Vitamins

The part that vitamins play in health is now better understood, and research in this field is likely to yield much of importance in the years ahead. This was demonstrated in studies of pellagra and primary anemia which it was found frequently masqueraded as senile psychosis in mental hospitals, and which now yield to treatment and often discharge from the hospital.

Arteriosclerotics

Studies of the relationship between fat metabolism and hardening of the arteries (causing anemia of the brain) appear to offer new hope in tackling this widespread disease of old age.

Mongolian idiot

Among other advances in the field of mental deficiency and feeblemindedness it it is notable that an understanding of “Mongolian idiocy" seems to be yielding to the joint research efforts of neuropsychiatrists, neuropathologists, obstetricians, and others. This condition in children is a heart-rendering tragedy which may strike any family at any time regardless of class or social status. Recent studies now indicate that this defect in the infant is not hereditary but rather is the result of some physiological accident occurring in the mother around the sixth week of pregnancy. The phenomenon is unexplained, but further research may turn up preventive techniques. Moreover, there is a new attitude developing toward what has traditionally been considered the hopeless cases of mental deficiency. The professional research people in this field are successfully classifying and selecting patients in some categories for special therapies with most constructive results, although for many categories the outlook remains bleak. The establishment of research centers in several States in this field is most auspicious.

Administrative research

Marked advances are being made in the administration of mental hospitals. Studies are being made of the hospital's social milieu, the organization and conduct of ward operations and their effect on the patient. Much headway is being made in a scientific approach to the use of volunteer help in the hospitals. Some institutions have found that a great deal of useful work can be done in the hospital by using relatively untrained but carefully selected and well-supervised part-time volunteers. A study of mental-hospital architecture and design now in progress promises to result in more efficient administrative arrangements with therapeutic gains for the patient. The concept of the mental hospital as merely one part of a community network of psychiatric services-each interrelated to the other-is gaining acceptance with corresponding benefits in terms of keeping more patients out of the hospitals and helping those who are discharged to readjust to community life. Within this concept the mental hospital is viewed as a kind of "defense in depth"-a last resort if other defenses fail. The American Psychiatric Association makes a persistent effort to raise standards of administration in the hospital to the end that what personnel is available may be used most effectively. The association has recently established a committee to certify qualified mental-hospital administrators.

Outpatient services

The techniques of treating patients in outpatient clinics have so advanced that it is probably safe to say that as many as one-third of the patients who are now treated successfully in the clinics would several years ago have been regarded as suitable only for hospital treatment. This is tremendously significant. Obviously treatment in an outpatient clinic is less costly than hospitalization. It allows the patient to remain at home while undergoing treatment, and it has the great therapeutic advantage of allowing the healing process to take place in the same environment in which the illness originated, avoiding the violent transition from the community to the hospital and finally back to the community again. From all points of view the development of outpatient services is a striking advance and greatly to be encouraged. Society, the family, the patient— all benefit from it.

IV. SOME MAJOR UNKNOWNS IN MENTAL ILLNESS

Effectiveness of therapies

No comprehensive research program for the evaluation of existing psychiatric therapies has ever been attempted. Such evidence as does exist is empirical and

remains statistically unvalidated. The American Psychiatric Association at the present time is planning an extensive research program in this field.

Specific causes of the major illnesses, particularly schizophrenia, manicdepressive psychosis, and paranoia. Until schizophrenia can be better understood and treated there is little hope that the overall mental-hospital population in this country can be substantially reduced.

The social, economic, and cultural factors underlying mental disease: It is not known, for example, whether mental lilness is actually increasing in this country, or whether the apparent increase is due to more prompt and accurate diagnosis, or to a variety of social, economic, and cultural factors such as the tension that results from an insecure world, the stresses of competition, the threats of atomic war, etc.

Interpersonal relations

Some forms of mental illness may be considered as a breakdown in interpersonal relations-family relationships, job relationships, etc. People react differently to the psychological isolation that emanates from the present age of specialization-apartment-house living, production-line jobs, etc. It seems clear that a study of this phenomenon would shed light on the etiology of schizophrenia and mental disease in general.

The methodology of measurement

Since psychiatry deals with the vagaries of human personality, it is fundamental that standards of measurement be developed in the field of emotions, perceptions, gratification, anxiety, pain, etc. For example, how measure the "recovery" of a patient? How evaluate progress?

Comparative analysis (epidemiology)

There is good reson to believe that manifestations of mental illness vary considerably from country to country. An epidemiological study carried out cooperatively by several countries should contribute a great deal to understanding the complexities of both the psychoses and the neuroses. Countries, such as the United States, which are highly organized to provide psychiatric care for its citizens at great cost, stand to benefit most from such cooperative international research.

Preventive psychiatry

This term properly refers to the avoidance of illness, as distinguished from early treatment to prevent mild cases from becoming serious. Preventive psychiatry, of course, cannot be dissociated from knowledge of the causes of mental illness which boils down to a matter of basic research. Some true preventive work is now being accomplished in guidance clinics, and schools, and through better child care generally. Psychiatry has contributed to some large industries by helping to establish better psychological atmospheres in plants. In many cases the elderly and the chronically ill have been helped to face their remaining years with a greater sense of comfort and security. But by and large progress in preventive psychiatry must be firmly rooted in the finding of basic research in the etiology of mental illness.

Public education

A distressing phenomenon in this field are the cyclical fluctuations in public interest and support for the mental hospitals. Some States experience à tremendous flurry of public concern about the hospitals-usually in connection with exposés of conditions, broadside campaigns to improve them, etc. All of a sudden a legislature will float a loan to build new hospitals. Then after a time interest seems to wither. Perhaps the State administration changes and has less interest in the mental hospitals than the previous one. In summary, a pe riod of great progress may be followed by a period of rapid decline. Techniques of public education must be developed which will prevent this and which will insure steady public support for gradual, systematic progress in the field. Character disorders

There is great need for research in this area since it encompasses delinquent children and adults, the criminals, and rebels against society generally. The group formerly considered as "hopeless psychopaths" falls in this category. The spread of juvenile delinquency and crime in this country suggests the urgent need of research into the mechanisms of these disorders. Enough is already known to indicate that intensive research in this field would be fruitful.

Too little money

VI. ARE FUNDS AVAILABLE?

At present only about $4.75 per mental patient is being spent on psychiatric research. This compares with $28.20 for polio, and $27.70 for cancer. In short, while some outstanding research is made possible by this kind of support, the total amount of money available is pitifully inadequate and out of all proportion to the relative importance of the disease. One might sound a particularly pathetic note by pointing out that there is not even money available to publish the results of the research that is now going on in the field.

Related inadequacies

It would, of course, be oversimplifying to state that the problem is entirely a matter of too little money. Manpower for research is remarkably short and research workers are not being trained in adequate numbers in this field. Facilities for research are likewise inadequate. Not many public hospitals in this country have laboratory facilities and the other equipment and pertinencies that are prerequisite to carrying on research. (The recent installation of laboratories in 14 out of 35 large Veterans' Administration hospitals is a great step forward.) Indeed, money applied immediately to the construction of laboratories and research centers would be spent most wisely.

Potentiality

On the encouraging side, we have the vast potentiality among the psychiatric clinicians of this country who are capable of doing research but are not being utilized. A great many of these doctors had laboratory and research experience in their younger days.

Danger of self-defeat

In considering the question of the amount of money that should be made available for research there is some danger that a circle of argumentation may develop which can be self-defeating for all concerned. One person may ask, Why should more money be appropriated for research when there is not sufficient personnel and facilities to carry it out? Another may reply that the only way of uncovering personnel and attracting them to research is to make financial support available. In other words, all parts of the circle must rotate at once if a rational approach to the problem is to be expected.

Defects in allotting research money

The current method of allotting money to research projects also leaves much to be desired. Under present arrangements, it is popular to allot so much money to a particular project for a specific length of time-usually 1 year. The research workers have no assurance that the project will be continued if more time is needed; or, if it is a Government grant, that money will be appropriated to continue the work. The uncertainty of being able to see a project through to its end is probably the greatest single defect of present procedures-and particularly so in psychiatry where it is so difficult to chart a course within a given time limit. Also it is generally overlooked that some individuals and groups of individuals are research minded in the ideal sense of the word; that is, they are wellsprings of ideas, and have the imagination and skill to carry them out. Much would be gained by making financial support available to such people and groups with no other binding directive than a simple go ahead signal to proceed where they will.

Conclusion

In conclusion, I should like to say categorically that any proposed research project in this field which is certified as a sound proposal by outstanding leaders in the field should receive whatever financial support it needs to be carried out. The amount now spent yearly on psychiatric research is around $6 million. If it were to jump to 13 or 30 million or more, it would be a small figure indeed to gamble on an all-out effort to empty the mental hospitals of America.

Dr. WORTIS. Mr. Chairman, for the purpose of saving time for the Members of the House and our committee, and this group of witnesses here I would like to attempt to give a closing statement at this time, if you please.

I think it has been clearly indicated that there is great need for more research and more funds for research to help meet this problem.

Also if we merely continue to build more institutions to care for those people, even though they are better fed, this will not solve the problem that we face.

I think another point I would like to emphasize is that there is a great need for more professional manpower, psychiatrists, psychologists, social workers, and nurses, as well as trained research personnel.

Next, we have concerned ourselves with the problem of psychiatric services in State hospitals which badly need improvement. Those services would save a great deal of money to people if the patients were given intensive and early treatment.

Also we need some help for institutions where the mentally subnormal are cared for.

There is also a need for more concentrated use of the newer therapeutic tools than are available.

We need more scientific advances, we need more incentive to get the mentally ill person back to a useful life and become self-supporting. Moreover, we need more concentrated attention directed toward this field of prevention, control, and public education.

I think I speak for all the members of this panel of experts when I say we thank your committee for this kind opportunity to come before

you.

We could go on for days, we realize, but we are mindful of your time and have tried to boil this material down to the smallest common denominator of fact and prospect.

Also to some of you, and I am sure to many of us in this room we may have, perhaps, in some places, oversimplified some of these problems. We did so in the service of clarity lest we get into professional jargon.

The problems we discussed are a little more difficult than some of us have intimated in our short statements today.

I thought I would like to make this short statement in the interest of briefing the hearing this morning.

Dr. STEVENSON. I would like, on behalf of the whole committee to express our appreciation to all of the members of the committee for the interest taken in this matter by the members of the committee on Interstate and Foreign Commerce of the House of Representatives. The CHAIRMAN. Thank you.

Mr. HESELTON. Mr. Chairman.
The CHAIRMAN. Mr. Heselton.

Mr. HESELTON. There is one point that has been in my mind in these hearings as we have gone along, and I think every panel of expert witnesses has stressed this. We see the need of more adequate appropriations. That is one matter. The other is the need of more trained personnel. I do not know what the total figures are today, but I imagine they would run into the thousands and thousands. That raises the question in my mind about what can this committee do in that field, and what can Congress do in that field.

Are there enough young people who want to be trained, but who cannot be trained, or is it a matter of stimulating interest among young people who can do it.

Dr. WORTIS. I think Dr. Felix has a statement on that.

Dr. FELIX. As regards the manpower situation there are people who want to be trained, but who cannot be because the training facilities

are overloaded. You will find some training facilities where they may be able to accommodate 1 or 2 more students.

On this point of overloading, 1 instance comes to my mind of 1 institution that has facilities for training 15 people at a time, but had applications from 200, and they were faced with the job of selecting out of that number 15 whom they felt to be the most apt.

So, there are people who can be trained if the facilities permit it, but a professor or a teacher can only effectively teach a certain number of students, because we who sit here, and our colleagues over the country represent not a production line kind of manufacturing, but a hand job, a Swiss watch kind of a job, if you will. We cannot do it en masse. We have to do it, to a great extent, by the preceptor system, where we have constant access to our students and where they can ask many, many questions.

This is the reason that we find more people, I believe, who want to go into this work than there are facilities with which to do the job.

Mr. SCHLAIFER. I think in addition to that, I am of the opinion that if anything is going to really happen in this field, and if we are going to do something about the problem, that it will not be done until there is interest on the part of lay people, professional people, and the interest-of Federal and State Governments and the general public, and I hope that you gentlemen in your wisdom, or judgment, after these hearings will be able to come out with some results that will be sort of a clarion call to the entire public and all of the groups to bring it all together in this field.

Mr. HESELTON. I have in front of me one of the volumes of the Report of the President's Commission on Health Needs of the United States in 1951, and I would like to read a couple of sentences with reference to personnel which is required, the first one of which is: Medical schools have between 200 and 500 unfilled faculty positions, mostly physicians.

Also:

To bring these figures up to standard for clinical departments alone would require the equivalent of 600 full-time physicians.

So there will be a shortage at least for the immediate future, as you do not educate physicians overnight.

The CHAIRMAN. Does that report set forth whether the deficiency is due to a lack of interest upon the part of those who could or should become teachers?

Mr. HESELTON. I have not found that, Mr. Chairman.

The CHAIRMAN. Or is it due to insufficient funds?

Mr. HESELTON. I do not happen to have an answer to either one of those questions.

Dr. WORTIS. May some of us comment about this point which has been made by Mr. Heselton.

I am a teacher in a medical school in the department of psychiatry at New York University and my colleague to the left, Dr. Braceland, has been dean of a medical school.

The medical schools of the country today need money.

It costs a good deal to educate a physician. It is different compared to a medical education in other parts of the world.