Trends in state and county mental hospitals in the U.S. from 1970 to 1992.

OBJECTIVE: The authors document changes in state mental hospitals from 1970 to 1992 in four areas: the number of hospitals, the average daily census, expenditures, and number of full-time-equivalent staff. METHODS: Data examined were derived from information collected in the Inventory of Mental Health Organizations and General Hospital Mental Health Services. RESULTS: From 1970 to 1992, the number of state hospitals dropped from 310 to 273, and their inpatient populations were drastically reduced (a 77 percent decrease), a continuation of a trend that began in 1956. Most of the reduction was due to the downsizing of existing hospitals rather than to hospital closings. A complex combination of medical, social, economic, legal, and political factors were responsible for the decrease. Although expenditures for state hospitals were nearly $8 billion in 1992, a 339 percent increase over 1970, the level of expenditures in current dollars has leveled off in recent years, and expenditures measured in constant dollars (adjusted for inflation) have actually decreased since the early 1980s. The number of professional patient care staff increased by about half, while nonprofessional staff decreased by about the same proportion. CONCLUSIONS: In the near future, it appears that state hospitals will continue to reduce their patient populations, although at a slower rate than in the past, and will continue to care for large numbers of persons who either are involuntarily admitted or do not have alternative living arrangements. However, state hospitals are likely to decrease in importance.

CMHS data highlights on: availability of psychiatric beds, United States: selected years, 1970-1990.

Despite the decrease from 474,190 to 250,541 between 1970 and 1990 in the overall number of non-Federal psychiatric beds (excluding "scatter" beds in non-Federal general hospitals), the trend was by no means constant over time. Between 1970 and 1982, a period of rapid deinstitutionalization of State mental hospitals, the number of beds in all organizations combined dropped precipitously from 474,190 to 222,666, led by State mental hospitals which decreased from 413,066 to 140,140 beds. This was the height of the community mental health center movement and the prevailing view of mental health administrators was that persons with mental illness could be cared for better in the community, rather than at State mental hospitals, far from their homes. Thus, some hospitals closed altogether, and many others closed wards and units as part of the downsizing process. Contrary to a decrease in the number of beds in State mental hospitals during the 1970-82 period, the number of beds in other organization types, in particular private psychiatric hospitals and separate psychiatric services of non-Federal general hospitals, remained relatively constant. The net result was a substantial decrease in the overall number of non-Federal psychiatric beds. In the 1982-90 period, a different phenomenon occurred. The number of beds in State mental hospitals was continuing to decline, but at a slower rate from 140,140 to 98,789, while the number of beds in other types of mental health organizations, particularly private psychiatric hospitals and separate psychiatric inpatient services of non-Federal general hospitals, expanded somewhat.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of inflation on expenditures by mental health organization between 1969 and 1990.

At first glance, the rise in current dollar expenditures for all mental health organizations from $3.3 billion in 1969 to $28.4 billion in 1990 seems enormous. However, if the annual expenditures are adjusted for inflation and expressed in constant dollars, the rise in expenditures is only from $3.3 billion in 1969 to $5.6 billion in 1990. Thus, most of the increase in expenditures by mental health organizations over the past two decades is due to inflation, with less than 10 percent due to increases in real purchasing power. Since both the number of private psychiatric hospitals and the expenditures they incurred increased dramatically between 1969 and 1990, these hospitals showed gains in absolute dollar amounts and in dollar amounts per capita, even if the expenditures are expressed in constant dollars. To a lesser extent, the same was true of RTCs. Although both VA medical centers and State mental hospitals showed increases in expenditures as measured in current dollars, if expenditures are expressed in constant dollars, these organizations showed net decreases. Their inpatient populations also decreased during this period. However, if expenditures per inpatient under care are examined, the reverse is true. The per patient expenditures for State mental hospitals increased between 1969 and 1990, even if the results are stated in constant dollars.(ABSTRACT TRUNCATED AT 250 WORDS)

Persons with substance use disorders in mental health organizations in the United States in 1988.

Data from a 1988 enumeration of mental health organizations and separate psychiatric services of non-Federal general hospitals in the United States were used to derive estimates of the number of person with alcohol and/or drug abuse (substance use) disorders in these organizations. For all organizations combined, the percent of persons with substance use disorders were 8% each in inpatient, residential treatment, and outpatient care and only 3% in partial care program elements. However, within type of program element, there was variation according to type of organization. It should be noted that the percent of persons with substance use in mental health organizations would be even greater than reported if: (1) the universe of mental health organizations surveyed was expanded; (2) the reporting period included persons receiving services throughout the year rather than on a single day; and (3) provision was made for including persons with a secondary diagnosis of substance abuse.

Fertility following excision of a symptomatic craniopharyngioma during pregnancy: case report.

A 27-year-old woman in the second trimester of pregnancy presented with bitemporal hemianopsia. Total resection of a craniopharyngioma restored normal vision, and she delivered a normal infant at term. Permanent hormonal replacement therapy was not needed. Subsequent spontaneous pregnancy and delivery indicate that fertility was preserved. Literature review shows this case to be unique. Even with new developments in stereotactic radiotherapy, total excision remains a potentially achievable surgical goal.

Staffing of mental health organizations, United States, 1988.

Between 1986 and 1988, the number of full-time equivalent (FTE) staff employed in specialty mental health organizations in the United States increased 7 percent, from 494,515 to 531,067. Much of this increase could probably be attributed to the increase in number of mental health organizations during this period, from 4,747 to 4,930. With the exception of State mental hospitals and VA psychiatric organizations, all of the other types of mental health organizations showed varying amounts of increase in FTE staff with the most notable gains being reported by private psychiatric hospitals, residential treatment centers for emotionally disturbed children, and multiservice mental health organizations. Of the 531,067 FTE staff employed in mental health organizations in 1988, 72 percent were classified as patient care staff and 28 percent as administrative and support staff. State mental hospitals and VA psychiatric organizations had slightly higher percentages of administrative and support staff (35 and 32 percent, respectively). Seventy percent or more of the staff employed in the various types of specialty mental health organizations in 1988 worked on a full-time basis, the two exceptions being freestanding psychiatric outpatient clinics and non-Federal general hospital psychiatric services in which full-time staff represented only 52 percent and 69 percent, respectively, of all staff. For the most part, the majority (50 percent or more) of each of the staff disciplines employed in mental health organizations worked on a full-time basis. The major exceptions were psychiatrists and other physicians, most of whom worked either on a part-time or trainee basis.

Partial care in mental health organizations: United States and each state, 1988.

Partial care is a relatively new and rapidly-growing form of mental health care consisting of a planned program of mental health treatment services generally provided in visits of 3 or more hours to groups of patients/clients. In 1970, only one-fourth of U.S. mental health organizations provided partial care services, and patient additions to partial care programs were 56 per 100,000 civilian population. By 1988, close to half of all mental health organizations provided partial care services, and the rate of additions was more than 5 times as high. However, large increases in the number or organizations providing partial care between 1984 and 1988 are due in part to changes in definitions that are elaborated on later in the report. In 1988, multiservice mental health organizations were the most numerous providers of partial care with 1,230 of 1,310 (94 percent) providing this program. This was followed by general hospital mental health services with 332 of 1,489 (22 percent) providing partial care and private psychiatric hospitals with 236 of 447 (53 percent) providing this program. Mental health organizations providing partial care were most numerous in populous States, particularly in California (with 187 mental health organizations providing partial care), New York (174 organizations), and Pennsylvania (131 organizations). There were 212,196 patients on the rolls of partial care programs of mental health organizations in the United States (including Territories) at the beginning of 1988, and 286,715 patients were added to these programs during the year. Multiservice mental health organizations were responsible for a majority of both patients on the rolls and patient additions during the year.(ABSTRACT TRUNCATED AT 250 WORDS)

Patient care episodes in mental health organizations, United States: selected years from 1955 to 1988.

The 4,930 mental health organizations providing mental health services in the United States during 1988 (excluding the Territories) generated just over 8.3 million patient care episodes (table 1). However, in order to compare 1988 data with those for other years dating back to 1955, outpatient and partial care programs administered by the Department of Veterans Affairs (formerly the Veterans Administration) (VA) need to be omitted (table 2). Thus the 7.8 million patient care episodes in 1988 (exclusive of VA outpatient and partial care programs) represented a more than four-fold increase over the 1.7 million patient care episodes in mental health organizations observed more than three decades earlier in 1955. The major shifts in patient care episodes over the period from 1955 to 1988 have been from inpatient to ambulatory care services in mental health organizations, and from State and county mental hospitals to community-based mental health organizations. For example, in 1955, 77 percent of all patient care episodes were inpatient episodes, and the remaining 23 percent were outpatient episodes. By 1988, inpatient episodes constituted only 28 percent of the total, while 66 percent were outpatient episodes, and 6 percent were partial care episodes (table 2 and figure 1). However, the relative distribution of inpatient, outpatient, and partial care episodes has been relatively stable since 1975. From 1955 to 1988, the primary locus of inpatient care shifted from State and county mental hospitals to non-Federal general hospitals. Also, by 1988, the locus of over one-half of the outpatient care episodes and almost two-thirds of the partial care episodes was in multiservice mental health organizations.

Availability and distribution of psychiatric beds, United States and each state, 1988.

The total number of non-Federal and Department of Veterans Affairs (VA) inpatient and residential treatment psychiatric beds in mental health organizations in the United States increased by almost 2 percent between 1986 and 1988, from 267,613 to 271,923. Excluding VA psychiatric beds in both years, the number of beds increased from 240, 739 in 1986 to 246,181 in 1988 (2.3 percent). This was in contrast to a 3 percent decrease observed nationally in all non-Federal hospital beds (psychiatric and other) during the 1986-88 period. As a result, non-Federal psychiatric beds comprised 21 percent of non-Federal hospital beds in 1988, compared to 20 percent in 1986. The overall growth in psychiatric beds between 1986 and 1988 was due to increases in number of psychiatric beds in private psychiatric hospitals, separate psychiatric services of non-Federal general hospitals, residential treatment centers for emotionally disturbed children, (RTCs), and multiservice mental health organizations, which more than offset decreases in psychiatric beds in State and county mental hospitals and VA mental health services. Between 1986 and 1988, the national pattern of an increase in psychiatric beds was reflected in 30 States, while the remaining 20 States and the District of Columbia showed decreases in psychiatric beds. Among the States, the availability of psychiatric beds, measured by bed rates per 100,000 civilian population, varied considerably in 1988. Thirty States and the District of Columbia had 100 or more beds per 100,000 civilian population, while 6 States had rates of fewer than 75 beds. Although the number of State and county mental hospital beds decreased between 1986 and 1988, these organizations accounted for the largest percentage of all psychiatric beds in 1988 (39 percent). The separate psychiatric services of non-Federal general hospitals ranked second in number of psychiatric beds in 1988, with 18 percent of the total followed by private psychiatric hospitals, with 16 percent; VA mental health services, with 10 percent; residential treatment centers for emotionally disturbed children with 9 percent; and multiservice mental health organizations, with 8 percent.

Outpatient care programs of mental health organizations, United States, 1988.

In 1988, 2,989 (60 percent) of the 4,961 mental health organizations in the United States (including the territories) offered outpatient care programs. A total of 5.8 million patient care episodes were generated by these organized outpatient programs. These episodes included 3.1 million outpatient additions, produced 54 million outpatient visits, and represented 67 percent of all patient care episodes in mental health organizations in 1988. Although the number of mental health organizations with outpatient care programs increased by less than one percent between 1986 and 1988, the number of outpatient additions showed an 11 percent gain during this period. Multiservice mental health organizations were the primary locus of outpatient care in 1988, accounting for 41 percent of the 2,989 mental health organizations providing this care. Ranking next in this respect, were free-standing psychiatric outpatient clinics, and the separate psychiatric outpatient services in non-Federal general hospitals, with 25 and 16 percent, respectively, of the total outpatient care programs. In general, these three organization types had similar rankings with respect to the volume of the outpatient caseload. By definition, all of the freestanding psychiatric outpatient clinics provided outpatient care, and almost all of the VA mental health programs and multiservice mental health organizations also offered this care (99 and 92 percent, respectively). In contrast, psychiatric outpatient care was available in only 37 percent of non-Federal general hospitals with separate psychiatric services, 36 percent of private psychiatric hospitals, 29 percent of State mental hospitals, and 22 percent of RTCs for emotionally disturbed children. Outpatient care was available in mental health organizations in all States in 1988, with every State having at least two or more organization types providing this service. In general, the most populous States had the largest number and the greatest variety of mental health organizations with outpatient care programs. Of the 2.87 million clients receiving outpatient care in mental health organizations at the end of 1988, 23 percent were under 18 years of age, 68 percent were 18 to 64, and 9 percent were 65 and older. Male outpatient clients slightly outnumbered female clients. The majority (77 percent) of the outpatient clients were white, with blacks representing 21 percent; native Americans and Asians/Pacific Islanders, the remaining two percent. Eleven percent of the total client population were reported to be of Hispanic origin.(ABSTRACT TRUNCATED AT 400 WORDS)

Expenditures and sources of funds for mental health organizations: United States and each state, 1988.

Expenditures. Expenditures by the 8 types of mental health organizations covered in this report totaled $23.1 billion in 1988 in the United States and territories. Three States (California, New York, and Pennsylvania) accounted for 30 percent of this total. Nationally, State and county mental hospitals (hereafter called State mental hospitals) accounted for the largest proportion of all expenditures (30 percent, down from 34 percent in 1986). Private psychiatric hospitals and multiservice mental health organizations had the next largest expenditures, each accounting for 20 percent of the total, followed by the separate psychiatric services of non-Federal general hospitals at 16 percent. Department of Veterans Affairs (VA) mental health services, residential treatment centers (RTCs) for emotionally disturbed children, freestanding psychiatric outpatient clinics, and freestanding psychiatric partial care organizations accounted for 6 percent, 6 percent, 3 percent, and less than one-half percent of total expenditures, respectively. State mental hospitals represented the largest expenditures of any single type of mental health organization in 23 States; expenditures of private psychiatric hospitals were largest in 12 States; and expenditures of multiservice mental health organizations were the largest in 10 States. The $23.1 billion total for 1988 represented a 25 percent increase over the 1986 figure but, when adjusted for inflation, the estimated increase (expressed in constant dollars) was only 10 percent overall and 8 percent on a per capita basis. Constant dollar expenditures of most types of mental health organizations increased between 1986 and 1988, with the largest increase occurring among private psychiatric hospitals (54 percent). In contrast, constant dollar expenditures decreased for State mental hospitals and VA mental health services. Sources of Funds In 1988, the funds received by mental health organizations totaled $23.4 billion. Of this total, $8.8 billion (38 percent) was provided directly by State governments, predominantly by State mental health agencies. Direct Federal funds, plus Medicare and Medicaid (including the State and local share of Medicaid), provided $6.5 billion (28 percent) of total funding. Fees from clients (including private insurance) provided $5.2 billion (22 percent); direct local government funds provided 7 percent; and all other sources, 5 percent. State governments provided 77 percent of the funds received by State mental hospitals and were also the largest single source of funds for multiservice mental health organizations (51 percent) and freestanding psychiatric partial care organizations (44 percent). VA mental health services were funded by the Federal government, while 62 percent of funding for private psychiatric hospitals came from client fees (including private insurance).(ABSTRACT TRUNCATED AT 400 WORDS)

Residential treatment centers and other organized mental health care for children and youth: United States, 1988.

Residential treatment centers (RTCs) for emotionally disturbed children are an important component of the mental health services delivery system in the United States. The 440 RTCs operating in 1988 represented 9 percent of all mental health organizations in the U.S. in that year. They served approximately 10 percent of the patients who received inpatient and residential treatment care and approximately 2 percent of outpatient psychiatric visits in organized settings. Their 39,000 full-time equivalent (FTE) staff and $1.3 billion expenditures were, respectively, 7 percent and 6 percent of the total for all mental health organizations. Between 1986 and 1988, the number of RTCs increased slightly, while the volume of residential treatment care changed little. However, partial care and outpatient care expanded in RTCs, with the number of visits in these categories increasing by 75 percent and 42 percent, respectively. FTE staff grew by 13 percent, and expenditures increased by 33 percent between 1986 and 1988. In 1988, RTCs were located in all States except North Dakota. The largest number were found in California (48), Massachusetts (38), and New York (28). By definition, all RTCs provided residential treatment care. About one-third of them also provided partial care and one-third provided outpatient care. The highest rates of additions to residential treatment care in RTCs per 100,000 civilian population were found in Minnesota and Colorado. Reflecting the role of RTCs as providers of care to children and youth, 94 percent of residential treatment patients in RTCs were under age 18. Seventy percent of residential treatment patients were male; 28 percent, black; and 10 percent, Hispanic. Approximately 94 percent had mental illness as their principal disability. In December 1988, 43,000 staff worked in RTCs; 14 percent were employed part-time, and 3 percent were trainees. Among others, the staff included approximately 900 psychiatrists, 300 other physicians, 1,700 psychologists, 4,800 social workers, and 1,000 nurses. Nationally, expenditures by RTCs averaged $5 per capita, but the highest per capita spending was $20 in Massachusetts and $14 in Arizona. The principal sources of funds for RTCs were local governments (the source of 33 percent of total funds available to RTCs), State mental health agencies (15 percent of funds), and other State government sources (21 percent of funds). RTCs focus their care on children and youth more than do any other type of mental health organization. At year-end in 1988, 64 percent of all the patients on the rolls of all types of programs in RTCs were under age 18.(ABSTRACT TRUNCATED AT 400 WORDS)

Mental health services of the Veterans Administration, United States, 1986.

The mental health services of the Veterans Administration (VA) form an important component of the organized mental health care delivery system in the United States. The 140 VA organizations delivering mental health care represented 3 percent of all mental health organizations in the U.S. in 1986, but accounted for approximately 11 percent of the average daily inpatient mental health census and 8 percent of outpatient mental health visits in organized settings. Their 33,000 full-time equivalent (FTE) staff and $1.4 billion in expenditures devoted to mental health care were approximately 7 percent of the respective totals for all mental health organizations. Between 1983 and 1986, the number of VA organizations offering mental health care increased by only 1, but inpatient mental health additions increased by 22 percent. Average length-of-stay for these inpatients declined by almost as much. Outpatient mental health additions increased by 30 percent, and FTE staff in VA mental health services grew by 10 percent. Mental health services were provided by VA organizations in all States except Alaska, Hawaii, Montana, and North Dakota in 1986. (Veterans are free to make use of programs outside their State of residence.) The largest numbers of mental health services, additions, and episodes were found in States with very large populations, such as California, New York, and Texas. However, the highest rates of additions and episodes per 100,000 civilian population were generally in States with small populations, and often in rural States. For example, Maine, South Dakota, Wyoming, and West Virginia were among the States with the highest rates of additions and episodes. Reflecting the composition of the total population in VA facilities, of 315,630 in VA mental health services, over 95 percent were male, a relatively large percentage (17 percent) were 65 or over, and very few were under 18 years old. About two-thirds were white, non-Hispanic; one-fourth were black, non-Hispanic; and 8 percent were Hispanic. About one-sixth were suffering primarily from drug or alcohol abuse; almost all the rest suffered primarily from mental illness. In November 1986, approximately 36,000 staff persons worked in VA mental health services. About 84 percent of these worked full-time; 9 percent, part-time; and 7 percent, as trainees. The staff included approximately 2,800 psychiatrists, 700 other physicians, 1,600 psychologists, 1,800 social workers, and 7,200 nurses. Three-fourths of the expenditures for VA mental health services went for staff, with other operating expenses consuming most of the remainder.

Staffing of mental health organizations, United States, 1986.

Between 1984 and 1986, the number of full-time equivalent (FTE) staff employed in specialty mental health organizations in the United States increased 12 percent from 440,925 to 494,591. Much of this increase could probably be attributed to the increase in the number of mental health organizations during this period from 4,438 to 4,747. With the exception of freestanding psychiatric outpatient clinics, which showed a 1 percent decrease, all of the other mental health organization types showed varying amounts of increase in FTE staff, with the most notable gains reported by private psychiatric hospitals, RTCs for emotionally disturbed children, and multiservice mental health organizations. Of the 494,591 FTE staff employed in mental health organizations in 1986, 70 percent were classified as patient care staff and 30 percent as administrative and support staff. Private psychiatric hospitals, State mental hospitals, and freestanding psychiatric outpatient clinics had slightly higher percentages of administrative and support staff (40, 35, and 33 percent, respectively), with consequent smaller percentages of patient care staff (60, 65, and 67 percent, respectively). For all other organization types, the percentages of patient care staff were higher, varying from 70 to 87 percent. Professional patient care staff constituted 47 percent of all FTE staff in mental health organizations in 1986, and other mental health workers (less than B.A.) represented only 23 percent of the total. Among each of the organization types, however, the percentages of professional patient care staff were generally higher, and the percentages of other mental health workers lower, with the major exception of State mental hospitals. Seventy-five percent or more of the staff employed in the various types of specialty mental health organizations in 1986 worked on a full-time basis, with the exception of freestanding psychiatric outpatient clinics and the separate psychiatric services of non-Federal general hospitals in which full-time staff represented only 53 and 67 percent of all staff, respectively. For the most part, a majority (50 percent or more) of each of the staff disciplines employed in specialty mental health organizations worked on a full-time basis. The major exceptions were psychiatrists and other physicians, most of whom worked either on a part-time or a trainee basis.

Availability and distribution of psychiatric beds, United States and each state, 1986.

The total number of psychiatric beds in mental health organizations in the United States increased 2 percent between 1984 and 1986, from 262,673 to 267,613. This was in contrast to a 4 percent decrease observed nationally in all non-Federal hospital beds between 1984 and 1986. As a result, non-Federal psychiatric beds comprised 20 percent of non-Federal hospital beds in 1986, compared to 19 percent in 1984. The overall growth in psychiatric beds between 1984 and 1986 was due to increases in psychiatric beds in VA medical centers, private psychiatric hospitals, and residential treatment centers for emotionally disturbed children (RTCs) which more than offset smaller decreases in psychiatric beds noted in State and county mental hospitals, multiservice mental health organizations, and separate psychiatric services of non-Federal general hospitals. Between 1984 and 1986, the national pattern of an increase in psychiatric beds was reflected in 31 States, while the remaining 19 States and the District of Columbia showed decreases in psychiatric beds during this period. Among the States, the availability of psychiatric beds, measured by bed rates per 100,000 civilian population, varied substantially in 1986. Twenty-seven States and the District of Columbia had 100 or more beds per 100,000 population, while 8 States had fewer than 75 beds per 100,000 population. Although the number of State and county mental hospital beds decreased between 1984 and 1986, these facilities accounted for 45 percent of all psychiatric beds in 1986. In the number of psychiatric beds available, State and county mental hospitals predominated in all but seven States. Nationally, the separate psychiatric inpatient services of non-Federal general hospitals ranked second in number of psychiatric beds in 1986, with 17 percent of the total; followed by private psychiatric hospitals, with 11 percent; VA medical centers, with 10 percent; RTCs, with 9 percent; and multiservice mental health organizations, with 8 percent.

Psychiatric outpatient care services in mental health organizations, United States, 1986.

In 1986, 2,967 mental health organizations, or 62 percent of all mental health organizations in the United States (including territories), offered psychiatric outpatient care services. A total of 5.6 million patient care episodes were provided by these organized outpatient services. These episodes involved a total of 47 million visits and 2.8 million additions, and represented 69 percent of all psychiatric patient care episodes in organized settings that year. Both the number of organizations with psychiatric outpatient care services and the number of outpatient additions to these organizations increased by approximately 4 percent between 1983-84 and 1986. Multiservice mental health organizations were the most prominent type of mental health organization in the provision of psychiatric outpatient care. They comprised 42 percent of the 2,967 organizations offering this type of care and were responsible for 54 percent of the outpatient additions, 53 percent of the episodes, and 54 percent of the visits. Next in importance were freestanding psychiatric outpatient clinics and separate psychiatric services in non-Federal general hospitals. They accounted for 26 percent and 17 percent, respectively, of organizations providing psychiatric outpatient care. Each provided 12 to 18 percent of outpatient additions, episodes, and visits. Over 90 percent of multiservice mental health organizations and Veterans Administration psychiatric organizations offered outpatient psychiatric care. In contrast, this form of care was offered by only 29 percent of State and county mental hospitals, 36 percent of private psychiatric hospitals, 37 percent of nonFederal general hospitals with psychiatric services, and 23 percent of residential treatment centers for emotionally disturbed children.(ABSTRACT TRUNCATED AT 250 WORDS)