RESEARCH WEEKLY: What Kinds of Beds Exist, and How Do They Fit into a Broader Continuum of Care?

(Mar. 14, 2018) Psychiatric care will continue to become increasingly bedless unless policymakers and researchers intervene, argues a new article published today in JAMA Psychiatry, co-authored by the Office of Research and Public Affair’s (ORPA) Elizabeth Sinclair.

The article argues that the loss of psychiatric beds in the United States has surpassed a crisis point. This is evidenced by overwhelming amounts of psychiatric patients being boarded in emergency departments or “streeted,” like the case of Rebecca, who was released onto the cold streets of Baltimore from the University of Maryland Medical Center emergency department clad only in a hospital gown. And like the case of Jamychael Mitchell, who died from starvation in jail while waiting for a psychiatric bed to open up in Virginia. Or like the case of Nakesha, who was homeless and died on the street, and who, regardless of whether or not she met New York’s outdated inpatient commitment standards, would have had a difficult time gaining access to psychiatric care in New York City due to increasing closures of psychiatric beds.

hospital-beds However, often missing from the beds crisis arguments is the important but overlooked question: “What kinds of beds exist and how do they fit into a broader continuum of care?”

Building from the latest ORPA report, Beyond Beds, the article suggests that until stronger definitions of what types of bed exist and how they fit into the broader system of care for individuals with serious mental illness, trying to determine the correct number of psychiatric beds that should be available in a community is futile.

The article was co-authored by Dominic Sisti, Ph.D., from the University of Pennsylvania Department of Medical Ethics and Health Policy, and Steven Sharfstein, MD, a previous president of Sheppard Pratt Health System and a Psychiatric Advisory Board member for the Treatment Advocacy Center. The collaborative effort between psychiatric services researchers, policy analysts, and ethicists points to a shift in conceptions around psychiatric beds, one that is moving towards addressing treatment capacities along the entire care continuum, similar to physical health care.

“By tethering assessments of system capacity to the number of beds, not only do we miscount, but also, importantly, we risk limiting our ability to address the needs of individuals with serious mental illness across the continuum of care. With a more nuanced lexicon, a survey of system capacity will become more precise, yielding well-informed policy ideas, and ultimately, improved care for patients,” Sisti and authors write.

No matter the lexicon, increasing inpatient psychiatric capacity is needed, and this will not happen until targeted payment reform. The Institution for Mental Disease (IMD) exclusion has fueled the mental health crisis we are in today and must be repealed before we can reverse this trend.

In response to Benedict Carey’s “Bring back asylums?”, published in the New York Times on March 6, 2018, Jeffrey Geller, MD, writes, “we need inpatient treatment for those who need that level of care and non-institutional treatment for those who need less intensive services. With the proper balance, we would not need jails and prisons to house people who belong in care settings.”

The question is, though, what types of beds exist in what treatment settings and how do these fit into the broader continuum of care? No one is advocating for bringing back the asylums that once housed up to 16,000 patients in one facility. Instead, we need to fund and fully develop a full continuum of psychiatric care, one that includes a full spectrum of comprehensive inpatient and outpatient services.