National Association of State Mental Health Program Directors
66 Canal Center Plaza, Suite 302
Alexandria, Virginia 22314

Assessment # 2

TREND IN PSYCHIATRIC INPATIENTCAPACITY, UNITED STATES AND
EACH STATE,
1970 TO 2014
August 2017
Alexandria, Virginia
Tenth in a Series of Ten Briefs Addressing: What Is the Inpatient Bed
Need if You Have a Best Practice Continuum of Care?
This work was developed under Task 2.2 of NASMHPD’s Technical Assistance Coalition
contract/task order, HHSS283201200021I/HHS28342003T and funded by the Center for
Mental Health Services/Substance Abuse and Mental Health Services Administration of
the Department of Health and Human Services through the National Association of State
Mental Health Program Directors.

Trend in Psychiatric Inpatient
Capacity, United States and EachState, 1970 to 2014
Technical Writers:
Ted Lutterman
Robert Shaw
William Fisher, Ph.D.
Ronald Manderscheid, Ph.D.
National Association of State Mental Health Program Directors
66 Canal Center Plaza, Suite 302, Alexandria, VA 22314
703-739-9333 FAX: 703-548-9517
www.nasmhpd.org

August 2017

This work was supported by the Center for Mental Health Services/Substance
Abuse and Mental Health Services Administration of the Department of Healthand Human Services.
Disclaimer: The views, opinions, and content expressed in this presentation do notnecessarily reflect the views, opinions, or policies of the Center for Mental Health Services(CMHS), the Substance Abuse and Mental Health Services Administration (SAMHSA), or
the U.S. Department of Health and Human Services (HHS).

Psychiatric Inpatient Capacity, August 20172

Table of Contents
Executive Summary ................................................................................................................................................................... 4
Recommendations for Better Monitoring Psychiatric Inpatient Capacity ............................ 5
Overview of the Report ............................................................................................................. 7
Introduction/Background ...................................................................................................................................................... 8
Use of Psychiatric Inpatient Services Today Are Different From Earlier Eras.................... 10
Availability of Psychiatric Inpatient Services in 2014.......................................................................................... 14
Psychiatric Inpatient Capacity in Mental Health Specialty Organizations .......................... 15
Rates of Psychiatric Inpatient Capacity and 24-Hour Treatment Capacity per 100,000
Population ....................................................................................................................... 16
Voluntary vs. Involuntary Status of Inpatients in Specialty Programs, 2014 ................. 16
Number of Organizations with Specialized Inpatient and Other 24-Hour Residential
Mental Health Treatment Programs ............................................................................. 19
Other Settings with Psychiatric Inpatient and 24-hour Residential Treatment in 2014 ... 21
General Hospitals Providing Mental Health Services In Non-Specialty Units ................ 21
U.S. Department of Defense (DOD) Facilities ..................................................................... 24
Use of Nursing Homes to Serve Individuals with Mental Illnesses .................................. 25
Inpatient Psychiatric Units in Jails and Prisons ................................................................. 26
Summary: All Psychiatric Inpatient and Other 24-Hour Capacity.......................................... 27
Trends in Psychiatric Inpatient and Other 24-Hour Treatment Since 1970 ........................................... 28
Trend in State and County Psychiatric Hospital Capacity ................................................ 30
Trend in Private Psychiatric Hospital Capacity ................................................................. 31
Trend in General Hospital Separate Psychiatric Unit Capacity ........................................ 33
Trend in VA Medical Center Psychiatric Capacity ............................................................. 35
Trend in Residential Treatment Center Psychiatric Capacity .......................................... 36
Trend in the Capacity of Other Specialty Mental Health Organizations .......................... 36
APPENDIX A: Variation in Psychiatric Inpatient and Other 24-Hour Capacity by State: 2014 .... 37
Inpatient Psychiatric Beds by State .................................................................................... 39
Other Mental Health 24-hour Residential Treatment Beds by State ............................... 41
Change in Psychiatric Inpatient Capacity over time, by State, 1982 to 2010 ................. 44
APPENDIX B: Focus on Care in State and County Psychiatric Hospitals.................................................... 47
Number of State Hospitals, Residents, Admissions, and Forensic Focus: 2016..................................... 48
Expenditures for State Psychiatric Hospitals ........................................................................ 51

Funding Sources for State Psychiatric Hospitals ................................................................... 53
Forensic Services within State Psychiatric Hospitals ........................................................... 54
Recent Trend in Patients Served in State Psychiatric Hospitals............................................... 56
Appendix C: Data Sources Containing Information about Psychiatric Inpatient and Other 24Hour Residential Treatment Capacity .................................................................................................................... 57
Acknowledgement ................................................................................................................................................................... 62

TablesTable 1: Number and Rate per 100,000 Population of Psychiatric Inpatients andOther 24-Hour Residential Treatment Patients at End of Year 2014 ...................... 15
Table 2: Patients in 24-hour Psychiatric Inpatient Settings in Specialty Mental HealthOrganizations, by Legal Status, 2014 .................................................................................... 17
Table 3: Number of Organizations Providing Psychiatric Inpatient Services or Other
24-hour Residential Treatment, 2014 .................................................................................. 19
Table 4: Mental Health (MH) Spending by Provider and Setting: Levels and Percent
Distribution, Selected Years ..................................................................................................... 22
Table 5: Discharges from Community Hospitals by Mental Health Diagnoses,
Average Length of Stay, and Calculated Residents on a Single Day, 2014 HCUP
Data .................................................................................................................................................... 23
Table 6: Psychiatric Inpatients and Other 24 hour Patients in Non-Specialty
Psychiatric Organizations, 2014 ............................................................................................. 27
Table 7: Trends Over Time in Psychiatric Inpatients and Other 24-Hour Treatment
Residents in Specialty Mental Health Organizations, 1970 to 2014 (Resident
Patients in the Facility on a Given Day) ................................................................................. 28
Table 8: Trends over Time in Residents per 100,000 Population Residents in
Psychiatric Inpatients and Other 24-Hour Treatment Beds in Specialty Mental
Health Organizations, 1970 to 2014 ..................................................................................... 28
Table 9: Number of Beds in 24-Hour Hospital Inpatient and Residential Treatment
Settings, by State/Territory: Number and Rate per 100,000 Population, April
2014 ................................................................................................................................................... 38
Table 10: Number of Organizations Providing Psychiatric Inpatient Beds, Number ofInpatients and Rate per 100,000 Population, April 2014 ............................................. 40
Table 11: Number of Organizations Providing Mental Health, Other 24-Hour
Residential Treatment Beds, Number of Patients and Rate per 100,000
Population, April 2014................................................................................................................ 42
Table 12: Number of Residents in Inpatient and Other 24-Hour Residential
Treatment Beds on the Last Day of Year, 1982 and 2010 ............................................ 44

Psychiatric Inpatient Capacity, August 20172

Table 13: Patients in Residence in Mental Hospitals (year End) 1922-1969, fromGeller, 2006 .................................................................................................................................... 47
Table 14: Number of State Psychiatric Hospitals, Residents at End of Year,
Admissions, Forensic Population, and Intended Use, 2016 ......................................... 48

FiguresFigure 1: Inpatient Settings Where Involuntary-Forensic Patients Were Served, 2014.............................................................................................................................................................. 18
Figure 2: Inpatient Settings Where Voluntary Patients Were Served 2014 ................. 18
Figure 3: Average Number of Inpatients and Other 24-Hour Residential Treatment
Services, by type of Mental Health Organization, 2014 ................................................. 21
Figure 4: Number of Residents in Psychiatric Inpatient and Other 24-Hour
Residential Treatment Beds at End of Year, 1970 to 2014 .......................................... 31
Figure 5: Number of Residents in Psychiatric Inpatient and Other 24-Hour
Residential Treatment Beds at Private Psychiatric hospitals, general hospitals
with separate psychiatric units, and Other MH providers at End of Year, 1970 to2014 ................................................................................................................................................... 32
Figure 6: Psychiatric Beds (Inpatient and Other 24-Hour Residential Treatment, per100,000 state population, 2014 .............................................................................................. 37
Figure 7: Psychiatric Inpatient Beds per 100,000 State Population, 2014 ................... 41
Figure 8: Mental Health Other 24-Hour Residential Treatment Beds per 100,000
State Population, 2014................................................................................................................ 41
Figure 9: Percent Change in Total Mental Health Residents in Inpatient and Other
24-Hour Treatment Beds, 1982 to 2014 ............................................................................. 46
Figure 10: SMHA Controlled Expenditures for Inpatient Mental Health Services inState Hospitals and Community-Based Mental Health Services, FY 81 - FY15..... 52
Figure 11: State Mental Health Agency Controlled Expenditures for State Psychiatric
Hospital Inpatient and Community-Based Services as a Percent of Total
Expenditures, FY 81 to FY 15 ................................................................................................... 52
Figure 12: Annual Percent Change in State Mental Health Authority Expenditures for
Mental Health Services in State Psychiatric Hospitals, Community Mental Health,and Total SMHA System, FY 81 to FY 15 .............................................................................. 53
Figure 13: Funding Sources for State Psychiatric Hospitals, FY 2015 ............................ 54
Figure 14: State Psychiatric Hospital Expenditures for Forensic and Sex OffenderServices and Percent of State Hospital Expenditures for Forensic and Sex
Offender Services, FY 1983 to FY 2015 ................................................................................ 55
Figure 15: Number of Residents in State Psychiatric Hospitals and Number of
Additions, 2007 to 2016............................................................................................................. 56

Psychiatric Inpatient Capacity, August 20173

Executive Summary
The shortage of psychiatric inpatient beds has become a major national issue, with thelack of availability identified as a major issue by policy makers, states, mental healthfamilies, academics, and popular media. Many reports regarding these shortages startwith the major decline in inpatient capacity in state psychiatric hospitals—a decrease ofover 500,000 beds since the 1950s. However, most analyses fail to include acomprehensive depiction of the total inpatient and other 24-hour mental health residential
treatment capacity across the nation or to address the changing trends in the use ofpsychiatric inpatient services.
Beds available to provide 24-hour mental health treatment to individuals requiring this highlevel of restrictive and expensive treatment exist in a variety of settings, including specialized
public and private psychiatric hospitals, psychiatric inpatient, and licensed residential
treatment units in general hospitals and other organizations, non-residential treatment centers(non-RTCs) for children and adults (organizations that provide intensive 24-hour treatment
services but that are not licensed as “inpatient” services), Veterans Affairs (VA) Medical
Centers, Department of Defense Medical Centers, and psychiatric inpatient units within jails
and prisons (these are beds not accessible to the general public). In addition, many general
hospitals without special mental health units also provide inpatient treatment for individuals
with mental illnesses (in “scatter beds”). Unfortunately, there is no single source of
information that documents all psychiatric inpatient capacity across the various types oforganizations that are providing these services.
This paper attempts to fill that need, combining information from multiple data sources toestimate the overall inpatient and other 24-hour inpatient capacity in the U.S. in 2014.
Trends over the past 44 years in the 24-hour mental health treatment capacity of eachsetting are examined when comparable historical trend data are available.
As of 2014, the year for which the most recent data on specialty mental health providers
are available, there were over 170,000 residents in inpatient and other 24-hour residential
treatment beds on any given night, an average of over 53.6 patients per 100,000
population. Although 170,000 residents in 24-hour treatment beds every day may seem alarge number, it reflects a 64 percent decrease in psychiatric residents from 1970. Whendata are adjusted for the growth in the population of the United States since 1970, thedecline in beds is an even greater 77.4 percent.
Underlying this decline in psychiatric inpatient capacity are major shifts in the location ofwhere individuals with acute psychiatric needs receive 24-hour care. It is true that stateand county psychiatric hospitals and VA Medical Centers have experienced large
reductions in psychiatric capacity, while private psychiatric hospitals and general hospital
specialty units have increased over time. However, both the state mental health and VA
systems have drastically reorganized their approaches to providing care over the past 44
years, shifting resources and workforce to focus on delivering community-based
outpatient services that have included intensive evidence-based services, such as
Assertive Community Treatment (ACT), designed to reduce the need for intensive
inpatient services. In 2014, only two percent of the 7.3 million mental health clients
served by State Mental Health Agencies (SMHA) were inpatients in a state psychiatric

Psychiatric Inpatient Capacity, August 20174

hospital and only four percent of the 1.5 million veterans with a mental illness served by
the VA received inpatient mental health services in a VA Medical Center.
In addition to changing where psychiatric inpatient services are delivered, there havebeen historic changes in how state psychiatric hospitals are utilized, the types of patients
they serve, and the services they provide. From the 1950s through the 1980s, state
psychiatric hospitals provided services to many elderly individuals, many with dementia
and other brain disorders no longer the focus of treatment in state psychiatric hospitals.
For example, in 1970, patients 65 and older represented 29.3 percent of residents in stateand county psychiatric hospitals, and there were 81,621 patients (24 percent) with adiagnosis of organic brain syndrome (of which 45,811 were 65 and older). Individuals
with diagnoses of intellectual/developmental disabilities (called mental retardation in the
1970s) were an additional 9 percent of residents.1
Today, due to coverage for older adults under the Medicaid and Medicare programs
implemented in the late 1960s, many elderly individuals with mental illness receive carein their own homes or in nursing homes or other residential providers that specialize in
Alzheimer’s and other dementia services. (In 2014, only 8.8 percent of state and county
psychiatric hospital patients were 65 and older.) 2 SAMHSA no longer routinely collects
detailed diagnosis information on residents in state psychiatric hospitals, but as of 2005,
only 3.8 percent of patients in state psychiatric hospitals had an
intellectual/developmental disability (formerly termed mental retardation) diagnosis.3
The focus of this report is on the total population receiving mental health inpatient andother 24-hour residential treatments. Children and adolescents may have very different
patterns of receiving inpatient and other 24-hour treatment than adults. For example,
many states no longer provide inpatient services for children in state psychiatrichospitals. However, detailing the differences between inpatient care for children andadults is beyond the scope of this report.

Recommendations for Better Monitoring PsychiatricInpatient Capacity
Various Federal organizations and associations collect different aspects of information
about psychiatric bed availability. However, different groups collect this information
using different measures and it is difficult in some cases to combine all the different data
in a way that allows us to fully understand the use of psychiatric inpatient and residential
treatment services. Some data systems count patients in inpatient and residential
treatment beds on a single day while others provide counts of total patients served over a
year and others count the number of discharges by mental health diagnoses. Only a few
1 Taube C., NIMH Statistical Note #112, Changes in the Age, Sex, and Diagnostic Composition of the

Resident Population of State and County Mental Hospitals, United States 1964-1973 (March 1974).
2 National Mental Health Services Survey (N-MHSS): 2014. Data on Mental Health Treatment Facilities.
BHSIS Series S-87, HHS Publication No. (SMA) 16-5000, Substance Abuse and Mental Health Services
Administration, Rockville, MD (2016).
3 Background Report, Admissions and Resident Patients, State and County Psychiatric Hospitals, UnitedStates, 2005, Substance Abuse and Mental Health Services Administration, Rockville, MD (September
2007)

Psychiatric Inpatient Capacity, August 20175

data sets currently have information about the number of admissions, the length of stay,or legal status of psychiatric patients.
To better understand the availability and use of inpatient beds, it will be important tocollect information that:
1. Compiles information across all settings using the same operational definition.
Currently the Substance Abuse and Mental Health Services Administration(SAMHSA) gathers information on residents on a single day for specialty
mental health providers, but does not gather information on general hospital
scatter beds, use of nursing homes, crisis residential facilities, respite beds,
Department of Defense (DOD) hospitals, etc. Other settings such as jails andprison where psychiatric inpatient capacity has been developed are notcurrently being counted by any organization.
AHRQ collects information for community hospitals (public and private) but
its collection focuses on discharges and does not readily distinguish specialty
units versus scatter beds. AHRQ also does not differentiate by client legal
status.
2. Compiles information on the intended and actual treatment use of various beds.
Are beds in various settings reserved for forensic patients, sex offenders, children,
short-term or long-term care, individuals with dual diagnoses of substance abuse,intellectual disabilities, serious medical issues, etc.?
Without a better understanding of how inpatient and residential beds areintended to be used, areas that may appear to have adequate overall capacity
may have critical shortages or be over capacity in services for specialized
services.
3. Better documents the role of emergency departments in a referral source.
Currently information on emergency room “boarding” of patients awaiting
psychiatric beds is largely anecdotal. Data systems that track patients bydiagnosis, legal status, and reasons for delay in emergency departments andinclude the use of EDs within the continuum of mental health care are
missing.
4. Includes, in state psychiatric bed registries designed to permit community mental
health agencies, emergency rooms, and courts to find available psychiatric beds
and thus maximize the efficient use of the limited supply of psychiatric beds, dataon access, distance from a patient’s home, and other factors that are associatedwith the provision of quality care.
Advances in heath information technology have the potential to greatly enhance theability to track the use of emergency departments, and psychiatric inpatient andresidential beds. Many state and private psychiatric hospitals have now implemented
electronic health records that have the potential to permit development of data systems
that can comprehensively document the use of psychiatric beds across systems and can beused to track the movement of patients between settings (for example, from an ED to a
general hospital and then on to a state psychiatric hospital). Although many mental health

Psychiatric Inpatient Capacity, August 20176

providers have EHRs capable of sharing electronic heath information data, very few
Health Information Exchanges (HIEs) currently include state psychiatric hospitals andother specialty mental health providers.
A case study or pilot study using HIE information that integrates information frommental health providers (community mental health and inpatient) and general hospitals
and other general health providers could test and demonstrate the potential for developing
systems that provide real time information about psychiatric bed availability and usage.

Overview of the Report
This report is organized into several sections and contains three appendices withadditional detailed information for interested users:

Introduction/Background: This section reviews some of the history and trends inpsychiatric inpatient and other 24-hour residential mental health treatment over the
past half-century and the more recent growing concerns that too much inpatient
capacity has been eliminated. This section also discusses how psychiatric inpatient
programs are being used differently today than they were historically.

Availability of Psychiatric Inpatient Services in 2014: This section discusses thelocation, number, and population ratio per 100,000 of mental health inpatient andother 24-hour residential treatment capacity using the most recent data available
across multiple settings.
o This section focuses on information from SAMHSA from specialty mental
health providers such as:state and county psychiatric hospitals,



private psychiatric hospitals,



general hospitals with special mental health inpatient units,

VA Medical Centers,

residential treatment centers (RTCs), andother mental health programs with inpatient and other 24-hourtreatment beds.

o Estimates of mental health inpatient and other 24-hour residential treatment
capacity in:

general hospitals without special psychiatric units (scatter beds),



DOD hospitals in the U.S.,

nursing homes, andother settings.

Trends in Psychiatric Inpatient Capacity 1970 to 2014: This section reviews thetrends in the availability of psychiatric inpatient and other 24-hour residential
treatment capacity over the past 44 years. Trends by resident patients and ratio of

Psychiatric Inpatient Capacity, August 20177

resident patients per 100,000 are discussed for all beds and by specific types ofmental health organizations.


Appendix A: This Appendix provides state-by-state information about theavailability of psychiatric inpatient capacity in 2016 and over time.

Appendix B: This Appendix provides detailed information about state psychiatrichospitals in 2016, including state-by-state information about their numbers, size,
characteristics, and trends in their financing and services.



Appendix C: This Appendix provides information about current and historic sourcesof data on inpatient psychiatric service capacity.

Introduction/Background
The availability of a safety net of services for individuals experiencing a psychiatric crisis
is a critical need in every state. After a half-century of downsizing of state and otherpsychiatric hospitals, there is widespread concern that too much of the capacity has been
eliminated. An internet search for the phrase “psych bed shortage” returns over 13
million results.
“Amid shortage of psychiatric beds, mentally ill face long waits for treatment”
PBS News Hour, August 2, 2016
“Nation’s psychiatric bed count falls to record low”
Washington Post, July 1, 2016
“Psychiatric beds disappear despite growing demand”
USA Today, May 12, 2014
“A dearth of psychiatric hospital beds for California patients in crisis”
NPR, April 14, 2016
“Going, Going, Gone: trends and consequences of eliminating state psychiatricbeds, 2016” Treatment Advocacy Center, June 2016
Reports of shortages of available intensive psychiatric inpatient services were cited by
Congress in passing the 21st Century Cures Act, as well as in various academic andadvocate reports.4, 5, 6.
A 2015 study of SMHAs by the NASMHPD Research Institute (NRI), found that manystates (35 of 46) are experiencing shortages of psychiatric hospital beds. Of the states
experiencing bed shortages, 20 states reported insufficient acute beds in private
psychiatric and general hospitals and 17 states reported experiencing a shortage of shortterm beds in state psychiatric hospitals.7 More states (23) were experiencing a long-term
4 Fuller D.A., Sinclair E., Geller J., Quanbeck C., & Snook J. Going, Going, Gone: Trends and Consequencesof Eliminating State Psychiatric Beds, 2016, Treatment Advocacy Center (2016),
http://www.treatmentadvocacycenter.org/going-going-gone.
5 Sharfstein S.S., & Dickerson F.B., Hospital Psychiatry for the Twenty-First Century. Health
Affairs 28(3), 685-688 (2009).
6 Appelbaum P.S., The ‘Quiet’ Crisis in Mental Health Services, Health Affairs 22(5), 110-116 (2003).
7 NRI 2015 State Mental Health Agency Profiles System.

Psychiatric Inpatient Capacity, August 20178

bed shortage in state psychiatric hospitals, and 12 states were experiencing a bed shortagein private psychiatric and general hospitals. Twenty-six states reported a shortage of beds
for “forensic status” patients committed by the courts for evaluation or long-term stays.
In 25 of 35 states experiencing a shortage of psychiatric hospital beds, the shortage led toincreased waiting lists for state hospital beds. In 16 states, the shortage led to increased
waiting lists for beds in private psychiatric hospitals or general hospitals. In eight states,
the shortage also resulted in overcrowding in state hospitals, and nine states experienced
resistance to the planned closure of additional state hospital beds. In three states, theshortage of psychiatric beds caused an increased dependency on emergency departments,
where persons could be kept until a bed becomes available. In three states, the shortage ofbeds in individuals’ communities caused geographic expansion in the search for available
beds, resulting in greater average distances between an individual’s home community andthe hospital where the individual is ultimately served.
The shortage of bed capacity is often attributed to the closure of state psychiatrichospitals. But the data presented in this report show that most of the state psychiatrichospital bed capacity that has been closed was actually closed decades ago, with the rateof downsizing drastically slowed in recent years.
The Federal government and the courts have established a variety of Federal laws andrules—laws and rules that continue to exist today—that strongly direct states to minimize
institutional care. The Medicaid Institutions for Mental Disease (IMD) rule limiting the useof Medicaid payment in hospitals for much of the adult population, the prohibition against
using Mental Health Block Grant (MHBG) funds for inpatient services in any setting, andFederal disability laws such as the Civil Rights of Institutionalized Persons Act of 1980
(CRIPA) 8 and regulations implementing the Supreme Court’s Olmstead decision 9continue to emphasize the development of community-based alternatives to inpatient care.
State governments responding to these incentives have increased their expenditures forcommunity-based mental health services at a rate more than ten times greater than theirexpenditures for state psychiatric hospitals. During the 35 years between Fiscal Year
(FY) 1981 and FY 2015, state hospital expenditures increased 159 percent, an increase
dwarfed by the 1,528 percent increase in community mental health expenditures.
The much smaller state psychiatric hospitals of 2017 now focus increasingly on
specialized populations that are often difficult to treat or simply cannot be accommodated
in other settings. State psychiatric hospitals are increasingly responsible for providing
treatment to forensically-involved patients and sex offenders not deemed safe to treat incommunity settings. Many states have responded by shifting responsibility for someclient groups previously provided by state psychiatric hospitals to other settings:
More than 20 states no longer serve children in their state psychiatric hospitals.

Many states have adopted policies that require initial admissions for civil statuspatients in local hospitals and only treat civil status patients for whom it can be

8 42 U.S.C. § 1997 et seq.

9 Olmstead v. L.C., 527 U.S. 581 (1999).

Psychiatric Inpatient Capacity, August 20179

demonstrated that continuing inpatient treatment after initial hospitalization isrequired.
The large number of elderly patients who were once served in state psychiatrichospitals have largely been shifted to services in community and residential
settings that specialize in dementia, Alzheimer’s, etc., Moreover, few patients“age in” and become elderly after decades of hospitalization with lengths of stayin state hospitals measured in years.



Patients with intellectual or developmental disabilities used to fill many beds instate psychiatric hospitals, but with the development of community-based services
and supports for individuals with developmental disabilities, states have largely
closed state psychiatric hospital units that used to serve these patients. The
recently adopted Medicaid home- and community-based services regulations
requiring a shift away from isolating and institutional services is hastening thattransition even more.10

The impetus for closing of many of these state psychiatric hospital beds early on was, inpart, based on the availability of alternative acute inpatient beds in other organizations(often, general hospitals that, because they are not defined as IMDs, are able to bill
Medicaid for care that would otherwise require state funds if delivered in a state psychiatrichospital). However, the data presented in this report (see Tables 8 and 9) show that, despite
their ability to bill Medicaid and insurance, the trend in the number of specialty psychiatricbeds in general hospitals has been flat for years and has slightly decreased in recent years
as general hospitals found that psychiatric units were less profitable than other types of
medical units, shifting some psychiatric units to other medical/surgical purposes. Managed
care, evident first in the private insurance market and later under Medicaid, has limited
admissions and length of stay for psychiatric patients.
In a 2015 survey of state mental health agencies conducted by NRI, although the majorityof states identified shortages of acute psychiatric bed capacity, state solutions to theseshortages did not involve reopening closed state hospital beds. Instead, the state response
was to develop a set community alternatives including: working with general hospitals toopen or reopen beds, funding residential crisis beds, funding crisis response teams, andincreasing other evidence-based community-based services such as ACT and Supportive
Housing, which are designed to minimize institutionalization.

Use of Psychiatric Inpatient Services Today Are Different
From Earlier Eras
The decline in psychiatric inpatient capacity over the past 60 to 65 years has been part ofa historic transformation of how and where services to individuals with serious mental
illness are provided. Until the 1960s, the Federal collection of information about mental
health services focused exclusively on psychiatric hospitals, as those were the primarylocations where individuals with serious mental illnesses received services.

10 42 CFR Parts 430, 431, 435, 436, 440, 441 and 447.

Psychiatric Inpatient Capacity, August 201710

Today, psychiatric beds are used as one part of a continuum of mental health care forindividuals in acute crises—individuals with complex needs that are not being met bycommunity services, often with multiple diagnoses—and individuals with criminal justiceinvolvement who are sent to psychiatric institutions by the judicial system for evaluations
and treatment. In 2014, state mental health systems provided mental health services to
7.3 million individuals, but only 493,517 (6.8 percent) of those individuals received
inpatient psychiatric services during the year (2 percent received mental health services instate psychiatric hospitals and 4.8 percent in other psychiatric inpatient settings).11
Although less than 2 percent of clients received services in state psychiatric hospitals,
states expended $9.4 billion providing those intensive services (23 percent of total State
Mental Health Agency (SMHA) expenditures.12 The average cost per patient day for carein a state psychiatric hospital was $664 in FY 2015 (over $242,000 for a year of care).13
The shift of state mental health services from state psychiatric hospitals to community
mental health services and supports reflects a transition over 50+ years in mental healthtreatment philosophy and treatment objectives. Several authors14, 15 have investigated
how the development of first-generation antipsychotic and antidepressant medications in
the 1950s permitted the movement of patients out of state psychiatric hospitals that had
grown into large institutions—some of which were essentially “warehousing” over
10,000 patients with little successful treatment prior to the new medications. In 1963,
President Kennedy pushed the adoption of the Community Mental Health Act (CMHA),16
funding the establishment of comprehensive community mental health centers across thecountry. One of the explicit goals of the CMHA was to reduce the use of psychiatrichospitals by adopting a philosophy of making community mental health centers thecentral location for mental health services, including inpatient care as a key service).
Implementation of the CMHA never met the goals originally envisioned and failed to end
the need for specialized psychiatric hospitals. In 1982, the CMHA was transitioned into
the MHBG.17 The MHBG directs community mental health funds through each state’s
SMHA, with the requirement that the state use the MHBG funds to plan and implement
comprehensive community-based mental health service systems that would minimize theuse of restrictive inpatient care. The MHBG statute requires SMHAs to enable
individuals receiving comprehensive community mental health services to function
outside of inpatient or residential institutions, to the maximum extent of theircapabilities.18 In implementing the MHBG, SAMHSA also developed and worked withstates to implement Community Support Program (CSP) model services that uses trained
mental health case managers to help individuals with serious mental illnesses access the
11 2014 SAMHSA Uniform Reporting System. Data available at:

http://www.samhsa.gov/data/us_map
12 NRI 2015 State Mental Health Agency-controlled Revenues and Expenditures Study.
13 NRI 2015 State Mental Health Agency-controlled Revenues and Expenditures Study.
14 Frank R., Gleid S., Better But Not Well, Mental Health Policy in the United States since 1950,
Johns Hopkins University Press, Baltimore, MD (2006).
15 Parks J., Radke A. & Haupt M, The Vital Role of State Psychiatric Hospitals, NASMHPD, Alexandria,
VA (July 2014), http://www.nasmhpd.org/content/vital-role-state-psychiatric-hospitals-july-2014-0
16 Public Law 88-164.
17 42 U.S.C. §§290bb-31 et seq. and §§300x et seq.
18 42 U.S.C. § 300x-1.

Psychiatric Inpatient Capacity, August 201711

services and supports necessary to live in their own communities. While appropriations
for the MHBG have failed to keep up with inflation and population growth, the MHBG
remains a critical source supporting state development of comprehensive community
mental health systems designed to minimize the use of hospital level of care.
During the 1980s and 1990s, the National Institute of Mental Health (NIMH), SAMHSA,
and others developed evidence-based model community-based mental health treatment
options, with the goal of helping individuals with serious mental illness to receive
services in their own communities and avoid hospitalizations—services such as ACT,
supportive housing, supported employment, Cognitive Behavioral Therapy (CBT), andrecovery-focused psychosocial rehabilitation services.
The development of community-based services over the past 50 years was further
supported by passage of state and Federal laws that drastically increased financial support
for community mental health services, in particular the expansion of Medicaid andMedicare as major sources of reimbursement for community mental health services, andthe passage state and Federal mental health parity laws which mandated that private
insurance plans reduce restrictions on payment for mental health services that are not onparity with restrictions on payment for analogous medical/surgical services. In the 1990s,
the use of managed care for both private insurance and Medicaid increased the potential
funding of community mental health services, but also added new levels ofoversight/utilization review that limited payments for psychiatric inpatient care.19
Finally, since the 1970s, the Federal Government, through a series of laws and court
cases has been actively pursuing policies that reduce the use of psychiatric hospitals
unless absolutely necessary. Federal policy has challenged inappropriate hospitalizations,
incentivized community-based treatments, and supported the development of communitybased alternatives to hospitalization such as ACT and SAMHSA’s CSPs focus on casemanagement for individuals with serious mental illnesses.
Some of the Federal policies that explicitly limit funding or use of psychiatric inpatient
services include:
1. Federal Medicaid IMD Coverage Limitations (1965) — When the Social Security
Act Amendments of 196520 creating the Medicaid program were enacted, they set
limits on Medicaid payment for services in IMDs. Over the years, exceptions to thelimits were carved out for inpatient services provided to older adults and children.
The current Medicaid regulations prohibit Federal Medicaid matching payments for
adults’ ages 22 to 64 in inpatient and other 24-hour residential treatment settings ininstitutions with more than 16 beds where more than half the patients have a mental
illness.21 The IMD rule has incentivized states to shift acute psychiatric treatment for
adults from state psychiatric hospitals (which are IMDs and thus unable to bill
Medicaid) to general hospital psychiatric beds (which are able to bill Medicaid). For
example, if a state closes an acute unit in a state hospital that relied on $10 million in
19 Dickey B., Norton E.C., Normand S.L., Fisher W.H. & Azeni H., Managed Mental Health Experience in

Massachusetts, Paying for Services: Capitation and Managed Behavioral Health Care, David Mechanic
editor, pp. 115-124, San Francisco, CA, Jossey-Bass (1998).
20 Public Law 89-97 (1965).
21 42 C.F.R 441.13(a)(2).

Psychiatric Inpatient Capacity, August 201712

state general revenue funds, the state can use that $10 million as a match for Medicaid
billing of acute psychiatric inpatient services in a general hospital. That approachleverages an additional $10 to $20 million of Federal Medicaid funds (the Federal
Medical Assistance Percentage (FMAP) match rates range from 50-50 to 18-82
depending on a state’s per capita income level).
A recent change to Medicaid managed care regulations22 also allows coverage of 15days or less in a month for residential substance use disorder services and psychiatricinpatient services in a hospital providing psychiatric or substance use disorder
inpatient care or a sub-acute facility providing psychiatric or substance use disordercrisis residential services through the capitated payments made to Medicaid managed
care organizations.23
Medicaid Disproportionate Share Payments (DSH) have allowed some states toreceive reimbursements from Medicaid for providing services to individuals without
insurance. However, while Medicaid DSH has been an important source of funding
for some state and private psychiatric hospitals, the use of DSH to cover IMD
services varies considerably from state to state.24 The Affordable Care Act (ACA) has
increased the number of individuals with insurance coverage and, as a result, the
ACA is scheduled to phase out DSH funding over the next few years. If DSH funds
are eliminated, an additional Federal source of support for psychiatric inpatient care
will disappear.
2. Mental Health Block Grant (MHBG) Law —The MHBG law requires SMHAs to use
block grant monies to “enable individuals receiving comprehensive community mental
health services to function outside of inpatient or residential institutions, to the maximum
extent of their capabilities”. The MHBG statute prohibits any expenditures of MHBG
funds for inpatient services.25
3. Civil Rights of Institutionalized Persons (CRIPA) — The Federal law designed toprotect the rights of individuals in state and local psychiatric hospitals, nursing
homes, institutions for individuals with intellectual/developmental disabilities, or incorrectional facilities has been the basis of a number of lawsuits and settlements
focusing on overuse and inappropriate care in state psychiatric hospitals. The goal ofthat litigation is frequently the reduction in use of inpatient care and an expansion ofcommunity-based alternatives.
4. Americans with Disability Act of 1990 (ADA)26 – The ADA is a Federal statute thatprohibits unjustified segregation of individuals with disabilities. In 1990, the Supreme
Court determined in the Olmstead decision27 that the ADA applies to patients in state
psychiatric hospitals and that states must undertake reasonable accommodations to
22 81 Federal Register 27498 et seq. at 27555 to 27557 and 27861.
23 42 C.F.R. 438.6(e).

24 Draper D., McHugh M., Achman L. & Kuo S., Medicaid Financing of State and County Psychiatric

Hospitals: Special Report (2003).
25 42 U.S.C. § 300x-1.
26 Public Law 101-336; 42 U.S.C. § 12101 et seq.
27 Olmstead v. L.C., 527 U.S. 581 (1999).

Psychiatric Inpatient Capacity, August 201713

support the community integration of individuals with mental illnesses. The Olmstead
decision has been the focus of much litigation and many settlements that havefocused on inappropriate or overuse of institutional care.
5. Fair Labor Standards Act and the 1973 Souder v Brennan Federal Court
Decision28-- Although not often cited as a reason for deinstitutionalization, the Federal
District Court for the District of Columbia held, in a 1973 decision, that hospitalpatients who perform work within state institutions are entitled to payment for theirlabor, even where such employment is considered to be therapeutically advisable forthe patient. The result of this decision was that volunteer patient laborers working instate hospitals to maintain the hospital (working in the laundry, kitchen, maintenance or
to grow food in rural areas on hospital farms) or in workshops contained within thehospital that produced products for the hospital and outside sale now needed to receive
minimum wage for hours worked.29 An example of the impact of this decision is foundin a 1974 Michigan budget document that appropriated $800,000 for wages for patientsin state hospitals, citing the Souder decision.30 After the Souder decision, the increased
costs of having to paying for kitchen, laundry, workshops farms and other state hospital
operations led some states to closed their workshops and farms and downsize thehospitals.

Availability of Psychiatric Inpatient Services in 2014
Beds available to provide 24-hour mental health treatment to individuals requiring a highlevel of restrictive and expensive treatment are available in a variety of settings, including
specialized psychiatric hospitals, psychiatric inpatient and licensed residential treatment
units in general hospitals and other organizations, RTCs for children and adults(organizations that provide intensive 24-hour treatment services but are not licensed as“inpatient” services), DOD and VA facilities, nursing homes, and psychiatric inpatient
units within jails and prisons. Unfortunately, there is no single source of information that
documents all psychiatric inpatient capacity across the various types of organizations thatare providing these services. This paper combines available information from multiple
data sources to estimate the overall inpatient and other 24-hour inpatient capacity in the
U.S. in 2014.
The most recent year for which information on psychiatric inpatient capacity is available
across multiple settings is 2014. The SAMHSA National Mental Health Service Survey(N-MHSS) documents inpatient and other 24-hour mental health treatment beds inorganizations that provide specialized mental health units. Organizations covered by
SAMHSA surveys include (1) state and county psychiatric hospitals, (2) private
psychiatric hospitals, (3) general hospitals with psychiatric units, (4) VA Medical Centerswith psychiatric units, (4) RTCs for Children and Adults, and (5) other mental healthtreatment organizations that provide inpatient or other 24-hour treatment beds(organizations such as community mental health centers). RTCs are a type of mental
28 Souder v. Brennan, 367 F. Supp. 808 (D.D.C. 1973).
29 Blaine J. G. & Mason J. H., Application of the Fair Labor Standards Act to Patient Work Programs at

Mental Health Institutions: A Proposal for Change. BCL Rev, 27, 553 (1985).
30 Advocate, Michigan Society for Mental Health Inc., Summer Issue 1974, Vol. 1, No. 7.

Psychiatric Inpatient Capacity, August 201714

health treatment provider that provides specialized mental health residential treatment(usually licensed separately from inpatient beds) that has grown rapidly in their capacity
over the past decades.
In addition to the organizations surveyed by SAMHSA, a number of other types oforganizations provide psychiatric inpatient and residential treatment beds, including(1) general hospitals without specialty psychiatric units (hospitals that provide psychiatriccare in “scatter beds”), (2) DOD hospitals, (3) nursing homes, (4) psychiatric treatment
units in jails, and (5) psychiatric treatment units in prisons. This paper includes a
discussion of both VA and DOD psychiatric inpatient capacity, because although thesetwo Federal agencies served a limited set of eligible individuals, persons with eligible forservices from the VA or DOD may show up in other inpatient and residential treatment
settings during a psychiatric emergency. In addition, the availability of inpatient andresidential mental health treatment capacity from these specialized Federal programs mayhelp reduce demand on civilian population providers.

Psychiatric Inpatient Capacity in Mental Health Specialty
Organizations
SAMHSA and its predecessor agency, the Alcohol, Drug Abuse, and Mental HealthAdministration, have been routinely conducting surveys of all specialty mental healthproviders since the 1970s. These surveys, called the Inventory of Mental HealthOrganizations (IMHO) in the 1980s and 1990s and recently revised into the National-Mental
Health Services Survey (N-MHSS), compile information on the number of specialty mental
health providers that provide psychiatric inpatient and residential services and information on
the number of residents in these facilities on the last day of the year.
The 2014 N-MHSS documents that 170,200 individuals were patients in specialty
psychiatric beds at the end of the year (see Table 1). Sixty percent of those individuals
were residents in licensed inpatient beds at the end of the year, and 40 percent wereresidents in other types of 24-hour residential beds at the end of the year.
Table 1: Number and Rate per 100,000 population of psychiatric inpatients and other 24-hourresidential treatment patients at end of year 2014
Patients in Other 24-Hour
Residential Treatment
at End of Year
Rate Per
100,000
Residents Percent Population

Patients in Inpatient and Other
24-Hour Residential Treatment
at End of Year
Rate per100,000
Residents Percent Population

Type of Organization

Patients in Inpatient Settings
at End of Year
Rate Per
100,000
Residents Percent Population

State & County
Psychiatric Hospitals

37,209

37%

11.7

2,698

4%

0.8

39,90723%

12.6

Private Psychiatric
Hospitals

24,804

24%

7.8

3,657

5%

1.2

28,46117%

9.0

30,864

30%

9.7

589

1%

0.2

31,453

18%

9.9

3,124

3%

1.0

3,886

6%

1.2

7,010

4%

2.2

1,851

2%

0.6

41,07960%

12.9

42,93025%

13.5

General Hospital with
Separate PsychiatricUnits
VA Medical Centers
Residential Treatment
Centers (RTCs)

Psychiatric Inpatient Capacity, August 201715

Other Specialty
Mental Health
Providers with
Inpatient/Residential
Beds
Total in specialty MH
Provider Organizations

3,499

3%

1.1

16,94025%

101,351

100%

29.7

68,849

100%

5.3

21.7

20,43912%

6.4

170,200

100%

53.6

Source: Table compiled by NRI from SAMHSA 2014 N-MHSS Tables 2.3 and 2.5

Among specialty inpatient providers, state and county psychiatric hospitals were thelargest single source of beds, with 37,209 patients on the last day of the year, followed bygeneral hospitals with separate psychiatric units. Among specialty mental healthproviders with residential treatment beds, RTCs (with 41,079 patients on the last day of
the year) and other specialty mental health providers (such as community mental healthcenters), were the second largest setting for other 24-hour psychiatric treatment patients
Since many other specialty providers are in some cases part of the state’s public mental
health system, either through direct operation by the SMHA or through contractual
arrangements of various kinds, combining these other specialty providers with state
psychiatric hospitals leaves the public system as still the largest provider of 24-hour
psychiatric services.

Rates of Psychiatric Inpatient Capacity and 24-Hour Treatment
Capacity per 100,000 Population
In analyzing the use of psychiatric inpatient capacity between states and over time, it isimportant to factor in the differences in the size of individual state populations andpopulations over time. A standard method used to adjust for variation in population sizeand growth over time is to calculate a ratio per 100,000 population (dividing the numberof patients by the relevant population number and then multiplying by 100,000).
Using this approach, in 2014, there were a total of 29.7 psychiatric inpatient residents per
100,000 population in specialty mental health providers and an additional 21.7 patients
per 100,000 in 24-hour residential treatment beds. A total of 53.6 residents per 100,000
were in various specialty psychiatric treatment beds on the last day of 2014.

Voluntary vs. Involuntary Status of Inpatients in Specialty
Programs, 2014
Psychiatric patients may enter inpatient and other 24-hour residential treatment facilities
either on a voluntary basis or involuntarily, under their state’s civil commitment statute,
if they are determined by a court to be at risk to harming themselves or others as a resultof the symptoms of their mental illness. There are two types of involuntary admissions
that are tracked in the SAMHSA datasets: “involuntary, non-forensic” (persons civilly
committed) and “involuntary, forensic” (individuals ordered by a criminal court toevaluation or treatment). Classes of forensic patients include individuals sent to hospitals
for assessment of competency to stand trial (CST), competency restoration before trial for
individuals found incompetent to stand trial (IST), Not Guilty by Reason of Insanity(NGRI), Guilty but Mentally Ill (GBMI), patients transferred from jail or prisons for
Psychiatric Inpatient Capacity, August 201716

psychiatric treatment not available in those settings, and, in some states, convicted sexual
offenders requiring psychiatric treatment.
In 2014, just under half (46 percent) of psychiatric inpatients in specialty settings were
voluntary patients, while 34 percent were “involuntary, non-forensic” and 19 percent
were “forensic” patients.
Table 2: Patients in 24-hour psychiatric inpatient settings in specialty mental health organizations, bylegal status, 2014

Voluntary Patients
Number

Percent

Involuntary, nonForensic
Number Percent

Involuntary,
Forensic
Number Percent

State And County
6,523
18%
13,64037%
17,046
Psychiatric Hospitals
Private Psychiatric
15,691
63%
7,876
32%
1,237
Hospitals
General Hospitals With
Separate Psychiatric
18,801
61%
11,278
37%
785
Units
VA Medical Centers
2,501
80%
476
15%
147
RTC For Children
370
81%
60
13%
28
RTC For Adults
578
55%
289
27%
189
Other facilities providing
specialized psychiatric
2,545
66%
1,197
31%
94
inpatient care
Total
47,00946%
34,81634%
19,526
Source: Table compiled by NRI from SAMHSA 2014 N-MHSS Tables 3.1a and 3.2a.

46%
5%
3%
5%
6%
18%
2%
19%

Table 2 shows that the legal status of patients differs significantly by type of treatment
setting. Forensic status patients were the largest patient group (46 percent) in state andcounty psychiatric hospitals, but were 18 percent or less of every other psychiatricinpatient setting.
Patients voluntarily admitted comprised the largest groups in all settings other than stateand county psychiatric hospitals. However, only 18 percent of patients in state and county
psychiatric hospitals had a voluntary legal status. The low percentage of voluntary
patients in state and county psychiatric hospitals may reflect policies developed in somestates that reserve state psychiatric hospital beds for involuntary civil and forensic
admissions and direct persons seeking voluntary admission into other settings.
The majority of involuntary, forensic legal status patients (87 percent) were patients instate and county psychiatric hospitals. Only six percent were residents in private
psychiatric hospitals and four percent were in general hospital special psychiatricinpatient units (see Figure 1).

Psychiatric Inpatient Capacity, August 201717

Figure 1: Inpatient Settings Where Involuntary-Forensic Patients Were Served, 2014

Privatepsychiatrichospitals
6%

Generalhospitals withseparate
psychiatric units
4%

VA Medical
Centers
RTCs for1%
Children0%State and County
Psychiatrichospitals
87%

RTCs for Adults
1%
Other Programs
1%

Inpatients with voluntarily admitted in psychiatric inpatient beds were most frequently
served in general hospitals with separate psychiatric units (40 percent) and in private
psychiatric hospitals (33 percent). Only 14 percent of patients voluntarily admitted werein state and county psychiatric hospitals.
Figure 2: Inpatient Settings Where Voluntary Patients Were Served, 2014

Generalhospitals withseparate
psychiatric
units
40%
Privatepsychiatrichospitals
33%

Psychiatric Inpatient Capacity, August 2017

VA Medical
Centers
5%
RTCs forChildren
RTCs
1%
for
Adults1%
Other
Programs
6%
State andCountyPsychiatrichospitals
14%18

Number of Organizations with Specialized Inpatient and Other 24Hour Residential Mental Health Treatment Programs
In 2014, there were 1,986 different mental health organizations nationally providing
psychiatric inpatient services and, nationally, 2,573 mental health organizations providing
24-hour residential (i.e., non-hospital) mental health treatment. General hospitals werethe most frequent setting providing psychiatric inpatient care, representing 55 percent oforganizations providing inpatient treatment and 30 percent of psychiatric inpatients.
Private psychiatric hospitals were the second largest group of providers of inpatient care,with 21 percent of psychiatric inpatient organizations serving 24 percent of psychiatricinpatients. State and county psychiatric hospitals represented only 10 percent of theorganizations providing psychiatric inpatient care, but since they were the largest
organization in terms of beds, they served 37 percent of psychiatric inpatients in 2014.
RTCs were the most common type of organization providing other non-inpatient 24-hourtreatment services in 2014 — 79 percent of all organizations providing other 24-hourtreatment serving 60 percent of residents — followed by other specialty mental healthorganizations (12 percent of organizations serving 25 percent of residents) and private
psychiatric hospitals (4 percent of organizations, representing 5 percent of residents).

Psychiatric Inpatient Capacity, August 201719

Table 3: Number of Organizations Providing Psychiatric Inpatient Services or Other 24-hour Residential
Treatment, 2014
Patients in Inpatient Settings at End ofYear

Number ofOrganizations

NumberResidents

Average
Residents
Per
Organization

State & County Psychiatric
Hospitals

202

37,209184.2

Private Psychiatric Hospitals

420

24,804General Hospital with Separate
Psychiatric Units

1,097

30,864

VA Medical Centers

91

3,124

Residential Treatment Centers(RTCs)

58

1,851

Year/Setting

59.1
28.1
34.3
31.9

Patients in Other 24-Hour Residential
Treatment at End of Year

Number ofOrganizations

NumberResidents

Average
Residents
Per
Organization

35

2,698

77.1

96

3,657

38.1

32

589

18.4

67

3,886

58.0

2,026

41,07920.3

Other Specialty Mental Health
Providers with
118
3,499
317
16,94053.4
29.7
Inpatient/Residential Beds
Total Specialty MH Providers
1,986 101,351
367.3
2,573
68,849265.3
Note, Many organizations provide both inpatient and other 24-hour residential treatment services. Source: 2014 SAMHSA NMHSSTable 3 and Figure 3 show that, on average in 2014, state and county psychiatrichospitals have the largest capacity for psychiatric inpatient services, averaging 184
patients per hospital, followed by private psychiatric hospitals with an average of 59
patients per hospital. VA Medical Centers averaged 34 patients per hospital, and general
hospitals with separate psychiatric units averaged 28 inpatients per hospital
Among other 24-hour mental health residential treatment providers, state and county
psychiatric hospitals had the largest patient populations—with an average of 77.1 patients
per state and county hospital providing this service—followed by VA Medical Centerswith 58 patients per hospital, and other specialty mental health providers (53.4 patients
per organization).
Other sources of mental health inpatient capacity, such as general hospital scatter beds
and DOD facilities, will be discussed in the next section.

Psychiatric Inpatient Capacity, August 201720

Figure 3: Average Number of Inpatients and Other 24-Hour Residential Treatment Services, by Type of
Mental Health Organization, 2014

Average Number of Patients Served

200

184.2

Average Number ofInpatients

180
160
140

Average Number Other 24Hour Residential Patients

120
100
80

77.1
59.1

60

58.0
38.1

40
20
0

State & County
Psychiatric
Hospitals

PrivatePsychiatric
Hospitals

28.1

18.4

GeneralHospitals with
Separate Psych
Units

53.4

34.3

31.9

VA Medical
Centers

Residential
Treatment
Centers

20.3

29.7

Other (CMHCs
and MultiService MH
Centers with
Inpatient beds)

Type of organization providing specialized mental health inpatient or other 24-hourresidential treatment

Other Settings with Psychiatric Inpatient and 24-hour Residential
Treatment in 2014
In addition to the specialty mental health organizations that are included in the SAMHSA
surveys, patients needing psychiatric treatment often receive intensive 24- hour services
in several other settings that do not have a primary focus of mental health treatment (andthus are not the focus of SAMHSA surveys). These include general hospitals without
specialty psychiatric units, DOD medical centers, and nursing homes, as well as specialty
psychiatric units being operated by jails and state prisons to address the needs ofincarcerated patients with major mental illnesses.

General Hospitals Providing Mental Health Services In
Non-Specialty Units
In 2014, there were 4,999 community (general) hospitals in the United States,31 of which
1,167 had specialty psychiatric units that reported to SAMHSA.32 In some areas of thecountry—particularly rural and frontier areas—there may be no specialized psychiatricbeds available, and in other areas the limited number of available psychiatric beds may
31 Facts on U.S. Hospitals, American Hospital Association (2014),

http://www.aha.org/research/rc/stat-studies/fast-facts2014.shtml.
32 SAMHSA N-MHSS 2014.

Psychiatric Inpatient Capacity, August 201721

all be filled when a person is needs admission for intensive psychiatric services. Most
general hospitals provide acute inpatient services to patients with mental health disorder;when these services are provided in general hospitals without special psychiatric units
these are often labeled psychiatric “scatter beds”.33
No routine data collection exists that identifies “scatter beds” in general hospitals, but theFederal Agency for Health Care Research and Quality (AHRQ) produces annual reports
through its Healthcare Cost and Utilization Project (HCUP) that allows identification ofpatients discharged from all general hospitals through various diagnostic groupings. This
database has been used by other researchers to estimate the use of general hospital scatterbeds to provide mental health inpatient care. Using HCUP data, SAMHSA researchers
found that scatter beds accounted for 36 percent of general hospital mental healthexpenditures in 2014 (see Table 4 below).34
Table 4: Mental Health Spending by Provider and Setting: Levels and Percent Distribution, Selected Years
Expenditures in Millions

Hospital Percent Distribution

1986

1992

1998

2004

2009

2014

1986

1992

1998

2004

2009

2014

All Hospitals$13,527$20,354$22,056$29,217$37,732$49,414

100%

100%

100%

100%

100%

100%

General Hospitals
General Hospitals,
Specialty Units
General Hospitals,
non-specialty Units$5,276$8,621$12,024$16,284$22,124$32,226

39%

42%

55%

56%

59%

65%

$3,053$6,197$8,696$10,919$15,308$20,714

23%

30%

39%

37%

41%

42%

$2,223$2,425$3,328$5,365$6,816$11,513

16%

12%

15%

18%

18%

23%

Specialty Hospitals$8,251$11,733$10,032$12,932$15,608$17,188

61%

58%

45%

44%

41%

35%

Substance Abuse and Mental Health Services Administration. Behavioral Health Spending and Use Accounts, 1986–2014. HHS
Publication No. SMA-16-4975. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2016.

For this report, NRI utilized the AHRQ HCUPnet system to query 2014 data on general
hospitals to identify all discharged patients with an ICD-10 diagnosis in AHRQ’s “mental
health” cluster of diagnoses. Because data comparable to the SAMHSA surveys ofresidents in psychiatric inpatient beds on a single day are not available from the HCUP
data, NRI used HCUP data on total discharges by diagnosis throughout the year, alongwith average length of hospital stay for each diagnosis, to calculate total patient days
during the year and then divided that number by 365 days a year to estimate a proxy of
how many mental health patients were in served in general hospitals on a single day. To
calculate how many of those mental health patients in general hospitals were in scatter
beds, as opposed to psychiatric units in general hospitals with data already collected by
SAMHSA, NRI then subtracted this estimate from the SAMHSA reported 30,864
patients in general hospitals with special psychiatric units.
Table 5 below shows there were a total of over two million patients with a mental healthdiagnosis discharged from community hospitals in 2014. Mood disorders (39.9 percent
33 Slade E.P. & Goldman H.H., “The Dynamics of psychiatric bed use in general hospitals,”

Administration and Policy in Mental Health/Mental Health Services Research, 2015 March 42(2): 139146 (2015).
34 Behavioral Health Spending and Use Accounts, 1986–2014, HHS Publication No. SMA-16-4975,
Substance Abuse and Mental Health Services Administration, Rockville, MD (2016).

Psychiatric Inpatient Capacity, August 201722

of discharges) and schizophrenia and other psychotic disorders (28.7 percent ofdischarges) were the most frequently identified diagnoses. Persons with discharge
diagnoses of schizophrenia also had the longest average length of stay of any of themental health diagnostic groups.
Applying the NRI approach to estimating average daily census for this diagnostic group,the 2,024,853 reported discharges translated into an average of 38,870 patients on asingle day. When NRI subtracted the 38,870 total general hospital mental health patientsfrom SAMHSA’s estimate of 30,864 patients in general hospitals with separate
psychiatric units, NRI calculated there would be an average of 8,006 patients with mental
illness being served in general hospital scatter beds on an average day. The 8,006 mental
health patients per day would be a ratio of 2.52 patients per 100,000 population. (SeeTable 2 above).
Table 5: Discharges from Community Hospitals by Mental Health Diagnoses, Average Length of Stay, andCalculated Residents on a Single Day, 2014 HCUP Data

Total number ofdischarges: N

LOS (lengthof stay),days (mean)

Estimatedpatients on single
day (Discharges
x LOS / 365)

Estimated %of Patients

Adjustment disorders

36,465

3.554

355.0

0.91%

Anxiety disorders

39,205

4.873

523.4

1.35%

Attention-deficit, conduct, and disruptive behavior disorders

11,715

7.914

254.0

0.65%

Delirium, dementia, and amnestic and other cognitive
disorders

110,265

9.986

3,016.8

7.76%

Developmental disorders

1,910

7.044

36.9

0.09%

Disorders usually diagnosed in infancy, childhood, oradolescence

4,605

8.826

111.3

0.29%

Impulse control disorders, NEC

9,240

8.115

205.4

0.53%

Mood disorders

851,074

6.655

15,518.5

39.92%

Personality disorders

6,215

6.208

105.7

0.27%

Schizophrenia and other psychotic disorders

388,835

10.485

11,169.5

28.74%

Alcohol-related disorders

344,395

4.825

4,552.2

11.71%

Substance-related disorders

217,050

4.986

2,965.1

7.63%

Suicide and intentional self-inflicted injury

2,665

3.789

27.7

0.07%

Screening and history of mental health and substanceabuse codes

1,215

8.477

28.2

0.07%

38,870100.00%AHRQ Mental Health Diagnosis Groups

Total of any Mental Health Diagnosis

2,024,853

Psychiatric Inpatient Capacity, August 201723

U.S. Department of Defense (DOD) Facilities
The Department of Defense operates 18 hospitals in the United States that provide
services to 72,440 patients in 2014. Patients with “mental disorders” (identified by using
ICD 10 diagnosis codes) were the largest single diagnostic group of all patients served in2014, with 15,931 patients (see Table 6. The data in Table 6 also allows a comparison of
the ratio of hospital use for mental disorders and other medical conditions.)
Table 6: Hospitalizations, ICD-10 Diagnostic Categories, Active Component, U.S. Armed Forces, 2012,2014, and 2016
2012

2014

2016

No.

Ratea

Rank

No.

Ratea

Rank

No.

Ratea

Rank

Mental disorders (ICD-10: F01–F99)
Pregnancy and delivery (ICD-10: O00–
O99, relevant Z-codes)b

20,69014.9(1)15,93111.9(1)16,56312.9(1)17,27712.4(2)15,55411.6(2)

15,21911.8(2)

Injury and poisoning (ICD-10: S00–T98)

10,684

7.7

(3)

7,415

5.5

(3)

6,752

5.2

(3)

Musculoskeletal system (ICD-10: M00–
M99)

7,232

5.2

(5)

6,128

4.6

(5)

5,929

4.6

(4)

Digestive system (ICD-10: K00–K95)

7,907

5.7

(4)

6,540

4.9

(4)

5,677

4.4

(5)

4,550

3.3

(6)

3,298

2.5

(7)

3,241

2.5

(6)

3,789

2.7

(7)

3,559

2.7

(6)

2,171

1.7

(7)

Genitourinary system (ICD-10: N00–N99)

2,632

1.9

(9)

2,216

1.7

(9)

2,041

1.6

(8)

Respiratory system (ICD-10: J00–J99)

2,521

1.8

(10)

1,862

1.4

(10)

1,972

1.5

(9)

Circulatory system (ICD-10: I00–I99)

2,743

2.0

(8)

2,295

1.7

(8)

1,852

1.4

(10)

Nervous system and sense organs (ICD10: G00–H95)

2,222

1.6

(11)

1,745

1.3

(12)

1,729

1.3

(11)

Neoplasms (ICD-10: C00–D49)

2,102

1.5

(12)

1,803

1.3

(11)

1,655

1.3

(12)

1,804

1.3

(13)

1,467

1.1

(13)

1,174

0.9

(13)

1,408

1.0

(14)

1,240

0.9

(14)

1,055

0.8

(14)

903

0.6

(15)

727

0.5

(15)

622

0.5

(15)

Congenital anomalies (ICD-10: Q00–Q99)

426

0.3

(16)

353

0.3

(16)

278

0.2

(16)

Hematologic disorders (ICD-10: D50–D89)

374

0.3

(17)

307

0.2

(17)

259

0.2

(17)

89,26464.2

72,44054.1

68,18952.9

Major diagnostic category (ICD-10)

Signs, symptoms, and ill-definedconditions (ICD-10: R00–R99)
Other (ICD-10: V00–V98, except
pregnancy-related)

Skin and subcutaneous tissue (ICD-10:
L00–L99)
Infectious and parasitic diseases (ICD-10:
A00–B99)
Endocrine, nutrition, immunity (ICD-10:
E00–E89)

Total

In response to an NRI request for information about the number of patients with mental
illnesses who are in a bed in a DOD military health facility on a single day, theDeployment Health Clinical Center developed a report that lists the number of inpatient
stays during the first six months of 2017 and the number of mental health beds available
in each hospital under normal operating conditions (see Table 7). The DOD analysis
identified a regular capacity to serve an average 289 mental health inpatients per day inthe 18 military health facilities located in the U.S.

Psychiatric Inpatient Capacity, August 201724

Table 7: Military Health Facilities under Normal Operating Conditions Have Accounted for 7,742 Stays toDate in FY 2017 (Excludes Substance Abuse inpatient)35

Facility Name
AF-H-673rd-ELMENDORF
AF-MC-60th MED GRP-TRAVISNMC SAN DIEGOACH EVANS-CARSONAMC EISENHOWER-GORDONACH MARTIN-BENNING
ACH WINN-STEWARTAMC TRIPLER-SHAFTERWALTER REED NATL MIL MED CNTR
ACH LEONARD WOOD
AMC WOMACK-BRAGG
NH CAMP LEJEUNE
AMC WILLIAM BEAUMONT-BLISSAMC BAMC-FSH
AMC DARNALL-HOOD
FT BELVOIR COMMUNITY HOSP-FBCH
NMC PORTSMOUTH
AMC MADIGAN-LEWISCity
ELMENDORF AFBTRAVIS AFBSAN DIEGOFT CARSONFORT GORDONFT BENNINGFT STEWARTHONOLULU
BETHESDAFT LEONARD WOOD
FT BRAGG
CAMP LEJEUNEEL PASO
FORT SAM HOUSTONFT HOODFORT BELVOIRPORTSMOUTH
TACOMA

State
AK
CA
CA
CO
GA
GA
GA
HI
MD
MO
NC
NC
TX
TX
TX
VA
VA
WA

# MH Inpatient
Stays (to June
2017)
98
190
1,137
377
199
306
217
718
389
199
293
486
435
453
558
329
897
461
7,742

# of MH Inpatient Beds
Available under Normal
Operating Conditions
6
7
42
14
16
16
6
14
16
10
12
20
18
16
18
12
32
14
289

Use of Nursing Homes to Serve Individuals with Mental Illnesses
With support from Medicaid, Medicare, and private health insurance, nursing homes havebecome one of the major sites for long-term health care, not only for elderly individuals,
but also for patients with complex health conditions who do not need intensive inpatientlevel care but are unable to live independently and need active nursing and other services.
Nursing home residents may have a variety of mental health-related diagnoses, including
major mental illnesses such as schizophrenia, depression, and bipolar disorders, as wellas other brain diseases related to aging such as Alzheimer’s disease and other dementias.
The Centers for Medicare and Medicaid (CMS) maintain a Minimum Data Set (MDS)
that includes information about major diagnoses of patients in nursing homes. Since moststate psychiatric hospitals currently focus on serving persons with major psychiatricillnesses, and have ceased to focus on Alzheimer’s and dementia disorders for elderly
individuals,36 for purposes of this estimate of psychiatric bed capacity, we have limited
the count of nursing home capacity to residents with schizophrenia or bipolar disorders.
(In 2015, 38 SMHAs reported responsibility for Alzheimer’s services are no longer a
responsibility of the SMHA and are instead the responsibility of a different state
government agency.)

35 Psychological Health Analytics Information Paper: Inpatient Mental Health Beds within the Military

Health System, Deployment Health Clinical Center, Defense Health Agency, Falls Church, VA
Deployment Health Clinical Center (June 2017).
36 NRI 2015 State Mental Health Agency Profiles System

Psychiatric Inpatient Capacity, August 201725

In 2014, there were 183,534 individuals with a diagnosis of schizophrenia or bipolar
disorders residing in nursing homes (11 percent of nursing home residents).37 The MDS
system identifies much higher numbers of residents with other mental disorders—
620,245 residents (48 percent) had a diagnosis of depression and 381,265 residents (29.6
percent) had a diagnosis of anxiety disorders).38
But we advise caution: while this report identifies more than 180,000 patients withserious mental illnesses in nursing facilities, it is not possible to determine from the MDS
database if a patient is residing in a nursing facility due to a mental health diagnosis or
due to other health conditions that require nursing facility level of care.

Inpatient Psychiatric Units in Jails and Prisons
The level of mental illness among inmates in prisons and jails is enormous, withestimates ranging from 15 percent to 20 percent of inmates in prison and up to 44 percent
of individuals in jails having a mental illness.39 Many of the inmates in jails and prisons
do not require the intensive level of mental health treatment of an inpatient psychiatricunit. Only a portion of the population of inmates with mental illness requires intensive
inpatient psychiatric treatment and, for most of these patients, the need for inpatient
psychiatric treatment is likely short-term acute care to stabilize their illnesses. In a few
states, inmates with mental illness who need an inpatient level care may be transferred toa state psychiatric hospital to receive intensive inpatient services. (The companion
Forensic Trends White Paper details some of the number of patients transferred from jails
and prisons to state psychiatric hospitals.)
To meet the acute psychiatric inpatient needs of inmates with mental illnesses, some jails
and prisons have opened and staffed inpatient mental health units within theircorrectional facilities. Unfortunately, these units are not subject to the routine SAMHSA
data collection efforts and no comprehensive and historical data on the treatment capacityof these units has been identified. The Federal Bureau of Justice Statistics (BJS) indicates
it is planning to include identification of such resources in its 2019 cycle of surveys ofjails and prison.

37 The number of residents in nursing facilities with an active diagnosis of schizophrenia or bipolar

disorders was calculated by NRI using MDS data made available from Brown University’s Long-TermCare Focus system. http://ltcfocus.org/ "Shaping Long Term Care in America Project at Brown
University, funded in part by the National Institute on Aging (1P01AG027296)."
38 CMS MDS 3.0 Frequency Report: Residents on April 1, 2014, CMS MDS Data System, Source
Queried 6/11/17, https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Dataand-Systems/Minimum-Data-Set-3-0-Public-Reports/Minimum-Data-Set-3-0-FrequencyReport.html.
39 Bronson J., Ph.D. & Berzofsky M. D.P.H.. Indicators of Mental Health Problems Reported by Prisoners
and Jail Inmates, 2011-12, Office of Justice Programs, U.S. Department of Justice (June 2017),
https://www.bjs.gov/content/pub/pdf/imhprpji1112.pdf.

Psychiatric Inpatient Capacity, August 201726

Summary: All Psychiatric Inpatient and Other 24-Hour Capacity
Despite the lack of inventory data for mental health inpatient beds in jails and prisons, theaddition of psychiatric inpatients in general hospital scatter beds and DOD healthfacilities add an additional 8,295 inpatient beds being used by mental health patients in2014 to the 101,351 inpatient beds identified by the SAMHSA N-MHSS survey, a totalof 109,646 inpatient beds serving patients. This equates to a ratio of 32.2 inpatient
psychiatric beds occupied per 100,000 population serving mental health patients in 2014.
(Note that total bed capacity is larger, as not all beds in hospitals are filled every night.)
In addition to the inpatient psychiatric beds, estimates of the number of individuals withserious mental illnesses (schizophrenia and bipolar disorders) served in nursing homes
add an additional 183,534 residential treatment patients to the 68,849 mental healthpatients identified by the SAMHSA N-MHSS study. Therefore, an estimated 252,383
patients with mental illness were in a 24-hour residential treatment bed in 2014 (a ratio of
79.5 per 100,000 population).
Table 8, below, shows the combined estimate that 362,029 individuals with mental illness
were in either an inpatient or other 24-hour residential treatment bed during a day in2014. The 362,029 mental health patients in a mental health inpatient or other 24-hourresidential treatment bed when adjusted for the U.S. population means there were 114.0
patients per 100,000 population in an overnight bed on a single day in 2014.
Table 8: Psychiatric Inpatients and Other 24 Hour Patients in Non-Specialty Psychiatric Organizations,2014

Patients in Inpatient Settings
at End of Year

Year/Setting
General Hospitals
without Specialty
Psychiatric Units
Department of Defense
Hospitals
Nursing Homes patients with diagnosis of
schizophrenia or bipolar
disorders

Residents

Rate Per
100,000
Population

8,006
289

Psychiatric Treatment
Units in Jails

Estimate Not
Available

Psychiatric Treatment
Units in Prisons

Estimate Not
Available

Total non-specialty MH
Providers
Total Specialty
Providers from the
SAMHSA N-MHSS
Total Known
PsychiatricInpatient/Residential

Patients in Other 24hour Residential
Treatment at End ofYear

Residents

Rate per100,000
Population

2.52

8,006

2.52

0.09

289

0.09

183,534

57.78

Residents

183,534

Rate Per
100,000
Population

Patients in Inpatient andOther 24 hour
Residential Treatment at
End of Year

57.78

Estimate
Not
Available
Estimate
Not
Available

8,295

2.61

183,534

57.78

191,82960.39

101,351

31.9

68,84921.7

170,200

6.4

109,64634.5

252,38379.5

362,029

114.0

Psychiatric Inpatient Capacity, August 201727

Trends in Psychiatric Inpatient and Other 24-Hour
Treatment Since 1970
Since 1970, the number of individuals resident in a psychiatric inpatient or other 24-hourresidential treatment bed on any given day has decreased by over 300,000 (a decrease of
63.9 percent). Most of this decline has been observed in state and county psychiatrichospitals, where patient census decreased by 89 percent, and VA Medical Center
psychiatric units, with decreases of 86 percent. However, some of the other types of
specialty mental health providers increased the number of inpatient and other 24-hourresidential treatment patients they served in that time. Private psychiatric hospital
inpatient census increased by 17,498 or 159.6 percent. Patients in general hospitals withseparate psychiatric units increased by 13,645 (76.6%). RTCs increased by 29,441 (218.3
percent). And other specialty mental health providers increased by 12,913, or 171.6
percent (see Table 9).
Table 9: Trends Over Time in Psychiatric Inpatients and Other 24-Hour Treatment Residents in Specialty
Mental Health Organizations, 1970 to 2014 (Resident Patients in the Facility on a Given Day)
GeneralOther
Hospitals(Inpatient &Privatewith
VA
Residential
PsychiatricSeparate
MedicalTreatment
Year/Setting
Hospitals
Psych Units
Centers
RTCs
beds)
1970
10,96317,80851,696
13,4897,526
1975
11,576
18,851
31,85016,307
12,138
1979
12,921
18,753
28,693
18,276
11,188
1983
16,07932,127
20,187
15,791
23,0791986
24,591
34,47424,322
23,171
20,152
1988
29,40434,85819,49923,301
20,186
1990
32,26838,327
17,23327,785
20,768
1994
26,51935,84118,01929,49354,142
1998
20,80437,053
14,32929,04956,216
2000
16,11327,3858,228
30,272
38,746
2002
17,85828,4608,386
35,70937,5182010
24,02532,395
5,602
41,536
12,845
2014
28,461
31,4537,010
42,93020,439Percent Change Over Time1970 to 1979
-62.1%
17.9%
5.3%-44.5%
35.5%
48.7%
1979 to 1990
-35.5%
149.7%
104.4%-39.9%
52.0%
85.6%
1990 to 2000
-37.4%-50.1%-28.5%-52.3%
9.0%
86.6%
2000 to 2010-22.7%
49.1%
18.3%-31.9%
37.2%-66.8%
2010 to 2014
-9.0%
18.5%
-2.9%
25.1%
3.4%
59.1%
1970 to 2014-89.2%
159.6%
76.6%-86.4%
218.3%
171.6%
Annualized Percent Change
1970 to 1979
-10.2%
1.8%
0.6%
-6.3%
3.4%
4.5%
1979 to 1990
-3.9%
8.7%
6.7%
-4.5%
3.9%
5.8%
1990 to 2000
-4.6%
-6.7%
-3.3%
-7.1%
0.9%
6.4%
2000 to 2010
-2.5%
4.1%
1.7%
-3.8%
3.2%
-10.5%
2010 to 2014
-2.3%
4.3%
-0.7%
5.8%
0.8%
12.3%
1970 to 2014
-4.9%
2.2%
1.3%
-4.4%
2.7%
2.3%
Source: Table created by NRI using historical data from NIMH, SAMHSA, and SAMHSA N-MHSS 2014
State &CountyPsychiatric
Hospitals
369,969
193,436
140,355
117,084
111,135
100,615
90,572
72,096
63,76556,716
52,61243,85439,907

Total
psychiatricInpatient &Residential
Care
471,451
284,158
230,186
224,347
237,845
227,863
226,953
236,110221,216
177,460
180,543
160,257
170,200-51.2%-1.4%-21.8%-11.7%
6.2%-63.9%
-7.7%
-0.1%
-2.4%
-1.2%
1.5%
-2.3%

Due to the growth in the population in the United States since 1970, the decrease inpsychiatric bed capacity as a ratio of patients per 100,000 population (see Table 10) showed
Psychiatric Inpatient Capacity, August 201728

an even greater total capacity decline than the decline in the total number of patients in Table
8. From 1970 to 2014, the number of patients in psychiatric beds in specialty providers
declined from 236.8 patients per 100,000 population to 53.8 patients in beds per 100,000
population (a total reduction of 77 percent—an average annual drop of 3.3 percent per year).
Table 10: Trends over Time in Residents per 100,000 Population, Residents in Psychiatric inpatientsand Other 24-Hour Treatment Beds in Specialty Mental Health Organizations, 1970 to 2014

Year/ Setting

State &CountyPsychiatric
Hospitals

GeneralHospital with
PrivateSeparate
VA
Psychiatric
PsychiatricMedicalHospitals
Units
Centers
Rate per 100,000 population

1970
1975
1979
1983
1986
1988
1990
1994
1998
2000
2002
2010
2014

185.80
91.50
63.00
50.40
46.50
41.20
37.10
27.80
23.70
20.10
18.30
14.23
12.56

5.50
5.50
5.80
6.90
10.30
12.00
13.20
10.20
7.70
5.70
6.20
7.80
8.96

1970 to 1979
1979 to 1990
1990 to 2000
2000 to 20102010 to 20142010 to 2014

-66.1%-41.1%-45.8%-29.2%-11.7%-93.2%

5.5%
127.6%-56.8%
36.8%
14.9%
62.9%

8.90
8.90
8.60
13.80
14.40
14.30
15.70
13.80
13.80
9.70
9.90
10.51
9.90

26.00
15.10
13.30
8.70
10.20
8.00
7.10
7.00
5.30
2.90
2.90
1.82
2.21

Percent Change Over Time

-3.4%
82.6%
-38.2%
8.4%
-5.8%
11.3%

-48.8%-46.6%-59.2%-37.3%
21.4%-91.5%RTCs

Other(Inpatient &Residential
Treatment
beds)

Total
psychiatricInpatient &Residential
Care

6.80
7.70
8.20
6.80
9.70
9.50
11.40
11.40
10.80
10.70
12.40
13.48
13.52

3.80
5.70
5.00
9.90
8.50
8.30
8.50
20.90
20.90
13.70
13.00
4.17
6.43

236.80134.40103.90
96.50
99.60
93.30
93.00
91.10
82.20
62.80
62.70
52.01
53.58

20.6%
39.0%
-6.1%
26.0%
0.3%
98.8%

31.6%
70.0%
61.2%
-69.6%
54.4%
69.3%-56.1%-10.5%-32.5%-17.2%
3.0%-77.4%

Annualized Percent Change
1970 to 1979
-11.3%
0.6%
-0.4%
-7.2%
2.1%
3.1%
1979 to 1990
-4.7%
7.8%
5.6%
-5.5%
3.0%
4.9%
1990 to 2000
-5.9%
-8.1%
-4.7%
-8.6%
-0.6%
4.9%
2000 to 2010
-3.4%
3.2%
0.8%
-4.6%
2.3%
-11.2%
2010 to 2014
-3.1%
3.5%
-1.5%
5.0%
0.1%
-3.1%
-5.9%
1.1%
0.2%
-5.5%
1.6%
-5.9%
1970 to 2014
Source: Table created by NRI using historical data from NIMH, SAMHSA, and SAMHSA N-MHSS 2014

Psychiatric Inpatient Capacity, August 2017

-8.7%
-1.0%
-3.9%
-1.9%
0.7%
-3.3%

29

Figure 4: Number of Residents in Psychiatric Inpatient and Other 24-Hour Residential Treatment Beds at
End of Year, 1970 to 2014

State & County Psych
Hospitals

350,000

Private Psychiatric Hosp

300,000

General Hospital with
Separate Psych Units

250,000

VA Medical Centers

200,000

RTCs

150,000

Other (Inpatient &Residential Treatment beds)

100,000

2014

2012

2010

2008

2006

2004

2002

2000

1998

1996

1994

1992

1990

1988

1986

1984

1982

1980

1978

1976

1974

0

1972

50,0001970

Number of Residents in Inpatient and Other 24Hour Mental Health Beds, end of year

400,000

Year

Tables 9 and 10 and Figure 4 show that not all types of organizations experienced
changes in psychiatric bed inventory at the same rates or in the same direction. Whilestate and county psychiatric hospitals and VA Medical Centers both display long-term
reductions in inpatient census, other types of organizations providing specialized mental
health beds experienced much more complicated bed inventory patterns over time.

Trend in State and County Psychiatric Hospital Capacity
In 1970, state and county psychiatric hospitals provided 78 percent of the psychiatricinpatient and other 24-hour mental health residential treatment capacity. Since 1970, stateand county psychiatric hospital case load on a single day has decreased by over 330,000
patients. However, most of the decrease in state and county psychiatric hospitals beds
occurred over 30 years ago—during the 1970s, with a decrease of 229,600 patients
between 1970 and 1979, a reduction of 62 percent. The rate of downsizing of state andcounty psychiatric hospitals has drastically slowed in the last 15 years. From 2001 to
2010, state and county hospital census declined by 2.5 percent per year. From 2010 to2014, state and county hospital census declined by an even slower 2.4 percent per year.
It is important to note that the role of state psychiatric hospitals has changed greatly since1970. NIMH data from the 1970s shows that, in that era, state psychiatric hospitals hadlarge numbers of patients age 65 and older, and that many patients had diagnoses ofdementia or developmental/intellectual disorders (conditions not the focus of treatment instate psychiatric hospitals today). In 1970, patients age 65 and older—some of whom
had been hospitalized for decades—represented 29 percent (99,087) of the residents in
Psychiatric Inpatient Capacity, August 201730

state and county psychiatric hospitals.40 Elderly patients in 1970 represented over threetimes the 2014 capacity of state and county psychiatric hospitals. In 2014, the number ofpatients age 65 and older had dropped by over 96 percent from 1970; only 9 percent(3,630 residents in inpatient or other 24-hour residential treatment beds in state andcounty psychiatric hospitals were 65 and older.41
In the 1970s and previously, state and county psychiatric hospitals also provided beds for
substance use disorder and developmental disability patients—services that now are often
provided in other community-based settings outside of psychiatric hospitals. In 1971,
NIMH identified “alcohol disorders” as the second most frequent diagnosis for maleresidents in state and county psychiatric hospitals (second only to schizophrenia
disorders).42
NIMH data on admissions to state and county psychiatric hospitals in 1969 indicated that25.7 percent of admissions were for alcohol disorders and an additional 2.9 percent were
for drug disorders. In addition, 2.7 percent of admissions were for mental retardation and10.8 percent were for organic brain syndromes (58.1 percent of admissions for patients
65 and older were with diagnoses of organic brain syndrome).43 In total, 42.1 percent ofstate and county psychiatric hospital admissions in 1969 were for diagnoses not typicallyreasons for admission to state psychiatric hospitals today.
In 2014, many states restricted access to their state psychiatric hospitals to involuntary
patients or patients who have already had an initial psychiatric hospitalization at a general
hospital or private psychiatric hospital and, after their initial acute hospitalization, requirecontinuing inpatient treatment. The current mix of patients served in state psychiatrichospitals by legal status is very different from years ago. An NIMH Statistical Note withdata from 1972 found that 48.6 percent of inpatient admissions to state and county mental
hospitals were voluntary admissions.44

Trend in Private Psychiatric Hospital Capacity
On the last day of 2014, private psychiatric hospitals had the third highest number ofpsychiatric inpatients, with 28,461 patients. Since 1970, the number of residents inprivate psychiatric hospitals has increased by 179.6 percent (an average increase of 2.2
percent per year). Table 9 shows that the inpatient capacity of private psychiatrichospitals has fluctuated greatly since 1970.
From 1970 to 1990, the number of residents in private psychiatric inpatient beds
increased by 194 percent (from 10,963 patients to 32,268 patients), but during the 1990s
the number of patients in private psychiatric hospitals were drastically reduced; half of
40 Taub Carl A., State Trends in Resident Patients – State and County Mental Hospital Inpatient Services

1967-1973. NIMH Statistical Note 113 (February 1975).
41 2014 N-MHSS.
42 Redick Richard A., Utilization of Psychiatric Facilities By person Diagnosed with Depressive Disorders,
NIMH Statistical Note 103 (March 1974).
43 Taub Carl A., Diagnostic Distribution of Inpatient Admissions to State and County Mental Hospitals
1969, NIMH Statistical Note 49 (April 1971).
44 Meyer N., Legal Status of Inpatient Admissions to State and County Mental Hospitals, United States
1972. NIMH Statistical Note 105 (May 1974).

Psychiatric Inpatient Capacity, August 201731

the 1990 patient load was eliminated by 2000. However, since 2000, the number ofpatients in private psychiatric hospitals has again increased (up 77 percent since 2000).
Figure 5, below, focuses on the trend in private psychiatric hospitals, general hospitals,
and other mental health settings from 1970 to 2014 and shows how each of these three
types of organizations had a growth in psychiatric patient population during the 1980s,
experienced a reduction in capacity during the 1990s, and then experienced growth again
since 2000.

60,00050,00040,00030,00020,000Private Psychiatric Hosp

2014

2012

2010

2008

2006

2004

2002

2000

1998

1996

1994

1992

1990

1988

1986

1984

1982

1980

1978

1976

1974

0

1972

10,0001970

Number of Residents in Inpatient and Other 24Hour Mental Health Beds, end of year

Figure 5: Number of Residents in Psychiatric Inpatient and Other 24-Hour
Residential Treatment Beds at Private Psychiatric Hospitals, General Hospitals with
Separate Psychiatric Units, and Other Mental Health Providers at End of Year, 1970
to 2014Year

General Hospital with Separate Psych Units
Other Mental Health Provider Organizations (Inpatient & Residential Treatment beds)

Much of the growth of psychiatric inpatient capacity during the 1980s has been attributed
to states eliminating certificate-of- need (CON) laws that required review and approval
by state governments for hospitals to open or close beds.45 Dr. Jeffrey Geller, in one ofthe very few published histories of private psychiatric hospitals,46 found that, by the endof the 1980s, “states without certificate of need laws had an average 33 percent more forprofit psychiatric beds than did regulated states.”47

45 Frank R.G., & Garfield R.L., Managed Behavioral Health Care Carve-Outs: Past Performance andFuture Prospects, Annual Review of Public Health 28, 303-320 (2007).
46 Geller J.L., A History of Private Psychiatric Hospitals in the USA: From Start to Almost FinishedPsychiatric Quarterly 77:1 (March 2006), https://link.springer.com/article/10.1007%2Fs11126006-7959-5.
47 Ibid.

Psychiatric Inpatient Capacity, August 201732

After the rapid growth in private psychiatric bed capacity during the 1980s, there was a
rapid reduction during the 1990s. Dr. Geller describes the 1990s as the settings’ “nadir.”Geller identified several major reasons for the reduction in private psychiatric hospitals
during the 1990s, including a previous rate of expansion by several large hospital chainsthat led to a surplus of private psychiatric beds, which in turn led to financial losses due
to an inability to fill those beds.
In addition, Dr. Geller cites the following factors:
1. The widespread introduction of managed care in the early 1990s, with utilization
management that required approval of inpatient psychiatric stays, leading to large
reductions in insurance coverage for psychiatric inpatient stays.
2. A scandal involving several large private hospital chains recruiting patients,
which led to lawsuits and the closure of several for-profit private psychiatrichospital systems.
3. A focus on providing psychiatric care in the “least restrictive alternative” setting
during the 1990s which promoted the development of alternative service
modalities to avoid inpatient hospitalization. These alternatives included crisis
services and other non-hospital-based acute care and treatment services.
Somewhat surprisingly, however, since the start of the 21st Century, the inpatient
treatment capacity of private psychiatric hospitals has been steadily increasing. Potential
explanations for this growth include the adoption of mental health parity laws by manystates and the 2008 passage of the Federal Mental Health Parity and Addictions Equity
Act,48 the passage of the Affordable Care Act,49 the reduced capacity of state psychiatrichospitals that have continued to shrink in size and, in many states, an increasing focus on
using state psychiatric hospitals to serve the forensic population and/or the patient
population needing continuing treatment.

Trend in General Hospital Separate Psychiatric Unit Capacity
General hospitals with separate psychiatric units have followed a pattern similar to
private psychiatric hospitals, with major growth during the 1980s (doubling of capacityfrom 1980 to 1990), during the era of major state hospital downsizing, and then decreasedby 28.5 percent from 1990 to 2000. The use of managed care and utilization review

48 Public Law 104-204.
49 Public Law 111-148.

Psychiatric Inpatient Capacity, August 201733

during the 1990s is often cited as an explanation for the decrease in general hospital
psychiatric beds during the 1990s.50, 51, 52
From 2000 to 2001, the capacity of general hospitals with separate psychiatric units grewby 18 percent, but from 2010 to 2014, the capacity of general hospitals declined slightly(down 3.6 percent). There are multiple media reports of hospitals closing psychiatricunits due to the psychiatrist shortage because they cannot recruit and retain psychiatrists
to provide inpatient treatment.53
In his October 2014 article in Psychiatric Bulletin, psychiatrist Mark Russakoff described
the financial pressures on general hospital psychiatric units—that, despite their ability as
non-IMD facilities to bill Medicaid, they have lower profit margins than othermedical/surgical units. This has resulted in some general hospitals closing their
psychiatric units, even when there is demand for psychiatric beds.
In the past, a well-run psychiatric in-patient unit could be a modest profit centre.
The landscape has changed dramatically for general hospitals. The chief
financial officer will tell you that the psychiatric units do not perform as well as
the medical surgical units. The psychiatric unit occupies space where morelucrative medical surgical services, such as invasive cardiology and advanced
surgery patients, could be located. A number of hospitals have made the businessdecision to close their psychiatric units in favour of these more remunerative
services. These decisions are not simply evidence of greed. The profit margins ofmost general hospitals are razor thin, well below what Wall Street would accept
for a company. Hospitals need to generate money where they can, and that
includes consideration of the opportunity costs of low-performing units.54
Further research into reasons why general hospital psychiatric units have recently declined incapacity is needed, as many states have adopted policies promoting the use of general
hospitals to provide psychiatric services as an initial admission site for acute care. These
policies both take advantage of the ability of general hospitals to bill Medicaid for psychiatricinpatient care and promote the provision of acute care services closer to a patient’s home thanstate psychiatric hospitals that may be located miles away. In these states, the use of the state
psychiatric hospital is reserved for patients who require continuing inpatient care after an

50 Foley D.J., Manderscheid R.W., Atay J.E., Maedke J., Sussman J. & Cribbs S., Highlights of Organized

Mental Health Services in 2002 and Major National and State Trends. Mental Health, United States,200-236 (2004).
51 Mechanic D., McAlpine D.D. & Rochefort D.A., Mental Health and Social Policy: Beyond Managed
Care, Pearson Higher Ed (2013).
52 Dickey B., Norton E.C., Normand S.L., Fisher W.H. & Azeni H., Managed Mental Health Experience in
Massachusetts. Paying for Services: Capitation and Managed Behavioral Health Care, David Mechanic(editor), pp. 115-124, San Francisco, Jossey-Bass (1998).
53 Parks J. The Psychiatric Shortage: Causes and Solutions (2017),
https://www.thenationalcouncil.org/wp-content/uploads/2017/03/Psychiatric-Shortage_NationalCouncil-.pdf.
54 Russakoff L.M., Private In-Patient Psychiatry in the USA, Psychiatric Bulletin 38(5), 230-235(October 2014), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4180988/.

Psychiatric Inpatient Capacity, August 201734

initial acute treatment in the general hospital, and/or for forensic patients who require
treatment in a specialized secure psychiatric unit at a state hospital.
Data has not been historically available on the use of general hospital scatter beds toserve mental health patients in a non-psychiatric unit of the hospital. However, a reporton all general hospital patients (both in specialty psychiatric units and scatter beds)
published by the Federal Agency for Healthcare Research and Quality (AHRQ) in June2017 found that “The number of hospital stays for mental health/substance use increased
from 2005 to 2014, whereas the number of surgical stays decreased. All otherhospitalization types decreased less than 10 percent.”55 The AHRQ report found thatgeneral hospital stays for mental health and substance use increased by 12.2 percent
between 2005 and 2014.

Trend in VA Medical Center Psychiatric Capacity
In 1970, VA Medical Centers were the second largest system providing psychiatricinpatient and other 24-hour residential treatment, treating more than 51,979 patients on asingle day (11 percent of total capacity in 1970). Since the 1970s, over 86 percent of thepsychiatric bed capacity of VA Medical Centers has been eliminated due to a substantial
shift in the VA system to the provision of community-based mental health care. From2010 to 2014, the VA increased its inpatient and other 24-hour treatment capacity by 25
percent, to a total of 7,010 patients. In 2014, mental health patients receiving inpatient
services in VA Medical Centers were split between inpatient beds (45 percent of patients)and other 24-hour residential treatment beds (55 percent of patients). In addition to
inpatient services, the VA in 2014 operated an extensive array of community-based
services and supports (including intensive programs based on the ACT model) to
minimize the need for psychiatric inpatient care.
VA officials indicate the treatment focus of VA Medical Center psychiatric units haschanged in recent years. The major diagnoses of patients being served in VA Medical
Centers has shifted from major mental illnesses such as schizophrenia and bipolar
disorders to post-traumatic stress disorders (PTSD), traumatic brain injuries (TBI), andsubstance abuse disorders.
In 2014, the VA healthcare system served almost 5.7 million veterans, of whom 34
percent were identified as potentially having a mental illness and 1.43 million (25percent) of those receiving services had a confirmed mental illness. Veterans receiving
outpatient mental health care totaled 1,533,391, while 62,272 veterans spent at least onenight in a psychiatric inpatient unit operated by the VA and an additional 34,381 veteransspent at least one night in a VA Medical Center-operated residential mental healthtreatment bed (2.2 percent of veterans with a confirmed mental health diagnosis).56

55 McDermott K.W. (IBM Watson Health), Elixhauser A. (AHRQ) & Sun R. (AHRQ), Trends in Hospital

Inpatient Stays in the United States, 2005–2014, HCUP Statistical Brief #225, Agency for Healthcare
Research and Quality, Rockville, MD June 2017,. www.hcup-us.ahrq.gov/reports/statbriefs/sb225Inpatient-US-Stays-Trends.pdf.
56 Greenberg G. & Hoff R., 2014 Mental Health Fact Sheet: National, VISN, and VAMC Tables – All
Veterans, Northeast Program Evaluation Center, West Haven, CT (2010‐Present).

Psychiatric Inpatient Capacity, August 201735

Trend in Residential Treatment Center Psychiatric Capacity
An RTC is a 24-hour institution that provides mental health and/or substance abuse
services. RTCs are licensed with less intensive staffing requirements than inpatient units,
but still provide mental health treatment and other therapeutic services, as well as support
services. RTCs for children may also include educational supports, including classroom
instruction to permit children and adolescents to continue their educational progress
while receiving mental health services.
The number of mental health patients in beds in RTCs has grown faster than at any othertype of inpatient site, with an increase of over 218 percent from 1970 to 2014. In 2014,
over 25 percent of all patients in an inpatient or other 24-hour residential treatment bed
were in an RTC, up from 3 percent in 1970. Nationally, there were 58 RTCs providing
inpatient care and 2,206 RTCs providing other 24-hour residential treatment to
individuals with mental illness. A total of 41,079 patients were in an RTC in 2014,
making RTCs the largest specialty mental health organization type providing inpatientand other 24-hour residential treatment. As Table 7 shows, RTCs are the only setting
providing inpatient and other 24-hour residential treatment that had an increase incapacity over each of the decades from 1970 to 2014.

Trend in the Capacity of Other Specialty Mental HealthOrganizations
Other specialty mental health organizations, including community mental health centers,
multi-service mental health programs, and other licensed mental health providers offer
both inpatient and other 24-hour residential treatment beds. The bed capacity of theseother specialty providers grew substantially from the 1970s through the 1980s. Theircapacity as a group peaked in 1996, with an increase of over six-fold from 1970 to 1996.
However, since 1996, the bed capacity in these other specialty providers has decreased by
63 percent. The net change from 1970 to 2014 shows an increase of 171 percent (growthfrom 7,526 patients in 1970 to 20,439 patients in 2014).

Psychiatric Inpatient Capacity, August 201736

APPENDIX A: Variation in Psychiatric Inpatient andOther 24-Hour Capacity by State: 2014
There is considerable variation across the states in their psychiatric inpatient and other24-hour residential mental health treatment capacity. The 2014 N-MHSS provides stateby-state numbers of total beds offering inpatient or other 24-hour residential treatment.
States vary from as few as 353 beds in North Dakota to 17,908 beds in New York.
On average, inpatient beds were 58 percent of the total beds and residential treatment
beds were 42 percent of beds. States varied from a mix of 20 percent of psychiatric beds
being inpatient and 80 percent other residential beds (South Dakota), to a high of 90
percent of beds being inpatient beds and 10 percent residential treatment beds in Nevada.
To adjust for the variation in the size of state populations, the authors of this paper
calculated the ratio of beds per 100,000 state population in Table 9 and Figure 6, which
follow.

Figure 6: Psychiatric Beds (Inpatient and Other 24-Hour Residential Treatment, per 100,000 State Population,
2014

Psychiatric Beds per 100,000
Population
26 to 50 (13)50 to 67 (14)67 to 85 (12)85 to 135 (12)Psychiatric Inpatient Capacity, August 201737

Table 9: Number of Beds in 24-Hour Hospital Inpatient and Residential Treatment Settings, byState/Territory: Number and Rate per 100,000 Population, April 2014
State
Number of Beds (inpatient & Residential)
U.S. Total
182,516
Alabama
3,223
Alaska861
Arizona
3,278
Arkansas
2,636
California
14,553
Colorado
2,292
Connecticut
2,657
Delaware560
District of Columbia
739
Florida10,921
Georgia
3,149
Hawaii
1,130
Idaho
955
Illinois
6,576
Indiana
4,974
Iowa
2,031
Kansas3,877
Kentucky
2,825Louisiana
2,330
Maine
1,218
Maryland
4,010
Massachusetts
4,887
Michigan
4,152
Minnesota
2,917
Mississippi
2,787
Missouri
5,389
Montana
1,057
Nebraska
1,410
Nevada739
New Hampshire
1,022
New Jersey
5,412
New Mexico
1,312
New York
17,908
North Carolina
4,195North Dakota
353
Ohio
5,340
Oklahoma
2,558
Oregon2,717
Pennsylvania
8,940
Rhode Island
895
South Carolina
2,356South Dakota
684
Tennessee
4,112
Texas
9,387
Utah
2,309
Vermont
737
Virginia
4,220
Washington
3,114
West Virginia
1,524
Wisconsin
2,812
Wyoming
523
U.S. territories
1,953
Table created by NRI from N-MHSS Table 4.7

Total Beds per 100,000 population
56.8
66.7
120.5
48.8
89.1
37.7
43.1
74.0
60.1
112.7
55.1
31.4
82.3
58.6
51.2
75.4
65.4
134.6
64.3
50.3
91.7
67.4
72.5
41.9
53.5
93.6
89.1
103.7
75.2
26.1
77.1
60.6
63.3
90.8
42.6
48.2
46.1
66.3
68.5
70.0
85.1
49.2
80.5
63.0
35.0
78.6
117.7
51.4
44.4
82.4
48.9
90.0
54.3

Table 10 shows that the highest ratio of total mental health beds per 100,000 population (bothinpatient and other-24-hour residential treatment) was in Kansas (134.6 beds per 100,000
population) and Alaska (120.5 beds per 100,000 population). The lowest ratio was in Nevada(26.1 beds per 100,000 population) and in Georgia (31.4 beds per 100,000 population).

Inpatient Psychiatric Beds by State
Table 10 and Figure 7, below, show information from the 2014 SAMHSA N-MHSS for
psychiatric inpatient beds and patients using per 100,000 state population ratios.
Table 10: Number of Organizations Providing Psychiatric Inpatient Beds, Number of Inpatients and Rateper 100,000 Population, April 2014
State
U.S. Total
Alabama
AlaskaArizona
Arkansas
California
Colorado
Connecticut
DelawareDistrict of Columbia
FloridaGeorgia
Hawaii
Idaho
Illinois
Indiana
Iowa
KansasKentuckyLouisiana
Maine
Maryland
Massachusetts
MichiganMinnesota
Mississippi
MissouriMontana
Nebraska
NevadaNew Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
OregonPennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington

Number of
Inpatient
2,032
Facilities
35
7
33
33
121
21
29
5
6
133
40
10
15
84
64
31
23
32
56
13
36
66
58
38
38
57
10
15
12
9
54
10
166
51
7
79
44
18
106
8
26
4
44
95
15
6
49
30

Inpatient
Clients
101,351
1,116
243
1,398
1,166
13,318
1,222
1,693
393
450
5,950
1,407
321
462
3,965
3,385
671
993
1,116
1,971
411
2,060
2,405
2,441
1,445
1,352
3,062
886
632
726
308
3,497
591
9,544
2,402
116
2,447
1,454
888
4,976
485
1,274
105
1,773
5,691
580
154
2,081
1,843

Psychiatric Inpatient Capacity, August 2017

Inpatient clients
per 100,000
31.6
population
23.1
34.0
20.8
39.4
34.5
23.0
47.2
42.2
68.6
30.0
14.0
23.4
28.3
30.8
51.3
21.6
34.5
25.4
42.6
30.9
34.6
35.7
24.6
26.5
45.4
50.6
86.9
33.7
25.7
23.2
39.2
28.5
48.4
24.4
15.8
21.1
37.7
22.4
38.9
46.1
26.6
12.4
27.2
21.2
19.7
24.6
25.3
26.3

Inpatient Beds
106,236
1,442
278
1,651
1,344
9,086
1,217
1,530
430
490
6,745
1,918
381
580
4,361
2,818
814
1,156
1,665
2,204
537
2,293
2,463
2,652
1,347
1,651
3,606
390
797
663
398
3,856
787
10,906
2,651
199
2,938
1,747
964
5,650
545
1,440
136
2,239
6,310
750
169
2,570
1,922

Inpatient Beds
per 100,000
33.1
population
29.8
38.9
24.6
45.4
23.5
22.9
42.6
46.2
74.8
34.0
19.1
27.8
35.6
33.9
42.7
26.2
40.1
37.9
47.6
40.4
38.6
36.5
26.8
24.7
55.4
59.6
38.2
42.5
23.5
30.0
43.2
38.0
55.3
26.9
27.2
25.4
45.3
24.3
44.2
51.8
30.1
16.0
34.3
23.5
25.5
27.0
31.3
27.4

39

Number ofInpatient
State
Inpatient 18
Clients818
West Virginia
Facilities
Wisconsin
34
1,513
Wyoming
8
187
U.S. territories
30
1,964
Table created by NRI from SAMHSA 2014 N-MHSS

Inpatient clients
per 100,000
44.2
population
26.3
32.2
54.6

Inpatient Beds
per 100,000
50.3
population
21.2
36.8
33.0

Inpatient Beds
931
1,218
214
1,187

States varied from a high of 10,906 psychiatric inpatient beds in New York and 9,086
beds in California to a low of 105 psychiatric inpatient beds in South Dakota and 169
beds in Vermont.
When calculated as a ratio of psychiatric inpatient beds per 100,000 state population,states varied from a high of 74.8 beds per 100,000 population in the District of Columbia
and 59.6 beds per 100,000 population in Missouri to a low of 16 beds per 100,000 in
South Dakota and 19.1 beds per 100,000 in Georgia.
Figure 7: Psychiatric Inpatient Beds per 100,000 State Population, 2014

Psychiatric Inpatient Beds
per 100,000 Population
16.0 to 26.5
26.5 to 34.3
34.3 to 42.7
42.7 to 94.4

Psychiatric Inpatient Capacity, August 2017

(13)
(13)
(12)
(13)

40

Figure 8: Mental Health Other 24-Hour Residential Treatment Beds per 100,000 State
Population, 201424-hour Residential Treatment Beds
per 100,000 Population
2.7 to 20.2
20.2 to 28.8
28.8 to 38.8
38.8 to 94.4

(13)
(13)
(12)
(13)

Other Mental Health 24-hour Residential Treatment Beds by
State
Table 11 and Figure 8, which follow, show the number of organizations in each stateproviding mental health residential treatment, the number of patients receiving mental
health residential treatment, the number of residential treatment beds, and the ratio of
residential treatment beds per 100,000 state population.
In 2014, states varied from Louisiana and Nevada having a low of four organizations
offering residential treatment services for mental health to a high of 184 organizations in
California and 180 in New York.
Other 24-hour residential treatment beds for mental health varied from a low of 76 beds
in Nevada and 126 beds in Louisiana to a high of 7,002 beds in New York and 5,467 bedsin California. The ratio of other 24-hour residential treatment beds per 100,000 state
population varied from a low of 2.7 beds per 100,000 in Maine and Nevada to a high of
94.4 beds per 100,000 in Kansas and 90.7 in Vermont.

Psychiatric Inpatient Capacity, August 201741

Table 11: Number of Organizations Providing Mental Health Other 24-Hour Residential Treatment Beds,
Number of Patients and Rate per 100,000 Population, April 2014

State
U.S. Total
Alabama
AlaskaArizona
Arkansas
California
Colorado
Connecticut
DelawareDistrict of Columbia
FloridaGeorgia
Hawaii
Idaho
Illinois
Indiana
Iowa
KansasKentuckyLouisiana
Maine
Maryland
Massachusetts
MichiganMinnesota
Mississippi
MissouriMontana
Nebraska
NevadaNew Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
OregonPennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington

Number of
Residential
Facilities
2,573
60
27
114
36
184
56
50
14
^
115
30
15
9
115
74
33
28
39
4
62
62
90
34
49
24
41
24
25
4
24
40
15
180
158
12
101
22
73
102
24
30
12
57
57
27
44
48
41

Residential
Patients
68,849
1,613
534
1,478
1,249
4,824
1,008
1,099
124
300
3,988
1,197
386
251
2,538
1,933
1,023
1,635
1,127
125
564
1,831
2,257
1,444
1,201
1,139
1,663
787
570
64
493
1,585
472
6,517
1,312
187
2,384
694
1,613
2,852
368
722
533
1,649
2,750
1,112
545
1,327
1,272

Residential Patients
per 100,000
population
21.4
33.4
74.7
22.0
42.2
12.5
18.9
30.6
13.3
45.8
20.1
11.9
28.1
15.4
19.7
29.3
32.9
56.7
25.6
2.7
42.4
30.8
33.5
14.6
22.0
38.2
27.5
77.2
30.4
2.3
37.2
17.8
22.8
33.0
13.3
25.5
20.6
18.0
40.7
22.3
35.0
15.1
62.7
25.3
10.2
37.9
87.1
16.2
18.1

Psychiatric Inpatient Capacity, August 2017

Residential
Beds
76,280
1,781
583
1,627
1,292
5,467
1,075
1,127
130
249
4,176
1,231
749
375
2,215
2,156
1,217
2,721
1,160
126
681
1,717
2,424
1,500
1,570
1,136
1,783
667
613
76
624
1,556
525
7,002
1,544
154
2,402
811
1,753
3,290
350
916
548
1,873
3,077
1,559
568
1,650
1,192

Residential Beds
per 100,000
population
23.7
36.8
81.6
24.2
43.7
14.1
20.2
31.4
14.0
38.0
21.1
12.3
54.6
23.0
17.2
32.7
39.2
94.4
26.4
2.7
51.3
28.9
36.0
15.1
28.8
38.1
29.5
65.4
32.7
2.7
47.1
17.4
25.3
35.5
15.7
21.0
20.7
21.0
44.2
25.7
33.3
19.1
64.5
28.7
11.5
53.1
90.7
20.1
17.0

42

Number ofResidential
Residential
State
Facilities
Patients
West Virginia
17
360
Wisconsin
29
1,071
Wyoming
11
276
U.S. territories
30
803
Table developed by NRI from N-MHSS Table 4.8

Residential Patients
per 100,000
population
19.5
18.6
47.5
22.3

Psychiatric Inpatient Capacity, August 2017

Residential
Beds
593
1,594
309
766

Residential Beds
per 100,000
population
32.1
27.7
53.2
21.3

43

Change in Psychiatric Inpatient Capacity over time, by State, 1982 to 2010
States vary widely in how the number of residents in inpatient and other 24-hour residential treatment has changed over the past 20
years. Table 12, below, shows information by state for the years where state-level data are available (1982 to 2010).
Table 12: Number of Residents in Inpatient and Other 24-Hour Residential Treatment Beds on the Last Day of Year, 1982 and 2010

State
Alabama
AlaskaArizona
Arkansas
California
Colorado
Connecticut
DelawareDistrict of Columbia
FloridaGeorgia
Hawaii
Idaho
Illinois
Indiana
Iowa
KansasKentuckyLouisiana
Maine
Maryland
Massachusetts
MichiganMinnesota
Mississippi

Residents in State and County Psychiatric
Hospitals

Residents in All other Specialty Psychiatric
Organizations

1982
2,209
188
350
386
6,699
1,007
2,431
620
2,090
5,259
4,810
232
262
4,064
3,151
1,107
1,339
897
2,255
669
3,647
2,950
4,602
2,334
2,122

1982
1,839
45
1,420
973
10,069
1,579
2,461
202
605
3,826
2,466
103
126
4,794
1,787
1,343
1,608
1,483
1,059
847
1,969
4,796
4,056
2,534
870

2010
1,381
64
283
221
3,772
502
622
210
314
2,169
1,082
222
128
1,392
1,022
210
732
388
996
142
1,081
399
822
232
1,110

Change
-828
-124
-67
-165
-2,927-505-1,809-410-1,776-3,090-3,728-10-134-2,672-2,129
-897
-607
-509
-1,259-527-2,566-2,551-3,780-2,102-1,012% Change
-37%
-66%
-19%
-43%
-44%
-50%
-74%
-66%
-85%
-59%
-78%
-4%
-51%
-66%
-68%
-81%
-45%
-57%
-56%
-79%
-70%
-86%
-82%
-90%
-48%

2010
2,167
412
1,772
1,361
7,956
1,089
2,464
410
229
7,266
3,217
225
459
5,608
2,952
1,781
751
2,767
1,138
758
2,369
4,610
3,196
2,162
1,708

Change
328
367
352
388
-2,113
-490
3
208
-376
3,440
751
122
333
814
1,165
438
-857
1,284
79
-89
400
-186
-860
-372
838

% Change
18%
816%
25%
40%
-21%
-31%
0%
103%
-62%
90%
30%
118%
264%
17%
65%
33%
-53%
87%
7%
-11%
20%
-4%
-21%
-15%
96%

Residents in Any Psychiatric Inpatient and othermental health 24-hour Treatment Bed
1980
4,048
233
1,770
1,359
16,768
2,586
4,892
822
2,695
9,085
7,276
335
388
8,858
4,938
2,450
2,947
2,380
3,314
1,516
5,616
7,746
8,658
4,868
2,992

2010
3,548
476
2,055
1,582
11,728
1,591
3,086
620
543
9,435
4,299
447
587
7,000
3,974
1,991
1,483
3,155
2,134
900
3,450
5,009
4,018
2,394
2,818

Change
-500
243
285
223
-5,040-995-1,806-202-2,152350-2,977112
199-1,858-964-459-1,464775-1,180-616-2,166-2,737-4,640-2,474-174% Change
-12%
104%
16%
16%
-30%
-38%
-37%
-25%
-80%
4%
-41%
33%
51%
-21%
-20%
-19%
-50%
33%
-36%
-41%
-39%
-35%
-54%
-51%
-6%

Residents in State and County Psychiatric
Hospitals
Missouri
2,455
1,360
-1,095-45%Montana
351
155
-196
-56%
Nebraska
738
434
-304
-41%
Nevada
133
300
167
126%
New Hampshire
639
150
-489
-77%
New Jersey
5,347
2,604
-2,743-51%
New Mexico
212
85
-127
-60%
New York
26,5203,959-22,561-85%
North Carolina
3,714
817
-2,897-78%
North Dakota
765
305
-460
-60%
Ohio
5,551
1,032
-4,519-81%
Oklahoma
1,728
397-1,331-77%
Oregon
1,156
645
-511
-44%
Pennsylvania
10,8981,841-9,057-83%
Rhode Island
695
112
-583
-84%
South Carolina
3,556
443
-3,113-88%
South Dakota
476
198
-278
-58%
Tennessee
2,581
493-2,088
-81%
Texas
6,754
3,502
-3,252
-48%
Utah
323
409
86
27%
Vermont
269
50
-219
-81%
Virginia
5,066
1,561
-3,505-69%
Washington
1,208
1,955
747
62%
West Virginia
1,643
248
-1,395-85%
Wisconsin
1,332
527
-805
-60%
Wyoming
350
122
-228
-65%
Grand Total
140,140
43,200-96,940-69%
Average
2,748
847-1,901-56%
Median
1,643
443
-897
-65%
Minimum
133
50-22,561-90%
Maximum
26,520
3,959
747
126%
Source: SAMHSA 1982 IMHO and 2010 N-MHSS

Psychiatric Inpatient Capacity, August 2017

Residents in All other Specialty Psychiatric
Organizations
2,298
3,134
836
36%
204
584
380
186%
426
817
391
92%
151
314
163
108%
254
778
524
206%
2,443
2,856
413
17%
390
804
414
106%
10,561
10,560
-1
0%
2,274
1,649
-625
-27%
137
470
333
243%
4,392
4,021
-371
-8%
888
1,629
741
83%
862
1,542
680
79%
5,782
7,244
1,462
25%
384
706
322
84%
520
1,152
632
122%
485
834
349
72%
1,438
1,808
370
26%
5,791
4,561
-1,230
-21%
609
1,546
937
154%
333
737
404
121%
2,840
2,716
-124
-4%
1,169
2,459
1,290
110%
536
1,172
636
119%
2,844
1,571
-1,273
-45%
262
505
243
93%
101,133
114,996
13,863
14%
1,983
2,255
272
70%
1,343
1,629
352
36%
45
225
-2,113-62%
10,561
10,560
3,440
816%

45

Residents in Any Psychiatric Inpatient and othermental health 24-hour Treatment Bed
4,753
4,494
-259
-5%
555
739
184
33%
1,164
1,251
87
7%
284
614
330
116%
893
928
35
4%
7,790
5,460
-2,330
-30%
602
889
287
48%
37,081
14,519-22,562
-61%
5,988
2,466
-3,522
-59%
902
775
-127
-14%
9,943
5,053
-4,890
-49%
2,616
2,026
-590
-23%
2,018
2,187
169
8%
16,6809,085-7,595
-46%
1,079
818
-261
-24%
4,076
1,595
-2,481
-61%
961
1,032
71
7%
4,019
2,301
-1,718-43%
12,545
8,063-4,482
-36%
932
1,955
1,023
110%
602
787
185
31%
7,906
4,277
-3,629
-46%
2,377
4,414
2,037
86%
2,179
1,420
-759
-35%
4,176
2,098
-2,078
-50%
612
627
15
2%
241,273
160,257-81,016
-34%
4,731
3,102
-1,629
-10%
2,695
2,098
-590
-23%
233
447
-22,562-80%
37,081
14,5192,037
116%

From 1982 to 2010, nationally there was a 34 percent decrease in mental health residents
in inpatient and other 24-hour residential treatment beds, but there was a major difference
between state and county hospitals and other types of mental health organizations.
During this time period, there was a 69 percent decrease in the number of residents instate and county psychiatric hospitals, while all other mental health and other 24-hourresidential treatment organizations had a 14 percent increase.
From 1982 to 2010, the average state had a 56 percent decrease in residents in state andcounty psychiatric hospitals, but across states this varied from an increase of 126 percent
in Nevada (which built a new state hospital in Las Vegas to meet the needs of growing
population in that city), to a decrease of 90 percent in Minnesota (which completed amajor reorganization of their state hospital system that involved closing large institutions
and opening seven 16-bed acute inpatient programs around the state).
Figure 9 shows that Eastern states experienced the largest decrease in patients in inpatientand other 24-hour residential treatment from 1982 to 2010, while mountain states andAlaska experienced the largest increase in resident patients.

Figure 9: Percent Change in Total Mental Health Residents in Inpatient and Other 24-Hour Treatment Beds,
1982 to 2014

Percent Change in MH Residents
All Inpatient and Other 24-Hour Setting s
Increased 0% to 40%(12)Increased 40% to 126% (6)Decreased 1% to 23%(8)
Decreased 23% to 39% (11)Decreased over 39%(14)

APPENDIX B: Focus on Care in State and County
Psychiatric Hospitals
Public psychiatric hospitals have been providing services to individuals with serious
mental illness since before the founding of the United States, with the Colony of Virginia
opening what is now Eastern State Hospital in 1773. For most of American history, state
psychiatric hospitals were the primary source of psychiatric inpatient care in the U.S. andas a result, much more historical information exists about their services and clientele.
Dr. Jeffrey Geller, in his history of private psychiatric hospitals, reports data on thenumber of patients in public psychiatric hospitals and private psychiatric hospitals datingback to 1922 (see Table 13). In 1922, public hospitals (largely state psychiatric hospitals)
were serving 95.9 percent of all patients in mental hospitals. While the percentage ofpatients in state hospitals has steadily declined since then, Geller found that, even in
1969, 75 percent of patients were in public psychiatric hospitals. In contrast, only 37
percent of psychiatric inpatients were in state and county psychiatric hospitals in the 2014
SAMHSA’s N-MHSS.
Table 13: Patients in Residence in Mental Hospitals (Year End) 1922-1969, from Geller, 2006 57
Public hospitals b
Year
1922
1934
1938
1942
1946
1948
1950
1953
1954
1955
1956
1957
1960
1962
1965
1969

No. ofPatients
256,683
375,324
420,553453,806
468,711488,740
512,504
545,045553,979
558,922551,390548,626
535,540
515,540
475,202369,969

Percentof Total
95.9
93.0
91.9
90.9
88.6
87.8
87.4
87.2
87.4
87.5
87.2
87.2
86.6
86.1
85.1
75.0

Private hospitals
No. ofPatients
9,231
10,301
10,831
11,784
12,301
13,095
15,463
15,94915,771
16,46815,77315,013
15,645
15,833
14,614
10,963

Percent of
Total
3.4
2.6
2.4
2.4
2.3
2.4
2.6
2.8
2.7
2.8
2.7
2.4
2.5
2.6
2.6
2.4

a 1920’s–1940’s: U.S. Department of Commerce 1940’s–1960’s: NIMH.
b Excludes Veterans Hospitals

Until the passage of the Community Mental Health Act in 1963, community mental
health programs had been initiated in a few states, but in most states, “SMHA” meant“state hospital.” The vast majority of state expenditures and services for individuals withmental illness was devoted to state psychiatric hospitals. Similarly, data collection on
public mental health systems was largely focused on measuring care in state hospitals.

57 Geller, 2006.

Psychiatric Inpatient Capacity, August 201747

Efforts to recreate the functions of state hospitals in community-based settings has been thecornerstone of public mental health policy for more than 50 years. However, these efforts
have been only partially successful, and state hospitals, while diminished in number andbed capacity, retain a significant niche in the larger mental health system.58, 59
In 2016, there were 188 state psychiatric hospitals that served 40,845 patients on the firstday of the year and had 109,269 admissions during the year. Table 14 shows that statesvaried from having as few as one state hospital (in 16 states) to as many as 25 in New
York. The number of residents in state psychiatric hospitals ranged from a low of 22
patients in Vermont to a high of 6,663 patients in California. Residents per 100,000 state
population ranged from a low ratio of 2.5 per 100,000 population in New Mexico to ahigh ratio of 54.2 patients in Mississippi.
It is important to understand that the functions and populations being served in state
psychiatric hospitals today are very different from those of 50 years ago, when statehospitals were much larger, but comprehensive recovery-oriented community services
were not readily available and evidence-based practices such as ACT, Supported
Employment, Supportive Housing, Coordinated Specialty Care for First EpisodePsychosis, Crisis Intervention Teams, etc., had not been developed or widely
implemented.
In 2016, more than 80 percent of state psychiatric hospitals were accredited by the Joint
Commission and the hospitals that were not accredited tended to be stand-alone forensic
psychiatric hospitals. CMS-certified hospitals totaled 138. This was very different fromthe 1960s, when only 33 percent (97 out of 292 state psychiatric hospitals in 1966) wereaccredited.60

Number of State Hospitals, Residents, Admissions, andForensic Focus: 2016
Table 14 shows that many states now reserve their state hospitals for particular service
client groups or for long- or short-term care. Twenty-two states report they no longer
provide any inpatient services to children and six states limit their children’s inpatientcare in state psychiatric hospitals to short-term acute services.

58 Fisher W.H., Geller J.L., Pandiani, J. Assessing the Role of State Psychiatric Hospitals inContemporary Mental Health Systems, Health Affairs 28:676-684 (2009).
59 Fisher W.H., Geller J.L., McMannus D.L., Same Problem, Different Century: Issues in Recreating the
Functions of State Psychiatric Hospitals in Community-Based Settings, Fifty Years After
Deinstitutionalization: Mental Illness in Contemporary Communities. Advances in Medical Sociology, 17,
3-25, Perry, B.L. (ed.), Emerald Publishing LTD (2016).
60 2016 accreditation status from NRI State Profiles, 1966 data from NASMHPD Study #35,
“Accreditation of Public Institutions for the Mentally Ill and Mentally Retarded, Feb 2, 1966.

Psychiatric Inpatient Capacity, August 201748

Table 14: Number of State Psychiatric Hospitals, Residents at End of Year, Admissions, Forensic Population, and Intended Use, 2016

Admissions
per 100,000
Pop (2016)

Forensic
Percent of
Admissions(FY 2014)

Forensic
Percent ofResidents(end of
FY2014)

Children &Adolescents

Adults/Elderly

495

10.2

14.1%

42.7%

Acute & Long

Acute & Long

Acute & Long

1,432

193.0

0.3%

15.5%

Acute

Acute & Long

Acute & Long

74

1.1

62.0%

50.5%

Not Used

Not Used

Not Used

2,988,248

613

20.5

50.0%

59.0%

Acute & Long

Acute & Long

Acute & Long

39,250,017

3,899

9.9

NR

92.0%

NR

NR

NR

5,540,545

1,112

20.1

54.5%

60.8%

Acute & Long

Acute & Long

Acute & Long

14.7
13.9

3,576,452
952,065

839
368

23.5
38.7

35.1%
100.0%

35.6%
100.0%

Acute & Long
Not Used

Acute & Long
Acute & Long

Acute & Long
Acute & Long

275

40.4

681,170

411

60.3

5.0%

32.0%

Not Used

Long Term

Acute & Long

7

2,657

12.9

20,612,439

2,516

12.2

66.0%

69.0%

Not Used

Long Term

Acute & Long

5

991

9.6

10,310,371

3,319

32.2

8.2%

69.9%

Not Used

Acute & Long

Acute & Long

Hawaii

1

115

8.1

1,428,557

549

38.4

95.0%

88.0%

Not Used

Acute & Long

Acute & Long

Idaho

2

142

8.4

1,683,140

1,038

61.7

8.3%

9.0%

Intermediate

Acute & Long

Acute & Long

Illinois

7

1,261

9.9

12,801,539

5,254

41.0

10.2%

0.4%

Not Used

Acute & Long

Acute & Long

Indiana

6

728

11.0

6,633,053

408

6.2

23.9%

14.1%

Long TermLong Term

Acute & Long

Iowa

3

81

2.6

3,134,693

593

18.9

NR

1.0%

NR

NR

NR

Kansas

2

542

18.6

2,907,289

2,407

82.8

9.8%

23.6%

Not Used

Acute & Long

Acute & Long

Kentucky

3

400

9.0

4,436,974

8,568

193.1

8.2%

12.1%

Not Used

Acute

Acute & LongLouisiana

2

604

12.9

4,681,666

999

21.3

25.2%

75.0%

Not Used

Acute & Long

Acute & Long

Maine

2

115

8.6

1,331,479

376

28.2

54.0%

53.0%

NR

Acute & Long

Acute & Long

Maryland

5

982

16.3

6,016,447

783

13.0

75.5%

75.3%

Acute & Long

Acute & Long

Acute & Long

Massachusetts

2

571

8.4

6,811,779

1,085

15.9

60.0%

26.0%

Intermediate

Acute & Long

Acute & Long

Michigan

5

414

4.2

9,928,300

687

6.9

37.0%

39.0%

Acute & Long

Acute & Long

Acute & Long

Minnesota

8

204

3.7

5,519,952

1,245

22.6

0.2%

2.2%

Acute

Acute & Long

Acute & Long

Mississippi

4

1,621

54.2

2,988,726

1,812

60.6

1.2%

1.0%

Acute

Acute

NR

Missouri

6

1,133

18.6

6,093,000

590

9.7

43.7%

43.0%

Acute & Long

Acute & Long

Acute & Long

Montana

1

237

22.7

1,042,520

768

73.7

29.0%

25.0%

Not Used

Acute & Long

Acute & Long

Nebraska

4

302

15.8

1,907,116

212

11.1

18.0%

22.0%

Not Used

Acute & Long

Acute & Long

Nevada

4

223

7.6

2,940,058

3,615

123.0

4.0%

7.0%

Not Used

Acute

Acute & Long

Numberof State
Hospitals(2015)

Number of
Residents(Start of2016)

Residents
per 100,000
population(2016)State
Population:
2016

Alabama

3

604

12.4

4,863,300

Alaska1

63

8.5

741,894

Arizona

1

215

3.1

6,931,071

Arkansas

1

204

6.8

California

5

6,663

17.0

Colorado

2

494

8.9

Connecticut
DelawareDistrict ofColumbia

4
1

527
132

1

FloridaGeorgia

State

State
Hospital
Admissions(2016)

Hospitals are used for Short or Long-Term Care
Forensic
Patients

Number ofResidents(Start of2016)

Residents
per 100,000
population(2016)

Admissions
per 100,000
Pop (2016)

Forensic
Percent of
Admissions(FY 2014)

Hospitals are used for Short or Long-Term Care

State
New Hampshire

1

143

10.7

1,334,795

1,930

144.6

0.0%

0.0%

New Jersey

4

1,599

17.9

8,944,469

2,065

23.1

4.1%

11.4%

New Mexico

1

53

2.5

2,081,015

579

27.8

15.0%

36.0%

NR

New York

25

4,076

20.6

19,745,289

6,389

32.4

19.9%

28.0%

Acute & Long

NR

NR

North Carolina

3

804

7.9

10,146,788

1,872

18.4

2.0%

1.3%

Acute & Long

Acute & Long

Acute & Long

North Dakota

1

137

18.1

757,952

652

86.0

7.0%

35.0%

Not Used

Acute & Long

Acute & Long

Ohio

6

1,028

8.9

11,614,373

6,933

59.7

15.0%

66.0%

Not Used

Acute & Long

Acute & Long

Oklahoma

2

385

9.8

3,923,561

1,285

32.8

10.8%

54.3%

Acute

Acute & Long

Acute & Long

Oregon

1

594

14.5

4,093,465

919

22.5

40.0%

40.0%

Not Used

Long Term

Acute & Long

Pennsylvania

6

NA

NA

12,784,227

NA

NA

47.0%

15.0%

Not Used

Acute & Long

Acute & Long

Rhode Island*

1

119

11.3

1,056,426

62

5.9

79.0%

29.0%

NR

NR

NR

South Carolina

4

657

13.2

4,961,119

1,145

23.1

11.3%

26.2%

Acute & Long

Acute & Long

Acute & LongSouth Dakota

1

213

24.6

865,454

1,742

201.3

0.4%

0.0%

Acute & Long

Acute & Long

Acute

State
Population:
2016

State
Hospital
Admissions(2016)

Forensic
Percent ofResidents(end of
FY2014)

Numberof State
Hospitals(2015)

Children &Adolescents

Adults/Elderly

Forensic
Patients

Acute

Acute & Long

Acute & Long

Not Used

Acute & Long

Acute & Long

Acute & Long

Acute & Long

Tennessee

4

478

7.2

6,651,194

9,281

139.5

0.8%

13.2%

Not Used

Acute & Long

Acute & Long

Texas

11

2,351

8.4

27,862,596

14,317

51.4

45.2%

48.5%

Acute & Long

Acute & Long

Acute & Long

Utah

1

303

9.9

3,051,217

321

10.5

34.7%

32.1%

Long Term

Acute & Long

Acute & Long

Vermont

1

22

3.5

624,594

60

9.6

3.0%

3.0%

Not Used

Acute & Long

NR

Virginia

9

2,799

33.3

8,411,808

6,083

72.3

31.0%

37.0%

Acute & Long

Acute & Long

Acute & Long

Washington

3

1,207

16.6

7,288,000

1,898

26.0

46.0%

30.0%

Acute & Long

Acute & Long

Acute & Long

West Virginia

2

261

14.3

1,831,102

1,062

58.0

14.0%

44.0%

Not Used

Acute & Long

Acute & Long

Wisconsin

2

992

17.2

5,778,708

4,397

76.1

8.2%

1.6%

Acute

Acute & Long

Acute & Long

Wyoming

1

124

21.2

585,501

210

35.9

29.0%

30.0%

Not Used

Acute & Long

Acute & Long

Total

188

40,845

12.6

323,127,513

109,269

33.8

28%

34%

14 = Both

39 = Both

43 = BothMedian

3

446

11.1

4,436,974

1,074

28.0

18%

30%

6 = Acute

3 = Acute

1 = Acute

Maximum

25

6,663

54.2

39,250,017

14,317

201.3

100%

100%

2 = Long

4 = Long

0 = Long

Minimum

1

22

2.5

585,501

60.0

1.1

0%

0%

22 = Not Used
5 = NoResponse

1 = Not Used
4 = NoResponse

1 = Not Used
6 = NoResponse

Number of Admissions and Residents from 2016 URS Table 6
Short Term-Acute is defined as less than 30 day length of stay
Number of State Psychiatric Hospitals, Percent Forensic, and Use of State Hospitals from 2015 State MH Profiles* Rhode Island has state-operated psychiatric inpatient beds that are part of a general hospital
Note: State Hospital Admissions & Discharges can be duplicated (e.g., one client can have multiple admissions/discharges during the year)

Psychiatric Inpatient Capacity, August 201750

A few states focus their adult state psychiatric hospital services on short-term (less than
30 day) acute services, but most states currently use their psychiatric hospitals for both
short- and long-stay adult patients. Twelve states now have policies for civil statuspatients requiring public general and local hospitals to be used as an initial admission site
for psychiatric inpatient treatment before utilizing state hospital facilities.
To control admissions to state psychiatric hospitals, 20 states give community mental
health providers some control over admissions. Community mental health providers may
conduct pre-admission examinations and, in some states, have financial incentives tominimize unnecessary use of state psychiatric hospitals.61
As discussed in the section of this paper on trends over time, state psychiatric hospitals in2016 are focused very differently than they were 40 to 50 years ago. In the 1970s and in
earlier eras, state psychiatric hospitals served large numbers of:

elderly patients, many with diagnoses of dementia;



individuals with intellectual/developmental disorders (what was then called
mental retardation); and

long-stay patients who had been in the hospital for years because comprehensive
community-based services and housing supports had not been developed andmedications were not as effective in permitting movement into community-based
settings.

From 1981 to today, state governments have drastically changed where they provide
mental health services and where their financial support is spent for services. As
discussed earlier, only 2 percent of the 7.3 million mental health consumers served bystate mental health systems in FY 2015 received even one day of care in a state
psychiatric hospital. However, the care those patients received was very expensive care.
States expended $9.7 billion providing inpatient services in state psychiatric hospitals.

Expenditures for State Psychiatric Hospitals
Advocates sometimes charge that states have reduced funding of state psychiatrichospitals, but states were expending $5.8 billion more on state psychiatric hospitals in FY
2015 than they were in 1981 (an increase of 143 percent).62 What states have done isdrastically increase their funding for community mental health services over this sametime period. Community mental health expenditures by SMHAs systems increased from
$2 billion in 1981 to $32.6 billion in FY 2015, an increase of 1,427 percent. The result of
the much slower increase in state psychiatric hospital expenditures and huge growth incommunity mental health expenditures has resulted in a major shift in the focus of care ofstate systems (see Figure 10).

61 NRI 2015 State Profiles.

62 NRI FY 2015 State Mental Health Agency Revenues and Expenditures Study.

Figure 10: SMHA-Controlled Expenditures for Inpatient Mental Health Services in State Hospitals andCommunity-Based Mental Health Services, FY 81 - FY15$35
$30

Expenditures in Billions$25

Community Mental Health

$20
$15
$10
$5

State Psychatric Hospital-Inpatient Services$0

Figure 11 shows that state psychiatric hospitals have decreased from 63 percent of total
SMHA expenditures in FY 1981 to only 22 percent of SMHA expenditures in FY 2015.
During this same time, the percent of SMHA budgets devoted to community-based
mental health treatment has increased from 33 percent to 75 percent. The balance (3percent) of SMHA spending is for central office administration.
Figure 11: State Mental Health Agency Controlled Expenditures for State Psychiatric Hospital Inpatientand Community-Based Services as a Percent of Total Expenditures, FY 81 to FY 15

80%
70%
60%

Community Mental Health
63%
60%

60%

66%

59%

70%

70%

72%

69%

70%

71%

72%

29%

27%

26%

26%

73%

76%
74%74%74% 75%

54%

50%
40%
30%

67%

48%

58%

49%

39%

43%
35%
33%

36%

37%

20%

32%

30%

28%

28%

26%

24%23%24%23%22%
25%

State Mental Hospital Inpatient

10%0%Figure 12 shows the change in SMHA-controlled expenditures for mental health bydecade, from 1981 to 2015. Expenditures for state psychiatric hospitals increased in every
Psychiatric Inpatient Capacity, August 201752

decade and averaged a 2.7 percent per year growth across the last 35 years. During themost recent five years (from 2010 to 2015) state psychiatric hospitals have experienced
the slowest expenditure growth of any time period.
Community mental health expenditures and total SMHA expenditures have grown much
faster than state hospital expenditures during each decade. There is also a trend of adecreased growth in expenditures for both community mental health and total SMHA
expenditures over each of the past 4 decades.
Figure 12: Annual Percent Change in State Mental Health Authority Expenditures for Mental Health Services inState Psychiatric Hospitals, Community Mental Health, and Total SMHA System, FY 81 to FY 15

12%1981 to 1990
1990 to 2001
2001 to 20102010 to 2015
1981 to 2015

11.2%
10.2%

Annual Percent Change in
Expenditurtes

10%
8.6%
8%
6%

6.8%
6.0%

6.0%

3.6%

4%
2%

7.9%

2.8%
1.1%

5.9%

5.6%

3.0%

2.7%
0.6%

0%
State Psychiatric Hospitals

Community Mental Health

SMHA Mental Health Total

Funding Sources for State Psychiatric Hospitals
State government tax revenues (primarily general fund appropriations by statelegislatures) comprise the major source of funding for SMHAs. Public and private
insurance plans have had a limited role in reimbursing state psychiatric hospitals formental health treatments. In FY 2015, more than $7.4 billion in state general and special
funds were expended for state psychiatric hospitals, representing 69 percent of total statehospital expenditures (see Figure 13). By comparison, state general and special funds
represented only 27 percent of SMHA-controlled community mental health expenditures
and Medicaid paid for 61 percent of community mental health services.

Psychiatric Inpatient Capacity, August 201753

Figure 13: Funding Sources for State Psychiatric Hospitals, FY 2015

State
Medicaid
Match
9%

Medicare3%
Federal Medicaid
13%

State General
Funds
69%

All other Federal
1%
Local
1%
First/Third Party
2%
Other Funds
2%

State Psychiatric Hospital Revenues: $10.7 billion

The Medicaid restriction on paying for services in IMDs limits the ability of both stateand private psychiatric hospitals to bill for services for adults ages 22 to 64 (services in
an IMD for children 21 and younger and older adults age 65 and older can be billed to
Medicaid). The IMD restriction is likely a major reason for the disparity in Medicaid
reimbursements for state psychiatric hospitals (22 percent vs 61 percent for community
mental health programs).

Forensic Services within State Psychiatric Hospitals
While overall state mental health expenditures have grown over time, there has been ashift within state psychiatric hospitals in most states to emphasize services for persons
admitted under a forensic status — i.e., criminal court-ordered evaluations and treatment.
State psychiatric hospital expenditures for forensic services have increased from $333
million in FY 1983 (7.6 percent of state psychiatric hospital expenditures), to 4.26 billion
in FY 2015 (43.9 percent of state psychiatric hospital expenditures). In five states, 70
percent of expenditures are now spent on services for forensic patients.
Figure 14 shows the growth in expenditures for forensic services since fiscal year 1983
(when NRI began collecting forensic expenditure data), both in expenditure amounts andas a percentage of total state psychiatric hospital expenditures. From FY 1983 to FY
2015, expenditures for forensic and sex offender services in state psychiatric hospitals

Psychiatric Inpatient Capacity, August 201754

grew at an annual rate of 8.3 percent while expenditures for civil status (non-forensic
patients) grew at only 0.9 percent per year.
Treatment of sex offenders in state psychiatric hospital began to grow after 1997,
following the U.S. Supreme Court decision in Kansas v Hendricks that the civil
commitment of violent sex offenders to psychiatric hospitals was constitutional.63 As of
2016, 20 states have enacted laws permitting the civil commitment of sex offenders.64

50%

$4.5

45%

$4.0

Forensic Exp
40%

$3.5

Forensic and Sex Offenders as Percent ofState Psychiatric Hospitals

$3.0

35%
30%

$2.5

25%
$2.0

20%

$1.5
$1.0

15%
10%

7.6%

2015

2013

2011

2009

2007

2005

2003

2001

1999

1997

1995

1993

1991

0%
1989

$0.0
1987

5%
1985

$0.5

Forensic & Sex Offender Expenditures as a
Percent of State Hospital Expenditures

Sex Offenders

1983

Forensic and Sex Offender Expenditures in State
Psychiatric Hospitals
Billions

Figure 14: State Psychiatric Hospital Expenditures for Forensic and Sex Offender Services and Percent ofState Hospital Expenditures for Forensic and Sex Offender Services, FY 1983 to FY 2015

The increased use of state psychiatric hospitals to serve forensic and sex offender
populations has grown to represent almost half of state psychiatric hospitals expendituresnationally; the vast majority of forensic patients receive inpatient services in state
psychiatric hospitals. Figure 14 shows that 86 percent of forensic status inpatients were instate psychiatric hospitals. A 2014 report by NASMHPD noted that the provision ofhighly secure specialized forensic and sex offender services is becoming a service typeunique to state psychiatric hospitals and is meeting increasing demand from court
systems.65

63 Kansas v. Hendricks, 521 U.S. 346 (1997).

64 NRI 2015 State Profiles.

65 Parks J., Radke A., and Haupt M, The Vital Role of State Psychiatric Hospitals, NASMHPD, Alexandria,

VA (July 2014), http://www.nasmhpd.org/content/vital-role-state-psychiatric-hospitals-july-20140.

Psychiatric Inpatient Capacity, August 201755

Recent Trend in Patients Served in State Psychiatric Hospitals
SAMHSA’s Uniform Reporting System (URS) now collects annual information on thenumber of “additions” (additions are both admission and readmissions) during the year
and the number of residents in state psychiatric hospitals on the first day of the year. The
inclusion of additions data (no longer collected in SAMHSA’s N-MHSS provider survey)
provides information beyond the information about current hospital census and bed
capacity. Figure 15 shows that while the number of residents in state psychiatric hospitals
declined slightly from 2007 to 2016, there has been a much larger decrease in the numberof additions to state psychiatric hospitals over that time period.
Figure 15: Number of Residents in State Psychiatric Hospitals and Number of Additions, 2007 to 2016

Number of State Psychitric Hospital Inpatient Residents at Startof Year and Additions During the Year, 2007 to 2016

Number of State Hospital Inpatients

200,000

Residents in Hospitalon First Day of Year
Additions During theYear

180,000
160,000
140,000
120,000
100,000
80,00060,00040,00020,000
0

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

MHBG URS Reporting Year

From 2007 to 2014, the URS data shows a 9 percent drop in the number of residents instate psychiatric hospitals on the first day of the year (a reduction from 44,995 residents
in 2007 to 40,845 in 2016). During this same time, the number of additions to state
psychiatric hospitals decreased by 41 percent (from 184,174 additions in 2007 to 109,269
in 2016).66

66 SAMHSA Uniform Report System Data Accessed on the SAMHSA Website,

https://www.samhsa.gov/data/reports-by-geography?tid=673&map=1.

Psychiatric Inpatient Capacity, August 201756

Appendix C: Data Sources Containing Information
about Psychiatric Inpatient and Other 24-Hour
Residential Treatment Capacity
As discussed previously, no single source of data exists that addresses all of the various
sources of mental health inpatient and other 24-hour treatment capacity. This paper
makes use of a variety of data sources from SAMHSA, AHRQ, CMS, and national
associations. Below is a brief descriptions of the content of various data sources used inthis report:
AHRQ Healthcare Utilization Project HCUP, 1997 to Present: The Agency for
Healthcare Research and Quality (AHRQ), established in 1989, is a Federal agency
charged with improving the healthcare system’s safety and quality. The Healthcare Costand Utilization Project (HCUP) is a comprehensive, nationwide, source of data on
hospital care with data as far back as 1997. HCUP is produced through a Federal, state,
and industry partnership. Because data comparable to the SAMHSA surveys on residents
in psychiatric inpatient beds on a single day are not available from the HCUP data, theauthors of this report used HCUP data on total discharges by diagnosis throughout theyear, along with average length of hospital stay for each diagnosis to calculate total
patient days during the year, then dividing that by 365 days a year to estimate a proxy of
how many mental health patients were in served in general hospitals on a single day. To
calculate how many of these mental health patients were in scatter beds, as opposed to
psychiatric units in general hospitals with data already collected by SAMHSA, theauthors then subtracted this estimate from the SAMHSA-reported 30,864 patients ingeneral hospitals with special psychiatric units.
Bureau of the Census -- Census of Patients in Mental Institutions, 1840-1946: The
Bureau of the Census began collecting data on mental institutions on a decennial basis in1840 and continued until 1900. In 1904, a census was conducted, but it was not until 1923
that a second one was undertaken. Beginning that year and continuing until 1946, the Bureauof the Census conducted an annual census of mental health facilities. In some years (1926 to
1930) the Census focused only on patients in state psychiatric hospitals. However, beginningin 1931, the annual census covered state, county and city, VA, and private psychiatrichospitals. Psychiatric wards in general hospitals were included annually beginning in 1939.
The 1947 census was conducted by the Federal Security Agency of the Public HealthService, which established NIMH in 1949.
Census of State and County Mental Hospitals, 1949 to 1980, conducted by NIMH
and the Center for Mental Health Services of SAMHSA: The Federal government has
been conducting censuses of mental institutions since 1840. NIMH was established in1949 and took over the census from the Bureau of the Census. There were a number of
iterations of the census. From 1949 to 1966, censuses were conducted annually. From1969 to 1980, NIMH conducted a census of state and county hospitals. When SAMHSA
was created, it assumed responsibility of for the annual census of state and county mental
hospitals. Results were published by SAMHSA each year in the report Additions andResident Patients at End of Year, State and County Mental Hospitals, by Age andDiagnosis, by State, United States. The annual report includes detailed national and statedata about admissions and residents in state and county psychiatric hospitals each year by
Psychiatric Inpatient Capacity, August 201757

14 different diagnostic groups, by age (0-18, 18-24, 25-44, 45-64, 65 and over) and by
race. Each state table shows number of patients in each cell, percent of patients, and rate
per 100,000 population. NRI has hard copies of these reports for selected years from1980 to 2005.
CMS Nursing Home Minimum Data Set (MDS), 1991 to Present: The Nursing Home
Minimum Data set was established by legislation in 1987. By 1991, most states required
nursing homes to begin implementing the MDS. The earliest version, MDS 1.0, wasphased out by 1999 and supplanted by MDS 2.0 which in turn was supplanted by MDS
3.0 in 2010. MDS has data about major diagnoses of patients in nursing homes. Since
most state psychiatric hospitals currently focus on serving patients with major mental
illnesses and have ceased to focus on dementia and other disorders for elderly
individuals, for the purpose of this estimate of psychiatric bed capacity, we have limited
the nursing home capacity count to residents with schizophrenia or bipolar disorders.
MDS data used in this report were acquired from Brown University, where it is available
to researchers with information about (1) total patients and (2) percent of patients with adiagnosis of schizophrenia and bipolar disorders.
DOD: 2017: The Department of Defense’s Defense Health Agency tracks information
about hospitalizations in DOD Medical Centers by diagnoses. Mental Health diagnoses
are identified in DOD reports as the leading causes of inpatient stays in DOD Medical
Centers in the US. Standard DOD reports show the number of hospitalizations during a
12-month period, but do not provide information on bed capacity on a single day. (SeeMedical Surveillance Monthly Report).
To develop an estimate of mental health bed capacity, NRI staff reached out to staff at the
Department of Defense. Justin Curry, PhD, Associate Director, PH Performance &Analytics Deployment Health Clinical Center Defense Centers of Excellence for
Psychological Health and Traumatic Brain Injury was very helpful. DOD conducted ananalysis for us that identified the number of beds available for mental health patients
under usual conditions (noting that in emergency situations, the number of beds countdoes not include substance use disorder inpatient stays).
Inventory of Mental Health Organizations (IMHO), 1980 to 2008: The IMHO was abiennial national survey of specialty mental health providers conducted by ADAMHA
from 1980 to 1990 and by SAMHSA from 1992 to 2008. The Inventories collected
information about: the number of inpatient beds; the number of inpatient, outpatient, andpartial care admissions; average daily census; end of year census; staffing; and, in someyears, revenues by source. The types of organizations included in the inventories were thefollowing:

Psychiatric hospitals (public and private), which were facilities primarily
concerned with providing inpatient care to people with a mental illness (there wasno distinction made at the time between hospitals and 24-hour residential
treatment facilities;

RTCs for children;Mental Health Partial Care Providers, which were free-standing and offered only
day or night partial care;

Psychiatric Inpatient Capacity, August 201758Multiservice Mental Health Providers, which provided services in two or moreprogram elements in a setting that was not a psychiatric hospital, general hospital,
or RTC;Community Mental Health Centers (CMHCs); andGeneral hospitals with separate psychiatric services, which were hospitals that
had separate psychiatric units or provided outpatient care.

Results are available in two NIMH and SAMHSA publication series Mental Health
United States, and Mental Health Statistical Notes.
National Mental Health Services Survey (N-MHSS), 2010 to Present: SAMHSA’s
National Mental Health Services Survey (N-MHSS) collects information on the numbers
and characteristics of all mental health facilities in the United States and its territories
annually. The N-MHSS is the only source of state- and national-level data on publiclyand privately-operated specialty mental health providers, including public and private
psychiatric hospitals, non-Federal general hospitals with separate psychiatric units, VA
Medical Centers, RTCs for children and adults, outpatient facilities, partial
hospitalization facilities, and multi-setting facilities. N-MHSS compiles information on
the number of specialty mental health providers that provide psychiatric inpatient andresidential services, as well as information on the number of residents in a bed in thesefacilities on the last day of the year. N-MHSS cycles with data about inpatient and other24-hour residential patients are available for 2010 and 2014.
National Spending Estimates, 1984 to Present: SAMHSA has collected data on
expenditures for mental health and substance use disorder treatment services since 1984
and has published the data annually since 1985. Behavioral health expenditures are also
compared to overall health care expenditures. The National Spending Estimate uses
HCUP data from AHRQ to estimate general hospital expenditures for mental health,including both specialty mental health and substance use disorder expenditures andscatter bed mental health and substance use disorder expenditures.
State Mental Health Agency Revenues and Expenditures Study, 1981 to Present,
Annually since 2001: NRI has collected data on the revenues and expenditures of state
mental health agencies since FY 1981 using a standardize methodology. Detailed funding
sources and expenditure information is depicted in three major categories (1) state
psychiatric hospitals, (b) community mental health services, and (3) SMHA central office
and administrative expenditures. Information was compiled every two to three years
from 1981 to 2001 and the study has been conducted annually since 2001.
Uniform Reporting System (URS), 2002 to Present: The URS includes data collectedfrom SMHAs as part of their annual MHBG reporting requirements. The data arecollected annually and cover all persons served by the SMHAs and in every service
setting. States report the data based upon their state fiscal year.
State Profiles System, 1994 to 2015: Through the State Profiles System (Profiles), NRI
has tracked SMHA initiatives in prevention and treatment of mental disorders. The
Profiles databases provide descriptions of each SMHA's organization and structure,service systems, eligible populations, emerging policy issues, numbers of consumers
served, fiscal resources, consumer issues, information management structures, andPsychiatric Inpatient Capacity, August 201759

research and evaluation initiatives. Questions within each of these categories are designed
to address specific needs of behavioral health leadership and other stakeholders interested
in public behavioral health systems, and support decision making, policy analysis, andresearch and evaluation initiatives.
VA, 2005 to 2014: The VA produces the National Mental Health Fact Sheet that report
data on mental health service capacity, amount of services provided, and service settingsfrom 2005 to 2014.

Psychiatric Inpatient Capacity, August 201760

Publication Sources Available by Year by Type of Data
Residents at End of Year in Psychiatric Hospitals and Residential Treatment Beds at end of year

VA
MedicalCenters

RTCs

Other
(CMHCs andMulti-Service
MH Centerswith Inpatient& Residential
Treatment
beds)

Year

State &CountyPsychiatric
Hospitals

PrivatePsychiatric
Hospitals

GeneralHospitals
withseparate
Psychiatric
Units

1970

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS 1992, Table
1.5 (page 27)

1975

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS 1992, Table
1.5 (page 27)

1979

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS 1992, Table
1.5 (page 27)

1983

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS 1992, Table
1.5 (page 27)

1986

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS 1992, Table
1.5 (page 27)

1988

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS 1992, Table
1.5 (page 27)

1990

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS 2004, Table
19.5 (page 208)

1994

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS 2004, Table
19.5 (page 208)

1998

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS 2004, Table
19.5 (page 208)

2000

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS 2004, Table
19.5 (page 208)

2002

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS

2010

N-MHSSN-MHSSN-MHSSN-MHSSN-MHSSN-MHSS

MHUS 2004, Table
19.5 (page 208)
N-MHSS* 2010,
SAMHSA report
Table 2.2, VA

Source2014

N-MHSSN-MHSSN-MHSSVA

N-MHSSN-MHSSN-MHSS* 2014,
SAMHSA report
Table 2.3, VA

1970

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS 1992, Table
1.3 (page 25)

1976

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS 1992, Table
1.3 (page 25)

1979

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS 1992, Table
1.3 (page 25)

1983

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS 1992, Table
1.3 (page 25)

Psychiatric Inpatient Capacity, August 201761

Publication Sources Available by Year by Type of Data (cont’d)Residents at End of Year in Psychiatric Hospitals and Residential Treatment Beds at end of year

VA
MedicalCenters

RTCs

Other
(CMHCs andMulti-Service
MH Centerswith Inpatient& Residential
Treatment
beds)State &CountyPsychiatric
Hospitals

PrivatePsychiatric
Hospitals

GeneralHospitals
withseparate
Psychiatric
Units

1986

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS 1992, Table
1.3 (page 25)

1988

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS 1992, Table
1.3 (page 25)

1990

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS 2004, Table
19.3 (page 205)

1994

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS 2004, Table
19.3 (page 205)

1998

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS 2004, Table
19.3 (page 205)

2000

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS* 2004, Table
19.3 (page 205)

2002

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS

MHUS* 2004, Table
19.3 (page 205)

Source* Note, N-MHSS data are "Inpatient Residents" (excludes Residential beds)

Acknowledgement
We would like to express our appreciation to Rani Hoff, Ph.D., from the U.S. Department
of Veterans Affairs and Justin Curry, Ph.D., from the Deployment Health Clinical Center,
U.S. Department of Defense for providing data and background information on
psychiatric inpatient services from their departments. We are greatly indebted to Joe
Parks, MD, Deborah Pinals, MD, Stuart Gordon, JD, and Christy Malik, MSW for theirthoughtful review and comments on this report.

Psychiatric Inpatient Capacity, August 201762