LIAISON ACTIVITIES WITH OTHER AGENCIES

On a daily basis, the NIMH works with about 100 units in some 30 other Federal agencies ranging from NASA to Agriculture. Between 80 and 100-about 30 percent of the Institute's professional staff are engaged in liaison activities with these agencies in a wide variety of fields. In some cases, staff serve full time on detail, or part time with particular agencies, for example, Peace Corps, OEO, HUD, St. Elizabeths Hospital, the National Crime Commission, FDA, and so forth. It is expected that in the course of carrying out its mission, these activities will increase in scope and number.

The resulting heterogeneity of programs and the subtle interrelationship of professional skills bent to a common set of goals has made the activities of the NIMH both the most varied and complex and one of the most delicately interwoven of any set of PHS programs. They offer, however, both the stimulus and the opportunity for innovative approaches and demand new modes of conceptual thought. The resultant research and training activities in the behavioral and social sciences as well as the clinical must range far beyond the traditional biological and biochemical approaches.

PROGRAMS FOR RESEARCH AND UTILIZATION OF RESEARCH FINDINGS

Further, the juxtaposition of service with research programs and of these programs with applied programs has yielded a program pattern within which (a) the findings of research can be most rapidly translated into techniques for treatment and care, and the training of new specialists; (b) developments and findings of control programs at the local and State level immediately signal the need for new emphasis in research, in manpower training, or in the provision of treatment facilities; (c) coordinated mental health data collection activities are simultaneously of immediate use to the bench scientist, to State and local control programs, and to the program planner and policymaker at all levels of government. In short, research, service, control, assistance, training, and demonstration programs have become inextricably interwoven in a basic pattern of mutual reinforcement which can be neither artificially reproduced nor fundamentally modified without program injury.

The mental health program has from its inception deliberately placed special emphasis and has made special programing efforts in the field of application and utilization of research findings.

COMMUNITY MENTAL HEALTH PROGRAM

For example, the Institute has brought together university trainers and State and local users of personnel to plan together. It has involved the universities directly in the new community mental health program and supports over 100 grants in community mental health training alone.

Mr. FLOOD. What is the community mental health training program?

Dr. YOLLES. It is a new approach to dealing with mental health problems in the community in this sense: Over many, many years the kind of treatment given has been on a 1-to-1 basis.

Mr. FLOOD. I have 500,000 people in my district and one psychiatrist and I cannot get any more. I have asked the armed services to beg, borrow, or steal more. Five hundred thousand people and one psychiatrist.

Dr. YOLLES. There is a tremendous shortage of psychiatrists.

A new community mental health center is being developed in one of your counties in Pennsylvania. It will be at Stroudsburg but it will cover Carbon County as well.

In relationship to the community mental health program we are trying to inculcate in the training of psychiatrists a concept of dealing with a community's need and helping to prevent illness, and not solely with the individual who comes in your office and whom you treat four times a week 1 hour a day. This requires a whole reorientation of thinking. In a sense it will overcome in part the shortage of psychiatrists. If you deal with general populations and try to prevent or ameliorate the problems of large groups rather than those of an individual alone, you have far greater success. I do not think any disease has been alleviated or controlled by treatment alone. So it is in the prevention of mental illness in a community that we place our greatest hope.

RESEARCH UTILIZATION CONFERENCE

In research, the "Research Utilization Conference" developed by the Institute has been a most successful tool in translating new findings into practice as well as in training of professionals.

In its report to the President, the Woolridge committee panel on the behavioral sciences concurred in this approach:

With the accelerated accumulation of new scientific knowledge, it becomes an even more pressing issue to maintain and develop mechanisms for the testing out and translating of fruits of research at the level of practical application. The close link between training and research at NIMH in partciular, appears therefore to have been a felicitous development. What we have said above about the relationship between research and educational functions applies just as well when we consider the relationship between research and community services activities.

The mental health program has grown over the years, but more striking are the dramatic changes which have evolved through use of the total approach in our efforts to improve the mental health of the Nation and to prevent mental illness among its citizens. These changes are the hallmarks of our work, and of our progress. But first let us place the program in perspective. What is the current status of mental health in the United States?

Within the past several years the gravity and urgency ofthe Nation's mental health problem has received substantially increased attention from the general public, from voluntary and professional groups and associations, from the Congress and from the President. The support for an enlarged national effort sprang from a growing awareness of the threat of mental illness to the people of the United States.

THREAT OF MENTAL ILLNESS TO PEOPLE OF THE UNITED STATES

Mr. FLOOD. What threat is there of mental illness to the people in the United States?

Dr. YOLLES. Take one example which we are concerned about. In spite of a declining number of patients in State mental hospitals in the United States, which has been a most gratifying experience, the

number of children under 14 admitted to such hospitals is increasing out of all proportion to either the numbers in the population or in relation to the total patients resident in State mental hospitals.

Mr. FLOOD. Of course the States have been derelict for generations. Dr. YOLLES. In not providing enough money to staff the facilities properly. The key is in the staffing and not in the size of the institutions because we have seen in the past ten years a change in attitude and a change in approach where you increase the number of people who work with patients. There is a change in attitude, a new hope, as regards chronic mental illness. Backward patients have suffered seriously from what we call an iatrogenic illness, that is an illness created by the doctor. We felt there was no hope and offered less and less. As a result the patients became sicker and became deteriorated. With the advent of the new drugs and new methods these developed new hope and more and more people have been discharged from the mental hospital.

Mr. FLOOD. Have you established halfway houses in this program? Dr. YOLLES. Yes. These are integral parts of many community health centers which we are supporting now.

There is overwhelming evidence that presently the Nation is neither operating to its capacity in providing adequate programs, services, or facilities for the mentally ill, nor is it utilizing to the fullest extent available knowledge concerning the spectrum of the mental illnesses.

This Nation spends upward of $312 billion a year on direct mental health services. A very large part of these expenditures is for custodial care and contributes little to the prevention or cure of the mental illnesses. Another $20 billion, it is estimated, is the cost to the Nation indirectly through loss of earnings, loss of output because of excess absenteeism and a lower productivity on the job, loss of tax revenues, etc. In 1964, it was estimated there were 610,000 psychiatric admissions to general hospitals. If one were to include those admissions which are called otherwise for various reasons, it is likely that the number would reach about two million or about eight percent of all admissions. About half of the Nation's hospital beds are still occupied by psychiatric patients and it is still true that mental illness touches one family in three and one person in ten requires treatment for a mental disorder at some time during his life. On humanitarian grounds alone our Nation cannot afford the continued loss of human resources represented by 19 million persons with mental and emotional problems. What progress have we then made?

MENTAL HOSPITAL POPULATIONS

For 11 consecutive years, the resident patient population has decreased in the country's State and county mental hospitals. During the past year, the decline was the sharpest to date-24,000 patients, or 4.9 percent-bringing us at this point to a level six percent below projections made on the basis of earlier downward patterns. Today, resident patients number 452,000-over 106,000 fewer than in 1955 when the downward trend began. If the pre-1955 pattern had continued uninterrupted, there would now be over 702,000 patients in our mental hospitals a quarter million more than is actually the case. This would have required additional expenditures since 1955 of over $2.5 billion for patient care, and approximately $2.2 billion for the con

struction of hospital beds. The savings represented here is four times the total NIMH appropriations for mental health programs during the 11-year period.

Mr. FLOOD. Before you go on, you always give us a chart projecting this population.

Dr. YOLLES. Yes. I will submit that later when I get to the charts.

SUICIDE AND THE MAJOR MENTAL HEALTH PROBLEMS

As our program has grown in scope, we have begun to focus our resources on the solution of major and pressing mental health problems. One such problem demanding new and expanded effort is posed by the 20,000 suicides committed annually in the United States. Suicide is the 10th leading cause of death in our country; in the 15 to 19 age group, suicide ranks third, exceeded only by deaths from accidents and cancer; among college students, it ranks second. The toll of suicide, however, cannot be communicated in statistics alone, for its psychological costs are high to both family and community. In addition to the trauma of death itself, each survivor of a suicidefamily members, friends, and associates must handle feelings of shame or guilt. No other kind of death in our society carries such stigma, or creates such lasting emotional scars.

Mr. FLOOD. Do you have anything similar to Alcoholics Anonymous for these people?

Dr. YOLLES. There are a number of them. One is called Rescue, Inc. The Los Angeles center, which is the largest and oldest, has been supported by the NIMH from the beginning.

The Institute's Center for Studies of Suicide Prevention, now under the direction of the Nation's leading authority in the field, will coordinate an attack on the problem, encompasisng support throughout the country of research, training, service, and demonstration activities, as well as of direct research programs within the Institute itself. In the interests of a nationwide prevention program, investigators are developing diagnostic and predictive tests to identify those who are high suicide risks; for example, through measurable changes in certain adrenal hormone levels which may serve as a biochemical indicator of extreme stress, and therefore of suicidal intent in depressed persons.

Our aim is not only to improve therapeutic techniques in dealing with the depressed and suicidal patient, but also to develop a large cadre of professionals in the field-physicians, teachers, lawyers, clergymen, nurses who are sensitive to new information in the area. Of special importance is the need to recognize the ways in which potential suicides signal their distress, the warnings they inevitably communicate as they desperately seek help. Two-thirds of those who attempt suicide have recently visited a physician, putting physicians, among others, in a strategic position to identify the potential suicide's "cry for help" and to respond adequately.

Through equally intensive and coordinated efforts, we are working toward the solution of other major problems as well; problems posed, for example, by the alcoholic, the drug abuser, the emotionally disturbed child, and the criminal and delinquent in our society.

The span of our efforts in such areas is reflected by our method in approaching problems of crime and violence. At the most basic level,

we are following leads that suggest the possibility of specific drug therapies for offenders, found to be atypical in their responses to medieation; in rehabilitation, we are developing programs of education and vocational opportunities for offenders, having demonstrated the value of such programs in reorienting the life of the criminal; and, in the interests of prevention, we are identifying those traits that may be common to offenders, and those characteristics, too, that may be unique to victims of violence. Recently, the Institute began support of a large-scale, university-based center for the study of violence in communities across the Nation. And staff members have served as consultants and advisers to the President's National Crime Commission.

RESEARCH

The basis of all our efforts is the Institute's research program, which continues to grow in size and variety. Over 40 percent of the NIMH research program is devoted to work in the behavioral sciences, encompassing studies designed to identify those physical, psychological, social, and cultural factors that shape human behavior; here too, the NIMH has been at the forefront of change in supporting and enlarging the role and the relevance of the behavioral sciences in the interests of the Nation's health. Such basic studies provide the groundwork for productive clinical and applied research directed toward the resolution of specific problems in mental health.

BIOLOGICAL SCIENCES

In the biological sciences, explorations in basic research have been the springboard for advances in a number of difficult areas, in the containment and control of the schizophrenic's deterioration, in the treatment of depression, in our ability to help decrease the abnormal cravings of the drug addict.

A few decades ago, physical mechanisms in mental illness were seldom the subject of rigorous scientific inquiry. Today, in contrast, studies by increasing numbers of productive scientists are converging on mechanisms in the body-errors in metabolism, or biochemical imbalances-which either trigger or perpetuate pathological behavior in man. Among them are investigators who search for unique blood factors associated with schizophrenia, or the role of brain chemistry in depression, or physical patterns in the addiction to alcohol and to drugs. Already clarified are a number of issues. For example, investigators have shown the causes of phenylketonuria, a form of mental retardation, and techniques for its prevention. And, through work in the Institute's laboratories, scientists are clarifying the mechanisms whereby the body handles catecholamines, those brain and body substances released especially under stress or anxiety, and that play important roles in psychiatric illness and in the patient's response to drugs.

We intend to continue our emphasis on research efforts focused on specific and critical problems. Because, after years of effort, it now appears likely that depression will be among the first major psychiatric illnesses to yield to curative measures, we have begun, for example, to devote increased energies to the development of newer and more rapid acting antidepressants. And, because of the promising new drugs