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would reject these as patients if they came with that label, and so they have to be admitted, and often honestly so because the nature of their disability is not recognized as nonorganic disease.
I mentioned four functionaries in the community, and perhaps the one who advises with people more frequently than anyone is the employer. There is the real test of the man's effectiveness. Of course, the courts find them in divorce actions also, but the employers find them, and some of them deal with those cases with remarkable humanity. Recently I was talking with the head of one medical service in one industry, and I was astonished at the extent to which they bend their practices to get alcoholics back. They feel it is a disgrace to discharge these people, and if they are confronted with no alternative, they sometimes promote a man from down below and put him alongside of the weak one that they are dealing with in order that they may retain him in his position. These are or this is a sort of general perspective on problems that
the spectrum, and I think the word "spectrum" is an excellent word when applied to this matter and which was referred to by Dr. Wortis, and you know when it comes to definition that that presents a real problem. I know what red is, but if somebody said "Where does red end and orange begin," I would be up against it, but I know what red is.
The CHAINMAN. That was a very complete statement as to the different types of cases. I wonder if there is another class that think they are all right and that everybody else is queer.
Dr. STEVENSON. There is a minority of us there. I thank you.
(The prepared statement of Dr. Stevenson follows:) STATEMENT BY GEORGE S. STEVENSON, M. D., THE NATIONAL ASSOCIATION FOR MENTAL
HEALTH, NEW YORK, N. Y. I am representing the National Association for Mental Health. That is a national citizens organization concerned with improvements in the care and treatment of the mentally ill and deficient, in the prevention of mental disorder, and the advancement of mental health. It was founded in 1909 by Clifford W. Beers, a former patient who suffered seriously from neglect as a patient in mental hospitals. The National Association for Mental Health has affiliated State associations in 29 States and over 200 local mental health associations. It is a member of the World Federation for Mental Health, which has similar objectives and operates on an international level. Each of these organizations focuses its effort upon activities carried on primarily within the scope which it represents.
The offering of testimony before this Federal body is a typical function of the national organization. In addition, it advises in the establishment of services, it promotes improvement in professional training, and promotes and supports research.
I personally am a psychiatrist, but my work has for years been organizational rather than clinical.
I hardly know where to begin in trying to bring before this committee an adequate perspective on mental illness. The allotment of time is so short and the problem so tremendous that I am bound to understate the case. You may have heard it said that mental illness is our No. 1 health problem and I shall try to explain why it occupies this unenviable position. The fact that you allow only 3 hours in which to gather a perspective on it leads me to question whether you are convinced that it is really a first-line issue. If you have doubts as to its position, I must hasten to say that you are not alone in this viewpoint. You are not exceptional. You are in large company and that is the main problem of those who are attempting to do something about mental illness.
I can hardly believe that members of our State legislatures could believe that this is our No. 1 problem and at the same allow the overcrowding of our mental hospitals to continue to be as serious as it is, and to allow only $3 a day on the average for the provision of every aspect of care and treatment. In many instances I know that the doubts about the importance of this field stem more from the will to disbelieve than from ignorance, for disbelief is bound to make those feel better who otherwise would recognize that they are parties to a serious neglect. Reducing the significance of mental illness makes those feel better who, because of their own unrational thinking-a fault into which all of us fall, think that their mental health is vulnerable. It makes those feel better who would economize at any cost. It makes those feel better who would put administrative expediency or administrative simplicity instead of patient care in first place in running an institution. For the more we try to do to serve patients, the more we must join hands with other State and local governmental and nongovernmental services and the more complicated administration becomes. For example, the great benefits offered by the Barden-La Follette Act of 1943 for vocational rehabilitation have been made known to our hospitals. It provides a service to recovered patients which in many cases the vocational history of the patient clearly calls for. Still in many places no advantage is taken of the opportunities offered under this act. It is this subordination of the mentally ill to expediency that blocks many other efforts that we are making in their behalf.
The research carried on today is extremely important, but is in no way a source of pride when one considers the immensity of the field and how much research should be going on. And the same may be said of professional training.
But it is obvious that this committee has not closed its mind as completely as many others have done and I sincerely congratulate you on that. You hare asked for frank comment and from your openmindedness endless gain can come.
Never has the association which I represent had resources to work with which are at all commensurate with the problem. After 44 years it is now just beginning to lay the foundation for adequate financing, but progress is slow and we are working against great odds. Our inclination, in fact our policy, is to conduct our campaign wherever possible through the medium of organized fund raising in communities, for we recognize that the opportunities to influence mental health reside with many community agencies and we cannot afford to set ourselves up in competition with or isolated from those other agencies. So far we have had only a pilot campaign and this year have raised in all about $1 million, all but about $100,000 of which is supporting the budgets of State and local mental health associations, for without strong State and local mental health associations we can expect neither adequate financial support nor adequate citizen action in building up the national, State, and local services and protections that are needed.
Many of the activities which this association has carried on in the past hare been transferred to other jurisdictions because they are more appropriately located there. For example, the collection and reporting of statistics is now a function of the Federal Government. Both the Federal Government and the American Psychiatric Association are now carrying on investigations of mental hospitals which formerly was a part of our work. The approval of training centers for psychiatrists again is no longer a function of this organization, being now appropriately carried on by a professional association. But it was our task to initiate these things.
Please keep in mind that in the case of no other illness do our States treat so many patients, nor does the Federal Government. In fact, well over half of the patients hospitalized under Federal auspices are frankly mentally ill cases, to say nothing of the psychoneurotic patients who are often classified under other medical and surgical categories. Most of the States fall far short of enough provision even of poor quality. I would remind you that New York provides 1 bed in its State mental hospitals for every 175 of its population, compared to an average of the whole country, which provides 1 to only about 330 of its population, barely half as much. I do not want to convey the false impression that New York has more mental illness than other States. By all indications there is no important difference in the incidence of mental disorders. Many of the other States just don't care for them. Instead of more than the 800,000 patients that it would be expected would be found in our State mental hospitals, on the basis of studies of incidence, we find about 300,000 less. This is a measure of the failure of the States to make provision for patients who are so severely ill that legal commitment is possible. And this figure does not include the million and a half mentally deficient who are the dullards, the alcoholics, the neurotics, and the other deviants.
This field offers many promising leads for research, leads that have not been followed up. Our researches have shown that in schizophrenia, which is the most common of the serious mental disorders in our mental hospitals, the adrenal glands are not behaving properly. This is a lead of such tremendous human significance that instead of a few laboratories in which biochemical research is beilig pursued, it would pay us to put 100 researchers in one place, sweeping through this problem and ferreting out every promising path of progress. An industry spending as much would certainly do it if it were confronted with a baffling obstruction to the success of its endeavor.
The mental illnesses of the aged, hardening of the arteries of the brain and the inactivation of brain cells, constitute the greatest group among the admissions to our mental hospitals. We suspect on good grounds that in many cases the deterioration has not gone so far as to be hopeless. The fault may be more a nutritional interference with the function of brain cells than the destruction of brain cells.
Where else in medicine would we find such promising leads passed by or given so little recognition? What other disease of major magnitude offers so much promise of recovery? Even with the limited resources of $3 a day, the results achieved are surprising, for in 1949, when 104,000 patients were admitted to our State hospitals, nearly 15,000 were discharged as recovered and over 32,000 as improved. What other illnesses result in such a tremendous loss of working years? Malzberg has shown that there is an average loss of 8.3 years by those who become mentally ill enough to be admitted to our State hospitals, and this average includes the senile and arteriosclerotic who break down so close to the actuarial limit of productivity that the loss is negligible.
It includes, on the other hand, the schizophrenic whose average loss is 20 years. Think how much saving has already been achieved by the empirical and superficial use of shock therapies and how much more the gain would be if research should lead us to more rational therapies and to ways of protecting the recoveries that we have brought about at great cost. Malzberg has shown again that on the average the loss in productivity per case is $9,932. This is a most conservative figure, for it is a loss calculated only after hospitalization, and many of these patients have suffered additional severe loss of working years because they have been sick a long time before reaching the hospital. Of course, there are other mental illnesses that bring the total up to as many as 9 million people, but many of those are not as seriously and economically incapacitated. What else completely incapacitates an estimated 2 million people for so long, 1 million psychotic and 250,000 low-grade mental defectives, uncounted severe alcoholics, and severe neurotics?
Mental illness is, as a rule, not a killing disease, and that partly accounts for the fact that it is not taken as seriously as some others. But there are more than 17,000 who commit suicide annually, and to that extent it is a killing disease.
What other disease calls as heavily upon the taxpayer as does mental illness? In the case of what other disease would the public tolerate a change of professional staff with a change of political administration? Fortunately, this is not the rule, but it happens far too often. What other illness is neglected until the patient becomes sick enough to be hospitalized? What other illness is a disgrace? What other disability than mental deficiency, involving 2 million cases, is represented by so few Federal research grants? What other disease than mental illness appears so often as a complication of other illnesses? Peptic ulcer, highblood pressure, and asthma are outstanding examples. Do you appreciate how often a doctor or a nurse is trained to the point of licensure with almost no preparation in this field?
So I could go on and on in supporting the fact that this is our No. 1 health problem. But if these facts are not impressive and conclusive, adding more will not serve any purpose. An organization such as I represent attempts to stand as the citizen's conscience in meeting it because it is composed of citizens who know, who understand, and who care.
But apart from treating and caring for mental illness, we are interested in its prevention, and things brings us almost immediately into a demand for research. There is so much that we do not know about prevention. We know enough that is firm with respect to prevention to give us courage, but beyond that our foundations are uncertain and we need research to solidify them. We are certain, for example, that if one does not suffer a syphilitic infection or if he is treated promptly, he will not suffer from general paresis. We can understand the meaning of prevention when we realize that this disorder which
35 years ago constituted 10 percent of the admissions to our mental hospitals is now with better preventive work providing only between 2 and 3 percent. There are a few other disorders in which prevention can likewise be confidently carried out. But in all they constitute only about 8 percent of all of the cases and do not include the mental illnesses of old age that are so abundant, nor schizophrenia.
It is true that we have important theories and leads and that we make every effort to promote preventive work even on a theoretical basis and even though the results are uncertain, for we are justified in leaving no preventive stone unturned. Only by applying what we know or even suspect do we learn and make progress. On the same basis we try to protect the recovered patient from relapse by seeing that he is not subjected to the conditions which broke him down originally. Proper occupation for about 15 percent of these patients seems to be important to their holding their gains, and yet as I have indicated before, this is not yet taken seriously enough because of administrative expediency.
Federal support of training and research has been emphasized by Secretary Hobby as being very appropriate Federal functions and great gains have been made through the partial realization of that principle. I say partial because much more could be done were the provision of research funds to the National Institute of Mental Health more extensive and more certain. A year-to-year support has its limitations for it forces a research worker to plan his work so that it can be completed within a 12-month period, when adequate pursuit of the research activity might call for a 5- or 6-year stretch. A short term project is uneconomical and frustrating to those who have long-range plans.
My organization is one of the pioneers in a coordinated and designed research program. For 18 years it has been spending money on research in dementia praecox, money supplied by the Northern Jurisdiction Scottish Rite 33o-at present $70,000 a year. There are about 17 research projects, but they are not independently conceived. They are 17 parts of a total interrelated plan and our effort is to weave a network of research about this disorder and gradually close in on it. I believe we are succeeding, but the speed with which the closing in takes place with that small amount of research money makes us impatient.
In addition to its work with schizophrenia, the National Association for Mental Health has on occasion devoted research funds to the study of psychosomatic problems, that is, a study of physical illness complicated by emotional disorders.
The job to be done in this field is so tremendous that an organization such as ours is forced to decide on priorities so that its resources may be applied most effectively and economically. In judging the priorities of any prospective activity or any area of the field, it asks itself certain questions. How seriously does the phase of mental illness under consideration or the proposal for action affect the people (patients) involved? Figuratively are we considering a pimple or a carbuncle? And next we ask how many people does this affect? Is it a common disorder like schizophrenia or is it a rare one? How seriously and extensively does it affect society? For example, does it disrupt a family? Is it related to crime? Does it handicap an industry? Does it upset a school or a college? Does it constitute a heavy tax burden? As a fourth question we ask: Where do we stand scientifically? How much do we know? What is the next step that we need to take and be sure that our feet are on solid ground?
And finally we ask: Has the public come along to a point where it is willing to back us up in doing what we should do? Often we find that the first four of these questions would lead us to vigorous action, but that the fifth question warns us that preliminary work must be done in order to bring about public backing. Sometimes, therefore, our sole effort is focused on public education when otherwise we are ready to move faster. Public education is essential in achieving our objectives. Public backing is the only safeguard for the legislator or Congressman who would move faster. We, however, recognize that education is an instrument leading to change and not an objective in itself, so that the audience, the objective and the message all must be clear before valid public education can be undertaken.
This organization has since its beginning provided both impetus and professional counsel in the establishment of diagnostic services, therapy, care, and rehabilitation. It has conducted demonstrations. Its most recent experiments have led the way to vocational rehabilitation for patients recovering in mental hospitals and for patients attending outpatient clinics. It is now clarifying the statutory and nonstatutory facts that affect State administration of mental hospitals. This organization has provided the main leadership to the country in the establishment of psychiatric clinics for children and in the training of personnel for such clinics. It now has a manual which is used by communities interested in establishing such service.
When we review the full range of the field, we appreciate how much we are not doing. Taking only the severely ill one need only ask: Where are the mentally ill? He is led immediately to a long list of social institutions which demand the attention of the citizen. This list would include somewhat in the order of importance the State mental hospitals, the Veterans' Administration hospitals, the city and county mental hospitals, the Public Health Service hospitals, serv. ices to the penal institutions, the Armed Forces hospitals, private mental hospitals, psychiatric departments of general hospitals, institutions for mental deficiency—both public and private, hospitals for alcoholics and drug addicts. In addition to this there are the known institutional community facilities that meet severe cases of mental illness, especially those coming to the private physician, courts, and other resources for helping people in need. We can't pass over any of these. We cannot escape the seriousness, the extent, the social implications, the scientific unknowns, and the public apathy toward this problem.
The CHAIRMAN. I believe Mr. Heselton has a question.
Mr. HESELTON. Doctor, I notice you are listed as representing the National Association for Mental Health, and I notice that in 1951 your association received quite a substantial increase in the amount of funds over the previous year. In 1950 it was $194,000 and in 1951, $600,000. I am inclined to believe that is because of the merging of a number of these groups, but I am not certain about that.
Dr. STEVENSON. That is right. Practically all of those funds in that year were received from foundations and other contributors whose efforts were merged.
Mr. HESELTON. That is all, Mr. Chairman.
Dr. STEVENSON. A part of it represented also confidence in the foundation and the feeling that this merging was a good thing.
The CHAIRMAN. Is anyone in a position to tell us what the overall cost of caring for these cases is in the different public and private institutions?
Dr. WORTIS. Yes.
The CHAIRMAN. I am just informed that that was in the record before I came in this morning.
Dr. WoRTis. Mr. Chairman, I believe Dr. Felix could give us these figures. They are available through his office and his staff.
STATEMENT OF DR. ROBERT H. FELIX, DIRECTOR, NATIONAL
INSTITUTE OF MENTAL HEALTH
Dr. Felix. Mr. Chairman, with your permission and in the interest of time, I will give one figure rather than the breakdown, but I will be glad to submit for the record the full information if you wish.
The cost of the care of patients in mental hospitals plus the cost including Veterans' Administration hospitals plus the cost for pensions of neuropsychiatric disability of veterans, Veterans Administration pensions, comes to about $10 million over $1 billion a year at the present time. For the past several years the annual figure has increased at the rate of around $100 million a year. I will let it go at that unless you want some more information.
The CHAIRMAN. That illustrates the tremendous problem that this presents. We could continue here for a week, and nothing would illustrate more clearly and more definitely than the statement that you have just made as to the immensity of this problem.