Thursday, July 12, 2018

Governments and Psychiatric Beds

I read a paper yesterday (1) on psychiatric bed policy with a focus on OECD (Organisation for Economic Cooperation and Development) nations.  The OECD has extensive data collection on their member nations and one of the metrics they collect is the number of psychiatric beds per 100,000 inhabitants.  I have demonstrated some of this data before.  For the purpose of this post I downloaded it to create the two graphs above that were used in the paper. One of the authors main points was transinstitutionalization - in this case sending people with serious mental illnesses to jails rather than psychiatric hospitals.  They demonstrate the rough inverse correlation between psychiatric beds and the rate of incarceration.  Throughout my career available psychiatric beds has always been a problem.  It has been a favorite topic on this blog.  I was interested in whether or not this group of authors had anything new to say.

In their introductory section, they provide the back drop with the numbers.  The American state hospital psychiatric beds fell 97% from 558,922 in 1955 to 37,679 in 2016.  In Minnesota, the drop was about 98.5% from 11,449 in 1955 to 175 currently.  Using the OECD data, the average was about 99 beds per 100,000 population in 1998 to 71 per 100,000 in 2015.  Only Germany trended in the other direction by increasing the number of beds.

They do a fairly good job of analyzing the risks of the bed shortage.  They cite rehospitalizations, prolonged stay in emergency departments, pressure to discharge patients from inpatient setting, more frequent involuntary treatment, and associated staff burnout.  They make the argument that higher rates of suicide are noted in community treatment compared to hospitals where suicide is less likely.  They believe acute inpatient care is less available to the acutely suicidal patient and that may account for some increase in the suicide rate. Scandinavian registry studies are cited as providing some confirmatory data with one group of authors stating that the reduction in beds was the "most probable explanation for the rising mortality."  A similar study in Finland where more community resources were available and the beds were at OECD averages described fewer suicides.

Community treatment is typically cited as a reason for the bed reduction.  In the USA, rationing is more clearly the reason since the community resources are rarely developed to compensate for the bed loss.  It is also unstated that the two treatments are not equivalent.  They cite the UK as having extensive community resources that were not enough to overcome the drop in beds leading to higher rates of suicide, transfers out of the area where the patient lives, and involuntary treatment. From the graph, the UK has more beds than the OECD average.

The history of transinstitutionalization is briefly discussed.  The Penrose Hypothesis was developed by Lionel Penrose who pointed out the inverse relationship between mental hospital and prison populations in 1939.  Other authors like Harcourt look at historical data and note the same relationship but discuss it from the perspective of the institutionalized population.  At one point in his book Harcourt suggests that people in the military and in nursing homes may need to be counted as being institutionalized.  Inspection of the bar graphs at the top of this page does illustrate some clear trends but it also illustrates that the relationship is complex and not all of the variables have been studied.  They include a third graph of the Gini coefficient that I did not include.  The Gini coefficient is a measure of income disparity (approaching 0 means less disparity).  The 10/17 countries with Gini coefficients  > 0.3 had the lowest number of psychiatric beds. In other words, more income disparity translates to fewer psychiatric beds.

The statistics about the incarcerated mentally ill in the USA are reviewed and the numbers are significant.  Twenty percent of the incarcerated population or 350,000 people per day are estimated to have serious mental illness.

The problems that I have written about on this blogs for years are highlighted including the declining length of stay and what the authors called revolving door admissions.  They point out that schizophrenia has the second highest readmission rate at 1 month compared with any other diagnosis (congestive heart failure is first).  The lengths of stay are not generally long enough to allow for adequate stabilization of severe psychiatric disorders and they provide the references.  I see this population of people as a steady state group that goes from jail to homelessness to a short stay in the hospital.  Substance use disorders are generally not addressed or treated in a cursory manner. 

The paper's strength is that they provide an estimate of what a reasonable number of psychiatric beds is for a given populations.  The Royal College of Psychiatrists established a standard that would give psychiatric patients the same access to high quality medical care as medical and surgical patients.  That includes 4 hour maximum time to wait for admission.  They also said that bed occupancy should not exceed 85% to allow for emergency admissions and the length of stay figure should be 2-4 weeks to allow for real improvement.  Using those parameters a US expert consensus group estimated that 50-60 publicly funded beds per 100,000 population were necessary. In case there is any difficulty reading the above graph, the point plotted was 25 beds per 100,000 US inhabitants - well below the estimated number.  In my home state of Minnesota, that number falls off the precipice to 3 publicly funded beds per 100,000!

A closing example is given of the situation in South Australia.  Hospital beds were closed to a level of 32 per 100,000.  Acute care occupancy exceeded 100%, emergency departments waits went up, acuity increased with increasing risk of the need for physical restraint, and the burden of care was often transferred to relatives and friends.  Reforms were enacted that led to an increase to 35 beds per 100,000 with associated 2 week lengths of stay and decreased rates of suicide.

This is an excellent paper for psychiatric societies and psychiatrists to read.  It documents the problems that we all see on a daily basis and provides some clear answers. The answer does not lie with continued or more perfect rationing.  Unfortunately the people who run these systems - largely bureaucrats in large state human services departments, the politicians who influence those bureaucrats, and administrators of most health care systems all see rationing as their only solution to the problem.  They are incentivized to ration and we (and our patients) are left picking up the pieces.

We finally have a paper that is making a stand against all of this rationing.     

George Dawson, MD, DFAPA

Supplementary 1: Data for the top graph was downloaded directly from the OECD and accessed today (July 12, 2018).

Supplementary 2: Data on incarceration rates was taken from the Prison Policy Initiative and accessed today (July 12, 2018).

For both graphs click on them for expanded and improved resolution.


1:  Allison S, Bastiampillai T, Licinio J, Fuller DA, Bidargaddi N, Sharfstein SS. When should governments increase the supply of psychiatric beds? Mol Psychiatry. 2018 Apr;23(4):796-800. doi: 10.1038/mp.2017.139. Epub 2017 Jul 11. PubMed PMID: 28696434.

2:  Osby U, Correia N, Brandt L, Ekbom A, Sparén P. Mortality and causes of death in schizophrenia in Stockholm county, Sweden. Schizophr Res. 2000 Sep 29;45(1-2):21-8. PubMed PMID: 10978869.

3: Bernard E. Harcourt, "From the Asylum to the Prison: Rethinking the Incarceration Revolution," 84 Texas Law Review 1751 (2005). Link

4:  Royal College of Psychiatrists. The Commission to review the provision of acute inpatient psychiatric care for adults.  OLD PROBLEMS, NEW SOLUTIONS: Improving acute psychiatric care for adults in England.  February 2016.  Link  This is a detailed look at bed capacity including current estimates and what can be done to improve it.


  1. You probably will not be happy with this comment, but, human history shows that the mentally ill are preyed on early and often when Society struggles.

    What do you expect from people, in my opinion these days, in positions of power influence and control, that they desperately want to avoid any attention on the mentally ill.

    Because a lot of these people who have power are themselves ill. You know my feelings about personality disorder and how it's more prevalent, and boy, after watching that hearing today with that FBI agent, did you see characterological features en masse.

    And those people aren't going to benefit from being hospitalized so, what can you do...

    Thank you for enlightening us though at least, be safe and well

    1. I agree with your observation about the mentally ill being preyed upon.

      There are certainly some times when they were approached in an enlightened manner, but in many cases that occurred in settings where they were removed from society. Even those periods could not last because the settings were generally dependent on the state for funding and it is always easier to put the money back in the general fund and use it to buy votes.

      Rather than a DSM type personality disorder, I see business and government systems taking people off the virtuous path. I read a philosophy piece just the other day comparing Aztec moral philosophy to that of the Greeks. The Aztecs saw it more as a group process, acknowledging that men are not perfect and they will make mistakes no matter how well schooled they are. They had a number of mechanisms in place for society to help individuals stay on the correct path and lead a virtuous life. That included consultation with elders about decisions. The Greeks has no similar mechanism and you either avoided mistake all together or were expected to correct them on your own.

      In American society we are poor excuses for ancient Greeks and definitely not Aztecs. There is very little suggestion of a social or cultural process. That leads to a few logical conclusions:

      1. You are generally on your own and cannot expect any material or spiritual help from society.
      2. You set your own standards. There are illusions to roles as citizens, religious roles, and various social roles - but the predominate one seems to be as a maker or money and accumulator of material goods.
      3. As a money maker the landscape is fairly wide open. Once again you set your own standards.

      I touched on this in a Twitter post, but I was around when managed care took over and my colleagues were running scared. They had reason to. Esteemed colleagues were fired and whole services displaced - basically as a power move to intimidate physicians. Up until that point - physicians were paid well but the focus was on patients care and there was always some academic component to it.

      Good physicians were being intimidated by businessmen who were basically acting like sociopaths. That hasn't stopped since. Those same attitudes eroded psychiatric care and led to the problems cited in the article and that I have cited numerous times on this blog.

      When I think of all of the characterological behavior directed at us over the past decades - some of those people did have personality disorders.

      But most were influenced by what I see as a typical business culture that is focused on making money at any expense.

  2. "... typical business culture *** is focused on making money at any expense." This is a natural and necessary response to pressures from investors and competitors and is the fiduciary duty of executives. The antisocial consequences can be minimized by shaping external pressures with regulatory restrictions, strategic tax structuring, citizen actions (criticism that tarnishes the corporate image, boycott) and collective moves by employees (mainly, union demands) that alter the expected bottom line, especially the short-term revenue flow. Business "culture" will not substantially change, but attitudes toward business in the larger society can put business in its place... and its place does not include healthcare (nor warfare, the justice system, the correction system, fire and police protection, and other areas where privitization has introduced industrialization). It would help if the citizenry could turn against politicians who seem to sell out areas where professional culture should be preserved (or re-introduced). It's currently popular to "get government out of..." whatever. Maybe society could come to "get corporations out of..." places where they inevitably will make things worse.

    1. Excellent point. I have always maintained that rationing for profits is not the way to reach the political Holy Grail of controlling health care inflation. How could it possibly be?

      The problem is that the government is an active partner here. There is no way that managed care rationing (the central cause of the publicly funded bed shortage) could happen without the active participation of federal and state governments.

      The scheme is so complex that it seems a lot of physicians don't get it but agree to fall in line for the latest perfect rationing scheme.

      I am also less convinced that there will be a movement to limit corporate influence. I keep going back to what I consider to be the paradigm for the government inventing businesses and that is credit reporting. I remember when that started in the 1970s, how it overcame a Congressional promise to not use Social Security Numbers as national identifiers, and how it has morphed into a trillion dollar business thanks to government friendly regulation. Nobody can opt out of that system and companies make money buying and selling our information.

      I think that Congress and state equivalent governments are committed to businesses more than citizens and have even adopted business strategies.

      In health care there may be no better example than the rationing of psychiatric beds.

  3. It appears that Japan is working hard to reduce the number of psychiatric beds in Japan. Maybe they can sent some of them our way.

    "Japan trails other countries in ‘deinstitutionalisation’, but there are signs of progress, says OECD

    Japan’s mental health system stands out amongst OECD countries for all the wrong reasons: high numbers of psychiatric beds and a high suicide rate. However, this hides a more positive story, according to the OECD’s Making Mental Health Count report. Japan is making good progress in reforming the mental health system, and introducing more patient-centred care. Falling numbers of psychiatric beds and a more stable suicide rate are testament to a recent commitment to change.

    Hospital care still dominant, but clear signs of change

    In almost all OECD countries, the dominant trend has been ‘deinstitutionalisation’ – the shifting of care away from hospitals and towards the community. This shift aims to promote patient-centred treatment. Patients often prefer care provided in the community to long hospital stays.

    Japan has lagged behind the deinstitutionalisation trend, and still has the highest number of psychiatric beds in the OECD, with 269 beds compared to the OECD average of 68."