Hon. J. Caleb Boggs, Governor of Delaware Hon. Luther W. Youngdahl, judge, District of Columbia Hon. Herman E. Talmadge, Governor of Georgia Hon. John S. Fine, Governor of Pennsylvania Hon. Dennis J. Roberts, Governor of Rhode Island Hon. Arthur B. Langlie, Governor of Washington Hon. William C. Marland, Governor of West Virginia Mr. Chairman and members, I am Charles Schlaifer, a layman, not a doctor. I am cochairman of the National Mental Health Committee, founding member of the National Association for Mental Health, and a member of the board of governors of the Menninger Foundation. I have just concluded a 3-year term as a member of the National Advisory Mental Health Council, of the United States Public Health Service. I am deeply honored to discuss with you the subject of how to reduce the burden of mental illness on our Nation. I am representing today the National Mental Health Committee, an educational group of private citizens and notable psychiatrists who for a number of years now have been sacrificing time from business and professional duties to further this research, and the training of manpower to apply its results. Most of all we are proud of the many State governors, other high-ranking officials and outstanding leaders who are honorary chairmen of our committee, all working to cut down spending for the care of advanced mental patients, by discovering and applying cures in the early stages. Gentlemen, mental illness is no longer a concern solely of its victims and their relatives. It demands the serious attention of all citizens who pay taxes. Mental illness is a community problem, a State and national problem. It is the gravest menace of all to the health of our people. Most of the other diseases throw the cost burden on the patients and their families. This is often a heavy personal strain. But with serious mental illness the cost soon exhausts all resources of the patient and his relatives, and when he finally breaks down completely and goes to the hospital, the burden becomes so great that it falls on all the other taxpayers as well. Year-in-year-out hospitalization is the most expensive form of medical care known to man. There is hardly anyone who is not indigent when the catastrophe of mental disorder strikes. Ninety-six percent of hospitalized mental patients are in tax-supported hospitals. According to a report just released by the research committee of the New York State Council of City and Village School Superintendents, 1 out of every 16 persons in the State will be confined to a mental institution at some period during his lifetime, and the number is steadily increasing. Unless immediate action is taken to counteract this dangerous trend, the report asserted, 1 out of every 12 children born this year in the State will sometime during his life suffer a mental illness severe enough to require hospitalization. Describing the staggering magnitude of the problem, Dr. David G. Salten, chairman of the research committee, observed that from 1940 to 1944, 135,000 men from New York State were rejected for service or discharged from the Armed Forces because of emotional and mental disorders. The State mental institutions, he continued, had 117,000 persons under treatment last year and “23,000 products of our schools were first admissions to mental hospitals." In the current State budget, the report noted, $119 million was appropriated for operating expenses of the Department of Mental Hygiene. This, it said, "represents more than one-fourth of the total appropriations for current operations for all State purposes." Capital outlays for the construction of additional mental hospitals, the report went on, amounted to $31 million, which is about one-fourth of the total State construction budget. "The basic question," Dr. Salten declared, "is whether there should not be more attention given to these conditions in their early and more curable phases, particularly during childhood. Every dollar of money or hour of effort directed toward prevention could provide a one-hundred-fold return to both the individual and society." Gentlemen, it is hard to realize what a terrific drain the mental disorders place on the country. Of all the hospital beds in the United States, over half are filled with mental patients. I have a chart which I would like to place before you which brings this out and the figures are taken from the Journal of the American Medical Association. This shows the amazing fact that on an average day there are more mental patients in the hospitals of the Nation than there are for all other illnesses combined. And the cost of care for these mental patients is simply astounding! The direct cash expenditure amounts to over 1 billion tax-dollars a year, shared about equally betwen the State governments and the Federal Government. Beyond that, the indirect costs of mental illness are several times greater. They include loss of earnings while the patient is in the hospital, loss of taxes on these earnings, loss of production to the Nation, social-welfare payments and cost of children's institutions when parents break down mentally. These indirect costs have to be taken into account as well, and they amount to several billion dollars a year. It seems to me that we can never forget this fact: Whether we like it or not, this cost picture has to determine the size of our effort to control mental illness. The future is certainly not bright. I was shocked to discover that since last year this spending for mental illness has mounted by more than $62 million. Estimates warn us that unless new cures are found and early treatment stepped up, we will be forced to spend around 15 billion tax dollars for the care of patients during the next 10 years. This is spending at the rate of $15 billion per year, instead of the $1 billion annually we are now spending. These figures are based on the rate of growth of mental hospitals during the last 5 years, combined with an actuarial study made for the Hoover Commission. The next question I would like to ask is: When are we going to cure more patients in the early phases, and save some of this money? How can we cut down the cost? There are numerous things that can be done to prevent substantial amounts of spending. I have sifted many proposals and they all boil down to three measures: First, the training of manpower to apply known treatments early; Second, research to find new, better cures and preventives; Third, enough preventive treatment centers at the community levelchannels to bring the research discoveries and treatments to the people who need them, in early, more treatable stages. We shall never be able to stop the appalling growth of our mental hospital population and reduce its size until we spade up our whole attitude toward training and research. We must ask ourselves, "Are we searching hard enough for new cures, training enough psychiatrists to reduct the hospital population?" That is our goal. That is the test for the proper scope of our effort. And the answer is we are not doing enough. We have been satisfied just to hold our finger in the dyke. We must see it as a much bigger problem than we have in the past, requiring much more money and resources than we have been devoting to it. This applies to construction of facilities as well as training grants, research project grants, and fellowships for both training and research. We have taken 1 step forward, but the patient pileup in the hospitals has pushed us 2 steps back. We have made a start, but the rising cost of patient care is a blunt warning that our training and research are inadequate at the present level. Gentlemen, that is what we are faced with, and that is why we say in spite of very laudable efforts so far, we are losing the battle against mental illness. As Americans we can be proud that the Congress of the United States had the practical vision to face this menace squarely and set up a program to meet it. A great deal has been accomplished since that time. One of the best examples of this is the remarkable record of the Army psychiatrists in Korea. Trained psychiatrists at battlefront first-aid stations began the treatment of psychiatric casualties immediately at the point of breakdown. They treated them as emergencies just the same as a bleeding wound from gunshot or shrapnel. The result was that in 2 weeks, 70 percent were back in active duty and a few weeks later 25 percent more were returned. Only 5 percent were sent home to veterans' hospitals. A number of the psychiatrists who achieved these dramatic results on the Korean battlefield received part of their medical training through fellowships under the National Mental Health Act program. These same curative skills can be applied in civilian life, as well as in Korea. As a matter of fact the treatments were developed by civilian psychiatrists. We have now reached the point were effective treatments exist for many patients, but not enough psychiatrists and community channels to reach the mentally ill who need the treatment. This is a far cry from the former days, when treatment was practically unknown. It is amazing and most encouraging to realize what has been done on a pilot scale by trained psychiatric manpower. For instance, since the establishment of a 13-bed psychiatric ward in St. Joseph's General Hospital at Savannah, Ga., commitments to the State mental bospital from that county have been cut 58 percent. Another example: During 1951 the outpatient clinic of the Boston Psychopathic Hospital kept out of the State hospitals 175 patients at a cost of onefourth the custodial hospitalization prevented. The inpatient service at this hospital so shortens the usual hospital stay, that operating costs over the life span of the patient are three-fourths the amount now spent on custodial care in the regular mental hospitals. Patient turnover is so increased that seven times the number of patients can be treated in the same number of beds as in a custodial-type mental hospital. Another example: The day hospital, a new-type treatment center, gives better treatment to patients at half the cost. In this unique facility, selected mental patients too ill for outpatient treatment, but not ill enough for 24-hour hospitalization, attend the day hospital from 9 to 5 and sleep home at night. To sum it up, on the basis of actual pilot experience it is estimated that onethird of those now entering mental hospitals could be kept out altogether through outpatient treatment at one-fourth the cost, and another third could have shorter hospital stay, at three-fourths the cost. This we could do by putting into practice the treatments already known. They are good, but not at all sufficient. We need quicker and better ones. Will research produce new cures? Well, when we look at what medical research has already accomplished, we can see that the answer is "Yes." Take, for instance, syphilis of the brain, which is the last stage of untreated syphilis. The rate of first admissions of these patients to New York State mental hospitals was cut in half from 1947 to 1951 as a result of the discovery and use of penicillin for the cure of syphilis. Another example is the discovery of niacin as a cure for pellagra, which used to send many patients to the mental hospitals. Another example is the discovery of electroshock therapy, very successful with mental illness of the menopause, certain aged patients, and others. Gentlemen, here are three examples of how research has cut down the spending for the chronic care of mental patients. If it had not been for this research, the spending for mental illness would be millions of dollars a year greater than it is now. But, gentlemen, beyond these achievements lies a great unknown. Psychiatric study during the last 8 or 10 years has led to a realization of how big and complicated the task of thoroughly understanding the mental disorders really it. Research has staked out important leads for further investigation. It has developed spectacular new research instruments, such as the electron microscope, the brain wave machine, the television microscope, the ultrasound equipment. Without these instruments we have been blocked in the past, but they are ready for full exploitation now. For instance, evidence is piling up that mental breakdown is unbelievably complicated, because it involves not only the patient's body, not only his thoughts and moods, not only his relations with other people, but how all of these affect each other. Research has to make discoveries in each of these areas of human nature, and then put all the findings together. Only in this way can investigators un-cover how mental disorders operate. If we just let our minds dwell on this prospect for a moment we can get an idea how complex and far-reaching this task is, how many topics of inquiry, how many research projects and trained scientists will be required to develop fundamentally new tratments for mental illness. It is not so baffling as it might seem, however, because the skilled researcher can see new leads accumulating every day in all these spheres of study. We are not working in the dark as we were some years back. During these last years since the National Mental Health Act we have moved up to the threshold of decisive advances, if we actually follow up these promising leads on an adequate scale. For instance, Stanley Cobb, M. D., Bullard professor of neuropathology, Harvard Medical School and Massachusetts General Hospital, has the following to say: "The recent addition to our knowledge of the physiology of the nervous system, and especially the effect of the hormones on human behavior, certainly make it seem more than a mere probability that the hypotheses and leads that we are now interested in can be transformed into practical projects for research that will pay off in the near future." According to Dr. Hudson Hoagland, research at the Worcester Foundation for Experimental Biology has demonstrated a definite relationship between brain mechanisms and the action of the glandular system. Since disturbances in brain function are an important element in mental illness, there is reason to hope that future work may lead to a chemical treatment of great aid to the psychiatrist in some forms of mental disorder, although other treatments, such as psychotherapy, may be used in conjunction with it. Also, Leo Alexander, MD., president of the Electroshock Research Association, stated recently: "It is definitely within the realm of possibility that shock treatments may some day be replaced by a variety of chemical effectors." It is important to bring out at this point a very important difference between mental illness and some of the major physical illnesses such as heart disease, cancer, tuberculosis, diabetes, and others. Mental illness is so complicated that we cannot expect to find the one cure for it through some pill, or serum, or vaccine. Drugs may help, but they cannot be simply prescribed for, and picked up at the drug store. They will always have to be used by the psychiatrist himself, as an aid to him in treating the patient. Thus in some other diseases if a cure is discovered it can immediately be made available all over the country. In other words, a channel already exists for bringing the treatment to the patient once it is discovered. In the case of mental illness, however, there is such a shortage of psychiatrists, so few clinics, so few general hospitals giving psychiatric service, that adequate channels to the community level do not exist for putting into practice the new treatments that have been and will be discovered through research. There are only about 7,000 psychiatrists now. We need 15,000 more, but are training only about 450 a year. Thus it is very clear that the need for training personnel and setting up these community services is all bound up with the need for research, much more urgently than with some other diseases. Add to that, of course, another point. When a person gets heart disease. cancer, diabetes, or some other disease, the cost of it falls upon himself or family. But when a person breaks down mentally the cost falls on the taxpayer. That is why in the case of mental illness more than some of the others, government has a duty to the taxpayers to develop research, training, and community services to cut down the cost of care. This brings us back to the program of the National Mental Health Act established by Congress to control this problem. However, right from the start, the trouble has been that there were never enough resources devoted to it to accomplish the task. As long as the patients continue to pile up in the hospitals year after year, it is pretty obvious that the research and the personnel to treat these patients is not sufficient to halt the rising trend. And unless we raise our sights to a much higher level we shall never get on top of the problem. Mental hospital officials in a recent survey stated that a least 4 percent of hospital operating cost should be devoted to research. This would amount to about $28 million annually, whereas only about $6 million a year is now available for research. Research against mental illness is far behind research against other major diseases more in the public eye. Total research funds available per patient under treatment in 1951 for the following diseases were: That is why for the past several years we have pressed for a much larger research effort. There is no other way out. In a major 2-year study of training and research just completed by the Council of State Governments, a poll of over 300 research workers throughout the 48 States revealed that the greatest obstacles to research are lack of money and lack of personnel who, after all, cannot be trained without money. This judgment was overwhelming. Three-fourths of these research workers stated that if they had adequate money and personnel they would be able to conduct many research projects of scientific consequence. Now, I have not said anything about the humanitarian or the social aspects of mental illness; nothing about juvenile delinquency, drug addiction among the youth, alcoholism, sex offenses, and other crimes; nothing about the breakup of homes and the high divorce rate. But you in Congress who are close to the people realize that they are anxiously concerned with keeping such problems under control. And it has been found that all these troubles go hand in hand with mental illness. Many of these people end up in the mental hospitals, adding to their own misery, building up the taxpayers' burden, and weakening our social fabric. I think you will agree with me, gentlemen, that now is the time to strengthen and not to weaken the moral and mental vigor of American life. It is no accident that in the dictatorship countries, in Hitler's Germany and in Stalin's Russia, psychiatry as we practice it in America has been rejected. We believe in the freedom of the individual, and healthy, vigorous family life. But the dictatorships subordinate everything to the all-powerful state. We know that the mental vigor and health of the American family is the greatest bulwark against turning to subversive activity and juvenile delinquency and drug addiction among the youth, and the breakup of homes and all the other problems that walk arm in arm with mental illness in its various forms. I have not said anything about the endless human misery resulting from mental illness, because I know we are all agreed on that. There is no victim of any other disease who could not walk into this room and speak up for himself. But you know yourself that we could not bring the living dead from the back wards of our mental hospitals in here before you. It would be too horrible; it would be past all bounds, and we could not do it. So therefore we have to speak to you for them, to speak for those who cannot speak for themselves. In conclusion I would like to make the following statement: It is my conviction, after a study of pilot programs in the psychiatric field, that the Nation's mental hospital population could be reduced by about onethird of its expected size, through an all-out program to train psychiatric personnel, and apply known treatments to potential hospital patients, and newly admitted patients. Even more important, an all-out research campaign to exploit promising leads recently developed, could produce new treatments for the major psychoses, which would eventually make further substantial inroads on the hospital population. Such an achievement would wipe out patient overcrowding, personnel shortages, and minimize the construction of new custodial hospitals, thus saving the |