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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

The shortage of psychiatric inpatient beds has become a major national issue, with the lack of availability identified as a major issue by policy makers, states, mental health families, academics, and popular media. Many reports regarding these shortages start with the major decline in inpatient capacity in state psychiatric hospitals—a decrease of over 500,000 beds since the 1950s. However, most analyses fail to include a comprehensive depiction of the total inpatient and other 24-hour mental health residential treatment capacity across the nation or to address the changing trends in the use of psychiatric inpatient services.

Beds available to provide 24-hour mental health treatment to individuals requiring this high level of restrictive and expensive treatment exist in a variety of settings, including specialized public and private psychiatric hospitals, psychiatric inpatient, and licensed residential treatment units in general hospitals and other organizations, non-residential treatment centers (non-RTCs) for children and adults (organizations that provide intensive 24-hour treatment services but that are not licensed as “inpatient” services), Veterans Affairs (VA) Medical Centers, Department of Defense Medical Centers, and psychiatric inpatient units within jails and prisons (these are beds not accessible to the general public). In addition, many general hospitals without special mental health units also provide inpatient treatment for individuals with mental illnesses (in “scatter beds”). Unfortunately, there is no single source of information that documents all psychiatric inpatient capacity across the various types of organizations that are providing these services.

This paper attempts to fill that need, combining information from multiple data sources to estimate the overall inpatient and other 24-hour inpatient capacity in the U.S. in 2014. Trends over the past 44 years in the 24-hour mental health treatment capacity of each setting are examined when comparable historical trend data are available.

As of 2014, the year for which the most recent data on specialty mental health providers are available, there were over 170,000 residents in inpatient and other 24-hour residential treatment beds on any given night, an average of over 53.6 patients per 100,000 population. Although 170,000 residents in 24-hour treatment beds every day may seem a large number, it reflects a 64 percent decrease in psychiatric residents from 1970. When data are adjusted for the growth in the population of the United States since 1970, the decline in beds is an even greater 77.4 percent.

Underlying this decline in psychiatric inpatient capacity are major shifts in the location of where individuals with acute psychiatric needs receive 24-hour care. It is true that state and county psychiatric hospitals and VA Medical Centers have experienced large reductions in psychiatric capacity, while private psychiatric hospitals and general hospital specialty units have increased over time. However, both the state mental health and VA systems have drastically reorganized their approaches to providing care over the past 44 years, shifting resources and workforce to focus on delivering community-based outpatient services that have included intensive evidence-based services, such as Assertive Community Treatment (ACT), designed to reduce the need for intensive inpatient services. In 2014, only two percent of the 7.3 million mental health clients served by State Mental Health Agencies (SMHA) were inpatients in a state psychiatric Psychiatric Inpatient Capacity, and only four percent of the 1.5 million veterans with a mental illness served by the VA received inpatient mental health services in a VA Medical Center.

In addition to changing where psychiatric inpatient services are delivered, there have been historic changes in how state psychiatric hospitals are utilized, the types of patients they serve, and the services they provide. From the 1950s through the 1980s, state psychiatric hospitals provided services to many elderly individuals, many with dementia and other brain disorders no longer the focus of treatment in state psychiatric hospitals. For example, in 1970, patients 65 and older represented 29.3 percent of residents in state and county psychiatric hospitals, and there were 81,621 patients (24 percent) with a diagnosis of organic brain syndrome (of which 45,811 were 65 and older). Individuals with diagnoses of intellectual/developmental disabilities (called mental retardation in the 1970s) were an additional 9 percent of residents.

Today, due to coverage for older adults under the Medicaid and Medicare programs implemented in the late 1960s, many elderly individuals with mental illness receive care in their own homes or in nursing homes or other residential providers that specialize in Alzheimer’s and other dementia services. (In 2014, only 8.8 percent of state and county psychiatric hospital patients were 65 and older.) 2 SAMHSA no longer routinely collects detailed diagnosis information on residents in state psychiatric hospitals, but as of 2005, only 3.8 percent of patients in state psychiatric hospitals had an intellectual/developmental disability (formerly termed mental retardation) diagnosis.

The focus of this report is on the total population receiving mental health inpatient and other 24-hour residential treatments. Children and adolescents may have very different patterns of receiving inpatient and other 24-hour treatment than adults. For example, many states no longer provide inpatient services for children in state psychiatric hospitals. However, detailing the differences between inpatient care for children and adults is beyond the scope of this report.