the need for carefully planned studies of the life, histories of mental-hospital patients designed to show the effects of changes in patterns of treatment and care on eventual outcome.

In this connection it is important also to follow up patients released from the hospital. On a nationwide basis we have only the crudest data about discharged patients. We need information such as the following:

Of patients who have been discharged, how many relapse and how soon? How are relapse rates related to diagnosis, sex, age on admission, length of hospitalization, therapy? Furthermore, we should like to know what social and environmental factors encountered by discharged patients are related to relapse or suecessful readjustment. Followup studies of patients discharged from tuberculosis sanatoriums have proven very profitable in our understanding of that disease. There is no reason to suppose that such studies would be less valuable in the study of mental illness. Accurate followup data on discharged mental patients can serve as the basis for discharge prediction techniques, weighting significant factors in the patient's life history, diagnosis, clinical course in hospital, degree of improvement, and expected family and community environment. Furthermore, better understanding of relapse factors would greatly aid the development of rehabilitation programs for patients, while they are still in the hospital and later when they have returned to the community.

Studies of admission rates

As our mental-health programs develop and, hopefully, as research turns up methods for preventing and controlling mental disorders, indexes will be needed to determine whether the incidence, prevalence, and course of specific mental disorders has been altered. As has been pointed out, first admission rates, long regarded as an incidence index for the psychoses, have been used to answer questions on whether there has been an increase or decrease in the incidence of specific disorders.

Such studies, however, no matter how carefully done, suffer from the limita tion that the relationship existing between 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 is not known. Hospitalization rates are a resultant of the incidence of mental disorder and a series of factors that determine the number of persons who are eventually admitted to mental hospitals, such as: Availability of mental hospital beds, availability and usage of other community resources for diagnosis and treatment of mental disorder (for example, general hospitals with psychiatric-treatment services, psychiatric clinics and private psychiatrists), and public attitudes toward hospitalization. Thus, to understand more fully the distribution and course of mental illness in the population it is necessary to study hospitalization rates in relation to these factors. The solution to this problem is difficult since it is dependent primarily upon development of practical case-finding methods and standardized diagnostic procedures for detecting various mental diseases in the general population.

A project in this category is in progress in Syracuse, N. Y., under the direction of Dr. Ernest M. Gruenberg of the New York State Mental Health Commission (4). This study deals specifically with psychoses associated with the aging process. These disorders are a serious problem for the mental hospitals, since the rates of admission have been increasing continuously over the years until now they constitute close to 30 percent of first admissions. A major objective of the Syracuse project is development of case-finding methods for detecting uphospitalized persons with senile psychoses, and relating this number of cases to the number of cases actually committed. Relationships between the hospitalized and nonhospitalized senile cases will be studied according to various social and economic factors. A further step will be the development of clinical and preventive services in the community to learn what effect adequate services can have on reducing the incidence of mental illness among the older residents. The starting point for this study is the records of the admissions of residents of Onondaga County to New York State civil and licensed mental hospitals for the period 1935-44.

Additional studies of this type are needed, taking as their starting point other major mental disorders.

Other epidemiological studies

A number of epidemiological research projects have been started in recent years.

Among the most interesting are the following studies:

The Stirling County project, under the direction of Dr. Alexander H. Leighton of Cornell University, is an intensive study of a county in Nova Scotia. Its major purpose is to explore relations between the distribution of psychiatric illness and sociocultural factors, particularly the stresses in the social environment. This research is divided into three operations. One consists of casefinding and case studies of all types of mental disorder by a psychiatric team. Extensive data are being gathered on possible or actual psychiatric cases from a variety of sources. Data are being obtained on persons hospitalized in mental and general hospital for psychosis, severe psychoneurosis, or psychosomatic complaints. A clinic has been set up to examine patients referred by physicians, clergymen, schools, police, unemployment insurance offices, and health, welfare, and other local agencies. These data will be studied to determine various ways in which to define and classify cases. The second operation is the development of screening tests applicable to the general population which will serve as a check on the completeness of other case-finding methods. The third operation is being carried out by a social-science team which is doing a study of sociocultural patterns and mapping various types of social stress in the community. To eliminate the effect of biases and preconceptions, the team doing the casefindings is working independently of the one mapping sociocultural factors. The two series of data will be merged and correlated to determine existing relationships.

The Yale project is the joint endeavor of a psychiatrist and a sociologist. Its directors are two Yale faculty members, Dr. F. C. Redlich and Dr. A. B. Hollingshead, who are investigating interrelations between social structure and mental illness. They have taken a census to determine the persons in a metropolitan area receiving psychiatric treatment, that is, persons in mental hospitals, attending mental hygiene clinics, or under private psychiatric care. Each patient was classified into 1 of 5 social strata. Correlations will be sought between an individual's position in the social structure of the community and the types of treated mental illness found. In addition the attitudes of persons in the various social strata toward mental illness and psychiatry will be studied, as well as the types of psychiatric treatment they obtain, and their clinical response to various treatment methods.

These and other current research projects such as that of Dr. Erich Lindemann at Wellesley, Mass., and that of Dr. T. A. C. Rennie in the Yorkville area of Manhattan, will undoubtedly provide much useful information relating to the cause and course of mental disorder in the population and to the development of psychiatric services to meet realistically the needs of the population.

TABLE 1.-Active cases of mental disorder in the Baltimore survey for the year 1936 (population: 55,129)

1 Involutional, with epilepsy, posttraumatic, and deliria not due to alcohol.

Actixe+inactive cases: 3,416-62.0 per 1,000.

Source: Lemkau, Tietze, and Cooper: A Survey of Statistical Studies on the Prevalence and Incidence of Mental Disorder in Sample Populations. Public Health Reports, vol. 58, p. 11, table 3.

TABLE 2.-Active and inactive cases of mental disorder in the Williamson County, Tenn., survey as of Sept. 1, 1938 (population: 24,804)

1 Specific types of psychoses were not broken down by whether the case was inactive or active. * General paresis, other organic states, posttraumatic, with alcoholism, and with epilepsy. Source: Lemkau, Tietz, and Cooper: A Survey of Statistical Studies on the Prevalence and Incidence of Mental Disorder in Sample Populations. Public Health Reports, vol. 58, p. 12, table 4.

TABLE 3.-Number of disability discharges of enlisted men from the Army, Dec. 7, 1941, through December 1945

Source: Army Service Forces, Office of the Surgeon General, Medical Statistics Division.

TABLE 4.-Resident patients at end of year in hospitals for the prolonged care of psychiatric patients, by type of control of hospital, and rates per 100,000 population, United States, 1941-50

Number of resident patients per 100,000 of the estimated population as of July 1 of the specified year. Base for total rate, years 1941-45, is total population. Base for all other rates is civilian population. Veterans' hospital data for the period 1941 through 1945 referred primarily to patients in VA neuropsy. chiatric hospitals. In 1946 and 1947, the data included patients in all types of VA hospitals and in other Federal hospitals. In 1948 through 1950, coverage was reduced somewhat to eliminate duplicate counting by excluding VA patients in other Federal hospitals. The bulk of these patients were in St. Elizabeths Hospital, Washington, D. C., and are therefore included in data for State hospitals.

Excludes patients in Iowa county homes. Also 1 hospital was transferred from city-State auspices in

1948.

RATE PER 100,000 CIVILIAN POPULATION

FIRST ADMISSION RATES FOR SELECTED DIAGNOSES,
BY AGE, TO STATE HOSPITALS FOR MENTAL DISEASE
UNITED STATES, 1949

Under 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70 and

15

over

AGE IN YEARS

FIGURE