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Article Excerpt
Deinstitutionalization represents one of the most widespread changes in mental health policy. This process has led to the massive transfer of severely mentally ill persons out of institutional care in favor of community treatment (Grob 1994). A crucial aspect of deinstitutionalization involves significant structural changes in the public mental health system. From 1970 to 2000, public psychiatric hospital beds dropped from 207 to 21 beds per 100,000 persons (Manderscheid et al. 2004). This reduction concerns mental health professionals and policy makers because the declining capacity of public psychiatric hospitals may jeopardize care for indigent, severely mentally ill patients that require treatment but lack sufficient economic resources.
Decreasing public psychiatric hospital beds (hereinafter public beds) would be efficient if the demand for beds similarly declined. However, the literature does not support this notion of efficiency; deinstitutionalization rarely, if at all, followed reduced demand for inpatient psychiatric care. Instead, ideological rhetoric, welfare programs, and fiscal considerations by states initiated and accelerated the process of deinstitutionalization (Cameron 1978; Gronfein 1985a; Mechanic and Rochefort 1990; Grob and Goldman 2006). Moreover, deinstitutionalization represents a rare social policy that was implemented faster and more extensively than anticipated (Mechanic and Rochefort 1990). Thus, public bed availability may have dropped below the level of demand. In this circumstance, public bed reductions may adversely affect mental health for persons with severe mental illness in a community.
The last decades have also experienced rapid privatization of the inpatient psychiatric market and proliferation of public community-based mental health programs (Manderscheid et al. 2004). It is unclear whether these augmented services could substitute for the reduction in public inpatient supply. If privatization does not influence the availability and quality of care, it should not, ceteris paribus, alter mental health of severely mentally ill patients. However, compared with public psychiatric hospitals, private psychiatric hospitals, particularly for-profit hospitals, preferentially treat insured patients and those with less severe, acute symptoms (Schlesinger et al. 1997; Mechanic 1999). The clear distinction of service clientele across different ownership types implies that private bed supply may not substitute for public bed supply. Moreover, due to its voluntary nature and chronic underfunding, community mental health care may not adequately treat severely mentally ill patients with a history of dangerousness, co-occurring disorders or arrests (Lamb, Weinberger, and Gross 2004). Nevertheless, increased supply of public community mental health resources provides free goods to the economically disadvantaged and may therefore buffer adverse effects of public bed reductions, improving community mental health.
Our main objective is to examine the relationship between the supply of public beds, as a proxy for deinstitutionalization, and population mental health. We focus on suicide rates as a measure of population mental health. Despite recent declines in national prevalence (McKeown, Cuffe, and Schulz 2006), suicide rates serve as a useful indicator of population mental health because of their strong association with severe psychiatric episodes (Black and Fisher 1992; Simpson and Tsuang 1996; Colton and Manderscheid 2006; Miller, Paschall, and Svendsen 2006; Saha, Chant, and McGrath 2007). We test whether private hospital psychiatric beds, separately for not-for-profit and for-profit hospital psychiatric beds (hereinafter, not-for-profit beds and for-profit beds, respectively), can replace public beds without increasing suicides. We also analyze whether the relationship between public bed reduction and suicide rates varies with the availability of public community-based mental health resources.
PRIOR STUDIES AND LIMITATIONS
Deinstitutionalization has also taken place, and been researched, outside the United States. In Sweden, mortality due to suicides among patients with schizophrenia increased when the number of psychiatric hospital beds declined (Salokangas et al. 2002). In Denmark, a significant negative association was found between the number of psychiatric beds and suicide mortality (Osby et al. 2000). A Norway study reported an increase in suicide mortality after psychiatric bed reductions (Hansen, Jacobsen, and Arnesen 2001). In the United States, Haugland et al. (1983) examined the mortality rate of 1,033 deinstitutionalized patients. The authors found that during a 3 1/2-year follow-up period, patients were approximately eight times more likely to die of suicide or accident than persons in the general population. This finding is in line with a greater risk of suicide among young deinstitutionalized patients served in a community mental health center (Pepper, Kirshner, and Ryglewicz 1981). In contrast, Bachrach (1996) and McGrew et al. (1999) reported general improvements in the quality of life and functioning among patients discharged and treated in community settings due to the closure of state psychiatric hospitals.
We believe that the deinstitutionalization process in the United States has been implemented without sufficient evaluation of possible health risks. Relatively few studies in this area appear in the published literature, and the extant work has several important limitations. We address the following limitations in the literature to inform policy in the era of community-based treatment.
First, the U.S. studies examined only subgroups of persons with severe mental illness such as patients discharged from psychiatric hospitals (Haugland et al. 1983) and former patients in state psychiatric hospitals who continued to receive treatment in the community after a discharge (Bachrach 1996; McGrew et al. 1999). However, a reduced supply of public beds, ceteris paribus, may also affect persons who did not use public psychiatric hospitals previously but require intensive care in restricted settings as well as those who did not access treatment after a hospital discharge.
Second, inpatient psychiatric care has become more privatized. In 2000, private psychiatric and general hospitals accounted for 24 and 46 percent of all inpatient treatment episodes, respectively, as compared with only 12 percent in state psychiatric hospitals (Manderscheid et al. 2004). In addition, evidence suggests that private hospitals may increasingly serve patients similar to those of public hospitals (Olfson and Mechanic 1996; Mechanic, McAlpine, and Olfson 1998). However, little research evaluates the increasing role of private entities in providing inpatient psychiatric care. To our knowledge, no research has explored whether an increased supply of private psychiatric beds could offset a reduction in public beds, with no adverse effect on population mental health.
Third, the interaction between public inpatient and community mental heath resources remains largely unexplored. A region with greater community mental health resources may be better positioned than other regions to absorb a shock from a public inpatient reduction. Given the significance of the public sector's provision of mental health services, policy makers may want to know the level of community resources required to mitigate the potential sequelae of reductions in public beds.
CONCEPTUAL FRAMEWORK
A change in psychiatric bed supply may relate to suicide rates because it may influence whether an individual obtains services at the time of need. Bed supply may also influence substance abuse because persons with severe mental illness may self-medicate their...
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