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Section VI: National Mental Health StatisticsPDF
version Chapter 18. Highlights of Organized Mental Health Services in 2000 and Major National and State TrendsRonald W. Manderscheid, Ph.D.; Joanne E. Atay, M.A. Alisa Male, M.A.; Beatrice Blacklow, M.P.H.; Christine Forest; Linda Ingram,
M.A. James Maedke; Jeffrey Sussman; Adrien Ndikumwami During the 30 years leading up to 2000, significant changes occurred in the number, capacity, structure, and operation of organizations providing mental health services in the United States. This chapter describes some of the changes that have occurred nationally in the delivery system, analyzes some of the policy implications of these changes for future planning purposes, and presents some comparative data by State. The source of most of the organizational data presented in this chapter is the periodic Survey of Mental Health Organizations and General Hospital Mental Health Services (SMHO; see appendix A) conducted by the Survey and Analysis Branch, Division of State and Community Systems Development, Center for Mental Health Services (CMHS), Substance Abuse and Mental Health Services Administration (SAMHSA). The SMHO is a complete enumeration of all specialty mental health organizations and separate psychiatric services of non Federal general hospitals, together with a sample survey that collects descriptive information on the number and types of services, capacity (number of beds), volume of services (numbers of episodes, additions, and resident patients), staffing, expenditures, and sources of revenue. The types of mental health organizations covered are State and county mental hospitals, private psychiatric hospitals, non Federal general hospitals with separate psychiatric services, Department of Veterans Affairs (VA) medical centers, residential treatment centers (RTCs) for emotionally disturbed children, and "all other mental health organizations," which includes multiservice mental health organizations, freestanding psychiatric outpatient clinics, and partial care psychiatric organizations. Definitions of these organization types are given in appendix A. This chapter examines four organizational focuses of the specialty mental health care sector:
Availability of ServicesNumber of Organizations and Service Settings The total number of mental health organizations in the United States1 increased between 1970 and 1998 from 3,005 to 5,722 (see table 1). However, there was a slight dip between 1992 and 1994, as well as a decrease between 1998 and 2000, from 5,772 to 4,546. Almost all the increase up to 1998 occurred as a result of gains in the number of private psychiatric hospitals, separate psychiatric services of non Federal general hospitals, RTCs, and "all other mental health organizations," because the number of State and county mental hospitals (hereafter referred to as State mental hospitals) and freestanding outpatient clinics (included in the rubric "all other mental health organizations") decreased, and the number of VA medical centers with psychiatric services remained relatively unchanged. Although the number of private psychiatric hospitals in 1998 was still more than twice the number in 1970, this represented a substantial decline from their 1992 peak. During the 2-year period between 1998 and 2000, the number of private psychiatric hospitals continued to decline by about 23 percent. Although the number of mental health organizations increased overall leading up to 1998, the number of organizations providing 24-hour hospital and residential treatment services peaked in 1994 and has decreased slightly since, from 3,827 to 3,202. For example, between 1970 and 1994, the number providing 24-hour hospital and residential treatment services nearly doubled from 1,734 to 3,827.2 This number declined between 1994 and 2000 to 3,202. The number providing less than 24 hour services rose consistently between 1970 and 1998, from 2,156 to 4,386.3 However, between 1998 and 2000 the number of mental health organizations providing less than 24-hour services decreased to 3,542. Number of Psychiatric Beds Although the number of mental health organizations providing 24 hour services (hospital inpatient and residential treatment) increased significantly over the 30 year period, the number of psychiatric beds provided by these organizations decreased by more than half, from 524,878 in 1970 to 215,221 in 2000 (see table 2). The corresponding bed rates per 100,000 civilian population dropped proportionately more in the same period, from 264 to 77. Beds in State mental hospitals accounted for most of this precipitous drop, with their number representing only 28 percent of all psychiatric beds in 2000, compared with almost 80 percent in 1970 (see figure 1). Trends in bed rates for specific organization types, shown in figure 2, indicate that the rates for private psychiatric hospitals and non Federal general hospital psychiatric inpatient services increased substantially between 1970 and 1990, with the greatest growth occurring between 1980 and 1990; throughout the 1990s, bed rates remained stable for non-Federal general hospitals but declined slightly between 1998 and 2000. In addition, bed rates for private psychiatric hospitals declined, although they remained above the rates for 1980 and earlier. The rate for RTCs was nearly flat from 1970 to 2000, while the rate for State mental hospitals and VA psychiatric organizations decreased substantially. The greatest increase from 1970 to 1998-from fewer than one bed per 100,000 population to 23 beds-occurred in the "all other mental health organizations" category, which includes the multiservice organizations (table 2). However, between 1998 and 2000, the bed rate for this category decreased to 16 beds. In each of the years shown, the number of "scatter" beds in non Federal general hospitals has been excluded. Scatter beds are those that are commingled with medical surgical beds in non Federal general hospitals, as distinguished from those that are in the separate psychiatric services of these hospitals. Volume of ServicesAdditions to 24 Hour Hospital and Residential Services The number of 24 hour hospital and residential treatment additions increased steadily between 1969 and 1998, from 1,282,698 to 2,299,959, with a slight decrease between 1998 and 2000 to 2,152,874. There was a corresponding increase in the addition rate from 644 per 100,000 civilian population in 1969 to 875 in 1994. The addition rate decreased in both 1998 and 2000 to 855 and 768, respectively (see table 3). In 1969, three quarters of the 24 hour hospital patients were about evenly divided between State mental hospitals and the psychiatric services of non Federal general hospitals. A constant and precipitous decline in the number of additions and the addition rate to State mental hospitals from 1969 to 1998, accompanied by substantial increases in these measures for the 24 hour services at non Federal general hospitals and private psychiatric hospitals, especially after 1979, shifted the volume of patient additions to these latter two organization types. By 2000, non Federal general hospital inpatient psychiatric services accounted for nearly 50 percent and private psychiatric hospitals for 25 percent of all inpatient additions, while the proportion of State mental hospital inpatient additions increased slightly, from nine percent to 10 percent, from 1998 to 2000 (table 3). Among the other mental health organizations, RTCs showed a more or less steady gain in addition rates between 1969 and 1990, but they dipped in 1992, peaked in 1994, and then dipped slightly in both 1998 and 2000 (see figure 3). From 1979 to 1998, VA inpatient additions as a proportion of all additions have been decreasing, from 12 percent to 7 percent (table 3). However, between 1998 and 2000 this category had a slight increase to 9 percent. Additions to Less Than 24 Hour Care Services From 1969 to 2000, the number of less than 24 hour service additions to mental health organizations more than tripled, from 1,202,098 to 4,615,125, and the corresponding addition rate per 100,000 civilian population more than doubled, from 604 to 1,647 (see table 4). Much of this increase occurred during the 1970s, when the number and rate of outpatient additions increased substantially in the "all other mental health organizations" grouping, encompassing freestanding psychiatric outpatient clinics, federally funded community mental health centers (CMHCs), and other multiservice mental health organizations (see figure 4). Since 1979, the overall increase in additions to less than 24 hour services has moderated, and, in fact, a slight decrease is noted between 1990 and 1992, generated mainly by a substantial decrease in outpatient additions to non Federal general hospital psychiatric services. The number of additions to these facilities resumed its increase in 1994. "All other mental health organizations" now includes the freestanding outpatient and partial care clinics as well as the multiservice organizations. In 2000, this category had more than 2.6 million outpatient additions, down from about 2.9 million in 1998. The less than 24 hour additions in the non Federal general hospital psychiatric services were second, with more than 1.2 million additions. Private psychiatric hospitals, RTCs, and the VA medical centers combined comprised more than half a million additions. Additions in State mental hospitals between 1998 and 2000 numbered more than 55,000. By category, the changes in number of 24- hour care additions since 1998 were mixed. Private psychiatric hospitals, non-Federal general hospital psychiatric services, VA medical centers, and RTCs showed increases, while State mental hospitals and all other mental health organizations showed decreases. Patients in 24 Hour Hospital and Residential Services The number of 24 hour hospital and residential patients generally decreased from 1969 to 2000, with increases since the previous survey in 1986 and 1994 (see table 5). The 1994 increase was due entirely to the inclusion of residential supportive patients who had been excluded in previous years. Thus, the decline from 1994 to 2000 continued a trend that had begun after 1986. In 1969, 24-hour hospital and residential patients numbered 471,451, but by 1992 the number had declined to 214,714. The number in 2000 was 182,837. The rate per 100,000 civilian population decreased from 237 in 1969 to 65 in 2000. Much of the decrease occurred before 1979, when substantial reductions occurred in the number of resident patients in State mental hospitals and in VA medical center psychiatric inpatient services. The total resident patient count has continued to decline as decreases in the State mental hospital, VA medical center, and private psychiatric hospital resident patient populations have not been offset by the relatively stable numbers through 1998 in non Federal general hospital psychiatric services and the increases in the number of RTCs and other organizations. VA medical center resident patient counts peaked in 1969, while private psychiatric hospital resident patient counts peaked in 1990; both categories continued to decrease throughout the 1990s and accounted for six percent and nine percent of patient counts, respectively, in 2000. In 1969, State mental hospitals accounted for the largest percentage of residents of psychiatric organizations, more than three-quarters. Their percentage of residents declined steadily, but they continued to treat more residential patients than any other type of treatment facility through 2000, when they were treating nearly 30 percent of residential patients. Patient Care Episodes Patient care episodes, unlike the other volume measures, provide an estimate of the number of persons under care throughout the year. They are defined as the number of persons receiving services at the beginning of the year in the 24 hour hospital and residential treatment and less than 24 hour care services of mental health organizations plus the number of additions to these services throughout the year. They are a duplicated count in that persons can be admitted to more than one type of service or can be admitted to the same service more than once during the year. The National Institute of Mental Health (NIMH) and CMHS have tracked patient care episodes since 1955. Over the ensuing 45 years, the locus of mental health care in the United States shifted from inpatient to ambulatory services, as measured by the number of patient care episodes. Of the 1.7 million episodes in 1955, 77 percent were in 24 hour hospital services and 23 percent in less than 24 hour services; by 1971, there were 4.2 million episodes, of which 42 percent were in 24 hour hospital services and 58 percent in less than 24- hour hospital services; by 2000, of nearly 11 million episodes, 22 percent were in 24 hour hospital services and 78 percent were in less than 24 hour hospital services, almost exactly the reverse of the 1955 distribution (see table 6 and figure 5). Along with the shift of patient care episodes from 24 hour hospital and residential treatment care to less than 24 hour services, a shift also occurred across organization types within these two services (Redick et al., 1994b). For example, State mental hospitals accounted for 63 percent of hospital and residential treatment episodes in 1955, compared with only 12 percent in 2000. Also in 2000, the majority of hospital and residential treatment care episodes were in private psychiatric hospitals (24 percent) and non-Federal general hospitals (46 percent; see figure 6). Compared with 2000, State mental hospitals and VA medical centers in 1955 saw a larger proportion of less than 24-hour care episodes. For example, State mental hospitals accounted for 11 percent of less than 24-hour care episodes in 1955 and one percent in 2000. Non-Federal general hospitals accounted for nine percent of these episodes in 1955 and 19 percent in 2000. The proportion of all other mental health organizations providing less than 24-hour care was higher in 1955 (80 percent) than in 2000 (69 percent; see figure 7). Staffing of Mental Health OrganizationsThis section has been updated since the publication of Mental Health, United States, 2000 with sample survey data from 1998 and inventory data on total staffing from 2000. Concomitant with increases in the number of mental health organizations and patients served by these organizations, the number of FTE staff employed by such organizations increased steadily between 1972 and 1998, from 375,984 to 680,310 (see table 7). In 2000 the total staffing decreased to 580,285. Almost all of this increase was attributed to patient care staff, which increased from 241,265 to 531,532, and to professional patient care staff, which increased from 100,886 to 304,449 during this period. In 1972, professional patient care staff comprised about 27 percent of all FTE staff, compared with 45 percent of all FTE staff in 1998 (see figure 8). Among the professional patient care staff disciplines, the largest gains over the 26 year period were noted for psychiatrists, psychologists, social workers, registered nurses, and other mental health professionals. Other mental health professionals increased more than fourfold during that period (table 7). By contrast, the number of other workers (with less than a B.A.) employed in mental health organizations showed a variable pattern of increases and decreases between 1972 and 1998, with a larger number reported in 1998 (227,083) than in 1972 (140,379). The number of FTE administrative, clerical, and maintenance staff increased from 134,719 to 148,778 in that period (table 7). As a percentage of all FTE staff, other mental health workers dropped from 37 percent in 1972 to 33 percent in 1998. The administrative and support staff declined from 36 percent in 1972 to 22 percent in 1998 (table 7). The mental health organization types that showed the largest proportional increases in number between 1972 and 1998 were private psychiatric hospitals, non Federal general hospitals with separate psychiatric services, RTCs, and "all other mental health organizations," which accounted for all of the increases in total FTE staff among mental health organizations during this period ( table 7a, table 7b, table 7c, table 7d, table 7e, and table 7f). Financing of ServicesThis section has been updated since the publication of Mental Health, United States, 2000 with sample survey data on resources and expenditures for 1998. Expenditures Total expenditures by mental health organizations in the United States, as measured in current dollars, increased more than eleven fold between 1969 and 1998, from $3.3 billion to $38.5 billion. However, between 1998 and 2000 total expenditures declined to slightly less than $33 billion. Additionally, when adjustments were made for inflation, that is, when expenditures were expressed in constant dollars (1969 = 100), total expenditures rose from $3.3 billion in 1969, peaked at slightly more than $5 billion in 1998, and declined to slightly more than $4 billion in 2000. This increase was not a monotonic increase over the period (see figure 9, table 8a and table 8b). Only $740 million, or two percent of the nearly $30 billion increase in current dollar expenditures between 1969 and 2000, represented an increase in purchasing power; the remaining 98 percent was due to inflation. All the specific organization types registered increases in current dollar expenditures between 1969 and 2000, but private psychiatric hospitals declined in 1992, 1998, and 2000; State mental hospitals have declined since 1994; VA medical centers showed declines in 1994, peaked in 1998, and declined again in 2000; and all other mental health organizations declined in 2000 (table 8a). (However, the per capita rates also show a decline between 1998 and 2000 for all types of organizations except non-Federal general hospitals with psychiatric services; see table 8a and figure 10). Although several organization types showed gains in 1998, when measured in constant dollars, all organizations showed no gains between 1998 and 2000 (see figure 11). As a result, the proportionate share of total expenditures changed significantly between 1969 and 2000 for some of the organization types. For example, State mental hospitals and VA medical centers comprised only 20 and four percent of total expenditures, respectively, in 2000, compared with 55 and 14 percent, respectively, in 1969; private psychiatric hospitals, separate psychiatric services of non Federal general hospitals, and all other mental health organizations comprised 11, 18, and 36 percent, respectively, in 2000, compared with 7, 9, and 7 percent, respectively, in 1969 (see table 8b and figure 12). Trends in per capita expenditures (the amount of expenditures per person in the civilian population of the United States) followed patterns similar to those noted above for the absolute expenditures among the various types of mental health organizations between 1969 and 2000. Only non-Federal general hospitals, RTCs, and all other mental health organizations showed consistent per capita expenditure increases throughout the period from 1969 to 1998. However, both RTCs and all other mental health organizations declined between 1998 and 2000. State mental hospitals, private psychiatric hospitals, and VA medical centers all had declining per capita expenditures beginning in 1992. Of these, only State mental hospitals declined straight through 2000 (see table 8a). When expressed in constant dollars, total per capita expenditures had an inconsistent net decline of $2.14 between 1969 and 2000, from $16.53 to $14.39. Patterns for the individual types of organizations were mixed: State mental hospitals and VA medical centers largely decreased, while "all other mental health organizations" had the largest increase, peaking in 1998, but declining in 2000 (table 8b). Revenues by Source In 1998, revenues of mental health organizations in the United States totaled $38 billion, an increase of $2.2 billion over 1994. Of the 1998 total revenues, 31 percent came from State mental health agencies and other State government funds, four percent from client fees, 37 percent from Federal Government sources (including Medicare and Medicaid), 10 percent from local governments, one percent from contracts, and 18 percent from all other sources (see table 9). The distribution of revenues by source for 1998 was similar to 1994 in that the highest percentage of funds (more than two-thirds) came from Federal and State government funding. The proportion of revenues from client fees declined from 1994 to 1998, primarily in private psychiatric hospitals and non-Federal general hospitals. The proportion of revenues from "all other sources" increased from 1994 to 1998. Looking at the revenues received by different mental health organization types, figure 13 shows that the largest proportion of revenues, 45 percent, went to all other mental health organizations. State and county organizations were next with 18 percent, followed by non-Federal general hospitals with 14 percent. The highest revenue increase, 72 percent over 1994, was for all other mental health organizations, whereas the largest revenue decrease, 47 percent from 1994, occurred in private psychiatric hospitals, which had an 11 percent share in 1998. Major revenue sources also varied among the different mental health organization types in 1998. As would be expected, State mental hospitals obtained most of their funding (59 percent) from State mental health agencies and other State government sources, but this was a drop from 71 percent in 1994 (table 9). Other sources increased over the period as a source of revenue for State mental hospitals. More than half (54 percent) of the funding for private psychiatric hospitals came from Medicare and Medicaid (an increase from 1994), while only 6 percent came from client fees (a large decrease from 44 percent in 1994). Medicaid was the largest source of revenue for RTCs, doubling to 32 percent from 1994. Medicaid also provided the largest amount of funding for all other mental health organizations, at 29 percent, a slight increase from 1994. Policy ImplicationsThis chapter provides data that allow for the analysis and planning of mental health service delivery.4 Time series data make it possible to map the trends and the evolution of mental health treatment. In addition, recent data-particularly those collected in 1994 and 1988-provide insight into the large scale transformations in health care service in the 1990s. Analysts of health policy are faced with new challenges following the reform of Federal health care and social service programs, and mental health policy is no exception to change and reform in social services. Number of Beds The substantial increase in the number of private psychiatric hospitals and non Federal general hospital psychiatric inpatient and residential services during the 1980s has generated mergers, consolidations, downsizing, and closings of some of these hospitals. During the 1990s, the number of general hospitals with inpatient psychiatric services has fluctuated slightly but has not markedly increased, and the number of inpatient beds has been even more stable. The number of private psychiatric hospitals declined somewhat from 1992 to 1994 and more sharply between 1994 and 1998, and the number of beds followed the same pattern. The effects of this trend are evident in the 1998 data for State and county mental hospitals. These facilities show a continued decline in their year-end resident patients and number of inpatient and residential beds as many State governments struggle to reduce their budgets by eliminating costly hospital and residential programs, stressing community care, and preventing admission to psychiatric beds when possible. This situation is becoming even more critical as responsibilities continue to shift to States. The shift to nonresidential care is shown by the 53 percent increase from 1994 to 1998 in additions to less than 24-hour care at State and county hospitals, compared with a nine percent drop in additions to inpatient and residential care. Another factor in the decline in the number of psychiatric inpatient and residential beds may be the increased use of managed care and other cost saving mechanisms, including the substitution of less than 24 hour services for inpatient and residential care to further reduce the length of hospital stays, thereby reducing the cost of employee care to businesses and insurance companies. Indications are that the number of psychiatric beds may continue to decline in the foreseeable future (Redick et al., 1994a). Patient Care Episodes Policy implications evident from the trend data on patient care episodes involve four main issues: (1) the future role of State mental hospitals, (2) the balance between community based and State mental hospital services, (3) the balance between hospital and residential and ambulatory services, and (4) the contracting by State mental health agencies for the provision of services through the private sector. As the number of hospital and residential episodes in State mental hospitals continues to decline, policymakers are confronted with momentous decisions. Of particular importance is the question of whether these facilities should be expanded or closed. Some argue that these hospitals have contracted in size to such an extent that persons with severe mental illness are being denied admission, so that further downsizing is unwise. Others argue that all persons, regardless of the severity of their mental illness, can be cared for in the community and that State mental hospitals should be phased out entirely. Confounding the options of the policymakers are economic pressures brought by communities and labor unions to keep the State mental hospitals open and to increase their size. State mental health agencies favor the expansion of community based services at the expense of State mental hospital services. Federal legislation promotes community based services to the exclusion of State mental hospital services in the distribution of community mental health service block grant funds to the States. Furthermore, between 1955 and 1994, aftercare services shifted from the State mental hospitals to community based facilities. Despite these facts, State mental hospitals still consumed 44 percent of total expenditures by State mental health agencies in 1998, down from 57 percent in 1994 (see table 9). In light of this situation, one of the major issues facing the mental health community today is how to strike a balance between the services of community based mental health agencies and those provided by State mental hospitals. The proper balance of hospital and residential with ambulatory services needs to be examined for treatment efficacy, as well as for cost benefit. Although the percentage of less than 24 hour care is now much greater than it was between 1955 and 1971, the proportion has remained almost the same since 1975. Decisions will have to be made about the role of ambulatory versus hospital and residential services and, in particular, about whether ambulatory services should be increased at the expense of hospital and residential services. The President's New Freedom Commission on Mental Health called for fully integrating people with mental illness into the community by enabling them to live, work, study, and participate in all activities. Staffing Accompanying the increase in the number of mental health organizations and their caseloads from 1972 to 1998 has been an increase in the number of FTE staff these organizations employ. Most of this increase (67 percent) occurred among the professional patient care staff, notably in the number of psychiatrists, psychologists, social workers, registered nurses, and other mental health professionals. The number of professional staff increased by 200 percent, compared with 10 percent for administrative, clerical, and maintenance (support) staff and 62 percent for other mental health workers (paraprofessional) staff. This can be attributed in large part to the expansion of community based mental health care services during this period, which has led to a greater emphasis on short term hospital and residential as well as less than 24 hour care and partial care services, with the primary goal of keeping clients functioning in their own communities. A feature of the contemporary evolution of health care service has been the replacement of higher cost professionals, particularly physicians, with other staff in less expensive labor categories, such as registered nurses and others. While the overall number of FTE staff in all mental health organizations increased in the 26 years between 1972 and 1998, the number of psychiatrists serving these mental health institutions increased at a slower rate than other professional staff. Between 1972 and 1998, the number of psychiatrists increased by 119 percent and the number of other physicians decreased by 11 percent. This compared with a 204 percent increase for psychologists, a 309 percent increase for social workers, and a 350 percent increase for other mental health professionals. As the trends in the number and rates per population associated with hospital and residential care (e.g., decreases in resident patients and psychiatric beds) appear to be leveling off and policies regarding the effectiveness of long term hospital and residential care versus short term hospital and residential and ambulatory care come under review, the future human resource needs of mental health organizations must be assessed, particularly whether the supply of paraprofessional and professional mental health care workers needs to be augmented or selectively reduced. Consideration must also be given to the substitutability of staff disciplines in certain situations. Managed Care In 1998, 66 percent of all mental health organizations were part of one or more managed care networks, compared with 40 percent in 1994. Non Federal general hospitals with separate psychiatric services and private psychiatric hospitals had the largest percentage of managed care participants- 92 and 81 percent, respectively. The next largest percentages were all others (56 percent), RTCs (46 percent), and VA medical centers (48 percent). The organizations least likely to be part of managed care networks were State mental hospitals (14 percent). Expenditures With the advent of health care reform, much interest has developed about the role of inflation in the increase of expenditures by mental health organizations. Both the number of private psychiatric hospitals and their expenditures increased dramatically between 1969 and 1998, but declines were seen in both current and constant expenditures between 1994 and 1998. Non Federal general hospitals with psychiatric services showed constant increases in expenditures and per capita between 1969 and 1998 as measured in current dollars, but they showed a constant decrease between 1990 and 1998 if measured in constant dollars. Yet their 24 hour care population continued to increase. VA medical centers, RTCs, and all other mental health organizations showed increased expenditures in both current and constant dollars and in per capita in 1998. Mental Health Services Data by StateIn conjunction with the preparation of national data for this chapter, CMHS tabulated the 1998 Survey data by State. In recent years, these State data have become increasingly important for managers of State mental health agencies, enabling them to compare their program statistics with those of other States and with national totals. In addition, State legislators, budget officers, and planners of mental health services frequently ask program administrators to furnish comparable statistical information from other States. Although State populations, programs, services, and funding patterns differ somewhat, State mental health program directors have usually identified enough similarities between their State and one or several others to make statistical comparisons. Among the most important factors in selecting other States for comparison is the need for States to have similarly organized services as well as somewhat similar populations. Geographical proximity may also be a relevant factor. Table 10, table 10a, and table 10b show the number of facilities in each State in each of the six facility types. Table 10 lists the number of facilities offering any services; table 10a lists the number providing 24- hour hospital inpatient and residential care; and table 10b lists the number in each State providing outpatient care. All three tables compare the number of facilities in 2000 with the numbers in 1992, 1994, and 1998. Figure 14, figure 15, and figure 16 show three key variables by State: (1) inpatient and residential treatment beds, (2) inpatient and residential treatment additions, and (3) outpatient additions. All three maps display rates per 100,000 civilian population on July 1, 2000. Psychiatric inpatient and residential treatment beds (figure 14) were least common in the Western States and most common in the Northeast. South Dakota had an unusually high rate of inpatient and residential beds for a Western State, whereas much of the Southeast has low bed rates. Inpatient additions (figure 15) displayed a similar regional pattern, being less frequent in the Western States than in the Eastern. A band of high admission rates extended from Kentucky westward through Missouri to Kansas and Oklahoma, and many of the adjacent States also had relatively high addition rates. In the East, South Carolina and Maryland had the lowest addition rates. High outpatient addition rates were found in a band of States ranging from Wyoming to Wisconsin (figure 16). Arizona, Arkansas, and a cluster of States in New England-Massachusetts, Connecticut, Rhode Island, Vermont, and Maine-also had high rates. The area with lowest rates was again the West, in Idaho and Nevada and some of the surrounding States. Texas and Nebraska also showed low outpatient addition rates. Data from the 1998 SMHO, similar to those presented in the figures, are available in unpublished form from CMHS. Comparative State data for 1983, 1986, and 1988 can be found in Mental Health, United States, 1992; for 1986, 1988, and 1990 in Mental Health, United States, 1994; for 1986, 1990, and 1992 in Mental Health, United States, 1996; for 1990, 1992, and 1994 in Mental Health, United States, 1998; and for 1992, 1994, and 1998 in Mental Health, United States, 2000. REFERENCES Redick, R. W., Witkin, M. J., Atay, J. E., & Manderscheid, R. W. (1994a). Availability of psychiatric beds, United States: Selected years, 1970B1990. Rockville, MD: Center for Mental Health Services. Redick, R. W., Witkin, M. J., Atay, J. E., & Manderscheid, R. W. (1994b). The evolution and expansion of mental health care in the United States between 1955 and 1990. Rockville, MD: Center for Mental Health Services. Witkin, M. J., Atay, J. E., & Manderscheid, R. W. (1994). The effect of inflation on expenditures by mental health organizations between 1969 and 1990. Rockville, MD: Center for Mental Health Services.
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