Bed Shortages

The national shortage of psychiatric beds and community treatment services is directly related to the increased criminalization of SMI. After arresting a person who is clearly in a mental illness-related crisis, an officer must decide whether to take them to jail or take them to a hospital or crisis center for treatment. Research suggests that officers may be less likely to take someone to a hospital when they believe that the person will not be admitted, an all too frequent occurrence in mental health care systems with state hospitals that are operating at or over capacity due to bed shortages.

The elimination of hospital beds for civil patients also contributes to the criminalization of SMI by eliminating a form of preventative care. For many years, civil commitment provided an opportunity for people with SMI to receive treatment before they decompensated to the point of becoming involved with the criminal system due to their severe symptoms. In fact, a 2023 study found a strong relationship between competency restoration orders and civil commitment orders in Oregon, suggesting that “neglecting civil commitment may well have contributed to the CST [competency to stand trial] crisis in Oregon.”

In 2023, almost half of states had a majority of their beds occupied by patients who had been committed to care through the criminal system. When most or all of a state’s psychiatric beds are used for patients who are involved with the criminal legal system, it leaves people with SMI who need long-term, hospital-level care and who have no criminal behavior with few options for treatment. When they are turned away from emergency departments or discharged before their symptoms have fully stabilized, they can go on to harm themselves, harm others, or engage in disruptive behavior that leads to arrest.

Thus, after being turned away from the hospital as voluntary civil patients, some people will deteriorate and experience increasingly severe symptoms. Although such patients may meet inpatient commitment criteria and would have gained access to state hospital beds as civil patients in the past, even those who are experiencing very serious symptoms are increasingly deemed ineligible for commitment to state hospital beds until they have been charged with a crime and are committed as forensic patients.

In 2016, TAC wrote, “The reality that an immeasurable number of people with treatable diseases only get treatment when they get sick enough to commit crimes that send them to jail and then to a forensic bed should be a source of national shame and outcry for reform.” In the 10 years since, the situation has gotten even worse. The number of beds occupied by civil patients per 100,000 population decreased by 17 percent from 2016 to 2023.

The shortage of state hospital beds also causes thousands of people with SMI who have not been convicted of crimes to wait in jail for a bed to open, so they can receive competency evaluation and restoration before they can stand trial.

One 2020 survey of state officials who were responsible for patients who required competency evaluation and restoration found that referrals for competency evaluation had been increasing in 82% of states and referrals for competency restoration had been increasing in 78% of states. State officials identified a shortage of community mental health services, crisis services, and psychiatric beds as the biggest contributors to the rising need for competency evaluations. The majority of patients who are found not competent to stand trial have psychotic disorders.

In 2023, TAC’s original reporting found that a total of 5,576 people with SMI were waiting for admission to a state hospital across 33 states. Among the 26 states that reported information about the duration of time spent in jail, inmates spent a median of two months waiting for a bed to open. When people with SMI are detained in jail while in the middle of a mental health crisis, they may gain additional charges due to disruptive behaviors that are symptoms of their illness, get sicker as they spend extended periods of time without treatment, or even die from preventable causes such as dehydration.

When the need for state hospital beds outpaces availability, states must make difficult choices about who to treat and how long to treat them. One approach to this issue is to discharge people as quickly as possible, sometimes with deadly consequences. Research suggests that shorter lengths of stays in treatment facilities are associated with an increased risk of suicide during the post-discharge period, and an increased risk of readmission within 30 days of admission.

Another approach is to treat people as long as is medically necessary, leading to longer waitlists and more people waiting in jail for competency restoration. While this approach may be associated with reduced readmission rates for patients, it can also cause states to be sanctioned with expensive lawsuits over unjust wait times for competency restoration.

The decrease in psychiatric beds has led to an increase in the amount of psychiatric care that takes place in emergency departments and has also led to a high rate of psychiatric boarding in emergency departments. A patient is considered to have been “boarded” in the emergency department when their “evaluation is complete and the decision has been made to either admit or transfer, but for whom there is no available bed.” Psychiatric patients are 4.8 times more likely to be boarded than non-psychiatric patients and are boarded for longer periods of time. Across the literature, average boarding times range from hours.

Psychiatric boarding is associated with a range of negative outcomes, including an exacerbation of symptoms because of the chaotic environment of the emergency department, decreased availability of emergency department staff, longer wait times for all patients, and increased rates of patients who leave without ever being seen.