The decades-long decline in admissions to state mental hospitals appears to
have reversed in the early years of this decade in 11 states, according to a
nationwide study in the January Psychiatric Services. The reasons for
that change and whether it will continue, however, are still unclear.
The 11 states that showed increases were California, Colorado, Florida,
Georgia, Kansas, Louisiana, Maryland, Michigan, North Carolina, Ohio, and
The number of admissions to public psychiatric hospitals in the United
States dropped from a peak of 475,000 in 1971 to fewer than 160,000 in 2002.
The number of "residents," that is, inpatients in state
psychiatric hospitals at year's end, went from 559,000 in 1955 to 47,000 in
2003, but recent years saw a change in both patterns of decline.
"The number of admissions rose by 21 percent from 2002 to 2005 after
a historic decline since 1971 because of deinstitutionalization," said
Ronald Manderscheid, Ph.D., the study coauthor and director of the mental
health and substance abuse program at SRA International in Rockville, Md."
[T]his study was the first to show growth of admissions and residents
in state psychiatric hospitals since the beginning of deinstitutionalization
The study team, which included Joanne Atay, M.A., and Raquel Crider, Ph.D.,
found that from 2002 to 2005, admissions in the 11 states rose by 23 percent,
while the number of hospital residents increased by only 1 percent. These
disparate percentages mean that more patients enter state psychiatric
hospitals, while fewer stay for long periods. But they may reflect a different
mix of patients as well, said Manderscheid, who formerly worked at the
National Institute of Mental Health and at the Substance Abuse and Mental
Health Services Administration.
In follow-up interviews with the researchers, hospital officials ascribed
the increase to an influx of forensic patients and people diagnosed with
schizophrenia (up 23 percent) and affective disorders (up 16 percent).
Ethnically, the largest increase came among whites and the lowest among
The number of men admitted went up by 28 percent and the number of women by
7 percent over that time, and there is about a 2:1 ratio overall of men to
women in both admissions and residents. Cultural factors may explain that
difference, said Manderscheid.
"Epidemiological data show that the incidence of mental illness among
women generally is higher than among men, but men diagnosed with mental
illness are perceived as more dangerous," he said.
That may jibe with one of the researchers' central conclusions. The
researchers speculated that the increase in forensic patients—which they
do not quantify—is due to the willingness of the courts to remand
persons with mental illness to state hospitals, especially in the absence of
sufficient community-based outpatient services. More research is needed to
elucidate how someone with mental illness moves through that system to become
a forensic patient in a state psychiatric hospital.
"We have to learn a whole lot more about how [a patient] gets defined
as a forensic mental health case as opposed to a criminal who gets mental
health treatment in prison," Manderscheid said. "We don't
understand this very well, and so we don't know how to intervene."
At least some of the increase in the number of forensic patients may be due
to policy changes in some states, said Robert Glover, Ph.D., executive
director of the National Association of State Mental Health Program Directors
"Sexually violent predators," defined as those who have served
prison terms but are still deemed a danger to the community, can be sentenced
indefinitely to mental health facilities in 22 states, said Glover in an
Budgets for these inmates have risen from 10 percent of total state
hospital funding to 33 percent, said Glover. Much new construction for public
psychiatric facilities can be attributed to the same factor. California has
committed $300 million for 1,500 new beds. He anticipates that more states
will use the public mental health system to house these individuals, even
though there is no evidence-based psychiatric treatment for them.
In addition, like all public entities, state mental health systems are
facing budget shortfalls, he said. A NASMHPD survey of 42 states found that 93
percent were implementing hiring freezes, 90 percent were cutting
administrative staff, and 40 percent were considering closing state hospitals
or cutting community services. The Massachusetts Department of Mental Health
laid off about 100 case managers early in January.
"Historically, when the economy gets bad, inpatient use rises, but
now the states don't have any other option but to cut personnel and
services," he said. As a result, he expects that any increase in the
number of admissions and residents will level off or decline shortly.
An abstract of "Changing Trends in State Psychiatric Hospital
Use From 2002 to 2005" is posted at<http://psychservices.psychiatryonline.org/cgi/content/abstract/60/1/29>.▪