By Rachel Crumpler and Taylor Knopf

North Carolina’s three state-run psychiatric hospitals — Cherry, Central Regional and Broughton — serve about 570 patients each day. But hundreds more who need inpatient treatment wait weeks — even months — for a bed to open.

The three state-operated facilities are designed to serve North Carolinians with the most complex mental health needs, including those who can’t be treated safely in community-based facilities. They provide inpatient mental health care regardless of a person’s insurance status or ability to pay, and patients often stay for long periods — more than 100 days on average, according to state data.

There could be more capacity for care, but about 300 of the state’s 901 psychiatric hospital beds sit empty every day because of persistent staffing shortages, leaving roughly one-third of the system’s capacity offline amid widespread need.

Exacerbating the need, more of the limited bed space is being occupied by people involved in the criminal justice system who need court-ordered treatment before proceeding to trial. That can mean that more people from the community experiencing mental health crises end up waiting weeks — or even months — in emergency rooms for beds to open. 

This bottleneck has caused the total number of annual admissions to state-run psychiatric hospitals to fall sharply over the past decade — despite no decrease in the need for care. In fiscal year 2013, 3,210 patients were admitted, and in fiscal 2025, there were just 875, according to N.C. Department of Health and Human Services data. That’s a 73 percent decline. 

The state has relied on Broughton, Cherry and Central Regional hospitals to serve North Carolinians with inpatient psychiatric needs since 2013, and since that time, staffing capacity and the acuity of the patient population has shifted over time — contributing to the decline in annual admissions.

State health officials expect pressure on the already overburdened state psychiatric hospitals to intensify with implementation of Iryna’s Law, passed in response to a fatal stabbing in August on a light rail train in Charlotte. The man accused of the crime has a criminal history and severe mental health challenges. A provision in the law, which is scheduled to take effect this December, orders more mental health evaluations to determine if people who are arrested should be involuntarily committed to receive forced treatment at a psychiatric facility. 

This would likely funnel more patients into an already-strained system that is struggling to keep up with demand for care. 

No additional mental health funding or staffing resources were included in Iryna’s Law.

“We are fully expecting, along with other inpatient hospitals, to see an increase in demand,” Karen Burkes, deputy secretary for facilities and licensure at the N.C. Department of Health and Human Services, told state lawmakers in December during a meeting of the House Select Committee on Involuntary Commitment and Public Safety.

The legislative committee, formed in response to passage of Iryna’s Law, has met monthly since November to study the existing involuntary commitment process and propose administrative and policy changes to improve it. The committee is expected to generate a report with its findings and recommendations in April. The limited capacity at state psychiatric hospitals has surfaced repeatedly in these discussions. 

To understand this challenge, NC Health News took a deeper look at who is in the state psychiatric hospitals and how the patient population has significantly changed over the past decade.

Who is in NC’s state-run psych hospitals?

Criminal defendants with deteriorated developmental or psychiatric status, and who are found to be unable to understand their court process are deemed “incapable of proceeding” to trial. These defendants account for more than one-third of patients in the state psychiatric hospitals — the largest share of patients. Often they cannot understand what is happening to them, nor can they help their attorneys with their defense. For their criminal cases to move forward, they must receive psychiatric treatment to restore their mental capacity. 

Patients under involuntary commitment orders make up more than one-quarter of the patient population, the second-largest group. Most often, these patients come from hospital emergency departments across the state. They’re commonly brought to an emergency department during a mental health episode by a concerned family member or by police who have responded to a 911 call.

If a medical provider determines that the patient is a danger to themselves or to those around them, they will file a petition with the courts for an involuntary commitment custody order. These petitions have increased significantly — by at least 97 percent — over the past decade, according to data compiled by NC Health News. Patients under involuntary commitment temporarily lose the right to make their own decisions while being treated for psychiatric problems or substance use. 

The patients with the most complex needs — and frequently who lack a way to pay for care — end up at the state’s psychiatric hospitals. Due to the complexity and high acuity of patients in these facilities, most beds do not turn over quickly, and there’s a wait to get in.

Why are there so many criminally charged patients in state psych hospitals?

The number of people referred by the courts for capacity evaluations and restoration services has ballooned in North Carolina — mirroring a national trend — and state-run psychiatric hospitals have long been the default site for that care.

In 2024, more than 2,600 capacity evaluations were completed, according to N.C. Department of Health and Human Services data provided to NC Health News — a 33 percent increase from 2020. Although the number of evaluations in 2025 declined for the first time in five years, 1,951 evaluations were nonetheless completed. About 55 percent — nearly 1,100 people — were found incapable of proceeding to trial and required long admissions for capacity restoration services.

As more defendants require capacity restoration, they are taking up a growing share of space in the three state psychiatric hospitals. 

The shift over time is stark. In fiscal year 2005, patients deemed incapable to proceed accounted for just over 1 percent of annual admissions to the state’s psychiatric hospitals. By fiscal year 2025, the share had surged to 36 percent of admissions, filling beds that otherwise would serve people from the community in mental health crises.

Until December 2022, the three state-run psychiatric facilities were the only places where court-ordered capacity restoration treatment was available. In an effort to ease the pressure on those facilities, North Carolina has launched three community-based and three-jail based capacity restoration programs. Even so, most court-ordered capacity restoration treatment is still in a hospital setting.

Demand consistently exceeds capacity. While criminally charged patients now occupy about one-third of hospital beds, many more wait in jail for months for an open bed. Their conditions often deteriorate during the wait because jails are ill-equipped to address serious mental health needs. As of Jan. 22, 122 people deemed incapable to proceed were waiting for admission to a state psychiatric hospital, according to DHHS data provided to NC Health News. During the first quarter of fiscal year 2026 — from July to September 2025 — the average wait time before admission for capacity restoration was 148 days, or about five months.

Once admitted, these patients receive capacity restoration services for an average of about 120 days before they are deemed restored or non-restorable, according to DHHS.

The rise of incapable to proceed patients has ripple effects across the mental health and justice systems.

“It affects multiple systems — the courts, the jails, the hospitals, the EDs, even private hospitals,” Robert Cochrane, DHHS’ statewide director of forensic services, previously told NC Health News. “They’re all impacted in some shape or form by this.”

How long do patients wait in the ER for a state psychiatric bed?

As more criminally charged patients fill the state’s psychiatric hospital beds, the number of operational beds has also declined, limiting overall admissions. This means community members in mental health crises in the community face longer waits for care — often in the ER — as they seek access to the same limited beds.

The state health department tracked and published the number of patients and how long they waited in emergency departments for admission to a state psychiatric bed from 2018 through 2022. The wait times increased through those years, even as the number of total patients declined. DHHS stopped tracking and releasing those reports in 2022, and instead DHHS tracks the availability of psychiatric beds in the state and keeps a waitlist for beds at the state hospitals, a department spokesperson told NC Health News.

Health officials have acknowledged that an emergency department is not the ideal place for people in mental health distress. It’s a bright, noisy and chaotic environment meant to stabilize acute medical needs. Some patients who end up languishing there for days or weeks at a time report being more traumatized by their experiences waiting for a psychiatric bed. 

With the dwindling capacity at the state hospitals, more mental health patients waiting in emergency rooms are treated at the growing number of private psychiatric facility beds. Unlike state hospitals, private facilities can refuse to admit patients who don’t meet their specific clinical, safety or insurance criteria. As of September 2025, North Carolina had 3,403 licensed behavioral health beds, with just over a quarter of those in the state’s three psychiatric hospitals.

Why is the wait for a state psychiatric bed so long?

Staffing shortages are a primary barrier preventing the state hospitals from serving more patients. A DHHS spokesperson told NC Health News on Feb. 4 that 12 of the 47 patient units across the three state-run psychiatric hospitals are not in operation due to insufficient staffing — roughly one-quarter of all units.

At a December meeting of the House Select Committee on Involuntary Commitment and Public Safety, Burkes, deputy secretary for facilities and licensure at DHHS, said that as of November 2025, the three state facilities had 380 health care technician and 314 registered nurse positions vacant — roles she described as critical to safely manage high-need patients.

“Those are the backbone to our health care system,” Burkes said. “It’s a much larger number [of vacancies] than we would like, and it’s something that we are working actively to reduce.”

To operate a single inpatient unit serving around 20 patients, Burkes said it takes 17 registered nurses, 42 health care techs and two psychiatrists. 

Over the past decade, overall staff vacancy rates at the three state psychiatric hospitals have ticked up from nearly 13 percent in fiscal year 2015 to about 26 percent in fiscal year 2025.

Low pay has been a significant factor hindering hiring and retention, Burkes said. North Carolina is the only state in the country without a state budget; General Assembly lawmakers are locked in a stalemate over a final plan. This means that state-employed staff, largely making less than market rate, have not received a raise in more than a year.

Gov. Josh Stein called attention to the issue during the signing of an executive order on mental health and public safety last week. 

“The units are there and they are empty, even though there is a long line of people waiting to get that kind of care,” Stein said. “Why? Because we’re not paying the nursing assistants enough money to hire enough of them to serve those people. It’s a travesty.”

Another contributing factor to extended waits is the dozens of patients who are clinically ready for discharge from the state hospitals but for various reasons can’t leave — whether waiting for a court date or lacking appropriate community placements.

“We have limited discharge options, especially for those with a history of aggressive and sexualized behaviors,” Burkes said.

As of Jan. 29, DHHS told NC Health News that 118 patients — nearly 21 percent of the patients at the state’s hospitals — had been identified as ready for discharge. 

“We pride ourselves on actually not discharging individuals until they are ready,” Carrie Brown, DHHS’ chief psychiatrist and chief medical director for North Carolina’s state-operated health care facilities, told lawmakers. “Our average length of stay is well over 100 days, which is incredibly thorough compared to the average private psychiatric hospital that sits around five days.”

With state psych hospitals at capacity, where else do patients go?

The number of state hospital beds has declined over the past 30 years. Large mental health institutions such as Dorothea Dix Hospital and John Umstead Hospital closed their doors nearly two decades ago. An overall shift toward prioritizing treatment based in community settings rather than hospitals was never fully realized in North Carolina as lawmakers failed to appropriate adequate funding. 

With fewer mental health treatment services overall, the need grew in numbers and acuity. When the coronavirus pandemic hit in 2020, emergency departments saw a surge in patients in mental distress who had nowhere else to go. 

Now the pendulum is swinging back toward inpatient psychiatric care and the creation of more inpatient beds. 

The state legislature allocated $835 million for behavioral health in 2023. Health officials have used some of that funding to create more facility-based crisis beds for short-term hospitalizations. 

The call for more psychiatric beds has resulted in the expansion of private psychiatric hospital beds. Last year, ECU Health and the for-profit behavioral health giant Acadia launched a new psychiatric hospital for adults and children in Greenville. In 2023, UNC Health partnered with the state health department to open a youth psychiatric facility in Butner. 

Nearly 75 percent of the inpatient psychiatric beds in North Carolina are outside of the three state-run psychiatric facilities, and for-profit facilities make up a growing portion of them. 

Some of these for-profit facilities have been repeatedly sanctioned by federal and state regulators for providing poor quality care and unsafe conditions for patients and staff. Behavioral health groups such as Acadia and Universal Health Services — which operate four psychiatric hospitals in North Carolina — were called out in a U.S. Senate Committee report and accused of putting profits over patient care. 

As more North Carolinians receive inpatient psychiatric care in these facilities, state officials are having ongoing conversations about how to ensure quality treatment and safety within private facilities. 

Mental Health Timeline Infographic by Taylor Knopf

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