a variety of reasons, Selective Service prevalence rates cannot be applied to general male population age 18-44 to determine the number of such individuals with mental disorders. However, these data emphasize the large loss of manpower to the Armed Forces for which mental disorders are responsible. Armed Forces data

Although Armed Forces experience is not applicable as a measure of mental illness prevalence in the general population, an indication of the magnitude of the problem insofar as these services are concerned is derived from the number of disability discharges because of neuropsychiatric reasons during World War II. Of 980,000 disability discharges from the Army during the period December 1941 through December 1945, 43 percent were for neuropsychiatric reasons (table 3).

Patients in mental hospitals

The most detailed data available on the mentally ill are derived from mental hospital records. These relate only to persons whose illness has been recognized and who are sufficiently ill to warrant admission into a hospital for longterm care of psychiatric disorders.

In the United States in 1950 there were 201 State, 111 county and city, 228 private hospitals for mental disease as well as the 33 VA neuropsychiatric hospitals. The persons admitted to these hospitals are those with the more serious mental diseases, primarily the psychoses. They constitute a major illness problem for the Nation because of their large numbers and the amount of care they require. The cost of their hospital care is prodigious. Combined, these hospitals spend more than $500 million annually for maintenance and care of patients.

At the end of 1950 there were 577,000 resident patients, or 3.8 per 1,000 population, in all long-term mental hospitals. About 85 percent of these patients were in State, 9 percent in Veterans' Administration, 4 percent in county and city, and about 2 percent in private hospitals.

There has been a continuous increase in the resident-patient populations of these hospitals since 1903, the earliest year for which reasonably comparable data are available, when the number of residents was only 150,000, or 1.9 per 1,000 population (table 4).

Many factors are responsible for this fourfold increase in number of patients and twofold increase in ratio of patients to general population: First, there is the possibility of a real increase in the incidence of mental illness, but this is difficult to determine; second, the fact that the population is aging means that many more people are brought into the age groups where rates of admission are the highest; third, there is a greater awareness of the problems of mental illness on the part of both the lay public and the medical profession, as well as increased public confidence in the management of these hospitals and the service they render; fourth, a considerable proportion of admissions fall into the group requiring extensive long-term care. Thus, with increasing admission rates, the absolute numbers of such patients will increase in the resident-patient population. The improvement in death rates over the years resulting from better medical care and the use of the new wonder drugs has also contributed to an increased resident population. Fifth, there has been a constant increase over the years in the availability of hospital space. However, mental hospital beds are still unequally distributed throughout the Nation, as may be seen from the variations found in the resident-patient rates of the States, ranging from about 2 per 1,000 population in New Mexico to 6 per 1,000 in New York State.

In a single year the movement of patients into and out of these hospitals is considerable. For example, as of July 1, 1949, there were 554,000 in residence and 87,000 in extramural care. In the following 12 months there were 260,000 admissions, 184,000 discharges, and 47,000 deaths. Thus, there were over 900,000 patients under the care and supervision of mental hospitals during that year. The rate of first admissions to long-term mental hospitals has long been used as an index of the incidence of the more serious mental disorders. A sizable literature exists concerning the characteristics of such admissions, especially of those entering State mental hospitals.'

Malzberg, B., Social and Biological Aspects of Mental Disease, Utica, N. Y. State Hospitals Press, 1940: Dayton, N. A., New Facts on Mental Disorders, Springfield, Ill.: Thomas, Charles C. (1940); Census of Patients in Mental Institutions, 1923-49.

39087-53-pt. 4-15

In 1949 there were 104,000 first admissions to State hospitals-a rate of 71 per 100,000 population. This rate rose from a low of 2 per 100,000 for persons under 15 years of age to 76 at 25-34 years, 93 for persons 35-54 years, 97 at ages 55-64 years, and 236 at ages 65 years and over (fig. 1 and table 5).

Data on first-admission rates can also be used to show that at least 8 percent of the infants born today will spend some part of their future lifetime in a mental hospital.

Hospital data also gives us information about the kinds of disorders found in relation to age at first admission. In the age range 15-44 years, schizophrenia and manic-depressive psychoses predominate. During the next decade of life, the involutional psychoses, general paresis, and alcoholic psychoses attain considerable importance. In the sixties, psychoses with cerebral arteriosclerosis and senile psychoses assume prominence, and these mental diseases of the senium continue to rise until the end of the life span.

Of the 500,000 resident patients in our State mental hospitals, one-quarter have been hospitalized for more than 16 years, one-half for more than 8 years, and three-fourths for more than 2.5 years. This resident population consists largely of a slowly accumulated core of schizophrenic patients who are admitted during youth or early maturity and stay, in many cases, for the rest of their lives. Although admissions of senile cases have increased greatly in the last decade, they constitute a relatively small proportion of resident population because of a high death rate following admission. Thus, the median duration of hospitalization for resident patients with mental diseases of the senium, who constitute 11 percent of the resident population and 27 percent of first admissions, is 2.4 years, while that for resident schizophrenics, who constitute 47 percent of the resident population and about 22 percent of first admissions, is 10.5 years (table 6).

The problem of the increasing rate of first admissions in the population aged 65 and over is too emphasized. Since 1940 there has been no marked change in the first admission rates to State mental hospitals in the age groups under 65 years. For persons in the age groups 65 years and over the 1950 rate is 20 percent higher than the 1940 rate. This has resulted in increasing the proportion of patients in the age group 65 and over among first admissions from 20 percent in 1940 to 25 percent in 1950 (an increase of 25 percent). In the same period of time the proportion of persons in the age group 65 and over in the general population has increased from 6.9 percent in 1940 to 8.1 in 1950 (an increase of 17 percent).

Limitations of hospital data

Studies of the hospitalized population have provided us with much useful information on the frequency of various mental disorders. However, it is difficult to use hospital data to generalize about the prevalence and incidence of similar disorders in the general population. We lack a basic fact-the relationship be tween the number of persons hospitalized for a given disorder and the number of persons in the population with the same disorder who never reach a mental hospital. Hospitalization rates are a resultant not only of the true incidence of mental disorder but of a number of factors such as availability of mental hospital beds, public attitudes toward hospitalization, and availability and use of other community resources for diagnosis and treatment (for example, general hospitals with psychiatric treatment services, psychiatric clinics, and private psychiatrists).

A point to be emphasized is that mental hospital data present an incomplete picture of the number of people under treatment. There are at least 153 general hospitals in the country with psychiatric facilities, many of which provide not only diagnosis but also intensive treatment. In 1949 there were 128,000 patients separated from the psychiatric services of such hospitals, of whom 85,000 were discharged back to the community, 3,000 died, and 40,000 were transferred to long-term mental hospitals. More data are needed on these patients, especially those returned to the community, as well as on the large number of adults and children seen in the 1,200 psychiatric outpatient clinics in the United States.5

Pennell, M. Y., Cameron, D. C., and Kramer, M., Mental Health Clinic Services for Children in the United States, 1950, Public Health Reports, vol. 66 (1951), pp. 1559-1572.

Patients in institutions for mental defectives and epileptics

At the end of 1950 there were 134,123 resident patients or 89.3 per 100,000 population in institutions for mental defectives and epileptics. About 95 percent of these patients were in public institutions and 5 percent in private institutions; 84 percent or 113,185 of these residents were mental defectives and the remaining 16 percent were epileptics. Table 7 shows the increase in resident patients in such institutions from 1941 to 1950 inclusive.

Table 8 shows the estimated number of such residents in public institutions by mental disorder in 1950 and the percentage distribution of age of these resident patients.

Problems of these institutions are much different from those faced by mental hospitals since almost all of these patients face an irremediable mental handicap. The institutions' primary goals are (1) to train as many of these patients as can be trained so that they might be released to live a useful and productive life outside of the institution, within the limits of their mental activities and (2) to provide adequate and humanitarian living conditions for those whose mental handicap is so great as to require their continued institutionalization for the full span of their life.

Hospitalized patients

No systematic study has been made of the overall economic costs of mental disorders to the Nation. However, an idea of their magnitude may be obtained by considering one part of the picture, namely, the costs of hospitalization.

During 1952 the State, county, and city mental hospitals spent $490 million for care and maintenance of their patients. Although this represents a considerable expenditure of money, it must be remembered that per capita expenditures per patient are still very small. When the 48 States are ranked by the magnitude of daily per capita expenditures for maintenance and care of patients in the State, county, and city hospitals for 1952, the median expenditure is only $2.30 per patient per day.

Another large continuing expenditure of public moneys is that made by the Veterans' Administration for the care and treatment of veterans with neuropsychiatric disorders. At the end of 1952 there were 56,400 neuropsychiatric patients in Veterans' Administration hospitals. During that year the cost of care for such patients amounted to $146,565,000.*

The cost of taking care of the mentally ill with public funds, including maintenance of such patients in public hospitals, VA pensions, and other State and local mental health activities in 1952 amounted to $1,041 million or about $2,900,000 per day. This is about $2,000 per minute, day and night (table 9).

The hospitalized individuals and their families also suffer severe economic losses. For example, Malzberg' has estimated that the 9,000 male first admission to State and licensed hospitals for mental disease in New York State for 1948 will lose a total of about 75,000 working hours (8.3 years per patient), equivalent to a loss in net future earnings of about $90 million, or $10,000 per patient. The 9,400 female first admissions will lose an estimated total of 77,000 working years (8.2 years per patient), equivalent to a loss in net future earnings of about $42 million, or $4,400 per patient.

Aside from humanitarian reasons, one of the most cogent factors which motivates research in a given health field is the desire to rehabilitate disabled individuals so that they may return to their proper places in society and become effective units in our economic system once more. Data available on new cases of cancer and on first admissions to long-term mental hospitals in 1947 show strkingly that mental illness affects to a much greater degree than cancer those individuals in the productive years of life. Some 34 percent of first reported cancer cases fall within the age range of 15-54 years as compared to 63 percent of first admissions to long-term mental hospitals. When comparison is made of male patients only, the disparity becomes even greater. Some 27 percent of male new cancer cases are 15-54 years of age upon diagnosis while 61 percent of male mental patients are admitted in this age range. This means a far greater amount of disability is caused by mental disease in the wage-producing years than by

cancer.

* Reports and Statistics Service, Division of Medicine and Surgery, Veterans' Administration.

Mental hospitals

Expenditures. The per capita maintenance expenditure for State mental hospitals in 1950 was $772.67 as compared to $719.30 in 1949 and $659.13 in 1948. There was considerable interstate variation reflecting in part geographical and fiscal year variation in the general price level and, in part, variations in the type and adequacy of care provided. The degree to which hospitals were selfsupporting by the production of their farms and their varying needs for such items as fuel, light, and water were also reflected in their per capita maintenance expenditures. For the country as a whole, about 61 percent of the State mental hospital maintenance dollar was spent for salaries and wages, 19 percent for purchased provisions, 6 percent for fuel, light, and water, and 14 percent for other items of maintenance. Here, also, there was considerable variation between States in the relative expenditures for various maintenance items. For example, 71 percent of New York's maintenance dollar was spent for salaries and wages while only 36 percent of Tennessee's dollar was spent for the same purpose. In 1948, for the country as a whole, 55 cents of each maintenance dollar went for salaries and wages, in 1949 it was 58 cents, and in 1950, as mentioned above, it was 61 cents. When annual per capita maintenance expenditures are compared for the State mental hospitals, county and city mental hospitals, and psychopathic hospitals for 1950, the psychopathic hospitals have a figure, $4,248, which is about 5.5 times that of the State mental hospitals, $772, and 5.3 times that of the county and city mental hospitals, $792.

Institutionalized persons

Improvement in standards of care and training in institutions for mental defectives and epileptics requires increased funds. Table 10 shows for the years 1940, 1945, and 1950, the total expenditures for the reporting public institutions, total maintenance expenditures, expenditures for salaries and wages and per capita maintenance expense with the relative percent increases for each of the cate gories listed and the percentage that salaries and wages are of total maintenance expenditures.

During 1950 the public institutions for mental defectives and epileptics spent about $92 million for care and maintenance of their patients. This indicated an average annual per capita expenditure of $745.60 or $2.04 per patient per day. Public assistance to patient and for family

According to the Bureau of Public Assistance of the Social Security Administration, a study was made in 1951 of the aid to permanently and totally disabled. At that time the total caseload was 93,000. Eleven percent of the cases were comprised of mentally ill and defective persons as follows:

If it is assumed that the 1953 total caseload of 173,000 is similar in composition to that in 1951, then there are 19,030 persons with mental illness or defect receiving such public assistance which amounts to about $880,000 per month.

A study is currently being made of recipients of old-age assistance. About 2 percent or roughly 50,000 of such recipients are considered to require considerable care due to a mental condition.

Trend of admissions of patients with psychosis associated with pellagra and with meningoencephalitis

The effect on the trend of admissions to mental hospitals once the etiology of a psychosis is determined and effective ways of preventing and treating it are worked out can be illustrated for two disorders, psychosis with pellagra and general paresis.

In South Carolina the first admission rate for psychosis with pellagra was at a peak value of about 3 per 100,000 population during the period 1922-24 and this disorder accounted for about 8 percent of all first admissions. Today an admission for this disorder is a rarity (table 11).

The first admission rate to State mental hospitals for patients with general paresis has also shown considerable decline. Between 1926 and 1945 the first admission rate for this psychosis was at a level of 4 to 5 per 100,000 and paretics constituted about 7 to 8 percent of all first admissions. Since 1945 there has been a consistent decrease in these first admissions until now the rate is about 2.4 per 100,000 and paretics constitute only 31⁄2 percent of all first admissions. Table 12 shows the decreases in these first admission rates specific for age. There have been considerable decreases in the first admission rates in practically all of the age groups. In the age groups 35-44 and 45-54 where we get the peak first admission rates for this disorder, the first admission rate is now about onehalf of what it was in 1933.

Follow-up studies on cohorts of admissions to and discharges from mental hospitals

The concept of the mental hospital merely as a place of custody is no longer acceptable. To make these hospitals effective in their modern role, we must learn more about the patient, what happens to him in the hospital, and what happens to him upon his return to the community.

Mental hospital populations constitute an ideal group to which to apply lifetable methods for decreasing their hospital experience. They consist of large groups of patients hospitalized for periods of time varying from a few days to many years. Their dates of admission to and separation from the hospital (either alive or dead) are known along with other data that are routinely reported such as sex, race, birth date, diagnosis, types of therapy. Despite the availability of these kinds of data, there have been very few studies designed to answer such questions as: Of patients admitted in a given year, what proportion remain in the hospital, are on convalescent care, discharged, or dead within 6 months, 1, 2, or 3 years following admission? How are discharge and death rates related to diagnosis, sex, race, age at admission, therapy, and other relevant factors?

To illustrate how useful the cohort method of analysis is in determining what has been happening to patients in mental hospitals over a long period of time, an attempt was made to answer the question, "What is the current experience of patients during the first year following admission in terms of the percent remaining in the hospital, out of the hospital, or dead, within the 12-month period following their admission? How does the current experience compare with that of some earlier period?"

The mental-hospital systems of 7 States were asked to follow each patient admitted for the first time in 1948 for a full 12-month period and to determine at the end of that time how many, by diagnosis, were still in the hospital, out of the hospital, or dead. "Out of the hospital" was defined as release to convalescent care or direct discharge, whichever came first. A similar set of data were found for patients admitted for the first time to New York State civil hospital system in 1914. It is believed that these data provide a reliable base line for comparison because of the outstanding quality of care the New York State hospitals have always provided. Table 13 compares the combined experience for 7 States with that of New York State in 1914. It is realized that such comparisons are rather hazardous to make, especially when rates are unadjusted for age, sex, comparability of diagnoses, and many other factors. Unfortunately more refined statistical data are unavailable so that it was not even possible to compare even one State in this series with itself over a long period of time. Nevertheless it is felt that this particular illustration is worth while to indicate the importance of life-table methods in the study of mental-hospital populations. The data in table 13 suggest that there have been important changes in the hospital experience of different types of mentally ill patients during their first year of hospitalization. To name only a few, the proportion of schizophrenic patients out of the hospital within 12 months is now 56 percent, as compared to 33 percent in 1914. The proportion of involutional psychotics out of the hospital has increased from 35 to 70 percent and there has been a striking decrease in death rate from about 22.5 percent to 4 percent. On the other hand, many more patients with mental diseases of the senium (42 percent as against 27 percent) are in the hospital at the end of the first year, a result of the striking decrease in mortality rate (from 56 to 42 percent) among such patients. These findings are generally in accord with the experience of most mental-hospital administrators. This table emphasizes that a mental hospital provides care for people with a variety of disorders, each of which has its own prognosis. It also emphasizes