Discussion

This review highlights that IPC in behavioral health settings remains an underdeveloped and understudied area. Across the published literature, a consistent theme is that conventional IPC frameworks—largely derived from acute care contexts—do not adequately reflect the structural, behavioral, therapeutic, and ethical complexities inherent to behavioral healthcare environments. Notably, much of the existing research regarding IPC in behavioral health environments was generated in response to the COVID-19 pandemic, which not only illuminated long-standing systemic vulnerabilities but also encouraged innovation, cross-disciplinary collaboration, and renewed attention to IPC practices in this historically understudied area.

Multiple publications underscore that behavioral healthcare settings face unique environmental and operational barriers to IPC. These environments are intentionally constructed for safety, visibility, and communal engagement rather than infection containment. Communal therapeutic areas, shared living spaces and bathrooms, and limited capacity for isolation make conventional IPC interventions—such as cohorting, distancing, and negative pressure ventilation—difficult to implement and sustain and increases the risk of spread of communicable diseases.^{Reference Rovers, van de Linde and Kenters1,Reference Fukuta and Muder2,Reference Brody, Parish, Kanellopoulos and Russ6–Reference Schultz, Miller and Stancill8} During outbreaks of infections with respiratory and enteric pathogens, these features were often linked to delayed containment and ongoing transmission. These structural and operational factors often created tension between IPC priorities and the ethical tenets of psychiatric care, where patient autonomy and maintenance of therapeutic rapport are essential.

Patient-related factors, such as, underlying medical conditions, medications, and underlying mental illness, compound these challenges, compound these challenges. Individuals with severe mental illness, dementia, or cognitive impairment may have limited insight or difficulty adhering to masking, hygiene, or isolation protocols and have challenges with symptom recognition/reporting. Behavioral symptoms such as agitation, impulsivity, or psychosis can necessitate close contact or physical restraint, elevating transmission risk for staff and other patients.^{Reference Rovers, van de Linde and Kenters1,Reference Li, Wang, Tan, Lee and Yang3,Reference Angelino, Lyketsos, Ahmed, Potash and Cullen7} Compounding these risks, staff often report barriers related to training, resources, and institutional support resulting in suboptimal staff compliance with IPC recommendations.^{Reference Rovers, van de Linde and Kenters1,Reference Lau, Lam, Siu, Tang, Suen and Lam9} Several studies reported that staff often lacked adequate IPC training, had limited access to PPE, and received unclear guidance on IPC protocols.^{Reference Li, Wang, Tan, Lee and Yang3,Reference Houben, van Hensbergen, den Heijer, Dukers-Muijrers and Hoebe4,Reference Schultz, Miller and Stancill8} Staffing shortages, burnout, and restricted availability of alcohol-based hand rubs further undermined IPC sustainability.^{Reference Fukuta and Muder2,Reference Houben, van Hensbergen, den Heijer, Dukers-Muijrers and Hoebe4,Reference Barnett, Esper and Foster10}

Despite extensive IPC challenges inherent to behavioral health settings, numerous studies found that adaptive, interdisciplinary strategies can effectively facilitate implementation and adherence to IPC best practices. Interdisciplinary collaboration, particularly between infection prevention, psychiatry, nursing, and facilities teams, consistently emerged as a critical facilitator of IPC success in these settings.^{Reference Houben, van Hensbergen, den Heijer, Dukers-Muijrers and Hoebe4} Programs that embedded IPC specialists within behavioral health governance structures achieved more coordinated outbreak responses, stronger policy enforcement, and improved cross-disciplinary communication.^{Reference Houben, van Hensbergen, den Heijer, Dukers-Muijrers and Hoebe4} Complementary strategies—such as ongoing staff education, leadership engagement, and behavioral health–adapted IPC policies—further strengthened compliance.^{Reference Rovers, van de Linde and Kenters1,Reference Li, Wang, Tan, Lee and Yang3,Reference Lau, Lam, Siu, Tang, Suen and Lam9} Transparent communication with staff and patients, coupled with the integration of IPC principles into regular psychiatric operations, also supported sustained adherence.^{Reference Rovers, van de Linde and Kenters1,Reference Schultz, Miller and Stancill8}

During infectious outbreaks, several adaptive strategies proved effective in supporting IPC implementation. Structured testing protocols, universal admission screening, and flexible spatial arrangements enabled facilities to balance IPC priorities with therapeutic needs.^{Reference Falgione, Snyder, Cannon and Huss5,Reference Brody, Parish, Kanellopoulos and Russ6,Reference Barnett, Esper and Foster10} Cohorting and “three-space” triage models—separating new admissions, confirmed cases, and noninfected units—were associated with decreased nosocomial transmission.^{Reference Brody, Parish, Kanellopoulos and Russ6,Reference Schultz, Miller and Stancill8,Reference Barnett, Esper and Foster10} Environmental modifications, including enhanced ventilation, spatial zoning, and digital surveillance systems, demonstrated feasibility without compromising safety or therapeutic goals.^{Reference Falgione, Snyder, Cannon and Huss5,Reference Angelino, Lyketsos, Ahmed, Potash and Cullen7,Reference Schultz, Miller and Stancill8} Data published during the COVID-19 pandemic found that technology-enabled interventions—including telepsychiatry, hybrid service delivery, and real-time feedback systems—supported care continuity while minimizing exposure risk.

This review has several limitations. The included articles were heterogeneous in design and quality, limiting generalizability. Publication bias likely favored outbreak and intervention reports over routine IPC practices, and most studies originated from high-income countries, leaving gaps in data from community and low-resource settings. No formal risk-of-bias assessment was conducted. Despite these, this review provides a comprehensive synthesis of themes and evidence gaps related to IPC in behavioral health environments.

This review highlights the scarcity of data regarding IPC best practices in behavioral health settings. Most evidence remains descriptive, underscoring the need for further research to inform behavioral health-specific IPC models. Effective IPC in behavioral health depends on tailoring approaches to the unique clinical, environmental, and psychosocial context of these settings. Future priorities should include developing evidence-based IPC guidelines for behavioral health settings, integrating behavioral health into IPC governance structures, and investing in environmental modifications and infrastructure that supports both safety and therapeutic goals.