State Hospital Admissions on Unexpected Upswing

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 Texas.

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 in 1955.”

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 African Americans.

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 (NASMHPD).

“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 interview.

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>.▪