interests me most is the suicide rate in students-it ranks third in the cause of death in this group and, if the truth were known, it is probably second. An unknown number of accidents which occur are really carefully planned and then too, for many diverse reasons, some suicides are deliberately not reported as such. While the total given nationally is 20,000, the true number is much higher and the number of suicide attempts is 10 times the number of successes. Fortunately, a number of cities now are developing suicide prevention services and the Los Angeles center, which has been operating more than 6 years and which is outstanding, has developed the basic knowledge, methods, and techniques for a nationwide prevention program-but increased funds will be required to continue research and to distribute widely the information which has been acquired.

The suicides of college students bother me very much. Although I am convinced, after 35 years experience, that one cannot with any certainty prevent a person from destroying himself when he is intent. and bound to do so, we must make sure that we do all we can to detect early signs of that intent and take steps to protect the individual who is inclined to self-destruction.

I was in the jail in Nuremberg about 20 years ago, and this struck me very forcefully. Here were men who were under the watchful eye of the military of four nations, constantly, 24 hours a day, and two of them managed to destroy themselves as you will recall.

One way to do this is through the health services of the institutions of learning, for psychiatrists in these services can detect the early signs of depression which, left untreated, might well result in serious. consequences. Farnsworth, who probably is more knowledgeable in the field of emotional problems in college students than anyone else, notes that a number of these individuals can be recognized in college health centers. Some institutions have psychiatrists in their health departments; others do not for various reasons-some financial, some because of lack of psychiatric assistance in the area; others seem to feel that this is not the concern of educators and I often wonder what these officials say to parents whose sons have had an emotional break. It must be difficult; maybe one has to have physical symptoms to attain respectability. Maybe, too, I am unfair in these statements.

As to the psychoses, of course, the greatest interest is probably exhibited in that congeries of symptom known under the catchall title of schizophrenia, a group of symptoms which has defined the efforts of some of the world's most brilliant men to arrive at its solution. It is probable that, when a solution of the problem is arrived at, it will encompass many other basic research ideas over and above the schizophrenic problem itself.

Major investigators are of the opinion that the most promising evidence for a biochemical abnormality lies in the area of transmethylation.

That is a chemical formula which is quite complex.

One recent study compatible with this idea was the demonstration of an abnormal catecholamine metabolite in the urine of some schizophrenics. The evidence is still preliminary that this substance is produced within the body and is not a component of the diet. There is no direct evidence that this material produces schizophrenic symptoms. Interest in a protein constituent of the blood of schizophrenics con

tinued strong; it also is apparently in the blood of some schizophrenics and it is capable of producing certain behavioral metabolic or cellular changes in experimental animals.

There are a number of such studies and, fortunately, no wild claims are being made regarding them. That has been our trouble in the past and has led to quizzical attitudes toward them. We seem to be playing around the edges researchwise and as yet cannot get things together. There is apparently a fatty acid compound found exclusively in the sweat of schizophrenics; what its significance is we do not know. Brain studies made by means of new instruments measure the electrical activity of the brain of schizophrenic patients through the intact scalp. This may lead to a demonstration of significant differences in the brain function between the mentally ill and the normals. No door can be left unopened and every lead must be

followed.

The social, psychological, and cultural factors of the illness are being investigated. One does not know how these factors and basic research findings can be gotten together to produce their devastating effects, but in some way they do. It is simply further evidence, however, that schizophrenia is not an isolated disease, but rather a combination of mental and emotional malfunctionings.

It is easier for the economically better situated and the more highly educated psychotic patients to stay out of hospitals and, if hospitalized, to get out of them. It is not clear as yet whether the improved prognosis for the first group is due to greater clinical improvement or to the greater supportiveness of the environment available to them outside. Though they seem to be free of major psychiatric symptoms 1 year later, their community adjustment leaves something to be desired.

As to treatment, phenothiazine drugs seem to be the treatment of choice. Symptoms can be controlled by this means. Studies show that a number of patients who earlier would have had to be hospitalized now can be maintained at home by drugs and a cooperative family. There is some evidence that those who improve on different drugs have different pretreatment symptoms and background histories. If these results hold up, they would provide a basis for assigning patients to that drug on which they are most likely to improve.

As to depression, research on its causes may be coming more fruitful. Studies underline the involvement of norepinephrine in the mechanism of action of both major classes of antidepressant drugs and it is evident now that two quite different drugs used to treat hypertension occasionally produce depressive illnesses; both groups cause a dramatic drop in the brain levels of norepinephrine. This evidence needs careful study and exhaustive research.

From Europe, and to a lesser extent from American studies, comes evidence now of electrolyte abnormalities in depression, and of the response to mania and possibly recurrent depression to treatment with an electrolyte, lithium ion. All of this, however, is in its earliest stages and we would do well to contain our enthusiasm about it.

I could go on and on, Mr. Chairman, but your time is valuable. At the end of the innumerable examples of research leads I would give, I would speak of the things we would urgently hope for, things which might be brought to pass if we continue our efforts. I would not

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imply that we could buy advances but I would suggest that now that so many fine research men are interested in our field we have higher hopes of accomplishment than ever before. All of this would add up to one thing, however, and that is crystal clear-a cut in the research budget of $2,374,000, at proposed by the administration, is unthinkable. Actually, the budget should be increased and we recommend the modest increase of $626,000 over the 1966 budget, or a total of $40,756,000.

We have already considered the demonstration projects (title V) and we agree heartily with Mr. Gorman that the important projects under this heading merit greater support or they will die of inanition. We recommend an additional $2 million be appropriated to aid the alcohol, drug, and suicide projects for the reasons I gave above. This would mean a total of $20,357,000 rather than the $18,357,000 in the official budget.

I think I need not comment on other aspects of the budget; that has been done very well by my colleague. I am aware of your dedicated interest, as you are of ours. I am aware, too, of the numerous calls upon the Congress for funds. I can only hope that now that we have finally started to get our patients out from behind forbidding large stone walls that we will not be slowed down or brought to a halt. Mental patients have had a bad time of it for a number of years. Lack of space, of personnel, of funds have dogged them always; theirs is not a popular cause and they have little appeal to the public at large. We can only depend upon you gentlement for help. Down through the ages the public has come to believe that our patients are a Government responsibility and in the main the citizens have failed to see the necessity for taking care of them, even as they do patients with physical illness.

It is probable that as long as man lives he will have emotions and, if he has emotions, they will get out of order and emotional disorder will never be popular or command sympathy or understanding in our culture. Man cannot go on his way unemotionally; God reserved that mood for cows. Therefore, when he gets upset, we must take care of him; hence this urgent appeal to you. Thank you for your courtesy and attention.

(The chart follows:)

Mr. FOGARTY. Thank you, Doctor. You just mentioned in passing the training of general practitioners in the field of psychiatry, which goes back to 1958. This is one area that Mr. Gorman and this committee can take some credit for.

Dr. BRACELAND. Yes, sir; I know, sir.

Mr. FOGARTY. You were a little lukewarm at that time.

Dr. BRACELAND. Yes, sir.

Mr. FOGARTY. And so was I, just like the Peace Corps. But it has turned out to be one of the most popular programs in this area. I understand by Mr. Gorman's testimony you are going to have to turn down at least a hundred doctors who want to go in the program. Mr. GORMAN. And many more who want to take the graduate

courses.

Mr. FOGARTY. You mentioned the August 1965, issue of the AMA Journal. Can you get that article and put the pertinent parts in the record?

Mr. GORMAN. Yes, sir.

(The article follows:)

DATA ON POSTGRADUATE COURSES FOR PHYSICIANS, 1965, FROM AUGUST 9, 1965, ISSUE THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION

Breakdown of continuing education courses by subject category:

Psychiatry: 253 courses.

General medicine: 177 courses.

Pathology: 98 courses.

Surgery: 93 courses.

Ophthalmology: 90 courses.

Obstetrics-gynecology: 86 courses.

Quote from JAMA article:

"The growth of psychiatry courses has been remarkable; the number has more than doubled in the past 2 years, probably because of financial support made

available through the National Institute of Mental Health and the cooperative efforts of the American Psychiatric Association and the American Academy of General Practice."

Mr. FOGARTY. You are not meeting anywhere near the needs now in trying to help these people to know something about psychiatry. I am surprised they want to go back to school again.

Dr. BRACELAND. It is very difficult because these men are individualists to begin with, or they would not be practicing medicine, and now they come back and become residents and are doing what they are told and they stand night and weekend watches. They do it gladly and they are good men.

Mr. FOGARTY. In the area of suicide, you mentioned something connected with the problem of education. What did you mean by that?

Dr. BRACELAND. The third greatest cause of death of college students in this country is suicide. They say it is the third, but really it should be the second, because many of the suicides that occur in college are carefully disguised. They are automobile accidents or other types of accidents which have been carefully arranged. Also, there is a natural reluctance on the part of physicians to label a number of things that are suicide, really suicide. Down to No. 2 in the cause of death. You know, Mr. Chairman, that 60 percent of the people who start college in this country drop out before the end of the 4th year; 20 percent of that 60 percent come back and finish. Many, many of the brightest kids in the classes have trouble emotionally. They are in need of emotional help. As the dean of freshmen at Harvard once stated, there are so many wonderful kids on the beach that it pays to have some good lifeguards handy in case some of them get beyond their depth. They do have serious emotional problems. So much is expected of them. They are under such pressure to make marks and to move on into graduate schools that they have trouble sometimes. Also, the culture outside is not exactly conducive to study many times.

Mr. FOGARTY. I thought it was just the other way around. I thought it was the average student that was burning the midnight oil every night to just stay in school that had these breakdowns.

Dr. BRACELAND. He has troubles, too. The reason I sound more knowledgeable than I am is that I have just written a foreword to Farnsworth's book called "Society, Education and the Young Adult." He knows more about it than anybody in the country. He is the chief at Harvard and Radcliffe and he was at Williams and MIT before that, and these are his views.

Mr. FOGARTY. Mr. Laird?

Mr. LAIRD. I do not have anything.

Mr. FARNUM. I don't have any questions.

Mr. FOGARTY. Dr. Braceland, you have a plane to make.

Dr. BRACELAND. If I can.

Mr. FOGARTY. There was one question I meant to ask you. You spent quite a bit of your time on the use of drugs. From reading the newspapers there seems to be a revolution going on down in the Food and Drug Administration.

Dr. BRACELAND. Yes.

Mr. FOGARTY. Maybe when Dr. Goddard gets through you might have to rewrite your statement because they are going back and testing some of these drugs you have been using for several years.