The transformation of the mental health system in the United States continues at an unabated pace. The philosophy of community treatment of severe mental illness, which has guided national mental health policies for several decades, is now evolving toward a recovery-oriented, consumer-operated, and culturally competent system. California's recent Mental Health Service Act of 2004 exemplifies this change (Scheffler and Adams 2005
). However, our study provides a cautionary note regarding this transformation as we find that downsizing of public inpatient mental health services may lead to increased suicide rates. If other conditions do not change, retaining public psychiatric hospital beds may have a suicide prevention effect.
To help gauge the cost-effectiveness of maintaining public beds, we estimated the cost per life-year saved due to retaining public beds. Using data on national expenditures for inpatient treatment in state psychiatric hospitals (US$7,447 million in 2002 dollars; see NRI 2006b
) and the number of public psychiatric hospital beds in 2002 (57,263 beds; see Manderscheid et al. 2004
), we estimate the cost of maintaining a public bed at US$130,049 per year. One public bed per 100,000 persons, therefore, costs US$236,428,082 (US$130,049 × 1,818 beds). Under the assumption that this additional retention of public beds prevents 1,988 years of potential life lost due to suicide, we estimate a cost to society of about US$118,928 per year of life saved. This amount appears substantially lower than suggested thresholds used to determine cost-effectiveness (e.g., US$200,000 per life-year; see Ubel et al. 2003
Our findings show that although the substitution of private beds for public beds did not affect suicide rates, it appeared to increase suicide rates when outlying states were removed. In addition, ceteris paribus, greater private beds did not reduce suicide rates. The substitution issue warrants further investigation. Nevertheless, our discovered effect of increasing community mental health funding may be promising because this spending may reduce the sequelae of public psychiatric bed reductions. We note that, at the current low level of community funding, a further reduction of public beds could yield adverse population mental health outcomes. Taken together, our results suggest that growth in community treatment options has not fully compensated for the reductions in the “safety net” capability of public beds.
The reader should interpret our results in light of several limitations. We report a positive, but nonrobust, relationship between community mental health funding and suicide. Advocates have suggested that community mental health resources inadequately serve a growing body of mentally ill persons in the community (Lamb, Weinberger, and Gross 2004
). Increased spending, therefore, may serve as a marker for increased mental illness in that state but may not reach adequate levels to prevent suicide. We, however, found that increasing community funding reduces suicide rates only above a particular level. These results likely arise from the fact that reduction of public beds led to increased suicide rates, but the growth of funding for community mental health remained below the level of need.
Another limitation includes measurement error in that suicide may be inappropriately classified as an accident or undetermined. Coroners appear more likely to misclassify suicides when, for example, they have fewer person-hours to investigate the case (Douglas 1967
; Rockett, Samora, and Coben 2006
;). This misclassification is largely unidirectional since the risk of ruling a nonsuicide as a suicide appears small (Moyer, Boyle, and Pollock 1989
; O'Carroll 1989
;). It remains possible, therefore, that states with relatively many health resources may more accurately measure suicides. This circumstance could bias results toward a positive association between public hospital beds and suicide. The fact that we discovered an inverse association, however, implies that measurement error of suicide may attenuate the true magnitude of the effect.
Other features of community mental health programs that we did not investigate (e.g., the effective organization and utilization of resources and services) may have important implications. For example, inpatient services in community mental health centers or comprehensive support programs may buffer the effect of public bed reductions. Although these features are reflected in our expenditure metric, data limitations precluded examination of their potential effects on suicide. We view this as an important agenda for future research.
This study focused on the contemporaneous effect of a change in mental health resources on suicide rates. However, it remains possible that mental health resources could influence suicides in the following year. We explored this possibility with 1-year lagged values of the main independent variables. The discovered coefficients on the lagged explanatory variables bolster our main findings as they provide the same implications as those from the contemporaneous variables, although the size of the associations was smaller. Future studies with a priori hypotheses of a lag structure, particularly with an emphasis on causal mechanisms, may help better understand the sequence of the effect of a change in mental health resources on population mental health.