factors as the role of life history factors on the development of schizophrenia, mechanisms underlying the psychosomatic illnesses, brain chemistry and chemical alterations resulting from the administration of drugs, patterns of emotional development, the psychology and psychophysiology of sleep and dreaming, relations between endocrine and behavioral processes, and behavioral processes from sociological and anthropological points of view.

In 1968, this Institute will continue the support of mental health career investigators and expand the program by new awards. With additional funds in the amount of $54,000 the requested appropriation would provide for 116 continuations, and for 5 new research career development awards.

An increase of $50,000 will provide for contracts for studies of mental health manpower needs.

MENTAL HEALTH SERVICES

The mental health services programs support a broad array of programs aimed at the improvement of the delivery of services to the mentally ill. These programs include:

1. The support of construction and staffing of comprehensive community mental health centers.

2. The improvement of the quality of care and competence of staff in state mental hospitals and institutions.

3. The administration of the mental health care administration aspects of the Social Security legislation.

4. The improvement of planning for comprehensive mental health services, and integration of mental health planning in the comprehensive health planning.

5. The coordination of Institute programs of regional, metropolitan and rural mental health.

Mental Health Care Administration: Created, in response to a long-felt need, the Mental Care Administration Branch will concentrate its activities on three major areas to promote the mental health aspects of the Social Security Amendments of 1965: Program Development, Certification and Consultation and Standards Development.

Studies have reported that over 25 percent of the 65 year old and older population (19 million people) have a psychiatric disorder which warrants intervention and that about 15 percent of persons in this age group have severe mental disorders. Approximately 55,000 aged persons are admitted to State hospitals alone each year and public and private psychiatric hospitals have a resident population over 65 years of age of over 150,000 people.

One of the major responsibilities of the Branch will be to take a leadership role in activities designed to insure that appropriate psychiatric services are available for persons requiring geriatric psychiatric care and treatment.

A recent survey of all general hospitals in the country revealed that only 17.3% routinely admitted psychiatric patients for treatment. An even smaller percentage provided an intensive and comprehensive treatment program for the aged mentally ill.

Active collaborative endeavors with the Social Security Administration and with national standard-setting professional organizations will have two main objectives; to increase the number of qualified providers of psychiatric services and to maintain quality control.

At the same time an intensified consultation and education program is required at the regional, state and local level to upgrade the scope and quality of treatment programs and to incorporate public and private hospitals, extended care facilities, community mental health centers and home health agencies into an effective mental health service program.

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Studies of Metropolitan and Regional Mental Health Programs: Established in July 1966, the new Center for Studies of Metropolitan and Regional Mental Health Problems has as its mission the exploration of the interrelationships between the Nation's metropolitan areas and the mental health of the more than 60% of American people living within those areas.

The first six months of the Center's operation have been devoted to surveying the field, opening channels of communication with other Federal agencies, and developing its program. A few Institute-supported projects which were already underway and are directly related to this subject area were transferred to the Center. They involve investigations of the dimensions of some characteristically urban problems-neighborhood blight, urbanization of migrants, and

homelessness.

The developing program of the Center is based on the overriding importance of fostering at the metropolitan area and regional levels the primary prevention of mental illnesses. The need is to introduce mental health considerations into every area of urban development, both physical and social. Toward that end the Center's training and research programs are being designed to produce better understanding of the phenomonology of urban life and the points of intervention through which mental health can be fostered.

Examples of the investigations the Center will seek to support in the coming year are: psycho-social reactions to physical and social density, an evaluation of community organization techniques in core central cities, modes of integration of mental health planning and urban development planning, and the dimensions of "community" as a viable concept of social organization in the urban setting. Hospital Improvement Projects: The purpose of the Hospital Improvement Project program is to provide support for demonstrations of improved methods of care, treatment, and rehabilitation of the mentally ill and mentally retarded in State mental hospitals. Its objectives are to improve therapeutic services and the quality of patient care, and to strengthen the role that State institutions can play as the comprehensive community mental health and mental reardation programs unfold.

The program was initiated in 1964. At the end of last year, 145 of our 302 State hospitals received awards through the program; among the 138 State institutions for the mentally retarded, 89 were the recipients of grants.

Eighteen States have grants for all of their eligible institutions in both categories. Every State has at least one hospital improvement grant. Only three States have no grants for any of their mental hospitals, and three other States have no grants for their institutions for the mentally retarded. Fifty-three percent of the institutions eligible to apply for hospital improvement grants have received them in the three years since the program was initiated. Two-hundred and twelve institutions have received both Hospital Improvement and Inservice Training Grants. There are now over 50,000 patients involved in current hospital improvement projects. New program development is only one aspect of the potential of this grant program. There are many indications that when an institution has been able to achieve a better therapeutic program and to stimulate staff into new ways of doing things, the gains made spread to other aspects of the Institutions' program and are likely to be irreversible.

During 1967, the Hospital Improvement Project program for institutions for the mentally retarded is being transferred to the Division of Mental Retardation, Bureau of Health Services, Public Health Service.

Over 80 percent of the funds in hospital improvement projects are spent for personnel to provide new therapeutic services. A major emphasis in mental hospitals has been placed upon programs that would improve treatment, training, and rehabilitation of the long-stay more severely ill.

A number of hospitals are developing treatment services for special groups, such as the aged, emotionally disturbed children, adolescents, or mentally ill prisoners. For example, in 22 States, hospital improvement grants have been used to support treatment services for emotionally disturbed children and adolescents in mental hospitals. In several States the grant has allowed the State to establish for the first time specialized services for children.

Some hospitals are using projects as one step in the reorganization of hospital service and the development of geographical based units. These units provide intensive care as well as longer term treatment for patients coming from a specified geographical area. They assist the hospital to become involved with community facilities in the area to achieve initial steps in the development of comprehensive mental health services.

While the progam is still too new for a formal assessment of its impact on patients, it is already clear that many of the severely disturbed "back ward" custodial patients are responding positively to the new treatment programs. This response is raising expectancies of what can be accomplished with "chronic" patients. For many of the institutions, projects are stimulating and assisting in the development of improved hospital-community coordination and the more effective use of available resources.

Over the past ten years, there has been a revolution in the human climate in many State hospitals. There have been changes in the role of the patient, changes in expectation as to patient behavior and changes in relationships between staff and patients and amongst staff. Not all hospitals have participated equally in this humanizing atmosphere. It is these hospitals that the hospital improvement program is designed especially to reach.

Inservice Training Program: The long range objectives of the Inservice Training Grant Program are to increase the effectiveness of staff in mental hospitals and institutions for the mentally retarded and to translate increasing knowledge into more effective services to the residents of these institutions. Major emphasis in this program has been placed upon training psychiatric aides, attendants, house parents and others similarly involved in direct patient care, since they constitute such a large and important treatment resource in mental hospitals and institutions for the mentally retarded.

During the first three years of operation of this program, inservice training grants were awarded in 181 State mental hospitals and 99 institutions for the retarded. This is 64 percent of all institutions eligible to apply. At least one inservice training grant has been made to a facility in every State. Twenty-one States have received grants for all of their eligible institutions. Forty-nine States have inservice training grants in at least one mental hospital; and institutions for the retarded in 45 States have been awarded inserive training grants.

Funds for 1966 were distributed as follows: 181 inservice training grants to mental hospitals totaling $4,171,028 and 99 inservice training grants to institutions for the mentally retarded totaling $2,182,000. During 1967, the Inservice Training program for institutions for the mentally retarded is being transferred to the Division of Mental Retardation, Bureau of Health Services, Public Health Service.

Primarily, four types of training are being provided under inservice training grant support. These are refresher training, continuation training, supervisory training, and instructor training. There are over 10,000 trainees directly involved in current projects.

A primary goal in the use of inservice training funds has been to prepare employees to work in new treatment programs and to achieve more positive attitudes and better understandings of the patient and his potential for recovery. Several mental hospitals have initiated training programs for employees recruited from new sources, such as high school students in vocational education programs or students from a nearby college, or they have provided training for community personnel working closely with the hospital.

Special attention has been given by the Institute's staff to planning and conducting regional conferences on inservice training collaboration with state and local inservice training personnel. In general, these conferences have been focused on assisting state and local inservice training personnel to develop their programs and in providing information on teaching method, curriculum development, administration, and evaluation. Conferences of this nature were held in seven of the nine DHEW Regions during 1966.

Mental Health Facilities: The staff of this branch is responsible for the Institute's program of assistance in the construction of community mental health centers. This program is discussed in the "Community Mental Health Resource Support" appropriation which follows.

Community Mental Health Centers Staffing: The staff of this branch is responsible for the Institute's program of assistance in the staffing of community mental health centers. This program is discussed under the "Community Mental Health Resource Support" appropriation which follows.

Included in this activity is a decrease of $4.000. An increase of $11,000 for annualization of positions new in 1967 is offset by nonrecurring items such as one less day of pay.

The objective of the Institute's Special Mental Health effort is to plan and administer programs directed toward specifically identified problem areas of special significance such as alcoholism, narcotic and other drug abuse, mental health of children and youth, crime and delinquency, and suicide prevention.

Each of these areas possesses certin common characteristics. They each are areas of critical public importance; they each require a multidisciplinary ap proach both in the conduct of research and delivery of services; in most areas, relatively little is known about underlying causation, and they all have requirements for additional specialized manpower in order to adequately respond to the requirements for new knowledge and improved patterns for the delivery of services.

In order to respond to the requirements of these special areas, and to better utilize the resources available to it, the Institute has developed a group of specialized centers to be charged with responsibility for the total Institute program activity in each of these key fields. Accordingly, these centers, now in the early stage of implementation, will serve as the national focus for research, manpower development, and services delivery in their fields.

The conception of alcoholism as a disease entity has gained public and professional acceptance during the last two decades. Health professionals have led the way, incorporating scientific and humanistic principles into their ap proach to alcoholism. More recently, our judiciary has taken cognizance of this contemporary approach, and courts are beginning to regard the alcoholic as a sick person in need of medical attention. In addition, our ultimate understanding of alcohol addiction will require the contributions of the social and behavioral sciences as well as those of biological disciplines.

Alcoholism is not an all-or-none disease but one composed of many subspecies. No formal definition of alcoholism is universally applicable because the disease is defined in part by the socioeconomic context in which it occurs. Thus, the person regarded as an alcoholic in a northern industrial city may not be seen as such in an isolated rural area. With certainty, however, alcoholism in all its subspecies is conspicuously present in virtually all socioeconomic groups in all contemporary cultures. While the reliability of our current data on alcohol-related problems is limited, certain findings suggest the extent of the overall problem.

It is estimated that there are between four and five million alcoholics in the United States. If one includes their families, perhaps 20 million people are directly affected by alcoholism. According to the World Health Organization. the United States has replaced France as the nation with the world's highest incidence of alcoholism.

Only a small proportion of all alcoholics-perhaps as few as 8%-are of the so-called "Skid Row" type. The vast majority in the United States are living

with their families, holding some kind of job, trying to keep a place in their communities. In 1964, some 11,000 deaths were attributed officially to alcoholism, but the actual number is believed to be far larger. Insurance companies calculate that the alcoholic's life expectancy is ten to twelve years less than that of the average person.

In some states, it is claimed that communities spend $50,000 to $100,000 in support of an alcoholic and his family during his lifetime. Costs to industry have been estimated at a minimum of $2 billion a year.

Alcoholism is the number one mental health problem in nine states, according to hospital diagnoses. Of the first admissions to state and county mental hospitals in 1963, one in seven was diagnosed as alcoholic. One out of every eight male patients seen in outpatient psychiatric clinics had an alcohol-related diagnosis.

In recognition of the magnitude and social impact of this problem, the National Center for Prevention and Control of Alcoholism has been established by the Institute to coordinate the Public Health Service activities in alcoholism, to formulate new programs, and conduct research studies in its own laboratories. Its general functions are:

(1) To provide leadership in planning and developing national programs concerned with alcoholism, in collaboration with other Federal agencies, national organizations, state and local governments and voluntary citizens' groups;

(2) To coordinate Institute research, training and service activities in the field of alcoholism;

(3) To foster the development of a wide range of basic and applied research studies of the interrelated biochemical, psychological, behavioral, clinical, pharmacological aspects of alcohol use;

(4) To coordinate and stimulate statistical and biometric programs for epidemiological and longitudinal studies of alcoholism and alcohol use; (5) To accelerate the application and research findings through consultation, demonstrations, field trials, and other mechanisms;

(6) To assist national, state and local organizations in improving and extending programs for the prevention of alcoholism and for the care, treatment, and rehabilitation of alcoholics;

(7) To give leadership in the development of inservice training and the continuation of post-graduate training to accelerate the use of current and new knowledge;

(8) To promote health education programs about alcohol for the general public by stimulating the development of educational materials and including pamphlets, books, and audio-visual methods.

The stimulation of new comprehensive training programs will receive high priority from the new Center. A major deficit in all alcoholism programs—research, training, and service has been the lack of trained people to carry out the many tasks. Professional training has been sadly neglected. Physicians are usually poorly prepared to handle alcohol-related problems when they meet them in their internships and residencies, and few investigators in basic science disciplines seem to appreciate the possibilities for research in alcoholism. It is reasonable to predict the future advances in our understanding and treatment of alcoholism will depend critically on supplementing and expanding current training programs for professionals. The Center will now initiate support of fellowships to provide stimulation for training personnel to engage in research and other activities in the field of alcoholism. Similarly, expansion and improvement of treatment services depend on the creation of adequate training programs for non-professionals.

Alcoholism is caused by a complex interaction of biological, psychological, and sociological factors. Because of this, the hope for developing a better understanding of the cause, natural history, and eventual cure of alcoholism lies in investigators from a number of disciplines working together as a team and directed toward a common goal.

A matter of high priority for the National Center for Prevention and Control of Alcoholism will be the development of university-based multidisciplinary research centers for the study of alcoholism and alcohol-related problems. At the present time only one such center exists in the United States (Rutgers University).

During the current year, staff of the Center will consult with a number of medical schools and universities to aid in preparation of program project grant