C. Extended and improved services: 1. Institutional: (a) Mental hospitals. (b) Psychiatric services in general hospitals. 2. More concentrated use of therapies. 3. Outpatient facilities. 4. Rehabilitation. 5. Prevention, control, and public education. PARTICIPANTS Dr. S. Bernard Wortis, professor of psychiatry and neurology, New York University College of Medicine. Dr. Francis J. Braceland, psychiatrist in chief, Institute of Living, Hartford, Conn. Charles Schlaifer, cochairman, National Mental Health Committee, New York City. Dr. Seymour S. Kety, Associate Director in Charge of Research, National Institute of Mental Health. Dr. Fillmore H. Sanford, American Psychological Association. Dr. George S. Stevenson, National Association of Mental Health. Dr. Robert H. Felix, director, National Institute of Mental Health. Dr. Richard Willey, executive assistant, the American Psychological Association. Dr. Daniel Blain, American Psychiatric Association. Mr. DOLLIVER. In order for the recorder to identify the witnesses and so that they can be known to the members of the committee, I would appreciate it if they would stand and introduce themselves in turn, starting with Dr. Wortis. When the introductions have been concluded, will you, Dr. Wortis, proceed to lead the discussion, following the general lines of the agenda or as you see fit. Dr. WORTIS. My name is Sam Bernard Wortis. I am professor of psychiatry and neurology at the New York University College of Medicine and director of the psychiatric and neurologic services of the university hospital at the New York University Bellevue Medical Center. I am consultant to several Federal agencies and several hospitals in the general metropolitan area of New York. I have also served as the president of the American Board of Psychiatry, the American Neurologic Association, and several other medical and neuropsychiatric organizations in America. I have also had the privilege of serving a 3-year term as a member of the National Advisory Mental Health Council to the Surgeon General of the United States Public Health Service. My colleague to my left is Dr. Braceland. Dr. BRACELAND. I am Francis J. Braceland, director of the Institute of Living, Hartford, Conn. I am a clinical professor of psychiatry at Yale University. I have been the dean of a medical school, and in wartime was chief of psychiatry for the United States Navy. I was head of psychiatry at the Mayo Clinic. I am secretary and president of the American Board of Psychiatry and Neurology. At present I am psychiatric consultant to the Surgeon General of the Navy and of the Army and am a member of the National Advisory Committee to Selective Service which was set up by Congress, and chairman of a committee to determine the competency of mentalhospital superintendents. My colleague on my left is Dr. Robert Felix. Dr. FELIX. I am Robert H. Felix, director of the National Institute of Mental Health, Public Health Service, United States Department of Health, Education, and Welfare. In addition to this I am clinical professor of psychiatry at Georgetown University and am on the faculty of the department of public health at George Washington University. I think that will be enough for me. My colleague on my left is Dr. George S. Stevenson. Dr. STEVENSON. I am George S. Stevenson, associated with the National Association for Mental Health. My chief responsibilities over a period of about 20 years have been as medical director. I have been president of the American Psychiatric Association and consultant to a number of Government agencies: Selective Service, the State Department, Labor Department, Public Health Service, Children's Bureau, and Vocational Rehabilitation. I was on the original National Advisory Mental Health Council. I am a resident of New Jersey. Dr. SANFORD. I am Fillmore H. Sanford, a psychologist. I have spent most of my life in teaching and research at Harvard University and the University of Maryland; and, most recently, at Haverford College. I am currently executive secretary of the American Psychological Association. Dr. KETY. I am Seymour S. Kety, associate director in charge of research of the National Institutes of Mental Health and Neurological Diseases and Blindness, which explains why it was my honor to be present at the meeting yesterday when discussions centered around neurologic diseases. I am also professor of clinical physiology at the University of Pennsylvania. I am a physician who has specialized in full-time research in physiology. My colleague on my left is Mr. Charles Schlaifer. Mr. SCHLAIFER. My name is Charles Schlaifer. I am one of the reasons we are here. I am one of the laymen, patients, that all the doctors are here to talk about. I am cochairman of the National Mental Health Committee. I have just completed a term as a member of the National Advisory Mental Health Council to the Surgeon General, United States Public Health Service. I am on the board of governors of the Menninger Association and am on the board of directors of the National Association of Mental Health. I am president of an advertising agency. My colleague on my left is Dr. Daniel Blain. Dr. BLAIN. I am Daniel Blain, the medical director of the American Psychiatric Association. At the present time I am clinical professor at Georgetown University School of Medicine. Formerly I was director of the Psychiatric and Neurology Services of the Veterans' Administration, for 22 years immediately following the war. At present I am on the expert committee on mental health of the World Health Organization and am consultant to the Public Health Service and the Veterans' Administration. Mr. DOLLIVER. You may proceed, Dr. Wortis. STATEMENT OF DR. S. BERNARD WORTIS, PROFESSOR OF PSYCHIATRY AND NEUROLOGY, NEW YORK UNIVERSITY COLLEGE OF MEDICINE Dr. WORTIS. Mr. Chairman, may I say for this group, and certainly for myself, that it is a pleasure to have the opportunity to come before this Interstate and Foreign Commerce Committee of the House of Representatives. I should like to start this symposium, if you like, by stressing a few facts concerning the backgrounds for the problems of mental health, but before outlining our problems and needs in this field more definitely may I state that the complexion of medical care and medical practice has been undergoing considerable change in the past 25 years. American society was first rural, then urban, and now is rapidly becoming suburban in its structure. It has only been a few years since physicians came out from behind their beards and their barbers" aprons, and not so many years since they laid aside their frock coats, their bedside manners, their toppers, and their special odoriferous. wake of disinfectant. Now we move about among our fellow men unmarked and unscented. Even though most of us look quite ordinary, certain aims have always been foremost in the minds of physicians, and these have been human conservation and the alleviation of pain and anxiety. We possess certain expert knowledge and skills that society needs; and happily in recent years our citizens and our Congress have joined medicine in these practical and unselfish aims toward human conservation and alleviation of pain and anxiety. When we look at the task that modern society has placed in the hands of its physicians, we soon find that the scope of medicine has broadened tremendously. For thousands of years the treatment of the sick was considered the primary task of medicine, while today the scope is infinitely broader. In addition to the general promotion of health and restoration of health, medicine now visualizes its function to include prevention and rehabilitation. The health record shows that in 1900 the average life expectancy of the average citizen in the United States was 47 years. Today our life expectancy at birth is close to 67 years, an increased expectancy of 20 years in the past half century; whereas in the previous half century, from 1850 to 1900, there was added only 7 years to the life span. Moreover, preventive health measures the use of antibiotics and improvement in surgical techniques, including advances in the science of anesthesiology-have radically changed the health picture. In 50 years medicine has made conspicuous progress in dealing with a variety of diseases-bacterial, protozoal, parasitic, and toxicdiseases due to dietary deficiencies and to disturbances of glandular secretions and metabolic disorders. We have yet to attain successs with many virus diseases, new growths, chronic diseases and that most important No. 1 health problem, mental and nervous illness. During the same 50-year period-that is, the last half century— certain things have been happening to the doctor. The vast expansion of medical science meant that no one physician could any longer encompass all we knew and medicine entered the "looseleaf age" where knowledge is vast and changing and could no longer be bound into a single static volume. This was one of the factors that started the era of specialization in medicine. You will remember that at the turn of the century there were individual migrations to Paris, Vienna, and Berlin, which bred our first crop of medical specialists, who returned home with broadened medical skills and a taste for better coffee and better beer. Now physicians from all over the world come here for the best medical training in all fields. The tide has turned considerably. Medical education has taken large steps forward. The investigative attitudes and methods entered our clinical hospital services, and soon we found that the old traditional academic borders of medicine were breaking down. Today, in the modern hospital care of patients, no one can tell where the basic sciences end and where the clinical services begin. They are both essential parts of a comprehensive health program and, happily, the social scientist has joined the team as well. Our present concern is with health and illness in their broadest dimensions. From diagnosis to cure we have come to rehabilitation, education, and prevention. Whereas the physician started as a single, self-sufficient unit, he now has changed and metamorphosed into a very complicated set of relationships. To be effective he must use the team of other physicians and the ancillary medical schools in clinical care, research, and teaching. Now, what has all this to do with our problem of mental health today? May I give you some statistical orientation proving that mental ill health is the Nation's No. 1 health problem. First, as has been said by our chairman, the number of mentally ill patients in the United States exceeds the number of patients suffering from any other type of illness. Second, approximately 50 percent of all hospital beds in the United States are needed and used for this group of illnesses, and I cite the figure of 662,500 out of a total of 1,425,000 beds. The need for treatment facilities, including both hospitals and clinics, is more acute than in any other field of medicine because of this large, continuing, and enlarging patient load. The personnel shortage of physicians in this field of medicine is acute, and greater, I believe than in any other field of medicine. We have about 8,000 qualified practicing psychiatrists and we need about 20,000. Our national average ratio of psychiatrists to patients in our State hospitals is about 1 to usually 250 patients. The fourth point I would like to make is that the amount invested in research in mental health from all sources-Federal, State, local, and private—amounts to less than 2 cents of every dollar spent for medical research. Our Nation spends approximately $6 million a year on research in the field of mental diseases, of which the Federal Government spends approximately $4 million. Approximately a half million dollars comes from private sources and private foundations; and approximately $12 million comes from State sources. Fifth, mental illness is only in part related to acute social stress; and a good portion is acute illness as opposed to chronic illness. The sixth point I would like to make is that mental ill health represents our greatest health problem in cost. As has been pointed out by our chairman today, approximately 40 percent of the total Federal budget for health care is for mental health; and approximately from one-sixth to one-third of State budgets in our larger States is for the care of the mentally ill. My own State of New York spends approximately $120 million out of a total budget of $380 million. Massachusetts spends $16 million out of a total budget of $58 million. Seventh, in addition to the problems of mentally ill patients in mental hospitals, conservative estimates based on incidence studies have shown that approximately 50 percent, 40 to 50 percent, of patients who are treated in general practice have psychiatric complications. My eighth point is that we do not know the basic causes of much mental illness, even though we can recognize mental disease today and the coloring that social or cultural factors may give such mental illness. Ninth, during the past 25 years psychiatry has concerned itself with more than the problems of the insanities. It not only concerns itself with grossly diseased conduct as seen in the psychoses-or the insanities, as commonly known-but also with the study, treatment, prevention and rehabilitation of personality maladjustments, delinquency and criminal behavior, instabilities, mental deficiencies, anxiety states and psychosomatic medical disorders. All these illnesses result from varying degrees of disturbance in either bodily structure or function, in psychological or social adjustment, or in the interpersonal relationships of human beings. The psychiatrist, gentlemen, is a physician who studies and treats behavior disturbances which may express themselves either as physical symptoms or mental illness or both, and which range from simple maladjustments to insanity. The 10th point I would like to make is that personality disorders were the cause of 18 percent of the draft rejections in World War II. This meant that 1 out of every 5 men examined was rejected for reasons of mental ill health. Eleventh, our tested knowledge in psychiatry as regards prevention is very inadequate and in many spots nonexistent. Twelfth, our programs for the evaluation of special treatment procedures are only just beyond their inception stage, and have just been developed in recent years. The 13th item I have is that the incidence of mental ill health in our population is a matter that needs much study. Morbidity studies are not available in most of medicine. The statistics many of you hear are mortality statistics. As to morbidity statistics, gentlemen, there are not very good studies so far available to us. The 14th point is that our knowledge of the specific causes of most very common types of mental illness that overcrowd our hospitals, such as schizophrenia, is meager and still speculative. Schizophrenia, sometimes called dementia praecox, constitutes the largest group of those patients hospitalized, and we are only beginning to learn how to get some of them well by newer methods of treatment. Fifteen, people are living longer because of general medical skills, but we have not learned how to slow down or prevent hardening of the arteries of the brain; and, therefore, more and more of the older people are being sent to mental hospitals. The number of persons 60 years and older has increased 25 percent since 1939, but the number of patients in this age group in mental hospitals has increased 58 percent. |