Dr. Steve Sharfstein Wulfson Memorial Grand Rounds

Transcript

1. With research assistance by Elizabeth Sinclair Hancq, MPH The Decrease in Psychiatric Beds and the Increase in the Suicide Rate: Correlation or Causation? Steven S. Sharfstein, M.D. President Emeritus, Sheppard Pratt Health System Clinical Professor, University of Maryland Wulfson Memorial Psychiatry Grand Rounds January 7- 8, 2020
2. Suicide vs. Beds in The United States Correlation or Causation?
3. Two Cases
4. Suicide is the 10th leading cause of death in the U.S. and responsible for more than 47,000 deaths in 2017. The CDC estimates that in 2017, 10.6 million American adults seriously thought about suicide and 1.4 million attempted suicide.
5. Suicide is the second leading cause of death for people 10-34 years of age. The fourth leading cause among people 35-54 years of age and eighth leading cause among people 55-64.
6. • Depression • Family history • Previous suicide attempts • Substance use • Cultural/religious beliefs • Physical illness • Isolation and loneliness • Access to lethal means (eg, guns) • Lack of access to mental health services Risk Factors/Correlates of Suicide
7. (Organization for Economic Co-operation and Development) OECD Suicide Rate
8. Suicide Method Number of Deaths Total 47,173 Firearm 23,854 Suffocation 13,075 Poisoning 6,554 Other 3,690 47,173 Deaths by Suicide in 2017 Suicide by Method (2017) Data Courtesy of CDC
9. Drug Overdose Mortality Versus Suicide
10. • An analysis released by the CDC’s National Center for Health Statistics reveals suicide rates in the U.S. “are at their highest since World War II.” • The data indicates that in 2017, 14 out of every 100,000 Americans died by suicide – a 33% increase since 1999.
11. •What about inpatient suicide? •“Ligature risk??”
12. Inpatient suicide rate is estimated to be 3.2 per 100,000 admissions per year nationwide. This is similar to the rate reported in VA mental health units at 4.2 per 100,000 admissions. Reference: William, S, Schmaltz, SP, Castro GM, Baker DW. Incident and method of suicide in hospitals in the United States. The Joint Commission Journal on Quality and Patient Safety, 2018; 000:1-8.
13. The suicide rate within 12 months of discharge was 2.4 per 1,000 psychiatric discharges. That equates to: One suicide in every 415 discharges. Attempted suicides occurred at a rate of: One in every 46 discharges. Reference: Forte A, Buscajoni A, Pompili M, Baldessarini RJ. Suicidal risk following hospital discharge. Harvard Review of Psychiatry, 2019; 27(4):209-216.
14. “More than one-quarter of all suicidal acts (26%) arose within the first month after discharge, 40% within 3 months, and 73% within one year.” Reference: Forte A, Buscajoni A, Pompili M, Baldessarini RJ. Suicidal risk following hospital discharge. Harvard Review of Psychiatry, 2019; 27(4):209- 216.
15. From 19th Century Asylums To 21st Century Inpatient Care
19. Accessible for the American Presidency Project: http://www.presidency.ucsb.edu/ws/?pid=9546 John F. Kennedy 35th President of the United States 1961 - 1963 50 – Special Message to the Congress on Mental Illness and Mental Retardations February 5, 1963
21. Second Half Of The 20th Century Deinstitutionalization • From 550,000 to 75,000 beds today, with less than 40,000 beds in the public hospitals • Economics (shift from state to federal funding) • Treatment (antipsychotic medication) • Use of community mental health and general hospital psychiatry • Legal issues (civil liberties) • Managed care
22. In 1999, Olmstead v. L.C. affirmed the right under ADA for people with disabilities to live in the least restrictive setting appropriate for their disabilities.
23. 37% reduction in psychiatric beds from 35 beds per 100,000 population in 1999 to 22 beds per 100,000 population in 2016 only 4 out of 35 Organization for Economic Cooperation and Development (OECD) countries (Italy, Chile, Mexico and Turkey) have less psychiatry beds than the U.S.
24. OECD Psychiatric Bed Rate
25. What Is The “Right Number For The “ Safe Minimum” • Germany – 127 (increase from 90 in 1991) • Switzerland - 91 • OECD average - 72 (down from 118 in 1991) • United States - 22 • Italy - 10
26. The Changing Roles of State and County Hospitals A 96% decrease: 1955: 559,000 beds (340 beds/100,000 pop.) 2016: 37,679 beds (11.7 beds/100,000 pop.) Today, state psychiatric hospitals provide mostly forensic services: Court-ordered evaluation Competency restoration Longer-term forensic commitment for NGRI
27. Between 1970 and 2014 there was a 77% decrease in the total population of psychiatric residents. A careful look reveals a dramatic fluctuation in capacity across subtypes of beds. For example, there was a 93% decrease in the number of psychiatric beds in state and county psychiatric hospitals.
28. In contrast, during that time, there was a - 63% increase in patients in private hospitals - 11% increase in patients in general hospitals with separate psychiatric units - 99% increase in psychiatric patients in residential treatment centers
29. The median length of stay in community hospitals in the United States declined from 42 days in 1980 to 6 days by 2014 and are associated with the very high 30-day readmission rate for individuals with schizophrenia (22.9%), second only to congestive heart failure (23.2%).
30. “Stuck Patients” Emergency departments Acute beds Day treatment programs Criminal Justice system
31. Emergency Room Gridlock • The absolute number of psychiatric visits to hospital emergency rooms rose 50% from 4.4 million in 2002 to 6.8 million in 2011 (National Ambulatory Medical Care Survey, 2002 – 2011) • Twice as many psychiatric as medical patients are stuck in ER’s longer than 6 hours, and many of these boarders remain in the ER for longer than 12 hours (Zhu et al, 2016)
32. Estimated that 26% of inmates in jails and 14% in state prisons suffer from a serious mental illness. Two million adults with mental health conditions glide through U.S. correctional facilities every year.
34. Lionel Penrose 1898-1972 Psychiatrist Medical geneticist Mathematician Chess theorist Lionel Penrose’s Hypothesis in 1939
35. Trans-Institutionalization
36. Acute: Private specialty hospitals General hospital units Scatter beds Psychiatric crisis centers Emergency departments What Kinds Of Beds Exist In The Continuum Of Psychiatric Care?
37. Intermediate: Forensic state psychiatric hospitals Transitional step-down beds Private specialty hospitals units What Kinds Of Beds Exist In The Continuum Of Psychiatric Care?
38. Long Term: Hospital-level State psychiatric hospitals Jails and prisons (beds behind bars) Residential Foster care Nursing homes Board and care or group homes Permanent supportive housing Other residential treatment centers What Kinds Of Beds Exist In The Continuum Of Psychiatric Care?
39. • Child and adolescent • Young adult • Geriatric • Eating disorders • OCD • Neuropsychiatry/Brain injury • Dual diagnosis: Substance use Subspecialty Inpatient Programs • Dual diagnosis: Intellectual Disability • Trauma/PTSD • Treatment resistant psychosis • LGBTQ/Transgender • Concierge/VIP
40. Permanent Supportive Housing (PSH) Services include: Case management Tenancy support Mental health and substance abuse treatment Supported Employment Housing First Permanent housing where support services are offered but not required to participate
41. A “System” For Mental Health Treatment and Recovery Must Include: Acute inpatient care Crisis intervention and emergency care Assertive community treatment Psychosocial rehabilitation Permanent supportive housing Supported employment Integrated “collaborative” primary care Peer support
42. Acute Inpatient Care: “Last resort” “Failure of the system” “A negative outcome” OR “Lifesaving” “Necessary component”
43. Opportunities or Goals of Acute Inpatient Care: Crisis stabilization and safety Comprehensive diagnostic formulation/reformulation Biological and psychological assessment Respite Family engagement Comprehensive discharge planning All Benefits that Support Recovery
44. Firearm fatalities per 100,000 population in 2015 H.H. Goldman, R.G Fran and J.P. Morissey (eds.) The Palgrave Handbook of American Mental Health Policy
46. 2017 Suicide Rate By State
47. 2017 Civil Bed Rate By State
48. Perhaps correlation or causation is the wrong question. The right question maybe “how many suicides could be averted if we had more beds ?”
49. What are the factors other than suicide that we need to measure to answer the broader question “ how many” beds should we have ?
50. What We Need To Know Hospital Key Performance Indicators • Out of area placements • Boarding in emergency rooms • Involuntary admission • Occupancy rates in psychiatric units • Average length of stay in psychiatric unit • Level of patient acuity and ward milieu • Discharge to homelessness • Readmission rates
51. • Rates of homelessness amongst SMI • Rates of SMI in homeless shelters • Rates of suicide • Rate of all cause mortality • Rates of crime by SMI • Rates of incarceration amongst SMI • Rate of SMI in jails • Burden on carers WhatWe Need To Know Population Indicators