APA Rings Alarm in Nation’s Capitol About Crisis in Mental Health Care

The crisis in American mental health begins in the hospital with a drastic, and growing, shortage of psychiatric beds, especially publicly funded state and county hospital beds. From there the crisis spreads to the nation’s city streets and to its jails and prisons, where the largest number of people with serious mental illness now reside. It will be exacerbated in coming years by the shortage—also expected to worsen—of psychiatrists and child psychiatrists.

But the crisis begins with a shortage of beds.

That’s the alarm bell that APA President Bruce Schwartz, M.D., has been ringing on Capitol Hill in a series of meetings with congressional representatives on both sides of the aisle and with administration officials. “The entire system is driven by the availability of inpatient beds, especially public beds,” Schwartz said.

APA is encouraging the Trump administration and Congress to sit up and take notice. In presentations to key congressional representatives and the White House Domestic Policy Council the last month, Schwartz explained that the safe minimum of public psychiatric beds is estimated to be approximately 50 per 100,000 population. Yet in 2016 there were a mere 11.7 state and county beds per 100,000 population.

That’s a staggering falloff when one considers that in 1955 there were 340 public psychiatric beds per 100,000 population. The total number of inpatient beds for patients with psychiatric disorders—including both public and private hospitals—has dropped 64% since 1970, to approximately 109,000 total beds, or 32 beds per 100,000. This decrease in beds was driven by the closure of state beds by legislatures, payment denials by managed care companies, and inadequate reimbursement rates under Medicaid and Medicare. In addition, the entire system of care needed to treat people with mental illness has been underfunded.

APA President-elect Jeffrey Geller, M.D., M.P.H., and APA CEO and Medical Director Saul Levin, M.D., M.P.A., also met recently with Housing and Urban Development Secretary Ben Carson, at his request, regarding the need for treatment and other services for people with severe mental illnesses living on the streets.

Compared with international figures, those 32 total inpatient psychiatric beds per 100,000 population is dismal. According to figures from the World Health Organization and the Treatment Advocacy Center, the United Kingdom has 46 beds per 100,000, France has 90, Switzerland has 91, and Germany has 128.

While the number of America’s inpatient psychiatric beds has dangerously declined, the number of people with serious mental illness has not—they have simply gone elsewhere: The proportion of mentally ill people in private hospitals has grown marginally between 1970 and 2007 (from 3% to 7%), as has the proportion of mentally ill people in general hospitals (5% to 8%).

The largest growth—and the figure that is most damning—has been the incarceration of people with serious mental illness. Today there are an estimated 229,800 patients with serious mental illness in the nation’s jails and prisons, comprising 69% of all psychiatric patients.

This picture is made more bleak by projections about the physician workforce: According to the Association of American Medical Colleges (AAMC), physician demand will grow faster than supply, leading to a projected total physician shortfall of between 46,900 and 121,900 physicians by 2032.

Psychiatrists will be in especially short supply. According to the AAMC, the psychiatric workforce is expected to decrease through 2024, with a shortage of between 14,280 and 31,091 psychiatrists. Starting in 2025, the workforce is then projected to expand, but not enough to make up the shortfall: the country will still be short between 3,400 to 17,705 psychiatrists in 2032.

Schwartz has also emphasized to lawmakers and administration officials that not only are hospitals already stressed by bed shortages, but unwise enforcement of ligature risks is compounding the crisis. In 2017, APA began to field concerns from administrators at many hospitals about increased monitoring and enforcement of citations by the Centers for Medicare and Medicaid Services (CMS) around elimination of ligature risks. In some cases, required repairs were costing exorbitant amounts of money and forcing bed closures.

Between April and June 2018, APA surveyed the membership to understand the extent of the problem. With 88 facilities from 34 states reporting, the survey found the following:

• 55 facilities reported receiving citations for ligature point/other self-harm risks.

• 10 facilities reported possible closing of inpatient psychiatric units.

• 14 facilities reported closing psychiatric beds.

• 23 facilities reported reducing other psychiatric services consisting of workforce reductions.

• The average fiscal impact was $3.64 million per facility, ranging from $500,000 to $10 million.

In comments to Psychiatric News, Schwartz reiterated the message he has brought to legislators and Trump administration officials—America’s mental health crisis touches everywhere in the country, but it begins with a shortage of beds for the sickest patients.

“Our hospitals are where we treat the most seriously mentally ill patients, and our state and county public hospitals serve our poorest patients,” Schwartz said. “Many patients need to be in the hospital longer than the brief stays they currently receive for crisis stabilization. Restoring an adequate number of public psychiatric inpatient beds is a priority and job one for reversing the mental health crisis that has spread to our streets and to our jails and prisons.”

At press time, the White House Summit on Mental Health was scheduled to take place. Schwartz will attend this meeting and advocate for quality care for people with mental illness and substance use issues. A report on the summit will appear in a future issue. ■