Caroline van Genk
Diana Roeg1,2
Maaike van Vugt- 1School of Social and Behavioral Sciences, Tranzo Scientific Center for Care and Wellbeing, Tilburg University, Tilburg, Netherlands
- 2Kwintes Housing and Rehabilitation Services, Zeist, Netherlands
- 3Trimbos Institute, Dutch Institute of Mental Health and Addiction, Utrecht, Netherlands
- 4HVO-Querido, Amsterdam, Netherlands
- 5Faculty of Social Sciences – HIVA, University of Leuven, Leuven, Belgium
Background: For the last four decades, there has been a shift in mental healthcare toward more rehabilitation and following a more humanistic and comprehensive vision on recovery for persons with severe mental illness (SMI). Consequently, many community-based mental healthcare programs and services have been developed internationally. Currently, community mental healthcare is still under development, with a focus on further inclusion of persons with enduring mental health problems. In this review, we aim to provide a comprehensive overview of existing and upcoming community mental healthcare approaches to discover the current vision on the ingredients of community mental healthcare.
Methods: We conducted a scoping review by systematically searching four databases, supplemented with the results of Research Rabbit, a hand-search in reference lists and 10 volumes of two leading journals. We included studies on adults with SMI focusing on stimulating independent living, integrated care, recovery, and social inclusion published in English between January 2011 and December 2022 in peer-reviewed journals.
Results: The search resulted in 56 papers that met the inclusion criteria. Thematic analysis revealed ingredients in 12 areas: multidisciplinary teams; collaboration within and outside the organization; attention to several aspects of health; supporting full citizenship; attention to the recovery of daily life; collaboration with the social network; tailored support; well-trained staff; using digital technologies; housing and living environment; sustainable policies and funding; and reciprocity in relationships.
Conclusion: We found 12 areas of ingredients, including some innovative topics about reciprocity and sustainable policies and funding. There is much attention to individual ingredients for good community-based mental healthcare, but very little is known about their integration and implementation in contemporary, fragmented mental healthcare services. For future studies, we recommend more empirical research on community mental healthcare, as well as further investigation(s) from the social service perspective, and solid research on general terminology about SMI and outpatient support.
1. Introduction
For the last three decades, there has been a shift in mental healthcare from a biomedical model to a more biopsychosocial model with a focus on rehabilitation, strengths, all areas of recovery, citizenship, empowerment, autonomy, and shared decision-making as leading principles (1–5). Still, the “social aspect” of the biopsychosocial model has long remained neglected (6). In 2007, human rights for people with disabilities were covered in the convention (7), and several community-based mental healthcare programs and services have been developed in Europe for these groups, enhanced by peer-to-peer initiatives and recovery colleges (8). Over the past few years, concepts such as social inclusion, citizenship, and participation have become the heart of the deinstitutionalization movement. Additionally, more and more people with mental healthcare issues receive outreach support. An indication of the development of intensive outpatient care for people with severe mental illness (SMI) is the development of (flexible) assertive community treatment ((F)ACT) teams. For example, in Netherlands in 2020, there were an estimated 400 FACT teams (9) and about 30% of people with SMI in England receive support from a specialist mental health floating outreach service (10).
In general, the definition of SMI consists of three criteria: a psychiatric diagnosis according to Diagnostic and Statistical Manual of Mental Disorders, illness duration of more than 2 years, and disability in functioning (11). A subgroup of people with SMI needs intensive care and support in daily living and receives residential care, supported housing in a 24/7 facility, or floating outreach (12). Most people with SMI who live in residential supported housing facilities have a strong preference to live independently in the community with flexible support with a view to a meaningful and fulfilling life (13). Nowadays, there are several community-based support services for these people who want to live independently, such as Housing First (HF). HF is an evidence-based housing intervention in the social domain that combats homelessness (14). It combines rapid access to permanent, nonabstinence-contingent ordinary housing and recovery-oriented mental health support teams (15). Individuals with SMI are at a higher risk of homelessness, and a high proportion of individuals experiencing homelessness are also living with mental illness (16). Therefore, measures should be available to prevent those who do not make use of, or leave, supported housing from becoming homeless.
Different services for mental health conditions have traditionally been separate from other services such as physical healthcare and social services. However, there is increasing emphasis internationally on developing a whole-system approach to improve the integration of these services to maximize an individual’s quality of life and social inclusion by encouraging their skills, promoting independence and autonomy to give them hope for the future. That leads to successful community living through appropriate support, with particular focus on patient-centered development and delivery (17–19). Furthermore, following the rehabilitation and recovery movement, care should involve all areas of living (20), and community-based mental healthcare thus should be a more integrated package of services. Many studies have appeared on the development and impact of multidisciplinary teams in mental healthcare (21, 22). A lot less research is available on supported housing services, including accommodation-based and floating outreach services, leading to a lack of evidence on what works in this area (23, 24).
In this literature review, we focus on all services for persons with SMI which are living independently in the community. These services aim to support these people in their daily life. This includes services initiated by treatment organizations, such as ambulatory interdisciplinary teams, as well as by welfare and supported housing organizations. Following McPherson et al. (25), who developed the simple taxonomy for supported accommodation (STAX-SA) to capture the defining features of different supported accommodation models, in this study we focus on supported housing services meant for persons moving forward from a hospital admission or a full-time staffed housing accommodation in a congregate setting with high support, toward more individual accommodation with no staff on-site. These services can be low or might need to be medium or intensive to support independent living for all (25).
Currently, there is a lack of research about what is needed to successfully provide this type of intensive support for people with SMI, and especially about how this support can be organized as an integrated community-based mental healthcare approach, including housing, rehabilitation, citizenship, all areas of recovery, empowerment, autonomy, and decision-making power. We aim to provide a comprehensive overview of existing and upcoming community mental healthcare approaches to discover the current vision and empirical findings on the ingredients of community mental healthcare. To do so, we will look in this review for both empirical evidence, as well as leading concepts in this research topic. The findings of this study contribute to the further development of community-based mental healthcare for persons with SMI and high-volume healthcare needs. This paper will address the following question: What are the current insights (both leading concepts and empirical findings) regarding a community mental healthcare system to support all persons with SMI in their independent living and recovery, and stimulate further social inclusion?
This review follows the PRISMA guidelines for scoping reviews (26). The completed PRISMA checklist is available on request from the authors.
2. Methods
2.1. Study design
We performed a scoping review, following the steps of the framework of Arksey and O’Malley (27): (a) identify the research question; (b) identify relevant studies; (c) select the studies; (d) chart the data; and (e) collate, summarize and report the results. A scoping review contributes to mapping rapidly the key concepts underpinning a research area and the main sources and types of evidence available (28).
2.2. Eligibility criteria
2.2.1. Inclusion criteria
We included papers published in English from January 2011 to December 2022 in peer-reviewed journals, aimed at 18 years and older adults with severe mental illness, focusing on stimulating independent living, integrated care, recovery, and social inclusion. For reasons of comparability, and fit in Western healthcare systems, studies were included if they were conducted in Western countries only (i.e., United States of America, Canada, countries in Western Europe, Australia, New Zealand, and Japan). Finally, all study designs were included, and we also included papers about interventions related to collaboration.
2.2.2. Exclusion criteria
Studies were excluded if (a) they primarily focused on treatment without support or care, (b) social inclusion or recovery was not the aim, (c) they focused on interventions that concentrated on one area of life and did not provide an integrated offering, or (d) if they focused on psychometric or physical diseases.
2.3. Search strategy
To find the right search terms for our search, we used the program Research Rabbit. This program helps to explore the literature of a research topic and links authors and papers on the same topic to each other. Before conducting the search, the research team determined the eight most relevant papers on this topic and added them to the program. With the function “similar work,” we added another eight relevant papers. Figure 1 shows these 16 relevant papers with the biggest bullets and shows that some papers have more in common with each other than others. The most common keywords from the 16 papers were the basis for our search terms.
Figure 1. Research Rabbit.
We formulated and combined search terms concerning: (a) population (Serious Mental Illness* OR Severe Mental Illness* OR SMI OR Mental Illness OR Psychiatric Disabilities); (b) the setting (Community Mental Health* OR Supported Housing OR Supportive Housing OR Supported Accommodation OR Community-based mental healthcare OR Independent Living OR Independent Housing); (c) outcomes (Recovery OR Psychiatric Rehabilitation OR Rehabilitation OR Participation OR Social Inclusion OR Empowerment); and (d) contemporary paradigm (Deinstitutionali* OR De-Institutionali* OR Community Living OR Integrated Care). To reduce the number of irrelevant studies, exclusion terms based on the eligibility criteria were added to the search strategy (e.g., somatic disease, dementia, and COVID-19).
We systematically searched the following electronic databases: PubMed, PsycInfo, Medline, and Cinahl (September 2021, updated in December 2021 and December 2022). These databases were chosen to cover medical (PubMed and Medline), psychological (PsycInfo), and nursing (Cinahl) literature. After the database search, we reviewed the reference lists from papers included by title and abstract to find missing important papers, and additionally, the volumes of the Journal of Integrated Care and the Community Mental Health Journal published in the same period (2011–2021) were reviewed. Finally, we added several papers manually in consensus with our research group that were found lacking in the results, but which did meet the inclusion criteria.
2.4. Study selection process
After the removal of duplicate papers by the first author, the papers were screened in three rounds. In the title, abstract, full-text screenings phase, and thematic analysis, the first author screened all the hits and the second and third authors screened a random sample of 5% to ensure, and reach consensus on, fidelity to the inclusion criteria.
2.5. Data analysis
A qualitative synthesis of included studies was performed using the method of thematic analysis. All papers were screened on elements of relevance (or ingredients needed) for current community mental healthcare with the aim to support persons with SMI in their independent living, recovery, and to stimulate further social inclusion. All papers were coded, and codes were synthesized into areas of ingredients.
3. Results
First, we present the descriptives in a PRISMA flow diagram, and a summary of the characteristics and quality of the studies included. Second, we present the results of our qualitative synthesis using thematic analysis.
3.1. Flowchart and summary of studies found
After the removal of duplicates and screening all papers on the title, abstract, and full text, the final sample consisted of 56 papers. Figure 2 shows the PRISMA flow diagram of the search.
Figure 2. PRISMA flowchart.
The 56 papers were published spread throughout our time frame, but by far the most papers were conducted in 2018 (n = 8), 2020 (n = 7), and 2021 (n = 9). Most of the papers were conducted in the United States (n = 17). Twenty-seven of the included papers were conducted primarily in Europe; the majority in the United Kingdom (n = 7), Netherlands (n = 5), and Sweden (n = 5). Four papers compared the situations in two countries: Australia and England, England and Italy, England and North Macedonia, and Canada and the United States. Other regions are Canada (n = 3) and Australia (n = 3). Four papers did not report their country, because they did not focus their research specifically on a country. We included 12 reviews, including three scoping reviews and four systematic reviews. In addition, we included 19 quantitative papers, including five RCTs and seven papers with a longitudinal design. We included 20 papers with a qualitative design, of which six were evaluative papers, seven opinion papers and seven descriptive papers. Finally, we included three mixed-methods studies and five expert papers. Table 1 shows the main information from the 56 papers found.
Table 1. Summary of papers included in the scoping review.
3.2. Thematic analysis
We found ingredients of community-based mental healthcare for persons with SMI in 12 areas: 1. multidisciplinary teams; 2. collaboration within and outside the organization; 3. attention to several aspects of health; 4. supporting full citizenship; 5. attention to the recovery of daily life; 6. collaboration with the social network; 7. tailored support; 8. well-trained staff; 9. using digital technologies; 10. housing and living environment; 11. sustainable policies and funding; and 12. reciprocity in relationships. The subcategories were indicated in the results in bold. Table 2 shows which ingredients were found in which papers, arranged by study design. All papers were classified into nine categories of study designs. The first category contains all types of reviews, including one systematic meta-analysis. The quantitative papers were divided into three categories: RCTs, cross-sectional, and longitudinal. The qualitative papers were also divided into three categories: evaluative (papers in which respondents shared their experiences with the researchers); opinion (in which participants are asked for their opinions about a phenomenon); and descriptive (papers describing a phenomenon). The remaining two categories are mixed-method and expert papers (papers without empirical research but with the opinion of the authors).
Table 2. Results of the thematic analysis.
3.2.1. Multidisciplinary teams
Multidisciplinary teams came up as important in twenty-five of the included papers. Five were reviews, three were RCTs, one was a quantitative cross-sectional paper, five were quantitative longitudinal papers and one a mixed-method paper. Additionally, two were qualitative evaluative papers, three were qualitative opinion papers, three were qualitative descriptive papers and two were expert papers.
Five papers recommend close involvement within different disciplines in multidisciplinary teams. Of these, three were qualitative papers (46, 47, 49), one expert paper (52), and one review (29). Therefore, one RCT finds positive results with regard to the health benefits for individuals for having received nurse practitioner services in a mental health setting to address primary care needs (34). In addition, two papers with a qualitative design emphasize adding an occupational therapist to a multidisciplinary team (44, 50). Finally, seven papers show the value of peer support to multidisciplinary teams; of which these seven papers, there are three reviews (29–31), three qualitative papers (47, 48, 51), and one expert paper (53).
An example of working in multidisciplinary teams is the (flexible) assertive community treatment ((F)ACT) teams. We found mainly empirical studies about the implementation and efficacy of (F)ACT and collaboration with (F)ACT teams. Of these, we found two reviews (32, 33), one RCT with positive results (35), and one RCT without significant results (36). In addition, six quantitative papers (37–42), one mixed-method paper (43), and two qualitative papers (44, 45) report on (F)ACT. Lastly, we found one review about the history of assertive community treatment (ACT) (32).
3.2.2. Collaboration within and outside the organization
Collaboration inside and outside the mental healthcare organization was studied in 20 of the included papers. Three were reviews, two were qualitative longitudinal studies, one was a quantitative longitudinal paper, three were qualitative evaluative papers, three were qualitative opinion papers, two were qualitative descriptive papers, two were mixed-method papers, and four were expert papers.
Intersectoral collaboration is often mentioned in the literature found. The collaboration between mental healthcare, physical care, and social service sectors was found in four qualitative papers (45, 46, 48, 49) and in one scoping review (54). In addition, collaboration between the government and the mental health sector was found in three qualitative studies (45, 59, 60) and one quantitative paper (40). Furthermore, we found three expert papers about collaboration in an integrated care system (3, 53, 63). Therefore, one systematic metareview (31), one mixed-method paper (57), one quantitative study (55), and one opinion paper (52) recommend an integrated care system with the integration of primary care in mental healthcare, and one descriptive paper shows an integrated mental health information system (62).
Growing evidence shows that integrative care is the new standard of care for people with mental illnesses, with the necessity of continuity of care from the emergency department to community mental health services. Continuity of care was found in two scoping reviews (29, 54), one quantitative longitudinal paper (56), and one qualitative paper (61).
Finally, two qualitative papers (59, 61) and one mixed-method paper (58) show the facilitators and barriers to intensive, intersectoral collaboration in community mental healthcare, such as cultural differences between the sectors as a barrier and face-to-face communication as a facilitator.
3.2.3. Attention to several aspects of health
Several aspects of health were studied in 18 of the included papers. Of these 15 papers, one was a systematic-meta review, two were quantitative longitudinal papers, one was a cross-sectional paper, eight were qualitative opinion papers, two were mixed-method papers, and four were expert papers.
Eight papers mention the focus on physical health in mental healthcare. Three qualitative, one mixed-method, and one quantitative paper report on the integration of physical health in mental healthcare (46, 55, 57, 65, 66). According to one expert paper, healthcare services need to recognize the far lower life expectancy among people with mental disorders and develop and evaluate new methods to reduce this health disparity (63). Respondents of a qualitative, opinion study stated that their main preoccupation and motivation was to be mentally well but they also recognized that many things that improve physical health also improved their mental health (67). In addition, one paper with a mixed-method design found that there is growing interest in models integrating physical healthcare delivery, management, or coordination into specialty mental health programs in the United States (58). One expert paper indicates the same (70). Finally, one systematic review found that this integration improves rates of immunization and screening for medical disorders, accompanied by positive effects on physical health, as well as improving general medical outcomes (31).
Another important aspect of health is cognitive functioning, which was found in two papers. One qualitative study mentioned that cognitive and physical health conditions might impact individuals’ ability to function in their daily lives during and after homelessness (48). In addition, one cross-sectional paper found that homebodies reported significantly poorer cognitive function than venturers (64).
In addition, we found two papers on psychosocial health. One quantitative study indicates that investment by teams to improve a patient’s psychosocial situation can lead to improvements in substance problems (41) and one expert paper aligns the importance of addressing social determinants of health within integrated care models for people with SMI (70).
Also, three qualitative papers (62, 68, 69) and one expert paper (52) emphasize the importance of positive health. The focus in positive healthis on the strengths, preferences, needs, and wishes of the service user, families, and communities that contribute to recovery.
Finally, two expert papers emphasize public health as actions seek to achieve equity between groups and a state of population-level health (52, 53).One expert paper shows the role of mental and public health promotion and prevention, taking the needs of the entire population into account (53).
3.2.4. Promoting full citizenship
Promoting full citizenship was a topic of relevance in 14 of the included papers. Three were reviews, two were RCTs, two were qualitative evaluative papers, one was a qualitative opinion paper, two were qualitative descriptive papers, and four were expert papers.
Human rights and destigmatization contribute to promoting full citizenship and are addressed in six papers (3, 29, 48, 53, 63, 82). One quantitative paper found that staffing intensity was negatively associated with human rights (82). One expert paper reports that historically the protection of human rights is one of the drivers for deinstitutionalization. Additionally, people with SMI experience more violations than others and suffer from stigma and discrimination (53). With this in mind, another expert paper states that mental health services should provide specific modules to reduce stigma and discrimination experienced by people with SMI (63). The same paper also states that some programs to reduce stigma and discrimination are presently active at the local level. They now need to be coordinated at the national level and adequately financed (63). In addition, providing training and coaching to health and social care staff on recovery and rights can reduce human rights violations that occur in the context of mental health services (53). One scoping review (29) found that there were an overwhelming number of anti-stigma campaigns from 1995 to 2015, but with a lowering trend of publication year over year on this topic.
In addition, several papers describe the Resource Group methodology that also promotes citizenship because the main feature of this methodology is that ownership and direction lie with the client. Of the included studies, there were two RCTs (73, 74) with positive results, one meta-analysis (71), one review (72), and one qualitative paper (75). Finally, we found some papers on self-reliance. Two qualitative papers describe that a recovery-oriented system of care should give a holistic view of a person’s strengths and build on the strengths and resiliencies of individuals, families, and communities (62, 69). One qualitative evaluative paper finds that FACT may support citizenship by relating to service users as whole people, facilitating empowerment and involvement (60).One expert paper states that signpost ways are needed for people to self-care, make useful contributions to society (52), and to be able to feel a fully-fledged citizen.
3.2.5. Attention to the recovery of daily life
Recovery of daily life was studied in 12 of the included papers. Of these 10 papers, one was a quantitative cross-sectional paper, one was a qualitative opinion paper, four were qualitative descriptive papers and four were expert papers.
We found several aspects of community-based support that contribute to recovery. According to one qualitative paper (68) and two expert papers (53, 63), mental health services should develop dedicated programs for recovery. Also, three qualitative papers (48, 49, 77) focus on gaining and regaining skills for more independent living in vivo. Moreover, two expert papers mention that signpost self-care options (52) and recovery colleges can contribute to the recovery of daily life (3). Besides that, one expert paper states that evidence-based, psychosocial interventions should be deployed to support individuals to achieve both personal recovery and increased independence (3). In addition, one qualitative study reports that occupational therapists should support clients in their recovery to find their best self (50). Lastly, one cross-sectional paper states that most of their respondents (64.8%) were not employed, but those who were working presented higher levels of functional capacity than those who were not (76).
3.2.6. Collaboration with the social network
Collaboration with the social network of the client was studied in 10 of the included papers. Of these 10 papers, three were reviews, two were RCTs, one was a qualitative evaluative paper, three were qualitative descriptive papers and one was an expert paper.
Many papers mention several models in which it is important to involve the clients and their social network in the recovery process. We found the collaboration with the social network papers applying the Resource Group methodology in two RCTs (73, 74), one meta-analysis (71), one review (72), and one qualitative paper (75). In addition, we found two qualitative descriptive papers that described approaches that place collaboration with the social network at the center of the client’s recovery process: namely, the Peer-Supported Open Dialogue (51), and the Active Recovery Triad (ART) model (68). Also, one expert paper and one qualitative paper mention that actively supporting the ability to empower and involve users and their families is important in community mental healthcare (3, 49). Finally, one scoping review suggests that network size is not consistently associated with reported loneliness, social support, recovery, or quality of life. A deep relationship with at least one supportive person may be more or equally valuable than a larger network (78).
3.2.7. Tailored support
Tailored support came up as important in eight of the included papers. Of these eight papers, one was a review, two were qualitative evaluative papers, three were qualitative descriptive papers, and two were expert papers.
Two expert papers and three qualitative papers state that mental healthcare should provide care that service users (and their family members) find accessible and acceptable (3, 60, 63, 80) and 24/7 available (77). In addition, one qualitative paper states that recovery-oriented care should be more effective when combined with support when required (49).One review found that support must also be flexible and user-driven (79). Therefore, one qualitative paper states that care should always be started with a Care Planning Meeting (68) and, according to one expert paper (63) and one qualitative paper (77), individualized care plans should be made through shared-decision making. Also, one expert paper states that care should be independent of location (63). Finally, we found two descriptive papers that describe that deinstitutionalization today means positive risk-taking and serious rethinking of questions in terms of distance, power, and language (77) and it provides new approaches to opportunity and safety (49).
3.2.8. Well-trained staff
Well-trained staff came up as important in eight of the included papers. Of these papers, there were two reviews, one quantitative cross-sectional paper, two qualitative descriptive papers, one mixed-method study, and two expert papers.
Two papers reported on education for mental healthcare staff. One review found that education for staff regarding identifying and responding to comorbidity is important (54).One qualitative descriptive paper states that peer-support open-dialogue teams should be trained in family systems (51). Furthermore, we found two expert papers and one qualitative paper that recommend the knowledge and use of evidence-based interventions and treatment by caregivers to provide social inclusion and recovery (49, 53, 63). In addition, one quantitative paper found that service teams should be of moderate size with adequate staffing to support service users in gaining and regaining skills for more independent living (82).One systematic review identified characteristics of well-trained staff, with practices that included routine monitoring and evaluation, good communication, equality between team members, and clear documentation practices (81). On the other hand, one mixed-method paper found difficulty in recruiting and retaining qualified staff (58).
3.2.9. Using digital technologies
Using digital technologies was studied in seven of the included papers. Of these seven papers, three were reviews, one was a qualitative descriptive paper, one was a mixed-method study, and two were expert papers.
One scoping review (29) found that digital platforms have an important role in improving the reach, scale, and accessibility of community-based support. Additionally, digital platforms add addressing public health issues and peer-led interventions are achieved effectively through the utilization of social media tools (29). Therefore, the same scoping review found that eHealth tools are becoming prevalent in the processes of promotion, prevention, and treatment in mental healthcare. In addition, the increased use of these eHealth tools continues to shape the future of community mental healthcare, particularly in low-access areas and areas where certain local expertise is lacking (29). Also, one expert paper states that the use of digital technologies should encourage self-care (52). Besides that, one mixed-method study and one systematic meta-review recommended the use of digital technology in electronic health records to enhance care coordination and promote integrated care (31, 58). Finally, one systematic review (81), one qualitative paper (63), and one expert paper (49) state that digital monitoring through technology may improve practices and patient outcomes.
3.2.10. Housing and living environment
Housing and living environment came up as important in five of the included papers. Two were reviews, one was a quantitative cross-sectional paper, one was a qualitative descriptive paper, and one was an expert paper.
One review (79) describes the principles of the supportive housing approach in the United States. In addition, one systematic review (24) found positive results with regard to supported accommodation on several outcomes and the importance of connection to, and affiliation with, the living environment.
Furthermore, one expert paper (52) and one quantitative paper (82) state that writing live manuals tailored to local needs helps to stimulate a grand alliance for health. Also, one qualitative paper (77) describes the cornerstones of the Trieste Model. Two of the cornerstones are actively working on the environment and the social fabric, and service accountability toward the community.
3.2.11. Sustainable policies and funding
Sustainable policies and funding came up as important in four of the included papers. Of these four papers, one was a scoping review, one was a qualitative descriptive paper, and two were expert papers.
One expert paper states that the integration of community mental healthcare services, sectors, and collaboration with the social network of the service user can be hindered by a financing system that favors institutional care. Therefore, it is recommended to create a flexible financing system that allows incentives for different services that address the relevant life domains of people with SMI in the community (53). Another expert paper states that financial barriers are also encountered when integrating general practitioner care and mental healthcare (70). In addition, one qualitative paper describes a successful financial model that was developed in Italy. The personal health budget includes all economic, professional, and human resources needed to trigger a process aimed at restoring a person – through an individual rehabilitation process – to an acceptable level of social functioning (49). Finally, one review found that improved reforms on national mental health policies and deinstitutionalization are important for community mental healthcare (29).
3.2.12. Reciprocity in relationships
Reciprocity in relationships is a topic of interest in three of the included papers. Of these three papers, one was a qualitative opinion paper, one was a qualitative descriptive paper, and one was an expert paper.
This topic is about the reciprocity in relationships between clients and caregivers, but also in contributions to society by all people. One qualitative paper shows the importance of establishing and maintaining contact between the caregiver with the service user, by building a mutual relationship of trust (68). Therefore, one expert paper found that all people, with or without mental health problems, should make useful contributions to society, including paid and voluntary work that helps strengthen the local community, appreciate those around them and increase their webs of trusted relationships (52). Finally, to promote reciprocity, one qualitative opinion study states that the use of person-centered strategies is important. This focus on a person’s interests and goals was frequently indicated to foster relationships, gain trust, and develop self-efficacy (46).
4. Discussion
4.1. Summary of main findings
With this scoping review, we aimed to give a comprehensive overview of existing and upcoming community mental healthcare approaches to discover the current vision explained in areas of ingredients. To our knowledge, there are still a few publications that attempt to combine all the necessary elements for community mental health (53, 83, 84). We found 56 papers that met the inclusion criteria. Thematic analysis resulted in 12 areas of ingredients for community mental healthcare. In this section, we answer our research questions and show what was striking in the found literature. Finally, we present the strengths and limitations of our scoping review and our conclusions.
We aimed to give an overview of the existing and upcoming insights on community mental healthcare for people with SMI. Based on the number of papers found, most attention is paid to several aspects of health, multidisciplinary teams, collaboration within and outside the organization, collaboration with the social network, and supporting full citizenship. However, empirical evidence from quantitative studies was found in only four of the 12 areas based on our included papers: multidisciplinary teams; collaboration with the social network; collaboration within and outside the organization; and supporting full citizenship. Nevertheless, the other areas that are not yet supported by evidence in this scoping review are no less important for community mental healthcare. Although no empirical research has yet been done on these topics, they are being addressed in several papers. This shows that there is increasing attention to them in the field.
Notably, given the low number of included empirical studies from the welfare or supported housing sector, we can conclude that little empirical research has been done on community mental healthcare in these sectors for this target group. The few empirical studies we from the mental health care sector and were primarily about (F)ACT and the Resource Group methodology. Even though (F)ACT has been around for a few decades, this shows that for the last 10 years (F)ACT has remained an important model within community mental healthcare for this target group to achieve recovery. Additionally, given the number of papers reporting on it and the evidence provided, collaborative mental healthcare within teams, organizations, and clients and their social network has been seen as important over the past decade.
In addition to the topics found that received attention for more than 10 years within community mental healthcare, such as recovery, tailored support, and multidisciplinary teams, we found several papers that are about more recent and innovative areas. Such as, reciprocity in relationships; sustainable policy and funding; using digital technologies; and supporting full citizenship. The results from this scoping review show that in recent years new shifts are taking place in the field of mental healthcare, whereby there is more attention paid to full citizenship, but empirical research is still lacking. Further, the more innovative areas were published in more recent literature, but frequently in expert papers. Due to the few RCTs found, we cannot conclude that these areas are also the most important, but we could say that these areas can form the basis for further research in community-based mental healthcare to provide social inclusion and recovery in the future.
Recovery was one of our research terms and we expected recovery to be an important part of our scoping review because more and more studies have been conducted on the areas of recovery. Ten included papers reported on the recovery of daily life, but no empirical studies were found on that topic. This is probably due to the exclusion of intervention studies that focus on a single life domain and did not seek collaboration, which is often the case in studies of recovery and all aspects of health. The upcoming attention to recovery-based care for persons with SMI is also shown in recent scoping reviews. Bitter et al. (85), in their review on recovery interventions for supported housing and clinical settings, found 53 papers, of which about a quarter of recovery interventions showed added value based on RCTs and half of them had initial promising results based on case studies and follow-up designs without a control group. Additionally, van Weeghel and colleagues (86) reviewed the conceptualization of recovery, showing that personal recovery is conceptualized as complementary to clinical recovery and represents processes rather than outcomes. They state that a broad framework of recovery is required, and more research is needed into the working mechanisms of personal recovery processes. Our search and the previous scoping reviews show that recovery is still a guiding concept for people with SMI that needs to be paid attention to both in today’s and future community-based mental healthcare, but more empirical research is necessary to find the working mechanisms that contribute to recovery.
Further, we found many papers concerning multidisciplinary teams. Peer supporters (29, 30, 47, 48, 51, 53), occupational therapists (44, 50), and nurses (34) are frequently mentioned as important disciplines in a multidisciplinary team, besides the regular disciplines of psychologists, psychiatrists, and social psychiatric care workers. Peer supporters have been a part of the (F)ACT teams for more than our searched 10 years (87). Adding peer supporters to multidisciplinary teams is found in seven papers, including three reviews. Because of this, there is much evidence that peer support adds value to multidisciplinary teams.
Additionally, intersectoral collaboration appears regularly in the literature. First, several papers studied the collaboration with primary care to provide the physical health of people with SMI and the importance of attention being paid to clients’ physical health in mental healthcare. This builds on previous research that shows that people with SMI experience premature mortality of around 15–20 years earlier than the general population (88), have a high prevalence of substance use disorder (89), and are at risk of the development of often preventable secondary health conditions (90, 91). Second, collaboration with the municipalities is recommended in the literature. The importance of collaboration between mental healthcare and community services is lacking in the papers. Currently, the mental healthcare sector seems the most important party in the found literature to support this target group. The collaboration between mental healthcare and municipal services is most often mentioned in papers about (F)ACT from Scandinavian countries (40, 45, 59, 60, 72). This is an enhancement of the multidisciplinarity, used in the (F)ACT program, that has been practiced and recommended for the last decades.
Intersectoral collaboration is often recommended in the literature found, but, notably, the literature found does not elaborate on what integrated collaboration should look like in practice. Possibly that is because other literature confirms that this collaboration is not easy to achieve (92). Integration can be defined as the search to connect the healthcare system (acute, primary medical, and skilled) with other human service systems (e.g., long-term care, education, and vocational and housing services) to improve outcomes (clinical, satisfaction, and efficiency). Leutz places full integration into the larger context of good human service practices by integrating services through linkage and coordination (92). Accordingly, we should not set full integration as the goal for community mental healthcare, rather, good connections and collaboration are more achievable.
In recent years, citizenship for people with (severe) mental health problems is a topic that has received increasing attention (93–95). Citizenship concerns one’s connections to the responsibilities, rights, roles, relationships, and resources offered to people in society (96). There have also been an increasing number of empirical studies, such as the cross-sectional study by Nesse and colleagues (97). This study suggests that citizenship and occupational meaningfulness may have positive implications for recovery. Additionally, Rowe and Davidson presented “recovering citizenship” as a concept and metaphor to capture the individual recovery process within the context and goal of a life in the community that the citizenship framework supports (98), and which is also about social inclusion and the full participation of individuals with mental illness in society (99).
Worthy of note is that just a few papers come from the leading journals on integrated community mental healthcare, which we explicitly searched, including the International Journal of Integrated Care and Community Mental Health Journal. Remarkably, the term “SMI” appears just once in the titles and abstracts of the volumes of 2011–2021 of the first journal. Moreover, in the Community Mental Health Journal we found several papers about community care, but only a few in combination with SMI. This confirms the idea that little research has been done on this topic. Besides that, many papers also seem to be written from the point of view of the mental healthcare sector. Loneliness, debts, and poverty are important topics in community care, but there does not yet seem to be much published about these main topics in social services because they did not show up in the results of the papers found. In addition, research in the shelter and supported housing sector is still limited (23, 24). We also noticed that social work as a distinct support sector alongside the mental healthcare sector that includes supported housing receives little attention in the literature found. It is recommended that there should be more attention paid in future research to mental healthcare from the community perspective in which the municipalities and social services play a larger role.
In this scoping review, we have chosen to exclude papers on interventions that focus on a specific area of life and do not provide an integrated offering for people with SMI only, because of the risk of investigating too broad a scope. In the last decade, some interventions have become an important and innovative part of community care but would be too much information to present in one scoping review. Consequently, we did not include papers about (returning to) work, and papers primarily focused on recovery. Nevertheless, interventions are the important link between theory and practice and are worth mentioning. The literature proves their importance because of the many available interventions for this target group to improve, for example, lifestyle (100, 101), internalized stigma (102), housing (103), employment (104, 105), cognition (106), social skills (107), and self-management (108). Therefore, the focus on psycho-social aspects of support for people with SMI in the included papers is limited. This may also be due to our focus on the broader literature and not on interventions that address these aspects more specifically.
Finally, it was difficult to compare the papers. One example is the difficulty of comparison in the context of national differences in legal frameworks and public policies. Not every recommendation could be implied in all societies. We tried to take this into account to some extent by including only Western literature. In addition, for both the target group and the outpatient setting, a very varied vocabulary is used in the various papers and the general terms do not mean the same in every article. First, the term “supported housing” is used for support to people in a 24/7 aggregated setting, but also with regard to clients who live independently in the community with 24/7 available support, which is what we were looking for. Second, the term “SMI” is interpreted differently. Some papers are limited to clients with schizophrenia and bipolar disorder, while other papers focus more on autism and anxiety. Other requirements for SMI are also handled differently. Several papers seem to focus more on common mental illnesses rather than SMI. This makes it hard to compare and generalize the different papers on this topic. Previous research has already indicated that varying terminology is used internationally to describe the different housing settings and approaches to the provision of housing and support (13). Further research is necessary to create general terminology with clear definitions of the outpatient setting.
4.2. Strengths and limitations
The main strength of our review is the broad and systematic search. We used several search strategies, including database search, hand-searching the reference lists and leading journals to find as complete an overview as possible of all papers on our topic. We have done everything possible to find all relevant papers from the past 10 years. To ensure that we did not miss innovative topics, we did not choose certain study designs as inclusion criteria. This also has the advantage that we could find enough papers. As a result, there are large differences between the study designs in the papers. This creates more difficulties when comparing the papers and ingredients. It is hard to conclude which ingredient is more important for community-based mental healthcare than another. Nevertheless, to the best of our knowledge, this is the first scoping review on all developments in community mental healthcare and gives a good overview of the current relevant topics. Notably, less than half of the included papers are empirical studies, and a large part of the included papers was composed of descriptive or opinion papers. More empirical research is needed on this subject.
Conducting a scoping review provides a broad view of the literature, but it also has some limitations. One of these includes the search terms. With these search terms, it was not possible to find everything in the field through database search due to the variation in terminology, and in recent years the main focus of the research has been on individual interventions. Despite all efforts, including the Research Rabbit software and hand-search, there is still the possibility that we missed some relevant papers. The second limitation of our study is the generalizability of the conclusions. We did not use search terms in our search strategy to find specific themes, such as citizenship and social work, but these themes are related to our search terms recovery, participation, social inclusion, and empowerment. The final limitation concerns citizenship. Despite the increasing attention being paid to citizenship in the scientific literature, we included only a few citizenship papers. Due to the target population of our broader study, we only included papers on adults with SMI while the citizenship papers focus on (common) mental illness. Nevertheless, the focus on citizenship is a relevant development that deserves attention in this scoping review.
5. Conclusion
This scoping review aimed to give a comprehensive overview of existing and upcoming community mental healthcare approaches to discover the current vision in the areas of ingredients. We found 12 areas of ingredients, including some innovative topics about reciprocity and sustainable policies and funding. There is much attention paid to individual ingredients for good community-based mental healthcare, but very little is known about their integration and implementation in contemporary, fragmented mental healthcare services. No earlier, international study has connected all the current elements of good community mental healthcare together. Thus, our research contributes to the existing research and adds value to future research on community-based mental healthcare. For future studies, we recommend more empirical research on community mental healthcare, as well as further investigation(s) from the social service perspective, and solid research on general terminology about SMI and outpatient support.
Author contributions
CvG contributed to the development of the search question and strategies, screening papers and analysis, and to the main part of the manuscript. DR and MvV participated in the development of the search question and strategies, participated in screening papers, the thematic analysis, and writing the manuscript. JvW and TvR participated in the development of the search question, strategies, and supervised advancement of the project. All authors contributed to the article and approved the submitted version.
Funding
This scoping review belongs to a broader project which received ethical approval from the Ethics Review Board Tilburg School of Social and Behavioral Sciences and was funded by three organizations for supported housing and shelter in Netherlands: Kwintes, Leviaan, and HVO Querido.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher’s note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
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Keywords: severe mental illness, community care, recovery, social inclusion, scoping review, current insights, human rights, independent living
Citation: van Genk C, Roeg D, van Vugt M, van Weeghel J and Van Regenmortel T (2023) Current insights of community mental healthcare for people with severe mental illness: A scoping review. Front. Psychiatry 14:1156235. doi: 10.3389/fpsyt.2023.1156235
Edited by:
Stefan Weinmann, Theodor-Wenzel-Werk, GermanyReviewed by:
Elaine Stasiulis, Rotman Research Institute (RRI), CanadaJohanna Baumgardt, Research Institute of the Local Health Care Funds (WIdO), Germany
Copyright © 2023 van Genk, Roeg, van Vugt, van Weeghel and Van Regenmortel. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Caroline van Genk, c.m.h.vangenk@tilburguniversity.edu