Asylum Hospital: The Rise and Fall of America's Mental Asylums

An asylum hospital was a large, usually state-run institution where people with mental illness were housed and treated, often for years. In the United States these mental health asylums grew into the state hospital system, which held a peak of 558,922 residents in 1955^[1]. Many of the people they confined had conditions now classed as serious mental illness, such as psychosis^[2].

The word itself meant refuge: in ancient Greece and Rome, an asylum was a place where persecuted people could seek sanctuary^[5]. Early American asylum mental hospitals borrowed that idea: rest, routine and distance from the conditions thought to cause madness. For current figures on how many Americans live with mental illness, see the national mental health statistics page.

Over time "asylum" gave way to "state hospital" and then "psychiatric hospital." Historians describe the change as more than a name: the institutions moved from small therapeutic retreats to overcrowded custodial facilities, and then, after 1955, were largely emptied^[2].

Before asylums, families cared for most people with mental illness, and severe cases often ended up in almshouses or jails^[4]. In 1752 the Pennsylvania Hospital in Philadelphia set aside basement rooms, fitted with wall shackles, for a small number of mentally ill patients^[4].

The first public hospital built for the purpose opened in Williamsburg, Virginia, in 1773, funded by the Virginia legislature^[4]. It still operates as Eastern State Hospital^[4]. Kentucky’s Eastern Lunatic Asylum in Lexington followed in 1824 as the first mental institution west of the Appalachians^[4].

Private asylums in Pennsylvania and Connecticut adopted moral treatment in the late 1810s and early 1820s, a model drawn from Philippe Pinel in France and the York Retreat in England^[2][3]. State-run asylums then took in people who had been held in jails and almshouses^[2].

Reformer Dorothea Dix pushed the expansion. After visiting a Massachusetts jail, she submitted her first "memorial" on conditions to the state legislature in 1843, and she helped found or expand more than 30 hospitals^[3]. By 1890 every state had at least one publicly supported asylum^[2][4].

Early asylums aimed to cure. Moral treatment depended on small caseloads, patients with recent onset of illness and steady public funding, and none of those held up^[2]. Industrialization and immigration in the 1840s and 1850s increased demand, and states answered with ever-larger buildings^[2].

Admissions skewed toward the poor. Public asylums came to serve mostly lower-income patients, including immigrants and people with what would now be called psychosis or chronic alcoholism, while wealthier, mostly voluntary patients went to private institutions^[2]. Race, ethnicity and gender influenced who was committed and how diagnoses were assigned^[2].

Commitment was easy. In one well-documented case, E.P.W. Packard was committed to an Illinois state institution by her husband after two physicians took her pulse at home and declared her insane. She was confined for 3 years and then campaigned to change commitment laws^[5].

Financing also filled the wards. State Care Acts, starting with New York’s in 1890, moved responsibility for patients from counties to states, so towns shifted older adults with dementia and others needing long-term care from almshouses into state hospitals^[2]. Admissions to state mental hospitals rose 240% from 1903 to the mid-20th century^[2].

As the patient population grew, public asylums turned into large, overcrowded institutions that "all but abandoned the goal of treatment in favor of containment"^[2]. Staff shortages, deteriorating buildings and restrictive, sometimes abusive practices were routine, and many patients stayed for the rest of their lives^[2]. Films and books such as The Snake Pit and One Flew Over the Cuckoo’s Nest later fixed that image in popular culture^[1].

Firsthand accounts made the conditions public. Former patient Clifford Beers described abusive treatment in his 1908 autobiography^[2]. During World War II, conscientious objectors assigned to state hospitals documented overcrowding, understaffing and abuse, and a 1946 Life magazine exposé showed patients lying unattended and held in heavy restraints^[2].

Treatments added to the fear. Before antipsychotics, care for schizophrenia included prefrontal lobotomy, electroconvulsive therapy and insulin coma therapy^[2]. The history of those procedures is covered in our posts on lobotomy and electroconvulsive therapy.

Deinstitutionalization is the policy-driven emptying of state mental hospitals that began in the mid-1950s^[2]. A 2013 review names three forces behind it: the belief that mental hospitals were cruel and inhumane, the hope that new antipsychotic drugs offered a cure, and the desire to save money^[5].

Medication came first. In 1955, chlorpromazine, sold as Thorazine, became the first antipsychotic approved for wide-scale use in the United States^[2]. That year Congress also passed the Mental Health Study Act, whose 1961 report, Action for Mental Health, called institutionalization debilitating^[2].

Federal law followed. In a February 1963 message, President Kennedy proposed to cut by half, "within a decade or two, the 600,000 persons now institutionalized for psychological disorders"^[1].

The Community Mental Health Act passed the Senate 72-1 and the House 335-18, and funded 150 million dollars in grants over 3 years toward building and staffing 1,500 community mental health centers^[1]. Only about 700 were built, and many focused on people with less disabling conditions^[2].

Medicaid, created in 1965, changed the incentives^[6]. Its institution for mental diseases (IMD) exclusion bars federal payment for care of adults aged 21 through 64 in psychiatric facilities with more than 16 beds, a rule designed to keep states primarily responsible for inpatient psychiatric care^[6]. Because Medicaid shared costs for patients moved to community hospitals and nursing homes, states had a reason to close the hospitals they funded alone^[5].

Courts narrowed confinement. Lake v. Cameron (1966) introduced the "least restrictive setting" standard, O’Connor v. Donaldson (1975) required danger to self or others for constitutional confinement, and Olmstead v. L.C. (1999) applied the Americans with Disabilities Act to unnecessary institutionalization^[5].

The decline was fast. The state hospital population fell by more than 75% between 1955 and 1980^[2], and by more than 90% by the early 2000s^[1]. Capacity followed: from 340 state psychiatric beds per 100,000 people at the 1955 peak to 43,318 beds, or 14.1 per 100,000, in 2010^[5].

Community care did not keep pace. Hospitals discharged hundreds of thousands of patients, and community mental health centers were often unprepared to care for people with chronic illness^[2]. Thousands moved to nursing homes, group homes and other institutional settings, a shift historians call transinstitutionalization^[2].

Others ended up homeless or in the justice system, cycling among acute care hospitals, jails, prisons and forensic facilities^[1]. The prevalence of mental illness in correctional facilities has led researchers to call jails and prisons the "new asylums"^[2]. Our posts on mental health in jails and prisons and homelessness and mental illness track those figures.

Outcomes for this population remain poor. People with serious mental illness die 10 to 20 years earlier than their peers^[2].

Not under that name, but public psychiatric hospitals still operate. Some of the earliest asylums remain open: Eastern State Hospital in Williamsburg and Eastern State Hospital in Lexington trace back to 1773 and 1824, respectively^[4].

Across all CMS-certified hospitals, the U.S. had 28.4 inpatient psychiatric beds per 100,000 people in 2023, almost unchanged from 28.1 in 2011^[7]. Beds in freestanding psychiatric hospitals rose from 16.8 to 19.5 per 100,000, while beds in general hospitals fell from 11.2 to 8.9^[7].

Many psychiatric hospitals are now privately run. Among psychiatric hospital records in the 2011–2023 study, 54.5% were for-profit and 31.5% were government-owned^[7]. Access is uneven: 1,449 counties, home to about 59.5 million people, had no inpatient psychiatric beds at any point in the study period^[7].

The 1965 IMD exclusion still limits federal Medicaid funding for adults aged 21 through 64 in large psychiatric facilities, and policymakers continue to debate how it affects access to inpatient care^[6].

Modern hospital stays are measured in days, not years. In 2016, U.S. community hospital stays with a principal diagnosis of schizophrenia and related disorders averaged 10.5 days and cost 8,900 dollars on average^[8].

That was the second-longest stay among mental and substance use diagnoses, after eating disorders at 13.6 days, while the average for all principal mental and substance use disorder stays was 6.4 days^[8]. Schizophrenia and related disorders accounted for nearly 1 in 5 of these stays^[8].

These figures cover community hospitals, not long-term state hospital or forensic units. Under the asylum system, by contrast, case studies document patients who remained institutionalized for the rest of their lives^[2].