Since the 1960s, the number of psychiatric beds in the United States has decreased dramatically as a result of the closure of the traditional asylum system and the shift to community-based mental health care. Between 1998 and 2013, the number of psychiatric beds in the US fell by 35%, from 34 to 22 per 100,000 people. During the same period, the age-adjusted suicide rate increased from 10.5 to 13.0 deaths per 100,000 people per year.1
On Wednesday, January 8, 2020, Steven Sharfstein, MD, MPA, the former president of the American Psychiatric Association (APA) and president emeritus of the Sheppard Pratt Health System in Baltimore, Maryland, delivered the Wulfson Memorial Grand Rounds at Weill Cornell Medical College in New York City. Dr Sharftsein’s lecture addressed the potential overlap between the rapid rise in the rate of suicides and the steady decrease in psychiatric beds in the United States over the past few decades.
In a viewpoint published in JAMA in December 2016, Dr Sharfstein and colleagues pointed out that the level of beds in the US remains well below the Organization for Economic Cooperation and Development (OECD) average of 71 beds per 100,000 people.1 They argued that “The national US suicide prevention strategy should include a necessary minimum number of psychiatric beds for patients at risk of suicide.” Although suicide rates have been linked to reduced public psychiatric bed supply,2 there has been conflicting evidence.3 In particular, the cases of Japan, a nation with a major suicide crisis and a high number of psychiatric beds, and Italy, with a relatively low suicide rate and a very low number of beds,4 present a challenge to this relationship.
To learn more about the suicide crisis in the US, Psychiatry Advisor spoke with Dr Sharfstein on Monday, January 13, 2020. The interview has been edited for clarity and length.
Psychiatry Advisor: In your lecture, you examined the decline in hospital beds and the simultaneous rise in suicides. Why look at this relationship?
Steven Sharfstein, MD, MPA: There has been an elimination of psychiatric beds and a trend toward very short stays, so much so that the US has one of the lowest numbers of acute inpatient beds per 100,000 people in the world. The average [number of beds] in OECD countries is 71, and in the US, it is 22 beds, per 100,000 people. There are only 4 countries that have fewer beds. We know from studies and anecdotally that people in emergency rooms cannot find a bed, and often wait for long periods. This has become a public health crisis, and there is no capacity to take care of psychiatric emergencies.
The biggest psychiatric emergency in most places is suicide, including cases of suicidal ideation or suicide attempts. The lack of beds is a contributor to the rapid increase in suicide rates for teenagers and adults, and the fact that we do not have a way of [enrolling] people into acute psychiatric settings efficiently and effectively.
We know that interrupting a suicidal impulse or getting in between a person and the method of hurting themselves can be life-saving. The chances that [people] will go on to commit suicide later are relatively low. Many people who have [attempted suicide] and not succeeded regret that they made that attempt. They have a much higher risk for a second attempt, but their chances of dying by suicide in their lifetime is around 7%.
Psychiatry Advisor: In your view, suicide is fairly preventable and relies on social connectedness. It may even relate to the diseases of despair hypothesis. Do you believe that suicides could rise because people are more disconnected and lacking social supports?
Dr Sharfstein: Absolutely. Society has become more disconnected, and there are not really systems of care, just individuals. The whole social fabric has frayed, and the sense of despair, isolation, and loneliness is certainly a piece of the story. There was a recent finding that up to a third of opioid overdoses may be suicides.5 We know that the risk factors for an opioid overdose overlap with those for successful suicides.
Psychiatry Advisor: Do patients seem more isolated and disconnected to you now? How do you think patients and the problems they face have changed over the course of your career?
Dr Sharfstein: The diseases of despair theory relates to a specific socioeconomic and demographic group. The most at-risk individuals are those living in rural areas. They are white, male, in their 40s to 50s, and in economically difficult spots. The relationship between employment and psychiatric hospitalization has been well documented in the literature. High unemployment feeds into high rates of people going into the hospital.
Psychiatry Advisor: Since 1999, the suicide rate for adolescents in the United States has increased 50% compared with 33% in the general population. Why such an extreme rise for young people?
Dr Sharfstein: Dr Richard Friedman wrote a column on this topic in the New York Times last week.6 He brought up one particularly interesting factor: when the black box warning on antidepressants was issued by the FDA, the rate of prescriptions for antidepressants for adolescents went down dramatically and the suicide rate went up. The data on suicidality and antidepressants were always sketchy, in my view. Yes, some kids have an increase in suicidal ideation, but there was never any compelling data that successful suicides happen with antidepressants. As soon as doctors became afraid, fewer kids were being treated. Depression is a potentially lethal illness, especially in adolescents. It is a compelling reason why there has been an increase in suicides: less use of life-saving antidepressant medications.
Psychiatry Advisor: In your opinion, why does suicide as an issue carry so much stigma?
Dr Sharfstein: Mental illness has stigma in part because it can be very frightening. The idea of someone close to you committing suicide is a frightening subject, and as a result it becomes stigmatized. In law and religion, it is criminal or a sin. At the same time, there is some increasing recognition that it is part of being human: the choice to live or to die is a human one. People are hurt when someone commits suicide. The victim is no longer around, but the loved ones are hurt. It is hard to destigmatize suicide, as it is hard to destigmatize serious mental illness.
Psychiatry Advisor: You mentioned Penrose’s Law in your lecture. With many patients now in the prison system, what do you think of the quality of care being provided there? What challenges do patients in the prison system face?
Dr Sharfstein: Prisons function in terms of containment and punishment, not for therapeutic purposes. The quality of prison psychiatry care is compromised by the culture of the prison. It is a place with lots of sensory deprivation, threats, and fear. As such, it is antitherapeutic to an extreme degree. For those with serious mental illnesses, it is a nightmare.
Psychiatry Advisor: What should physicians do to combat the rise in suicide? As a discipline, what should psychiatrists and psychiatric organizations, such as the APA, do to tackle these issues?
Dr Sharfstein: The practice of psychiatry needs to spend more time and effort working with general physicians to build their skills in both the diagnosis and treatment of depression and other mental disorders. I have been working as an embedded psychiatrist in a multispeciality group practice to help physicians screen for depression and suicide. Nearly half of all people who complete a suicide have not seen anybody in the medical field. The people who have seen somebody within the 3 or 6 months of a suicide often see a general physician. Physicians should be aware and be concerned. They have major role: a large percentage of general practice is mental health. People may have another medical problem, but the main reason they visit the doctor may be anxiety or depression. They need to have certain skills of diagnosis and treatment to be aware of the possibility of suicide.
Psychiatrists as specialists should have a leadership role in working with the rest of the medical field. The APA used to be at the forefront, working with various suicide associations and other patient groups to alert people to the signs and symptoms of depression and what can be done when someone is suicidal. The APA also has to be at the forefront in advocating for more psychiatric beds.
Psychiatry Advisor: Ultimately, you think increasing psychiatric beds would help combat the rise in suicides. What other issues do you think it would relieve?
Dr Sharfstein: In general, it would be better if more beds were available. There would be fewer people in jails; that is the big impact. A very typical situation: Someone with depression and suicidal thoughts who is on the margins and in despair may become homeless. They may arrive in the ER, but there are no beds and they are discharged. They leave and wander in the streets, then they commit a property crime and end up in jail. As a result, they find themselves looking at the bars and thinking about tying a sheet to the jail cell. It’s not an unusual story.
Psychiatry Advisor: Lastly, is there anything you would like to add?
Dr Sharfstein: I think we have to alert policymakers to the loss of psychiatric beds. One of the biggest advocates for more beds is President Trump. He comes at it from a different angle, which I don’t agree with: if you had more beds, then you would have less mass shootings. I think you would have fewer potential suicides, including by guns, if you had more beds, but I don’t think it would impact mass shootings. In the end, both of us agree that we need more beds.
1. Bastiampillai T, Sharfstein SS, Allison S. Increase in US suicide rates and the critical decline in psychiatric beds. JAMA. 2016;316(24):2591-2592.
2. Yoon J, Bruckner TA. Does deinstitutionalization increase suicide? Health Serv Res. 2009;44(4):1385-1405.
3. Gibbons RD, Hur K, Mann JJ. Suicide rates and the declining psychiatric hospital bed capacity in the United States. JAMA Psychiatry. 2017;74(8):849-850.
4. The Organization for Economic Cooperation and Development (OECD). Making mental health count: the social and economic costs of neglecting mental health care. Focus on Health. July 2014.
5. Liu D, Yu M, Duncan J, Fondario A, Kharrazi H, Nestadt PS. Discovering the unclassified suicide cases among undetermined drug overdose deaths using machine learning techniques [published online September 19, 2019]. Suicide Life Threat Behav. doi:10.1111/sltb.12591.
6. Friedman R. Why are young Americans killing themselves? The New York Times. January 6, 2020.