The continuous emptying of state psychiatric hospitals for the past half century has decimated the number of public psychiatric beds available for the treatment of acutely or chronically ill psychiatric patients in the United States.
Although they constitute a small subset of all persons diagnosed with mental illness, the most severely ill patients are in dire need of the specialized, intensive treatment that has been delivered since the early 1830s through state hospital systems. The elimination of these systems is producing significant public and personal consequences in communities nationwide.
In “No Room at the Inn: Trends and Consequences of Closing Public Psychiatric Hospitals,” we use data from the National Association of State Mental Health Program Directors Research Institute to report changes in the availability of public psychiatric hospital beds from 2005 to 2010 and to assess the consequences for individuals and society. In summary:
- The number of state psychiatric beds decreased by 14% from 2005 to 2010. In 2005, there were 50,509 state psychiatric beds available nationwide. By 2010, the number had shrunk to 43,318.
- Per capita state psychiatric bed population by 2010 plunged to 1850 levels. In 1850, at the beginning of the movement to provide more humane care by treating seriously mentally ill persons in hospitals, there were 14 beds per 100,000 population. In 2010, the supply was virtually identical at 14.1.
- Thirteen states closed 25% or more of their total state hospital beds from 2005 to 2010. New Mexico and Minnesota closed more than 50% of their beds; Michigan and North Carolina closed just less than 50%. Ten states increased their total hospital beds but continued to provide less than half the beds.
- The decrease in state psychiatric bed availability since 2005 is actually worse than the 14% that occurred 2005-2010. Completed or announced bed eliminations since 2010 will eliminate 4,471 additional beds.
Overall, many states appear to be effectively terminating a public psychiatric treatment system that has existed for nearly two centuries. The system was originally created to protect both the patients and the public, and its termination is taking place with little regard for the consequences to either group.
- Nationwide, closures reduced the number of beds available in the combined 50 states to 28% of the number considered necessary for minimally adequate inpatient psychiatric services. A minimum of 50 beds per 100,000 population, nearly three times the current bed population, is a consensus target for providing minimally adequate treatment. (By way of comparison, the ratio in England in 2005 was 63.2/100,000.)
- In the absence of needed treatment and care, individuals in acute or chronic disabling psychiatric crisis increasingly gravitate to hospital emergency departments, jails and prisons.
- These systems experience significant negative impacts as a result.
- The number of persons with mental illness who are homeless increased.In some communities, officials have reported as many as two-thirds of their homeless population is mentally ill.
- Hospital emergency departments are so overcrowded that some acutely ill patients wait days or even weeks for a psychiatric bed to open so they can be admitted; some eventually are released to the streets without treatment.
- Law enforcement agencies find service calls, transportation and hospital security for people in acute psychiatric crisis creating significant, growing demands on their officers and straining public safety resources.
- Jails and prisons are increasingly populated by individuals with untreated mental illness with some facilities reporting that one-third or more of their inmates are severely mentally ill.
- A statistically significant inverse association emerged between lower state-hospital spending and higher rates of arrest-related deaths. In a comparison of hospital expenditures–a measure of public psychiatric bed availability–for 2008 and rates of arrest-related deaths (2003-2009 cumulative numbers), those states that decreased funding for public hospitals experienced increased arrest-related deaths.
- A statistical trend emerged between public hospital bed populations and certain violent crimes, including homicide. States that closed more public psychiatric beds between 2005 and 2010 experienced higher rates of violent crime generally and of aggravated assault in particular (2010 data). A trend-level association between lower per capita hospital expenses and higher rates of aggravated assault also was found.
The elimination of dedicated psychiatric facilities for those with the most acute or profoundly disabling mental illnesses is wreaking devastating impacts on individuals in need of treatment and the communities in which they live.
We are calling for a moratorium on further public hospital bed closures until a sufficient number of psychiatric beds for acutely and/or chronically ill individuals is available either in state hospitals or community facilities.
Our study, “The Shortage of Public Hospital Beds for Mentally Ill Persons,” in 2008 proposed additional pathways for ameliorating the public hospital bed shortage. Time has only increased the need for the following measures and thus the urgency of the following:
- Holding state governors and mental health officials responsible for the shortage and demand that they create the number of public psychiatric beds needed to meet the minimum standards of treatment.
- Implementing and using assertive community treatment (ACT) programs and assisted outpatient treatment (AOT) in every community. Both programs have been shown to significantly decrease the need for hospitalization.
- Lifting the federal prohibition on the use of Medicaid (“Institution for Mental Diseases [IMD] exclusion”) in state hospitals so that decisions regarding treatment are made entirely on a clinical basis rather than a fiscal basis.
- Making the public aware that the shortage of public psychiatric beds contributes to a number of costly and sometimes dangerous social problems, including jails and prisons overcrowded with inmates who are acutely ill and untreated, emergency departments overcrowded with patients in psychiatric crisis, increased homelessness, and increased violence.