Hospital admission and community treatment of mental disorders in England from 1998 to 2012.

OBJECTIVE: The number of psychiatric hospital beds in England has declined since the 1950s. Since the early 2000s, mental health staff increasingly work in community treatment teams. We analysed recent trends in hospital and community treatment in England for eight mental health diagnoses.
METHOD: We obtained data from the UK Government Health and Social Care Information Centre covering the period 1998 to 2012. We analysed hospital admissions and length of stay for each diagnosis each year using linear regression. We studied associations among admissions, community treatment and hospital bed availability each year using structural equation modeling.
RESULTS: The number of mental health beds fell 39%, from 37,000 in 1998 to 22,300 in 2012. Hospital admissions for five diagnoses declined significantly (depression, bipolar disorder, schizophrenia, dementia and obsessive compulsive disorder, P<.01 or P<.001). The strongest decline for depression involved 1000 fewer admissions each year. Admissions for three disorders increased significantly (posttraumatic stress disorder, eating disorders and alcohol-related disorders, P<.01 or P<.001). Alcohol-related admissions increased most strongly, by more than 1700 a year, and were significantly associated with increasing liver fibrosis and cirrhosis admissions (Pearson's r=0.89, P<.001) across the National Health Service (NHS) and the affordability of alcohol (Pearson's r=0.76, P<.01). The median length of stay declined significantly for four diagnoses (P<.001); the other four diagnoses did not change significantly. Depression had the steepest decline of almost 1 less day in hospital per admission per year. Almost 300 more patients were sectioned under the Mental Health Act each year. Community activity had relatively little effect on admissions, and its direct effect was not significantly different from zero. Years with more psychiatric beds had more admissions.
CONCLUSIONS: Mental health bed numbers have declined significantly in England. Annual admissions and lengths of stay declined for a range of severe mental disorders including schizophrenia, bipolar disorder and depression. The fall in available beds can account for much of the decline in admissions. National reports of crisis team activity are not associated with declines in hospital admissions. There may be significant needs, especially of depressive patients, not being met by secondary community services, such as 24-hour observation and care. This calls for policy review and further epidemiological study of morbidity, mortality and health needs associated with mental disorder in the community.