Table 1.

Key findings of included studies.

No.	Title	Study Design	Citations	Main Objectives	Key Findings
1.	Factors associated with pasung (physical restraint and confinement) of schizophrenia patients in Bogor regency, West Java Province, Indonesia, 2017.	Policy analysis	(Laila et al., 2019) [7].	To analyze the development and implementation of Indonesia’s Free Pasung policy using the Walt and Gilson policy triangle framework, examining the policy context, content, actors, and processes involved.	• Most patients reside in rural areas.      • Pasung was initiated by the father, mother, or elder siblings.      • Patient’s aggressive or violent behavior, relapse, unemployment in the family, and negative attitude of the family were associated with pasung among patients with schizophrenia      • Patients with aggressive behavior are more likely to be Pasung than those with non-aggressive behavior.      • Among patients with aggression who were restrained (pasung), 77.7% of their pasung cases are due to patients' aggression.      • Unemployment in the family is the biggest contributing factor to pasung at the population level.      • If family unemployment were eliminated, the number of pasung cases in the entire population could decrease by 49.3%.
2.	Perceptions about pasung (physical restraint and confinement) of schizophrenia patients: a qualitative study among family members and other key stakeholders in Bogor regency, West Java Province, Indonesia 2017.	Cross-sectional study	(Laila et al., 2018) [8].	To identify factors associated with the use of pasung among schizophrenia patients in Bogor Regency, Indonesia, using quantitative analysis of secondary health surveillance data.	• According to family members, neighbors, and community leaders, the primary reason for implementing pasung was to ensure the safety of both the patient and those around them. Many patients exhibited aggressive behaviors, including physical violence toward their relatives and neighbors. In such situations, family members felt vulnerable and uncertain about how to manage the situation.      • Family and community members viewed pasung as the only viable option to protect both the patient and others from aggressive or destructive behavior. It was considered a practical solution for individuals with mental illness and had become a socially accepted norm. In some cases, patients expressed a desire to see a doctor or be transferred to a mental hospital, but their families often disregarded these requests for various reasons.     • Families struggled to afford mental healthcare costs, and even those with health insurance often found transportation expenses prohibitive. Additionally, they faced financial difficulties in providing food for patients with excessive eating habits. As a result, many families were unable to meet even their own basic needs.       • Mental health services in rural areas were severely limited, with low availability and accessibility. There was a lack of trust in the system, as treated patients often experienced relapses. In contrast, urban areas had better-coordinated mental health services, including medical care and psychological counseling aimed at behavioral change. Due to these challenges, families frequently turned to alternative treatments that were more readily accessible.     • The community had limited awareness of schizophrenia and how to care for individuals with the condition. In contrast, misconceptions and misunderstandings were widespread. Behaviors such as stopping aggression and obeying parents were mistakenly seen as signs of recovery, even when the patient was restrained in pasung.
3.	Aceh free pasung: releasing the mentally ill from physical restraint.	Qualitative study (focus group discussions and interviews).	(Puteh et al., 2011) [9].	To explore the perceptions and experiences of family members and other stakeholders regarding the use of pasung for schizophrenia patients in Bogor Regency.	• Of the 59 patients, the primary concern for 47 patients was their aggressive behavior. In the other 12 cases, the focus was on the patient's safety and well-being due to wandering, while a few cases cited various “special reasons.” For instance, some patients were restrained shortly after the launch of the Aceh Free Pasung program, with the hope that “someone from the government would come, release them, and take them to the hospital for treatment without any cost.”        • In most cases (86.4%), the decision to use pasung was made by the patient's family. In the remaining cases (13.6%), it was community leaders who decided to apply pasung.       • Patients who had been in pasung for longer periods were less likely to have had previous psychiatric treatment, whereas those with shorter durations of pasung typically had received treatment at least once.        • At the time of their release from pasung and admission to the hospital, 21 ex-pasung patients (35.6%) showed significant muscle atrophy in their legs or arms. Almost all of those with lower extremity atrophy experienced difficulty walking; about half were unable to walk at all, and all required physical therapy during their hospitalization.        • Many of the respondents mentioned that, in addition to previous hospital treatment, they had also sought care from traditional or religious healers. About a quarter of the patients who had never been hospitalized before the introduction of the new health insurance schemes cited the inability to pay for hospital services as the reason they had not sought treatment earlier.
4.	Evaluating the Indonesian free pasung movement: understanding continuing use of restraint of the mentally ill in rural Java.	Descriptive case study	(Hunt et al., 2023) [10].	To describe the implementation and outcomes of the “Aceh Free Pasung” program, which aimed to release and rehabilitate mentally ill individuals from physical restraint in Aceh Province.	• The Puskesmas system is central to mental health care but lacks specialized training and direct mental health services. While mental health data is recorded, no explicit mental health services are provided.      • Mental health care in Winong and nearby areas is limited, with referrals to other facilities required for more extensive care (sub-district Puskesmas).      • Secondary and tertiary care is also limited by insurance coverage and transportation costs, with significant gaps in access for low-income individuals, including many with mental illness. Many Indonesians, especially those with mental illness, are not registered in the national insurance scheme, making access to care more difficult for low-income groups.      • Continuity of care after discharge is problematic due to logistical issues, including long travel distances for medication. After discharge, patients ideally continue their treatment through outpatient primary care, but many patients fail to reach their intended facilities, and those who do often find the required medications unavailable, forcing them to travel long distances to obtain prescriptions.      • There is a significant gap in government-provided day care, rehabilitative, and residential care services in Winong, which has led to the emergence of a private residential care facility. The 2017 Ministry of Health Regulation emphasizes the importance of family support for individuals with mental illness to assist with care, rehabilitation, and reintegration into the community post-hospitalization. Rehabilitative services are meant to enhance patients’ social and vocational skills for reintegration. However, no day care or rehabilitative services, as outlined in the 2017 regulation, were found in the mental healthcare mapping in the area.      • When family support is absent, the government assumes responsibility for the care of individuals with mental illness, as per the Mental Health Legislation of 2014. The 2017 Ministry of Health Regulation mandates government-run residential care facilities, but no such facilities were available in Winong (Indonesia’s district) or surrounding areas during the 2015–2016 interviews. A private initiative, run by an individual, operated a residential care facility in Winong village to address the gap.
5.	Indonesia free from pasung: a policy analysis.	Mixed-methods evaluation study.	(Hidayat et al., 2023) [5].	To evaluate the effectiveness and challenges of the Indonesia Free Pasung movement by exploring continued practices of restraint in rural Java and the perspectives of mental health stakeholders.	• 1966–1998 (New Order Era): The government focused on institutionalized psychiatric care, increasing the number of psychiatric hospitals.      • 1977 Ministerial Decree: Encouraged public awareness against Pasung and instructed local leaders to address mental health issues in communities      • 1992 Health Law: Shifted focus toward community-based mental health support, acknowledging the connection between mental health, poverty, and unemployment.      • 1999 Human Rights Act: Recognized freedom from torture, including seclusion and restraint of mentally ill individuals, as a fundamental human right.      • 2010 ‘Towards Indonesia Free of Pasung’ Campaign: Launched to eliminate Pasung, backed by advocacy groups and media; Emphasized government responsibility in providing mental health services; Encouraged community health centers (Puskesmas) to be the first point of contact for treatment.      • 2011 Social Security Law: Provided financial support for low-income individuals, improving healthcare accessibility.      • 2014 Mental Health Act: Criminalized Pasung, though enforcement remained unclear.      • 2016 Disability Rights Law: Stressed protection against torture and mistreatment for individuals with disabilities, including mental illness.      • 2017 Stop Pasung Movement: Aimed to make Indonesia Pasung-free by 2019 (later revised to 2023); Introduced a Social Rehabilitation Program to reintegrate individuals previously subjected to Pasung.      • 2017 Ministerial Decree on Stop Pasung: Outlined the mental health service system, emphasizing community-based treatment and structured referral pathways.      • 2018 West Java Mental Health Regulation: Highlighted major gaps in mental health services: Only 20% of primary healthcare facilities provided mental health services; Limited resources, medications, and trained personnel; Access to psychiatric care was hindered by remoteness and lack of emergency services; Tertiary hospitals have become the main providers for severe cases.
6.	Family stigma correlation with shackling in schizophrenia patients in the Psychiatric hospital of Bali province.	Cross-sectional correlational study.	(Jayanti & Dharmaw an, 2017) [11].	To assess the correlation between family stigma and the use of pasung among schizophrenia patients at a psychiatric hospital in Bali Province.	• Lack of knowledge about mental disorders leads to poor treatment quality. Many families hide mental illness and quietly take patients to psychiatric hospitals to avoid social judgment.        • A strong relationship exists between family stigma and the practice of shackling schizophrenia patients. High willingness among families to shackle schizophrenia patients is driven by limited knowledge, lack of mental health facilities, and safety concerns.        • Chronically ill schizophrenia patients are perceived as dangerous due to behaviors like violence, property destruction, and aggression.
7.	“Family stigma” among family members of people with mental illness in Indonesia: a grounded theory approach.	Grounded theory qualitative study.	(Subu et al., 2023) [12].	To develop a theoretical understanding of how family stigma is constructed and experienced by family members of people with mental illness in Indonesia.	• Use of pasung is common in some areas of Indonesia for managing mental illness within families.        • Some families believe mental illness is caused by spirit possession (jinn, demons, or devils). As a result, they seek alternative treatments from shamans (dukun) or Islamic religious leaders.       • Some prefer to go for alternative or religious treatment, like Shamanic treatments, conducted by a dukun using traditional healing methods, or Islamic healing (Rukiyah): A method used by religious leaders to expel spirits.        • Families of mentally ill individuals face community rejection and social isolation. People avoid communicating with them, reinforcing exclusion and stigma.
8.	Introducing recovery-oriented practice in Indonesia: the Sukabumi Project – an innovative mental health programme.	Program description and process evaluation.	(Stratford et al., 2014) [14].	To describe and evaluate the Sukabumi Project, an innovative mental health program introducing recovery-oriented practices in Indonesia.	• Rehabilitation programs aim to develop essential life skills that help individuals reintegrate into society and become active members of their communities. A key aspect of fostering acceptance is demonstrating to families that, with proper treatment and support, individuals with mental illness can contribute positively to both their families and the broader community.      • Most families ultimately wish for their loved ones with mental illness to return home and reintegrate into family life. In cases where individuals become homeless, families often reach out to social welfare services, boarding houses, psychiatric hospitals, or informal networks to locate and bring them back.      • Many families resort to pasung (physical restraint) as a means of protecting both the individual and the community, especially in response to violent or disruptive behavior. However, this practice is largely driven by a lack of mental health education and limited access to affordable treatment, leaving families with no other options.      • To address these challenges, a community-based rehabilitation system is crucial. Such a system would provide necessary support to individuals facing mental health struggles, including those subjected to pasung or those who have been displaced due to homelessness or institutionalization.