Addressing psychiatric bed shortages

Decades after the US moved to deinstitutionalize behavioral healthcare—namely, closing psychiatric facilities in favor of community-based services—a growing number of policymakers and experts say more psych beds are key to fixing the country’s “mental health crisis.”

Lawmakers in states from Texas to New Hampshire have pushed to reopen shuttered inpatient beds or add new ones to meet the demand for behavioral health services, which grew during the Covid-19 pandemic. Some states—like New York and Virginia—are taking that a step further by expanding outpatient offerings at hospitals and clinics, funding supportive housing, and creating community treatment teams.

It’s not just happening at the state level. The Biden administration called for increasing mental health resources and providers in 2022, while Congress also included $4.25 billion for states to invest in psychiatric services in a 2021 spending bill.

“We’re starting to turn the culture and we now have funding coming out of the federal government much more so to address the shortages,” Robert Trestman, who chairs the American Psychiatric Association’s (APA) Council on Healthcare Systems and Financing, told Healthcare Brew. “The challenge is many jurisdictions aren’t prepared to pull together a comprehensive approach because they’ve never had the funding—didn’t have the people—to think it through. They’ve just been surviving.”

Advocates like Trestman have largely welcomed the increased public attention and funding for behavioral health initiatives and psych beds. They’ve said such scrutiny is necessary following years of underinvestment, even as some efforts yielded lackluster initial results.

Still, measuring the need for those services is tricky, both he and Jonathan Cantor, a Rand policy analyst who’s studied the issue, noted.

There’s no nationwide system for tracking psych beds and state-level data varies, complicating efforts to identify how many beds are available and to whom. Even widely cited figures—like the Treatment Advocacy Center’s 2008 estimate that 40 to 60 beds are needed per 100,000 people—is dated and requires more analysis, Cantor said.

Trestman put the number closer to 30–35 beds per 100,000 patients—about double the number currently available. That estimate, however, does not include community-based alternatives, like outpatient programs and services.

“The number of beds we need and the services to be provided in those beds has only gotten more complicated,” Trestman, who is also chair of psychiatry and behavioral Medicine at Virginia Tech’s Carilion Clinic, told Healthcare Brew. “Even the definition of what an inpatient psychiatric bed is is complicated.”

Measuring the problem

To get to the bottom of the questions surrounding psych beds, an APA task force—formed in 2020 to study the issue—worked with University of North Carolina and Research Triangle Institute researchers to create a model for policymakers to use when determining how to best address behavioral health needs in their jurisdictions.

The “Anytown, US” acute mental health crisis system model, released as part of the task force’s 2022 report, aims to help lawmakers understand mental health system dynamics, analyze their systems’ performance, and estimate capacity needs.

APA is now working with partners in Michigan to pilot the model in that state—and hopes to expand to other systems/states, said Trestman, who served on the APA task force.

So far, Michigan officials have largely just been feeding data into the model to help APA quantify metrics like the number of emergency room psych beds in use, the length of stay in those beds and how long patients have to wait for them, and the number of psych beds available in the state and private sector, he said. That data has also highlighted the correlation between nurse shortages and psych bed availability.

“These are the real-world problems that Michigan is helping us to learn about as they are helping to provide data to enhance the function of our model,” Trestman said. “We are working with the state to inform the model, to make it usable for other states.”

Rand analysts, who have also studied psych bed capacity needs in California, have applied for funding to conduct their own nationwide analysis, Cantor said. He argued that lessons from Rand’s work in California can help inform research in other states.

For example, the licensure data which Rand used to identify psychiatric beds in California was not always up to date. Analysts also faced challenges when it came to defining different levels of care. Those issues, Cantor offered, are likely not unique to California.

Beyond beds

According to Rand’s analysis, California needs about 50.5 inpatient psychiatric beds per 100,000 adults who require acute, sub-acute, and community/residential treatment. But the number of required beds varies across specific regions or counties, Cantor noted.

Analysts also found significant disparities in bed availability within patient populations. Patients with dementia and Covid-19, criminal justice histories, and ambulatory issues, as well as those requiring oxygen, faced more barriers when it came to accessing psychiatric care, Cantor said.

That finding, he argued, has largely been left out of the conversation surrounding psych bed availability, and requires more research.

“A lot of the analysis that’s been done historically just assumes that if there is a bed there, then it’s available to all folks,” he said. “We’re not really considering the fact that a bed might not be available or is less likely to be available for particularly vulnerable populations.”

Both Cantor and Trestman said their research supports a holistic, or “fabric of care delivery” approach to behavioral health that helps states, counties, and cities care for people beyond inpatient psychiatric beds.

Having “more robust alternatives” could also help reduce the number of inpatient psych beds required per 100,000 people, Trestman said.

“About 13% of the US population suffers from psychiatric distress; that’s a non-trivial number. Not everyone who suffers from this is able to get care. That has spillover effects in other areas,” Cantor said. “This could potentially have huge costs to society if we have a series of individuals who need care but don’t receive it.”