service expenditures and utilization data for community transition services, including projected spending, projected number of users served, reimbursement rates, projected spending per participant, and annual service provision per participant. RESULTS: In FY2021, 49 waivers (45.8%) from 28 states provided community transition services to people with IDD. A total of $7.21 million of spending was projected for community transition services for 2405 people with IDD, with an average spending per person of $2303. CONCLUSIONS: While community transition services can help promote the housing insecurity of people with IDD, there was wide variance in how these services were allocated to people with IDD in FY2021.

O trabalho de cuidadores em serviços residenciais terapêuticos: revisão de escopo / Work process of caregivers in residential therapeutic services: scope review / El trabajo de los cuidadores en los servicios residenciales terapêuticos: revisión del alcance

Objetivo: mapear produções nacionais e internacionais, relacionadas ao processo de trabalho de cuidadores em Serviços Residenciais Terapêuticos. Método: revisão de escopo realizada em bases de dados selecionadas e no buscador Google Acadêmico, de agosto a setembro de 2019. Resultados: foram identificadas 452 referências nas bases PUBMED e LILACS/BVS e 8.910 referências no Google Acadêmico. Após critérios de inclusão e exclusão, 10 artigos compuseram o estudo. Com base na Teoria de Processo de Trabalho em Saúde, três categorias foram definidas para análise da amostra encontrada. Conclusão: identificou-se que a equipe de cuidadores concentra sua ação sobre o objeto de trabalho, referido predominantemente como as pessoas moradoras da casa, utilizando instrumentos, ainda pouco elaborados, para a finalidade de ampliar autonomia e a gestão de conflitos no desafio da (re)inserção social e comunitária

Objective: to map national and international productions, related to the work process of caregivers in Therapeutic Residential Services. Method: scoping review conducted in selected databases and Google Academic search engine, from August to September 2019. Results: 452 references were identified in the PUBMED and LILACS/BVS databases and 8,910 references in Google Scholar. After inclusion and exclusion criteria, 10 articles composed the study. Based on the Health Work Process Theory, three categories were defined for analysis of the sample found. Conclusion: it was identified that the team of caregivers focus their action on the object of work, predominantly referred to as the people living in the house, using tools, still little developed, for the purpose of expanding autonomy and conflict management in the challenge of social and community (re)insertion

Objetivos: mapear producciones nacionales e internacionales, relacionadas con el proceso de trabajo de cuidadores en Servicios Residenciales Terapéuticos. Método: revisión de alcance realizada en bases de datos seleccionadas y en el motor de búsqueda Google Scholar, de agosto a septiembre de 2019. Resultados: se identificaron 452 referencias en las bases de datos PUBMED y LILACS/BVS y 8.910 referencias en Google Académico. Después de los criterios de inclusión y exclusión, 10 artículos compusieron el estudio. Con base en la Teoría del Proceso de Trabajo en Salud, se definieron tres categorías para análisis de la muestra encontrada. Conclusión: se identificó que el equipo de cuidadores centra su acción en el objeto de trabajo, predominantemente referido a las personas que viven en la casa, utilizando instrumentos, aún poco desarrollados, con el propósito de ampliar la autonomía y la gestión de conflictos en el desafío de la (re)inserción social y comunitaria