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Stepping back from deinstitutionalization?

April 1, 2009
by Ronald W. Manderscheid, PhD
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The jury is still out, but new data show some disturbing trends

Important new data I published recently with Joanne Atay and Raquel Crider (both with SAMHSA's Center for Mental Health Services) in Psychiatric Services show that for the first time in 50 years, the resident patient population of state mental hospitals has grown rather than declined.1 From 1955 to 2003, the number of resident patients decreased dramatically from 559,000 to about 47,000. However, between 2003 and 2005, this number climbed to almost 50,000.

Even more disconcerting, the number of admissions increased dramatically during the same period. Admissions peaked in 1971 at 475,000 and had declined every subsequent year through 2003, when they numbered fewer than 160,000. Yet between 2003 and 2005, they grew to almost 189,000-more than 21% in two years!

Has deinstitutionalization ended? Below I provide some information about why these trends are occurring so we can seek to answer this question.

Demographic changes

Our country is aging and becoming much more diverse. As early as 1990, we were able to show that with fixed prevalence rates of mental illness and expected changes in the composition of the U.S. population, state mental hospitals would experience growth by 2010. There are indications that demographic factors are clearly in play, as part of the increase in residents and admissions between 2003 and 2005 was due to growth in the number of consumers age 45 and older. Also, virtually all of the growth in residents was among minorities.

Growth of the forensic population

We asked states that experienced increases in their state hospital residents to tell us why this was occurring. The primary factor they identified was growth in the forensic population. Some states are constructing or considering new forensic facilities, and in some states more than half of all state mental hospital beds are occupied by forensic consumers. What is considerably less clear is the dynamic through which a person moves from community resident to forensic inpatient. Unless we develop an understanding of this dynamic, we simply won't know how to intervene.

Decline of community services

States also identified declines in community services as an important factor in the growth of their state hospital populations. Symptoms of this are lack of insurance coverage (1/3 of persons with mental or substance use conditions have no insurance, twice the national average); dramatic growth in use of hospital emergency rooms by people with mental illness; few community alternatives to inpatient care, such as community respite beds that can serve as an alternative to hospitalization; and courts that are more aggressively placing persons with mental illness into inpatient facilities because alternatives simply are not available. The data show that a growing proportion of state hospital admissions have schizophrenia or major depression, a strong indication that persons with these severe conditions are not receiving appropriate, high-quality care in their communities.

Decline of the social safety net

It also seems evident that the social safety net has developed new holes. Efforts to narrow the definition of case management or to restrict Medicaid coverage, and the failure of social safety net programs to keep pace with the growth of poor immigrant populations or the new poor who have been displaced by globalization, reflect this. We have known for a very long time that a strong network of social programs-housing, vocational training, social services-is essential to foster an enduring community life for mental healthcare consumers.

The jury is still out

I believe that the jury is still out on whether deinstitutionalization is ending. The ultimate answer will depend on how we respond to these disturbing data on our state mental hospitals. We should examine the findings of the President's New Freedom Commission on Mental Health for guidance, particularly its work on acute care. We also should take a broader view than just that of our specialty field to examine the role that various social and physical health determinants play in generating new cases of mental or substance use conditions.

Of course, we've made a lot of progress during the past 50 years. Some recent positive steps toward promoting community-based care include the fact that parity coverage for mental health and substance use care is now the law; Medicare co-pay reform has been enacted; health insurance reform is under way in some key states; and national healthcare reform is on the short-term horizon. But recent dramatic declines in budgets for community mental health services and our increasing national rate of criminal incarceration (approaching 4% of our population), including forensic mental health consumers in our state mental hospitals, portend difficult decisions in the very near future. In fact, we may be forced to choose between paying for forensic incarcerations in state mental hospitals and maintaining community mental health services in at least some states.

Ronald W. Manderscheid, PhD, currently Director of Mental Health and Substance Use Programs at the consulting firm SRA International, Inc., worked for more than 30 years in the federal government on behavioral health research and policy. He is a member of Behavioral Healthcare's Editorial Board.

To contact Dr. Manderscheid, e-mail