Does Deinstitutionalization Increase
Jangho Yoon and Tim A. Bruckner
Objectives. (1) To test whether public psychiatric bed reduction may increase suicide
rates; (2) to investigate whether the supply of private hospital psychiatric beds——sep-
arately for not-for-profit and for-profit——can substitute for public bed reduction without
increasing suicides; and (3) to examine whether the level of community mental health
resources moderates the relationship between public bed reduction and suicide rates.
Methods. We examined state-level variation in suicide rates in relation to psychiatric
beds and community mental health spending in the United States for the years 1982–
1998. We categorize psychiatric beds separately for public, not-for-profit, and for-profit
Principal Findings. Reduced public psychiatric bed supply was found to increase
suicide rates. We found no evidence that not-for-profit or for-profit bed supply com-
pensates for public bed reductions. However, greater community mental health spend-
ing buffers the adverse effect of public bed reductions on suicide. We estimate that in
2008, an additional decline in public psychiatric hospital beds would raise suicide rates
for almost all states.
Conclusions. Downsizing of public inpatient mental health services may increase
suicide rates. Nevertheless, an increase in community mental health funding may be
Key Words. Deinstitutionalization, suicide, community mental health, privatizat-
ion, psychiatric beds
Deinstitutionalization represents one of the most widespread changes in men-
tal health policy. This process has led to the massive transfer of severely
mentally ill persons out of institutional care in favor of community treatment
(Grob 1994). A crucial aspect of deinstitutionalization involves significant
structural changes in the public mental health system. From 1970 to 2000,
public psychiatric hospital beds dropped from 207 to 21 beds per 100,000
persons (Manderscheid et al. 2004). This reduction concerns mental health
professionals and policy makers because the declining capacity of public psy-
chiatric hospitals may jeopardize care for indigent, severely mentally ill pa-
tients that require treatment but lack sufficient economic resources.
rHealth Research and Educational Trust
Decreasing public psychiatric hospital beds (hereinafter public beds)
would be efficient if the demand for beds similarly declined. However, the
literature does not support this notion of efficiency; deinstitutionalization
rarely, if at all, followed reduced demand for inpatient psychiatric care. In-
stead, ideological rhetoric, welfare programs, and fiscal considerations by
states initiated and accelerated the process of deinstitutionalization (Cameron
1978; Gronfein 1985a; Mechanic and Rochefort 1990; Grob and Goldman
2006).Moreover, deinstitutionalization representsa raresocial policythat was
implemented faster and more extensively than anticipated (Mechanic and
Rochefort 1990). Thus, public bed availability may have dropped below the
level of demand. In this circumstance, public bed reductions may adversely
affect mental health for persons with severe mental illness in a community.
The last decades have also experienced rapid privatization of the inpa-
tient psychiatric market and proliferation of public community-based mental
health programs (Manderscheid et al. 2004). It is unclear whether these aug-
privatization does not influence the availability and quality of care, it should
not, ceteris paribus, alter mental health of severely mentally ill patients. How-
particularly for-profit hospitals, preferentially treat insured patients and those
with less severe, acute symptoms (Schlesinger et al. 1997; Mechanic 1999).
The clear distinction of service clientele across different ownership types im-
plies that private bed supply may not substitute for public bed supply. More-
over, due to its voluntary nature and chronic underfunding, community
mental health care maynotadequatelytreatseverely mentally ill patientswith
a history of dangerousness, co-occurring disorders or arrests (Lamb, Wein-
berger, and Gross 2004). Nevertheless, increased supply of public community
mental health resources provides free goods to the economically disadvan-
taged and may therefore buffer adverse effects of public bed reductions,
improving community mental health.
Our mainobjective is to examine the relationshipbetween the supply of
public beds, as a proxy for deinstitutionalization, and population mental
health. We focus on suicide rates as a measure of population mental health.
Despite recent declines in national prevalence (McKeown, Cuffe, and Schulz
Address correspondence to Jangho Yoon, Ph.D., M.S.P.H., Assistant Professor, Jiann-Ping Hsu
College of Public Health, Georgia South University, P.O. Box 8015, Statesboro, GA 30460-8015;
e-mail: firstname.lastname@example.org. Tim A. Bruckner, Ph.D., M.P.H., is an Assistant Professor at the
University of California at Irvine, Program in Public Health, Irvine, CA.
1386HSR: Health Services Research 44:4 (August 2009)
2006), suicide rates serve as a useful indicator of population mental health
becauseof their strongassociation withsevere psychiatric episodes (Blackand
Fisher 1992; Simpson and Tsuang 1996; Colton and Manderscheid 2006;
Miller, Paschall, and Svendsen 2006; Saha, Chant, and McGrath 2007). We
test whether private hospital psychiatric beds, separately for not-for-profit and
for-profit hospital psychiatric beds (hereinafter, not-for-profit beds and for-
profit beds, respectively), can replace public beds without increasing suicides.
We also analyze whether the relationship between public bed reduction and
suicide rates varies with the availability of public community-based mental
PRIOR STUDIES AND LIMITATIONS
Deinstitutionalization has also taken place, and been researched, outside the
United States. In Sweden, mortality due to suicides among patients with
(Salokangas et al. 2002). In Denmark, a significant negative association was
found between the number of psychiatric beds and suicide mortality (O¨sby
et al. 2000). A Norway study reported an increase in suicide mortality after
psychiatric bed reductions (Hansen, Jacobsen, and Arnesen 2001). In the
United States, Haugland et al. (1983) examined the mortality rate of 1,033
deinstitutionalized patients. The authors found that during a 31
period, patients were approximately eight times more likely to die of suicide or
accident than persons in the general population. This finding is in line with a
greater risk of suicide among young deinstitutionalized patients served in a
community mental health center (Pepper, Kirshner, and Ryglewicz 1981). In
contrast, Bachrach (1996) and McGrew et al. (1999) reported general improve-
ments in the quality of life and functioning among patients discharged and
treated in community settings due to the closure of state psychiatric hospitals.
been implemented without sufficient evaluation of possible health risks. Rel-
workhas several importantlimitations.Weaddressthe followinglimitationsin
the literature to inform policy in the era of community-based treatment.
First, the U.S. studies examined only subgroups of persons with severe
mental illness such as patients discharged from psychiatric hospitals (Hau-
gland et al. 1983) and former patients in state psychiatric hospitals who con-
tinued to receive treatment in the community after a discharge (Bachrach
Deinstitutionalization and Suicide1387
1996; McGrew et al. 1999). However, a reduced supply of public beds, ceteris
paribus, may also affect persons who did not use public psychiatric hospitals
previously but require intensive care in restricted settings as well as those who
did not access treatment after a hospital discharge.
Second, inpatient psychiatric care has become more privatized. In 2000,
private psychiatric and general hospitals accounted for 24 and 46 percent of all
inpatient treatment episodes, respectively, as compared with only 12 percent in
state psychiatric hospitals (Manderscheid et al. 2004). In addition, evidence
suggests that private hospitals may increasingly serve patients similar to those of
public hospitals (Olfson and Mechanic 1996; Mechanic, McAlpine, and Olfson
1998). However, little research evaluates the increasing role of private entities in
providing inpatient psychiatric care. To our knowledge, no research has ex-
plored whether an increased supply of private psychiatric beds could offset a
reduction in public beds, with no adverse effect on population mental health.
Third, the interaction between public inpatient and community mental
mental health resourcesmaybebetterpositionedthan otherregionsto absorb
a shock from a public inpatient reduction. Given the significance of the public
sector’s provision of mental health services, policy makers may want to know
reductions in public beds.
A change in psychiatric bed supply may relate to suicide rates because it may
influence whether an individual obtains services at the time of need. Bed
illness may self-medicate their symptoms when they experience limited access
Although public psychiatrichospitals have historically served as a safety
net provider for many severely mentally ill persons, it remains unclear
whether a reduction in public beds leads to higher suicide rates. The devel-
opment of psychopharmacology beginning in the 1950s enabled community
treatment of severe mental illness and reduced the need for long hospitaliza-
tion (Morrissey 1989; Mechanic and Rochefort 1990; Grob 2001). With con-
tinued advances of psychotropic medications and treatment, community
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Additional supporting information may be found in the online version of this
Appendix SA1: Author Matrix.
Figure S1. Year-To-Year Percent Changes in the Number of Public
Psychiatric Hospital Beds and Suicide Rates for Selected States, 1982–1998.
Table S1. Robustness Test Results for Tables 2–4.
Please note: Wiley-Blackwell is not responsible for the content or func-
tionality of any supporting materials supplied by the authors. Any queries
(other than missing material) should be directed to the corresponding author
for the article.
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