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 blog 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.




References:

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.