Nearly 34 percent of all first admissions to State mental hospitals are persons 60 years of age or over.

Sixteen, about 1 to 2 percent of our population is mentally subnormal.

The 17th point I would like to make is that our Nation's population has increased 14 percent since 1939, but there have been 17 percent more persons in mental hospitals during this period.

The 18th point is that this picture is not entirely gray or black— and I want to stress that-because today approximately 40 to 60 percent of persons suffering with schizophrenia can be helped by modern treatment methods. A generation ago a mental disease called involutional melancholia was hopeless in two-thirds of these patients, or in most instances. Today about two-thirds of these patients are discharged within a year of hospital admission.

Recent studies in a State hospital in Stockton, Calif., showed that with the use of intensive treatment of chronically ill mental patients physicians could triple the sick person's chances of recovery and discharge to useful work.

The 19th point is that the draft and Armed Forces statistics show that more than 212 million men were lost to the Nation's Armed Forces through mental and emotional illness and defect; enough men to constitute about 177 Army Infantry divisions.

We have learned a good deal since World War II in this field, and a very great amount since World War I. For example, in Korea, where each Army had a psychiatrist, assisted by battalion surgeons, twothirds of the breakdowns were rehabilitated and returned to duty without leaving the division. Only 4 percent needed to be returned to this country for treatment. This is a most dramatic improvement over World War II, when 8 percent were evacuated to the zone of interior; and that record was an improvement over World War I. when 15 percent were in this seriously disturbed category.

These statistics, gentlemen, are mirrored in the problems one sees in community and private practice. I am director of the Bellevue Psychiatric Division in New York City, which admits about 25,000 mentally ill people a year and is probably the most acute psychiatric service in the world. With acute active treatment there we are able to return approximately two-thirds of the patients who come to us. The 20th point I have is that the costs of mental illness to our Nation are colossal. It is a reasonable estimate that this will run as high as several billions of dollars each year. Let us consider some of the facts. Patients in public mental hospitals cost $467 million in 1951. This increased to $568 million in 1952, an increase of over $100 million. The cost of mentally ill in veterans' hospitals was $1261⁄2 million in 1951. This increased to $14612 million in 1952. If we add to this the costs of treatment of veterans in psychiatric out-patient departments, the compensation for these service-connected disabilities, and pensions for non-service-connected disabilities of a neuropsychiatric nature, all these items I have listed above cost the American people close to $1 billion in 1951-$959 million-and this increased to $1,041,000,000 in 1952.

Might I point out to you that these staggering figures do not include the costs for psychopathic hospitals, the cost for private mental hospitals, treatment in mental hygiene clinics that are not part of the Veterans' Administration system, nor do they include the larger

and immeasurable cost of economic loss in earning power and the income tax thereon that would be available to the Government and to our Nation of the mentally ill individual and his family.

Now, other speakers to follow me will tell us how funds available under the National Mental Health Act have helped with some of these problems by, first, the training of skilled medical and ancillary personnel; second, the beginnings of a skeleton community service. program in the States, which was spark-plugged by Federal funds; and, third, the beginnings of a research program. Federal funds have made possible some real improvements in these areas, for in the past 5 years the Federal program has provided funds for the training of some 2,200 or 2,300 professional personnel in the field of mental health as psychiatrists, clinical psychologists, psychiatric nurses and psychiatric social workers. Most encouraging is the pertinent fact that nearly 70 percent of these have entered public service.

Federal funds available under the Mental Health Act have significantly improved the teaching of psychiatry in undergraduate medical curricula throughout the country. It is worthy of note that approximately 5,000 trainees in psychiatric social work, 2,300 trainees in clinical psychology, 500 psychiatric graduate nurses, and 1,200 undergraduate nurses have benefited in their training programs through the National Institute of Mental Health.

Some of our discussion this morning, I am sure, will focus on what are some of the needs. Before I close and pass on to some of the other members of our mission here this morning who have prepared statements I would like to point up four needs, gentlemen.

We need to improve our State hospitals. They are improving too slowly, and unfortunately many are still "snake pits" and the shame of the States. Here the pressing need is for more trained personnel and more staff. We need at least twice or 211⁄2 times the number of psychiatrists. We need about 4 times the present number of graduate nurses trained in this field. We need about 8 times the number of Occupational therapists. We need about 5 times as many Ph.D.'s in clinical psychology as are now in the State mental hospitals. That is mentioning only a few of the staff needs.

Another category of urgently needed personnel in mental hospitals are what are called the psychiatric aides or attendants. Better schools and more adequate training standards must be established for this very essential group of workers in this field.

Secondly, we need more community-service clinics, guidance centers, and psychiatric services in local general hospitals. Here the need is very urgent, and the justification is real and the investment is more than practical, for in the earliest recognition and treatment of mental ill health we have the best method of preventing serious and chronic mental illness with its associated drain, both economic and personal. Third, I would say we must develop the field of preventive psychiatry. This is no easy job, for here we need much tested knowledge; and our greatest bottleneck is again in trained personnel.

Fourth, I would say we urgently need more research workers and more research facilities. More Federal aid must be authorized for the construction of such facilities and for the training and long-term support of skilled and gifted persons who will make a career of this essential work.

39087-53-pt. 4– 12

Now, with these opening remarks I would ask my colleague, Dr. Braceland, if he would have a word to say that might be of help to this group concerning some of the problems of the etiology, the causes of mental illness.

STATEMENT OF DR. FRANCIS J. BRACELAND, PSYCHIATRIST IN CHIEF, INSTITUTE OF LIVING, HARTFORD, CONN.

Dr. BRACELAND. Thank you, Dr. Wortis.

The CHAIRMAN. Doctor, we would be pleased to hear from you. Dr. BRACELAND. Mr. Chairman and gentlemen, before starting I would like to say it is a privilege to come here. My last appearance before a committee constituted to deal with such things was before Mr. Priest's committee following the war, when we were all in uniform and all very much distressed about what we had found and what we had been through, and fearful of what it portended. Due to the understanding and assistance and help through the grant of public funds and public and private interest, the picture is very much better. When we entered the war, when we came into the Navy from civilian life, we had fewer than 20 psychiatrists in the United States Navy. Fortunately, we were able to end up with 690 in various stages of preparation. We saw that we could not draw too much from the populace, so we started out to make some of our own.

We brought some of our problems before the committee and we received a great deal of help, and it was a privilege to have been part of that.

The picture, as Dr. Wortis points out, and as I sometimes fear, might look too vast to a committee. It might look like it is so broad and so overwhelming that people are liable to say, "Well, we cannot do anything about this," and put it aside. But that is not so, when one considers that not so many years ago there were no private practitioners of psychiatry in the United States.

We deal with the oldest disease known to man, yet we are one of the youngest specialities. There are evidences of mental illness as far as recorded history.

The CHAIRMAN. Doctor, you say it is one of the oldest diseases? Dr. BRACELAND. Yes, sir.

The CHAIRMAN. We have had that statement made to us about several diseases. Some of the witnesses endeavored to demonstrate it by the fact that diseases were found among the mummies of Egypt. I just mention that.

Dr. BRACELAND. We could not tell very much about the mummies, Mr. Chairman, but we do appear in the Scriptures and back in recorded history of the Peloponnesian Wars.

The experts who appeared before the committee this week, all of our colleagues, who are all very fine, were talking about diseases. It is our function to talk about the people who have diseases, so we might cross a few lines unintentionally.

This whole problem has been one which has frightened people because they do not know about it. They are afraid. There is nothing mystifying about the mumps or about a broken leg, but there is something mystifying about mental disease. When people are afraid they either neglect it or they fight something.

Now, to get to the point of what has been done and what can be done in the epidemiology of these diseases—that is, in their distribution in the population-the past 20 years has seen a change, as Dr. Wortis pointed out, in the admissions to mental hospitals.

When some of us started in mental hospitals the largest number of admissions were young people with a disease called schizophrenia. There are over 100,000 people admitted for the first time to State mental hospitals in a year, of which about 25,000 have schizophrenia. However, the senile and arteriosclerotic now constitute about 27 percent of first admissions.

There is not too much use-and this is with full knowledge of the humanitarian aspects of the problem-saving us from some chronic diseases-to have an inglorious end in a mental hospital with arteriosclerosis or senility. Therefore, that is a very important factor. It is a very important problem from all aspects, because the culture has changed. We are now an urban population. There is no longer the room for the older people on the farms, and in a two-room apartment it is very difficult for a man and his family to keep an aged parent. This is helping to add to our problems very seriously.

It is interesting to note that one study in Chicago showed that the admission rates for mental disorders showed that high rates were to be found in the densely populated areas, in Chicago around the central business district, and that the rates declined toward the periphery of the city. This was particularly true of this disease called schizophrenia; while the manic depressives, which probably have a hereditary background, among other things, showed a scatter throughout the city.

Now, also people who resided in areas which are not populated by their own ethnic groups showed a higher population or a higher rate numerically for mental disease. Of course, the major problem in interpretation of these findings is whether or not people with these difficulties gravitate to certain areas or whether certain areas produce people with mental disease. It is more probably the first.

Mr. HESELTON. Probably what?

Dr. BRACELAND. More probably the first; that it is due to this great crowding.

Some of these diseases which used to bother us very much have disappeared as a serious problem. Now, it is difficult to find a case of pellagra. I think there was one reported last year. Paresis, which used to fill the mental hospitals, a disease due to syphilis of the central nervous system, is now difficult to find. It is difficult to get a case to show to medical students, to show what they are like.

Twenty years ago, involuntary melancholia, a disease affecting women in middle life was a great problem. Incidentally, men in middle life have problems, also, although they are not quite as dramatic. Then it was known that two-thirds of those people had hopeless prognoses. Now the recovery rate, due to new forms of treatment and due to a different concept, is well up to 70 percent.

That is a particularly distressing disease. It is one which used to disturb the young physicians most. As you took the wife of a man from him at a mental hospital door in good nutrition, you knew in your own mind's eye that within a period of 8 months one would hardly recognize her. It was a distressing, depressing, unsettling

type of thing to deal with. That has been helped immeasurably. It has also been helped in the way that all of these things are going to be helped; by a combination of public and private collaboration and cooperation and the use of funds in research and in teaching and in the use, also, of the private clinics and the clinics for the public in the various cities.

There are various refinements made now in diagnosis which have come out of the laboratory, and there are various things which we have learned from the psychologists, from the sociologists in this cooperative effort, because man does not exist in a vacuum and he does not get mental disease in a vacuum. He gets it in the milieu in which he lives and in which he conducts his business.

The treatment and the rehabilitation is vastly improved. Now, we know we have to learn the hard way many things which were learned before; that idleness is a demoralizing influence. Now people in mental hospitals are encouraged, as a therapeutic measure, to work and to carry on various activities in addition to their treatment. Therefore, as a result of it the rehabilitation of the mentally ill, formerly not attempted, is now attempted very seriously and it is bearing fruit and bearing results.

This is not a gray picture or a black one. We need a great deal of public education. We need help and understanding.

The unfortunate thing is that, in the States, an effort is made spasmodically and then it is forgotten. When a cut has to be made in budgets, which we all know is essential, I fear that perhaps the mentally ill, who are the great silent people, are cut pretty heavily. This results in a cost in mental hospitals which in many places is below $2 a day for the care of mental patients; whereas in city hospitals it is around $16, and in private hospitals it is around $20, roughly. Therefore, you can see the type of care which might be given to these patients.

Dr. WORTIS. Might I interrupt you a second, Mr. Braceland?

I think Dr. Braceland has given you a figure of costs which indicates how costly this problem is. I think it might also be worth pointing out to you gentlemen that we are in a period now when there is a good deal of purchase of health insurance, if you like. I think you might all realize that health insurance programs as they exist today do not cover the cost of mental illness. No one of them does.

The reason this has never occurred is because it is just too costly for them to take a risk. This, therefore, falls on the family or the community or the country at large.

I think we have not stressed enough the fact that hospital insurance plans, health insurance plans, do not cover mental illness.

Excuse me, Dr. Braceland.

The CHAIRMAN. I would like to say for your information, Doctor, that it is the intention of this committee, when it has finished its study of diseases, to immediately take up the question of insurance, covering the diseases particularly of long duration. It would seem, from what little we do know about it at the moment, that there are plans of group insurance and otherwise to take care of the short or temporary illness, but for those of long duration there seems to be a little inconsistency. It is in that field that the average family is greatly in need.

Immediately following these hearings, commencing, I think, about the 15th of this month, we intend to make a further study of that whole