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Tenth in a Series of Ten Briefs Addressing: What Is the Inpatient Bed Need if You Have a Best Practice Continuum of Care?

September 05, 2017

In recent years, some state reports have documented an increase in the number of forensic patients being admitted to state psychiatric hospitals for inpatient services. The purpose of this study was to investigate these reported trends and their prevalence nationwide, and to explore the factors driving the trends if they exist.

States that are experiencing dramatic pressures accommodating forensic patients describe operating at full capacity. These states have also reported that the population of individuals who have increased in numbers the most are those found incompetent to stand trial, who require competency evaluations and/or restoration services. The purpose of this paper is to investigate two key questions: Has the number of forensic patients present within state psychiatric hospitals grown since 1999? Is the proportion of forensic patients in state psychiatric hospitals growing?

While overall national trend lines show a 76 percent increase in the number of forensic patients in state hospitals from 1999 to 2014, the trend is not consistent across all states. A few states report little change in their inpatient forensic populations. For the many states experiencing increases, the rise is mostly due to the increase in patients deemed incompetent to stand trial. For reasons that are explored in this paper, this is a phenomenon particularly evident during the past decade.

The overall nature of the forensic population is complex. Forensic patients (e.g. not guilty by reason of insanity and civilly committed sex offenders) may remain hospitalized for long periods of time. The more beds that are occupied by these patients, the lower the state hospital’s turnover rate, which means that there are fewer opportunities for the state hospital to admit new patients. Long periods of stay, low turnover rates, and an overall increase in the number of referrals for inpatient services from the courts have contributed to increasing waitlists in many states. Waitlists hinder the state’s ability to admit patients to their state psychiatric hospitals in a timely manner. These waitlists can lead to states being threatened with or held in contempt of court when there are active orders to admit individuals to the hospitals.

The results from this study indicate that, over a little less than two decades, states have seen an increase in the number of forensic patients who are present in their state hospitals. In order to cope with the increasing number of forensic patients in the state psychiatric hospitals, as well as those awaiting admission, states have indicated they are implementing a variety of methods. These methods include (but are not limited to): building more beds, adapting the admission process, modifying prioritization of the waitlists, building community- or jail-based programs (e.g. outpatient competency restoration programs, jail-based restoration programs, residential treatment centers), and fostering relationships with other systems (e.g. strengthening the bonds and communication between behavioral healthcare workers and criminal justice agents).