How drastic has been the decline in psychiatric beds? In 1970 there were 524,878 inpatient beds in the U.S., but by 1998 that number had dropped by about 50 percent to 261,903, according to data reported in the book Mental Health, United States, 2000, of which Manderscheid is coeditor.
According to Manderscheid, "This trend [of inpatient beds closing] might not be so troubling if we had a more viable system of care in the communities [with vocational rehabilitation, psychosocial rehabilitation, housing, and other services]. However, the system in most places in the U.S. is not really there."
The decline in inpatient beds is occurring for three reasons, said Manderscheid. "First, there have been legal cases, such as the Supreme Court’s Olmstead decision, which ruled that individuals must be treated in the least-restrictive setting possible. . . .Part of the importance of the Olmstead decision is to empower the formation of networks and coalitions that will improve our community-based mental health system." (On June 18 President George W. Bush signed an executive order directing federal agencies to work closely with states to ensure full compliance with the Supreme Court’s ruling in the Olmstead case and the Americans With Disabilities Act.)
These community resources are becoming more important than ever, he pointed out, because of the increased number of people diagnosed with mental illness in jails and prisons, the increased number of people without access to mental health care, and the decrease in resources to fund private-sector services in the community.
Manderscheid continued, "Second, there is a change in the consumer movement where consumers say they want to be in the community, not in hospitals. Finally, there is a changing financial environment where managed care diverts patients into less-expensive care that supposedly has the same effect."
Within these major changes, Manderscheid identified three underlying trends. First, there has been a continuous decline in inpatient beds in state hospitals since 1955. At the end of 1955 there were 558,922 patients in state psychiatric hospitals; in 1970 there were 413,066 beds in state and county psychiatric hospitals; and in 1998 there were 63,525 beds in state and county psychiatric hospitals.
"One key reason for this decline is that, because of the federal Institution for Mental Diseases [IMD] exclusion [in Medicaid law], Medicaid does not pay for the hospitalization of persons between the ages of 21 and 64 in state and county facilities. Thus, these patients were sent to community and general hospitals, which could be reimbursed."
Other important factors contributing to this decline are "the development of new treatment approaches and new psychiatric medications including the introduction of the antipsychotic thorazine in 1954, the effort by states to save money by moving patients out of state hospitals to other forms of care, and the effort to move people into the community, most recently reinforced by the Olmstead decision," said Manderscheid.
The second trend is that private psychiatric hospitals had an increase of more than 300 percent in the number of beds from 14,295 in 1970 to 44,871 in 1990. This increase occurred because these facilities found a market niche: They were reimbursed from Medicaid and from private insurance for treating children. This increase was followed by a decline in the late 1990s to 33,635 beds.
"This decline was due to managed care’s policy of treating patients in the least-restrictive setting," said Manderscheid.
The third trend is that the number of beds in nonfederal general hospitals with separate psychiatric services increased from 22,394 in 1970 to 54,266 in 1988. "This growth occurred because—unlike state hospitals in which there were IMD exclusions—these hospitals could receive Medicaid reimbursements not only for children and the elderly, but also for adults," said Manderscheid.
When asked whether shorter inpatient stays could compensate for the disappearance of thousands of psychiatric beds, Manderscheid told Psychiatric News, "It’s an important issue, but one that can’t be addressed adequately with the current information, [because] there are few or no data on this."
What about the increase in outpatient care—could this account for the decrease in inpatient beds? The number of people coming for care in ambulatory mental health settings increased more than 300 percent, from 1,202,098 in 1969 to 3,967,019 in 1998, said Manderscheid, citing data from Mental Health, United States, 2000. He continued, "More people are getting care, and we have expanded our ambulatory capacity. But this still begs the question of building community systems of care....[Without these], people can’t be maintained in the community. . . . Just because you offer psychotherapy, [this] is not sufficient," he said.
Despite the decline in inpatient beds, "good data on the human impact of these changes are not available," said Robert Rosenheck, M.D., the chair of APA’s Committee on Health Services Research and a professor of psychiatry and public health at Yale Medical School.
Although these data are lacking, Douglas Hughes, M.D., president of the American Association of General Hospital Psychiatry, highlighted one effect: Some emergency room staff have great difficulty finding inpatient beds for psychiatric patients. In fact, Hughes said, "a Boston Globe article published in the last year said that there were days. . .when ER hospital staff could not find any adolescent inpatient beds in all of New England and New York state."
Determining how low the bed count may eventually go is impossible at this time. According to Manderscheid, there isn’t any federal regulation stating that there must be a minimum number of psychiatric beds in the U.S., and Hughes noted, "There has not been any public outcry about cutting beds."
Despite some people’s assumption that psychiatric beds can only be removed from a hospital unit if they are not needed, this is, in fact, not always true: "Some hospitals can close inpatient beds even when people need them. There is no national regulation addressing this," said Manderscheid.
"A state-operated hospital has to ask the state if it can close beds; however, a private or general hospital in the community doesn’t have to ask anybody. It’s up to the decision of the [hospital] administrator.
"State regulations generally have to do with the opening of beds, not with closing them. I’m hard pressed to think of any state that has regulations regarding the closure of beds.
"Nobody is going to regulate to keep beds in place. What they are much more likely to do is to resonate to the idea that we have to build this community system" of mental health care. The Olmstead decision, he added, has provided a valuable impetus for constructing such a system.
The Supreme Court’s decision in Olmstead, Commissioner, Georgia Department of Human Resources vs. L.C. can be accessed on the Web at http://guide.lp.findlaw.com/casecode/supreme.html by clicking on "1999 Decisions" and "Olmstead vs. L.C." ▪