Expert Arguments for Trends of Psychiatric Bed Numbers: A Systematic Review of Qualitative Data

Types of Psychiatric Beds and Mental Health Services in 16 Latin American Countries, 1990-2020

OBJECTIVE

Latin America has undergone major changes in psychiatric services over the past three decades. The authors aimed to assess the availability of service data and changes in psychiatric services in this region during the 1990-2020 period.

METHODS

The authors formed a research network to collect data on psychiatric service indicators gathered between 1990 and 2020 from national registries in Argentina, Bolivia, Brazil, Chile, Colombia, Costa Rica, Dominican Republic, Ecuador, El Salvador, Guatemala, Honduras, Mexico, Panama, Paraguay, Peru, and Uruguay. Indicators included psychiatric beds in psychiatric and general hospitals overall, for children and adolescents, and for forensic populations; residential beds for substance use treatment; treatment slots in residential facilities and day hospitals; and outpatient facilities.

RESULTS

Data availability varied among countries, service indicators, and time points. The median prevalence of psychiatric beds decreased in psychiatric hospitals from 5.1 to 3.0 per 100,000 people (-42%) and in general hospitals from 1.0 to 0.8 (-24%). The median prevalence estimates of specialized psychiatric beds for children and adolescents (0.18) and for forensic populations (0.04) remained unchanged. Increases in prevalence were observed for residential beds for substance use treatment (from 0.40 to 0.57, 43% increase), available treatment slots in residential facilities (0.67 to 0.79, 17%), treatment slots in day hospitals (0.41 to 0.54, 32%), and outpatient facilities (0.39 to 0.93, 138%).

CONCLUSIONS

The findings indicate that treatment capacity shifted from inpatient to outpatient and community care. Most countries had a bed shortage for acute psychiatric care, especially for children and adolescents and forensic patients. More comprehensive and standardized mental health service registries are needed.

Deinstitutionalization, community-based care and incarceration of people with severe mental illness: Out of sight, out of mind?

Although the international literature points to a number of benefits from deinstitutionalization, such as limiting coercion, more cost-effectiveness of care systems, and better use of community care, it may be helpful to take a broader perspective on where coercion and institutionalization of people with severe mental illnesses (SMI) and/or substance use disorders frequently occur: in prisons and jails. In this comment, we propose to move beyond the inpatient/outpatient dichotomy.

Changes in rates of psychiatric beds and prison populations in sub-Saharan Africa from 1990 to 2020

Background

Psychiatric bed numbers (general, forensic, and residential) and prison populations have been considered indicators of institutionalization. The present study aimed to assess changes of those indicators across sub-Saharan Africa (SSA) from 1990 to 2020.

Methods

We retrospectively obtained data on psychiatric bed numbers and prison populations from 46 countries in SSA between 1990 and 2020. Mean and median rates, as well as percentage changes between first and last data points were calculated for all of SSA and for groups of countries based on income levels.

Results

Primary data were retrieved from 17 out of 48 countries. Data from secondary sources were used for 29 countries. From two countries, data were unavailable. The median rate of psychiatric beds decreased from 3.0 to 2.2 per 100 000 population (median percentage change = -16.1%) between 1990 and 2020. Beds in forensic and residential facilities were nonexistent in most countries of SSA in 2020, and no trend for building those capacities was detected. The median prison population rate also decreased from 77.8 to 71.0 per 100 000 population (-7.8%). There were lower rates of psychiatric beds and prison populations in low-income and lower-middle income countries compared with upper-middle income countries.

Conclusions

SSA countries showed, on average, a reduction of psychiatric bed rates from already very low levels, which may correspond to a crisis in acute psychiatric care. Psychiatric bed rates were, on average, about one twenty-fifth of countries in the Organization for Economic Co-operation and Development (OECD), while prison population rates were similar. The heterogeneity of trends among SSA countries over the last three decades indicates that developments in the region may not have been based on coordinated policies and reflects unique circumstances faced by the individual countries.

Minimum and optimal numbers of psychiatric beds: expert consensus using a Delphi process

The required minimum number of psychiatric inpatient beds is highly debated and has substantial resource implications. The present study used the Delphi method to try to reach a global consensus on the minimum and optimal psychiatric bed numbers. An international board of scientific advisors nominated the Delphi panel members. In the first round, the expert panel provided responses exploring estimate ranges for a minimum to optimal numbers of psychiatric beds and three levels of shortage. In a second round, the panel reconsidered their responses using the input from the total group to achieve consensus. The Delphi panel comprised 65 experts (42% women, 54% based in low- and middle-income countries) from 40 countries in the six regions of the World Health Organization. Sixty psychiatric beds per 100 000 population were considered optimal and 30 the minimum, whilst 25-30 was regarded as mild, 15-25 as moderate, and less than 15 as severe shortage. This is the first expert consensus on minimum and optimal bed numbers involving experts from HICs and LMICs. Many high-income countries have psychiatric bed numbers that fall within the recommended range. In contrast, the number of beds in many LMIC is below the minimum recommended rate.