Critical Elimination of State Psychiatric Beds Continues at Great Human Cost

The number of state psychiatric beds still available to serve the nation’s most ill and potentially dangerous psychiatric patients is at its lowest level ever recorded, setting off a crisis of unmet need throughout the country, according to a new report from the Treatment Advocacy Center, an Arlington, VA, nonprofit organization.

The June 2016 report, “Going, Going, Gone,” by Doris A. Fuller, chief of research and public affairs, and co-authors, surveyed the number of staffed psychiatric beds in state hospitals in all 50 states and the District of Columbia to find out how many state hospital beds remain and whom they serve. The report is the organization’s fourth state survey in 8 years.

The report found that only 37,679 staffed beds remain in state hospitals, a 17% drop in the bed population since 2010, when 43,318 beds remained, and a 96.5% drop from peak hospital numbers in the 1950s. This translates to 11.7 beds per 100,000 people--“fewer state hospital beds per capita than at any time since before the United States stopped criminalizing mental illness in the 1850s,” the authors point out. (In the mid-1950s there were 337 state beds per 100,000 people.)

Making matters worse, nearly 50% of remaining beds are occupied by forensic patients charged with or convicted of crimes. As more beds are diverted to the forensic population, fewer beds are left for people who haven’t committed crimes.

“‘Boarding’” patients in mental health crisis to wait in loud, chaotic hospital emergency rooms has become virtually universal as the number of beds for non-offenders has shrunk,” the report notes.

The closing of state-operated psychiatric beds, known as “deinstitutionalization,” has been going on since the mid-20th century. The trend was a result of financial incentives, new psychiatric medications, and policies driven by an ideal that every patient would be better off in small community settings than large facilities—an ideal that might have been sound but was incompletely realized. The hospitals closed, but community-based clinics did not replace them, or were defunded and closed, according to the report. In fact, the functions the hospitals once performed for people severely disabled by mental illness were lost, and the people who needed these functions were “transinstitutionalized” to jails and prisons, the report concluded.

Behind the reported figures, the tragedy of the shortage continues. Gravely ill and suffering people compete for inpatient beds that remain, a battle between civil and forensic patients. Children and adolescents in psychiatric crisis are backing up in emergency rooms because juvenile psychiatric beds are being diverted to adults, the report stated.

“The reality that an immeasurable number of people with treatable disease only get treatment when they get sick enough to commit crimes that send them to jail and then to a forensic bed should be a source of national shame and outcry for reform,” the researchers concluded.

The report makes recommendations for needed steps to increase the number of psychiatric beds, including the following:

• Determine how many psychiatric beds are needed to meet inpatient need and set supply targets.
• Identify and reform public policies that incentive bed shortages. Congress should direct and fund appropriate agencies to undertake a review of all federal policies that create financial incentives to close psychiatric beds, assess their impacts, and make evidence-driven reforms.
• Increase the use of successful diversion strategies that reduce hospitalization rates: assisted outpatient treatment, assertive community treatment, and sequential intercept model.

To read the report, visit www.tacreports.org/storage/documents/going-going-gone.pdf.