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A systematic review of the international published literature relating to quality of institutional care for people with longer term mental health problems

Tatiana L Taylor1, Helen Killaspy1*, Christine Wright2, Penny Turton2, Sarah White2, Thomas W Kallert3, Mirjam Schuster3, Jorge A Cervilla4, Paulette Brangier4, Jiri Raboch5, Lucie Kališová5, Georgi Onchev6, Hristo Dimitrov6, Roberto Mezzina7, Kinou Wolf7, Durk Wiersma8, Ellen Visser8, Andrzej Kiejna9, Patryk Piotrowski9, Dimitri Ploumpidis10, Fragiskos Gonidakis10, José Caldas-de-Almeida11, Graça Cardoso11 and Michael B King1

Author Affiliations

1 Research Department of Mental Health Sciences, UCL Medical School, London, UK

2 Division of Mental Health, St. George's University London, London, UK

3 Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus, Technische Universitaet Dresden, Dresden, Germany

4 CIBERSAM, Universidad de Granada, Granada, Spain

5 Psychiatric Department of the First Faculty of Medicine, Charles University, Prague, Czech Republic

6 Department of Psychiatry, Medical University Sofia, Sofia, Bulgaria

7 Dipartimento di Salute Mentale, University of Trieste, Trieste, Italy

8 Psychiatry, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands

9 Department of Psychiatry, Wroclaw Medical University, Wroclaw, Poland

10 University Mental Health Research Institute (UMHRI), Athens, Greece

11 Department of Mental Health, Faculdade de Ciencias Medicas, New University of Lisbon, Lisbon, Portugal

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BMC Psychiatry 2009, 9:55  doi:10.1186/1471-244X-9-55

Published: 7 September 2009



A proportion of people with mental health problems require longer term care in a psychiatric or social care institution. However, there are no internationally agreed quality standards for institutional care and no method to assess common care standards across countries.

We aimed to identify the key components of institutional care for people with longer term mental health problems and the effectiveness of these components.


We undertook a systematic review of the literature using comprehensive search terms in 11 electronic databases and identified 12,182 titles. We viewed 550 abstracts, reviewed 223 papers and included 110 of these. A "critical interpretative synthesis" of the evidence was used to identify domains of institutional care that are key to service users' recovery.


We identified eight domains of institutional care that were key to service users' recovery: living conditions; interventions for schizophrenia; physical health; restraint and seclusion; staff training and support; therapeutic relationship; autonomy and service user involvement; and clinical governance. Evidence was strongest for specific interventions for the treatment of schizophrenia (family psychoeducation, cognitive behavioural therapy (CBT) and vocational rehabilitation).


Institutions should, ideally, be community based, operate a flexible regime, maintain a low density of residents and maximise residents' privacy. For service users with a diagnosis of schizophrenia, specific interventions (CBT, family interventions involving psychoeducation, and supported employment) should be provided through integrated programmes. Restraint and seclusion should be avoided wherever possible and staff should have adequate training in de-escalation techniques. Regular staff supervision should be provided and this should support service user involvement in decision making and positive therapeutic relationships between staff and service users. There should be clear lines of clinical governance that ensure adherence to evidence-based guidelines and attention should be paid to service users' physical health through regular screening.