Observed Outcomes: An Approach to Calculate the Optimum Number of Psychiatric Beds

  • Richard O’ReillyEmail author
  • Stephen Allison
  • Tarun Bastiampiallai
Original Article


The number of psychiatric beds, in most developed countries, has decreased progressively since the late 1950s. Many clinicians believe that this reduction has gone too far. But how can we determine the number of psychiatric beds a mental health system needs? While the population health approach has advantages over the normative approach, it makes assumptions about optimal and minimum duration of hospitalization required for various psychiatric disorders. In this paper, we describe a naturalistic approach that estimates the required number of psychiatric beds by comparing the bed levels at which negative outcomes develop in different jurisdictions. We hypothesize that there will be a threshold below which negative outcomes will be seen across jurisdictions. We predict that hospital key performance indices will be more sensitive to bed reductions than the clinical and social outcomes of patients. The observed outcome approach can complement other approaches to determining bed numbers at the national and local levels, and should be a priority for future health services research.


Psychiatric beds Deinstitutionalization Health services research 



This study did not receive any funding.

Compliance with Ethical Standards

Conflict of interest

The authors have no conflicts of interest related to this article.

Ethical Approval

This article does not contain any studies with human participants or animals performed by any of the authors.


  1. Alakeson, V., Pande, N., & Ludwig, M. (2010). A plan to reduce emergency room ‘boarding’ of psychiatric patients. Health Affairs, 29(9), 1637–1642. Scholar
  2. Allison, S., Bastiampillai, T., & Castle, D. (2017). Victoria’s low availability of public psychiatric beds and the impact on patients, carers and staff. Australian & New Zealand Journal of Psychiatry, 52(1), 91–92. Scholar
  3. Allison, S., Bastiampillai, T., Licinio, J., Fuller, D., Bidargaddi, N., & Sharfstein, S. (2018). When should governments increase the supply of psychiatric beds? Molecular Psychiatry, 23(4), 796–800.Google Scholar
  4. Applebaum, P. S. (2015). “Boarding” psychiatric patients in emergency rooms: One court says “no more”. Psychiatric Services, 66(7), 668–670. Scholar
  5. Ashton, C. M., Del Junco, D. J., Souchek, J., Wray, N. P., & Mansyur, C. L. (1997). The association between the quality of inpatient care and early readmission: A meta-analysis of the evidence. Medical Care, 35(10), 1044–1059.Google Scholar
  6. Babalola, O., Gormez, V., Alwan, N. A., Johnstone, P., & Sampson, S. (2014). Length of hospitalisation for people with severe mental illness. Cochrane Database of Systematic Reviews. Art. No: CD000384.Google Scholar
  7. Backer, T. E., Howard, E. A., & Moran, G. E. (2007). The role of effective discharge planning in preventing homelessness. The Journal of Primary Prevention, 28(3–4), 229–243.Google Scholar
  8. Bastiampillai, T., Sharfstein, S. S., & Allison, S. (2016). Increase in US suicide rates and critical decline in psychiatric beds. Journal of the American Medical Association, 316(24), 2591–2592. Scholar
  9. Bender, D., Pande, N., & Ludwig, L. (2008). A literature review: Psychiatric boarding. Prepared for the Office of Disability, Aging and Long-Term Care Policy Office of the Assistant Secretary for Planning and Evaluation U.S. Department of Health and Human Services Contract #HHS-100-03-0027. Retrieved from
  10. Blüml, V., Waldhör, T., Kapusta, N. D., & Vyssoki, B. (2015). Psychiatric hospital bed numbers and prison population sizes in 26 European countries: A critical reconsideration of the Penrose Hypothesis. PLoS ONE, 10(11), e0142163.Google Scholar
  11. Bowers, L., Stewart, D., Papadopoulos, C., Dack, C., Ross, J., Khanom, H., Jeffery, D. (2011). Inpatient violence and aggression: A literature review. Section of Mental Health Nursing Health Service and Population Research Institute of Psychiatry Kings College London.Google Scholar
  12. Brennan, P. A., Mednick, S. A., & Hodgins, S. (2000). Major mental disorders and criminal violence in a Danish birth cohort. Archives of General Psychiatry, 57(5), 494–500.Google Scholar
  13. Burti, L., & Benson, P. R. (1996). Psychiatric reform in Italy: Developments since 1978. International Journal of Law and Psychiatry, 19(3–4), 373–390.Google Scholar
  14. Caplan, G., Board, N., Paten, A., Tazelaar-Molinia, J., Crowe, P., Yap, S. J., & Brown, A. (1999). Decreasing lengths of stay: The cost to the community. Australian and New Zealand Journal of Surgery, 69(6), 433–437.Google Scholar
  15. Chalfin, D. B., Trzeciak, S., Likourezos, A., Baumann, B. M., & Dellinger, R. P. (2007). Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Critical Care Medicine, 35(6), 1477–1483. Scholar
  16. Chang, G., Weiss, A. P., Orav, E. J., Jones, J. A., Finn, C. T., Gitlin, D. F.,.. . Rauch, S. L. (2011). Hospital variability in emergency department length of stay for adult patients receiving psychiatric consultation: A prospective study. Annals of Emergency Medicine, 58(2), 127–136 e1. Scholar
  17. Chow, W. S., & Priebe, S. (2013). Understanding psychiatric institutionalization: A conceptual review. BMC Psychiatry, 13, 169. Scholar
  18. Chow, W. S., & Priebe, S. (2016). How has the extent of institutional mental healthcare changed in Western Europe? Analysis of data since 1990. British Medical Journal Open, 6(4), e010188. Scholar
  19. Crisp, N., Smith, G., & Nicholson, K. (Eds.). (2016).Old problems, new solutions: Improving acute psychiatric care for adults in England. London: The Commission on Acute Adult Psychiatric Care. Royal College of Psychiatrists.Google Scholar
  20. Dae-Young, K. (2016). Psychiatric deinstitutionalization and prison population growth: A critical literature review and its implications. Criminal Justice Policy Review, 27(1), 3–21.Google Scholar
  21. Deutsch, A. (1948). The shame of the states. New York: Harcourt, Brace.Google Scholar
  22. Edwards, T., Wolfson, P., & Killaspy, H. (2012). A guide to good practice in the use of out-of-area placements. London, England: Royal College of Psychiatrists’ Faculty of Rehabilitation and Social Psychiatry. Retrieved from
  23. Fazel, S., & Danesh, J. (2002). Serious mental disorder in 23 000 prisoners: A systematic review of 62 surveys. Lancet, 359(9306), 545–550.Google Scholar
  24. Fazel, S., Khosla, V., Doll, H., & Geddes, J. (2008). The prevalence of mental disorders among the homeless in western countries: Systematic review and meta-regression analysis. PLoS Medicine, 5(12), e225. Scholar
  25. Fioritti, A. (2018). Is freedom (still) therapy? The 40th anniversary of the Italian mental health care reform. Epidemiology and Psychiatric Sciences. Scholar
  26. Flyckt, L., Löthman, A., Jörgensen, L., Rylander, A., & Koernig, T. (2013). Burden of informal care giving to patients with psychoses: A descriptive and methodological study. International Journal of Social Psychiatry, 59(2), 137–146. Scholar
  27. Folsom, D., & Jeste, D. V. (2002). Schizophrenia in homeless persons: A systematic review of the literature. Acta Psychiatrica Scandinavica, 105(6), 404–413.Google Scholar
  28. Forchuk, C., Russell, G., Kingston-MacClure, S., Turner, K., & Dill, S. (2006). From psychiatric ward to the streets and shelters. Journal of Psychiatric and Mental Health Nursing, 13(3), 301–308.Google Scholar
  29. Fuller, D., Sinclair, E., Geller, J., Quanbeck, C., & Snook, J. (2016). Going, going, gone: Trends and consequences of eliminating state psychiatric beds. A report from the Office of Research and Public Affairs. Arlington, VA: Treatment Advocacy Center. Retrieved from
  30. Gaetz, S., Donaldson, J., Richter, T., & Gulliver, T. (2013). The state of homelessness in Canada 2013. Toronto, ON: Canadian Homelessness Research Network Press. Retrieved from
  31. Gatov, E., Rosella, L., Chiu, M., & Kurdyak, P. A. (2017). Trends in standardized mortality among individuals with schizophrenia, 1993–2012: A population-based, repeated cross-sectional study. Canadian Medical Association Journal, 189(37), E1177–E1187. Scholar
  32. Gaynes, B. N., Brown, C., Lux, L. J., Ashok, M., Coker-Schwimmer, E., Hoffman, V.,.. . Viswanathan, M. (2015). Management strategies to reduce psychiatric readmissions. Technical Briefs, No. 21, Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from
  33. Goffman, E. (1961). Asylums: Essays on the social situation of mental patients and other inmates. Garden City: Anchor Books.Google Scholar
  34. Goldacre, M., Seagroatt, V., & Hawton, K. (1993). Suicide after discharge from psychiatric inpatient care. The Lancet, 342(8866), 283–286.Google Scholar
  35. Gordon, A. (1997). Psychiatric bed levels. Position paper. Ottawa: The Canadian Psychiatric Association.Google Scholar
  36. Green, L. (2003). How many hospital beds? Inquiry, 39(4), 400–412.Google Scholar
  37. Guaiana, G., O’Reilly, R., & Grassi, L. (2018). A Comparison of inpatient adult psychiatric services in Italy and Canada. Community Mental Health Journal. Scholar
  38. Harris, M. G., Buckingham, W. J., Pirkis, J., Groves, A., & Whiteford, H. (2012). Planning estimates for the provision of core mental health services in Queensland 2007 to 2017. Australian and New Zealand Journal of Psychiatry, 46(10), 982–994.Google Scholar
  39. Hartvig, P., & Kjelsberg, E. (2009). Penrose’s law revisited: The relationship between mental institution beds, prison population and crime rate. Nordic Journal of Psychiatry, 63(1), 51–56. Scholar
  40. Jacobs, R., Gutacker, N., Mason, A., Goddard, M., Gravelle, H., Kendrick, T., & Gilbody, S. (2015). Determinants of hospital length of stay for people with serious mental illness in England and implications for payment systems: A regression analysis. BMC Health Services Research, 15, 439. Scholar
  41. Johnson, S. (2011). Has the closure of psychiatric beds gone too far? No. BMJ, 343, d7410. Scholar
  42. Jones, R. (2013). Optimum bed occupancy in psychiatric hospitals. Retrieved from
  43. Kalseth, J., Lassemo, E., Wahlbeck, K., Haaramo, P., & Magnussen, J. (2016). Psychiatric readmissions and their association with environmental and health system characteristics: A systematic review of the literature. BMC Psychiatry, 16, 376. Scholar
  44. Kentish, B. (2017). Number of mental health patients treated hundreds of miles from home hits new high. Independent. Retrieved from
  45. Keown, P., Weich, S., Bhui, K. S., & Scott, J. (2011). Association between provision of mental illness beds and rate of involuntary admissions in the NHS in England 1988–2008: Ecological study. BMJ, 343, d3736. Scholar
  46. Killaspy, H., & Meier, R. (2010). A fair deal for mental health includes local rehabilitation services. The Psychiatrist, 34, 265–267.Google Scholar
  47. La, E. M., Lich, K. H., Wells, R., Ellis, A. R., Swartz, M. S., Zhu, R., & Morrissey, J. P. (2016). Increasing access to state psychiatric hospital beds: Exploring supply-side solutions. Psychiatric Services, 67(5), 523–528. Scholar
  48. Large, M. M., & Nielssen, O. (2009). The Penrose hypothesis in 2004: Patient and prisoner numbers are positively correlated in low-and-middle income countries but are unrelated in high-income countries. Psychology and Psychotherapy, 82, 113–119.Google Scholar
  49. Lauber, C., Eichenberger, A., Luginbühl, P., Keller, C., & Rössler, W. (2003). Determinants of burden in caregivers of patients with exacerbating schizophrenia. The Journal of the Association of European Psychiatrists, 18(6), 285–289.Google Scholar
  50. Lawrence, D., Hancock, K. J., & Kisely, S. (2013). The gap in life expectancy from preventable physical illness in psychiatric patients in Western Australia: Retrospective analysis of population based registers. BMJ, 346, f2539. Scholar
  51. Lebenbaum, M., Chiu, M., Vigod, S., & Kurdyak, P. (2018). Prevalence and predictors of involuntary psychiatric hospital admissions in Ontario, Canada: A population-based linked administrative database study. BJPsych Open, 4(2), 31–38. Scholar
  52. Lee, B. A., Tyler, K. A., & Wright, J. D. (2010). The new homelessness revisited. Annual Review of Sociology, 36, 501–521. Scholar
  53. Lee, S., Rothbard, A. B., & Noll, E. L. (2012). Length of inpatient stay of persons with serious mental illness: Effects of hospital and regional characteristics. Psychiatric Services, 63(9), 889–895.Google Scholar
  54. Madsen, T., & Nordentoft, N. (2013). Changes in inpatient and post-discharge suicide rates in a nation-wide cohort of Danish psychiatric inpatients, 1998–2005. The Journal of Clinical Psychiatry, 74(12), e1190–e1194. Scholar
  55. Markowitz, F. E. (2006). Psychiatric hospital capacity, homelessness, and crime and arrest rates. Criminology, 44(1), 45–72. Scholar
  56. McNicoll, A. (2015). Mental health patients sent hundreds of miles for beds as out of area placements rise 23 per cent. Community Care. Retrieved from
  57. McPherson, P., Krotofil, J., & Killaspy, H. (2018). What works? Toward a new classification system for mental health supported accommodation services: The simple taxonomy for supported accommodation (STAX-SA). The international Journal of Environmental Research and Public Health, 15, 190. Scholar
  58. Meszaros, J. (2017). Falling through the cracks: The decline of mental health care and firearm violence. Journal of Mental Health, 26(4), 359–365. Scholar
  59. Mulè, A., Sideli, L., Capuccio, V., Fearon, P., Ferraro, L., Kirkbride, J. B.,.. . Murray, R. M. (2017). Low incidence of psychosis in Italy: Confirmation from the first epidemiological study in Sicily. Social Psychiatry and Psychiatric Epidemiology, 52(2), 155–162. Scholar
  60. Mundt, A. P., Chow, W. S., Arduino, M., Barrionuevo, H., Fritsch, R., Girala, N.,.. . Priebe, S. (2015). Psychiatric hospital beds and prison populations in South America since 1990: Does the Penrose hypothesis apply? Journal of the American Medical Association Psychiatry, 72(2), 112–118. Scholar
  61. Munk-Jorgensen, P. (1999). Has deinstitutionalization gone too far? European Archives of Psychiatry and Clinical Neuroscience., 24(3), 136–143.Google Scholar
  62. Nicks, B. A., & Manthey, D. M. (2012). The impact of psychiatric patient boarding in emergency departments. Emergency Medicine International. Scholar
  63. Nordström, P., Gustafson, Y., Michaëlsson, K., & Nordström, A. (2015). Length of hospital stay after hip fracture and short term risk of death after discharge: A total cohort study in Sweden. BMJ, 350, h696. Scholar
  64. North, C. S., Eyrich, K. M., Pollio, D. E., & Spitznagel, E. L. (2004). Are rates of psychiatric disorders in the homeless population changing? American Journal of Public Health, 94(1), 103–108.Google Scholar
  65. O’Neil, A. (2016). The need for national data on “boarding” psychiatric patients in emergency departments. Psychiatric Services, 67(3), 359–360.Google Scholar
  66. OECD: Health Data 2009 (2009). Statistics and indicators for 30 countries. Paris, France: Organisation for Economic Cooperation and Development. Retrieved from
  67. Penrose, L. S. (1939). Mental disease and crime: Outline of a comparative study of European statistics. British Journal of Medical Psychology, 18(1), 1–15. Scholar
  68. Pirkis, J., Harris, M., Buckingham, W., Whiteford, H., & Townsend-White, C. (2007). International planning directions for provision of mental health. services. Administration and Policy in Mental Health and Mental Health Services Research, 34(4), 377–387. Scholar
  69. Pirkola, S., Sohlman, B., Heilä, H., & Wahlbeck, K. (2007). Reductions in postdischarge suicide after deinstitutionalization and decentralization: A nationwide register study in Finland. Psychiatric Services, 58(2), 221–226.Google Scholar
  70. Priebe, S., Badesconyi, A., Fioritti, A., Hansson, L., Kilian, R., Torres-Gonzales, F.,.. . Wiersma, D. (2005). Reinstitutionalisation in mental health care: Comparison of data on service provision from six European countries. British Medical Journal, 330(7483), 123–126.Google Scholar
  71. Primeau, A., Bowers, T. G., Harrison, M. A., & XuXu. (2013). Deinstitutionalization of the mentally ill: Evidence for transinstitutionalization from psychiatric hospitals to penal institutions. Comprehensive Psychology. Scholar
  72. Raphael, S., & Stoll, M. A. (2013). Assessing the contribution of the deinstitutionalization of the mentally ill to growth in the U.S. incarceration rate. The Journal of Legal Studies, 42, 187–222.Google Scholar
  73. Rosen, A., Mezzina, R., & Shiers, D. (2018). The future of psychiatry commission [Letter]. The Lancet Psychiatry, 5(1), 16–17.Google Scholar
  74. Royal College of Psychiatrists. (2011). Do the right thing: How to judge a good ward. Ten standards for adult in-patient mental healthcare. London: Royal College of Psychiatrists.Google Scholar
  75. Sealy, P., & Whitehead, P. C. (2004). Forty years of deinstitutionalization of psychiatric services in Canada: An empirical assessment. Canadian Journal of Psychiatry, 49(4), 249–257. Scholar
  76. Simpson, S. A., Joesch, J. M., West, I. I., & Pasic, J. (2014). Who’s boarding in the psychiatric emergency service? Western Journal of Emergency Medicine, 15(6), 669–674.Google Scholar
  77. Sinha, M. (2012). Portrait of caregivers, 2012. Spotlight on Canadians: Results from the general social survey. Statistics Canada. Government of Canada. Retrieved from
  78. Sisti, D. A., Segal, A. G., & Emanuel, E. J. (2015). Improving long-term psychiatric care: Bring back the asylum. Journal of the American Medical Association, 313(3), 243–244.Google Scholar
  79. Sisti, D. A., Sinclair, E. A., & Sharfstein, S. S. (2018). Bedless psychiatry – rebuilding behavioural health capacity. Journal of the American Medical Association Psychiatry. Scholar
  80. Slade, E. P., & Goldman, H. H. (2015). The dynamics of psychiatric bed use in general hospitals. Administration and Policy in Mental Health and Mental Health Services Research, 42(2), 139–146. Scholar
  81. Steadman, H. J., Monahan, J., Duffee, B., & Hartstone, E. (1984). The impact of state mental hospital deinstitutionalization on United States prison populations, 1968–1978. Journal of Criminal Law and Criminology, 75(2), 474–490.Google Scholar
  82. Swartz, M. S. (2016). Emergency department boarding: Nowhere else to go. Psychiatric Services, 67(11), 1163.Google Scholar
  83. Thornicroft, T., & Tansella, M. (2013). The balanced care model: The case for both hospital- and community-based mental healthcare. The British Journal of Psychiatry, 202(4), 246–248. Scholar
  84. Toneli, M. R. (1999). In defense of expert opinion. Academic Medicine., 74(11), 1187–1192.Google Scholar
  85. Torrey, E. F. (2015). Deinstitutionalization and the rise of violence. CNS Spectrums, 20(03), 1–8. Scholar
  86. Torrey, E. F., Entsminger, K., Geller, J., Stanley, J., & Jaffe, D. J. (2008). The shortage of public hospital beds for mentally ill persons. Arlington: The Treatment Advocacy Center.Google Scholar
  87. Tyrer, P. (2011). Has the closure of psychiatric beds gone too far? Yes. BMJ, 343, d7457 Scholar
  88. Virtanen, M., Vahtera, J., Batty, G. D., Tuisku, K., Pentti, J., Oksanen, T.,.. . Kivimaki, M. (2011). Overcrowding in psychiatric wards and physical assaults on staff: Data-linked longitudinal study. British Journal of Psychiatry, 198(2), 149–155.Google Scholar
  89. Vogel, M. (2014). Mental illness and criminal behavior. Social Compass, 8, 337–346.Google Scholar
  90. Vyssoki, B., Willeit, B., Blüml, V., Höfer, P., Erfurth, A., Psota, G.,.. . Kapusta, N. D. (2011). Inpatient treatment of major depression in Austria between 1989 and 2009: Impact of downsizing of psychiatric hospitals on admissions, suicide rates and outpatient psychiatric services. Journal of Affective Disorders, 133(1–2), 93–96. Scholar
  91. Wahlbeck, K., Westman, J., Nordentoft, M., Gissler, M., & Laursen, T. M. (2011). Outcomes of Nordic mental health systems: Life expectancy of patients with mental disorders. The British Journal of Psychiatry, 199(6), 453–458. Scholar
  92. Walker, E. R., McGee, R. E., & Druss, B. G. (2015). Mortality in mental disorders and global disease burden implications: A systematic review and meta-analysis. Journal of the American Medical Association Psychiatry, 72(4), 334–341. Scholar
  93. Wang, H., Dwyer-Lindgren, L., Lofgren, K. T., Rajaratnam, J. K., Marcus, J. R., Levin-Rector, A.,.. . Murray, C. J. L. (2012). Age-specific and sex-specific mortality in 187 countries, 1970–2010: A systematic analysis for the Global Burden of Disease Study 2010. The Lancet, 380(9859), 2071–2094.Google Scholar
  94. Wong, E. L., Cheung, A. W., Leung, M. C., Yam, C. H., Chan, F. W., Wong, F. Y., & Yeoh, E. K. (2011). Unplanned readmission rates, length of hospital stay, mortality, and medical costs of ten common medical conditions: A retrospective analysis of Hong Kong hospital data. BMC Health Services Research, 11, 149. Scholar
  95. Yoon, J., & Bruckner, T. A. (2009). Does deinstitutionalization increase suicide? Health Services Research, 44(4), 1385–1405. Scholar

Copyright information

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Authors and Affiliations

  • Richard O’Reilly
    • 1
    Email author
  • Stephen Allison
    • 2
  • Tarun Bastiampiallai
    • 2
  1. 1.Department of Psychiatry, Schulich School of Medicine & Dentistry, St. Joseph’s Health Care LondonWestern UniversityLondonCanada
  2. 2.Department of Psychiatry, College of Medicine and Public HealthFlinders UniversityAdelaideAustralia

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