Mental and behavioral health disorders have reached a historic peak. And once again, the nation’s lack of inpatient psychiatric beds has become a major point of concern, a renewed focus of researchers and an important story for journalists to follow.
Reporters should note that even before the pandemic, those who had championed community-based rather than hospital-based care for people with mental illness had been heavily rethinking the wisdom of closing psychiatric hospitals. A system of community-based care has yet to be built out.
During the pandemic, a record number of patients have sought mental and/or behavioral health care for the first time; the mental health of the severely mentally ill, including those who couldn’t get in-person medical appointments, often suffered. And the number of children needing psychiatric care increased, though the tally of pediatric psychiatric beds is particularly low.
In the last few months, newly published studies have cited everything from an accelerating decline in psychiatric beds that began roughly a half-century ago to difficulty accurately estimating just how many such beds the nation needs but doesn’t have.
That latter conundrum was explored in a Feb. 16 commentary published in JAMA Psychiatry, noting that there are acute-care hospital beds versus residential facility beds — but no national standard for distinguishing one type of arrangement from another when it comes to tallying the number. The same commentary also noted the failure to consider mentally ill people who are the hardest to place in psychiatric care. That includes those who are violent and mentally ill, arsonists and mentally ill people with dementia.
“What remains worrisome is that there are no standardized approaches or best practices for determining psychiatric bed need. …. In fact, what even counts as a psychiatric bed is a topic of debate,” wrote the Rand Corporation researchers.
“A root cause of this paralysis in estimating bed shortages is that states often have bottlenecks at multiple levels. For example, an acute inpatient hospital may be at full-bed occupancy because it is unable to transfer patients to a lower level of care that would be more appropriate; as a result, beds at this lower level of care are also operating at capacity. In this context, it may be imprudent to expand acute inpatient hospital beds when the source of the bottleneck pertains to bed capacity at the lower level.”
According to a separate Rand analysis, in California alone, it’s projected that there will be a 1.7% increase in the need for psychiatric beds between 2021 and 2026. Analysts recommended that California, the nation’s most populous state, build more infrastructure for treating hard-to-place psychiatric patients, including those involved in the criminal justice system. Also, it recommended that the state regularly report counts on psychiatric bed occupancy, bed waitlists, transfers between higher and lower levels of care, psychiatric patients who linger in emergency departments, and the race, income and other demographic identifiers of psychiatric bed patients and would-be patients.
Alongside the Rand reports, a global gauge of the need for inpatient psychiatric beds was published in January 2022 in Molecular Psychiatry. Surveying 65 experts from a mixture of 40 low- and high-income countries, including the United States, that analysis concluded that there should be an optimum of 60 beds per 100,000 and a minimum of 30 beds per 100,000 population.
In 2008, the Arlington, Va.-based Treatment Advocacy Center reported there were 17 beds for every 100,000 U.S. residents in 2005 after the closing of psychiatric hospitals that began in the 1990s. That report, based partly on recommendations from mental health experts, suggested 40 to 60 beds for every 100,000 residents would come closer to meeting a minimum of needs.
The advocacy center’s report concluded that there were 340 beds per 100,000 in 1955. The promise made at the time was that there would be enough community-based care to meet the needs of those with mental illness. That promise has not been kept, observers have said.
The pandemic definitely laid bare insufficient attention to mental health needs. The metric of hospital beds, however, is a partial and skewed sector of psychiatric services if the desired outcome is recovery or rehab. As the Rand report emphasizes, understanding the bottleneck leading to in-patient beds becomes important to meeting the need for services going forward. We should be cautious about describing one point of a continuum as if it’s the universally preferred option, The frequently quoted comparisons with historic patterns accentuates a profile that’s out of date given the other choices currently available but underfunded, such as respite care or crisis intervention. As Thomas Insel notes in Healing, hospitalization is an acknowledgment that the system is wanting. In-patient beds are on the service continuum, but won’t remedy the void.