hospitals. This organization has provided the main leadership to the country in the establishment of psychiatric clinics for children and in the training of personnel for such clinics. It now has a manual which is used by communities interested in establishing such service.

When we review the full range of the field, we appreciate how much we are not doing. Taking only the severely ill one need only ask: Where are the mentally ill? He is led immediately to a long list of social institutions which demand the attention of the citizen. This list would include somewhat in the order of importance the State mental hospitals, the Veterans' Administration hospitals, the city and county mental hospitals, the Public Health Service hospitals, services to the penal institutions, the Armed Forces hospitals, private mental hospitals, psychiatric departments of general hospitals, institutions for mental deficiency-both public and private, hospitals for alcoholics and drug addicts. In addition to this there are the known institutional community facilities that meet severe cases of mental illness, especially those coming to the private physician, courts, and other resources for helping people in need. We can't pass over any of these. We cannot escape the seriousness, the extent, the social implications, the scientific unknowns, and the public apathy toward this problem. The CHAIRMAN. I believe Mr. Heselton has a question.

Mr. HESELTON. Doctor, I notice you are listed as representing the National Association for Mental Health, and I notice that in 1951 your association received quite a substantial increase in the amount of funds over the previous year. In 1950 it was $194,000 and in 1951, $600,000. I am inclined to believe that is because of the merging of a number of these groups, but I am not certain about that.

Dr. STEVENSON. That is right. Practically all of those funds in that year were received from foundations and other contributors whose efforts were merged.

Mr. HESELTON. That is all, Mr. Chairman.

Dr. STEVENSON. A part of it represented also confidence in the foundation and the feeling that this merging was a good thing.

The CHAIRMAN. Is anyone in a position to tell us what the overall cost of caring for these cases is in the different public and private institutions?

Dr. WORTIS. Yes.

The CHAIRMAN. I am just informed that that was in the record before I came in this morning.

Dr. WORTIS. Mr. Chairman, I believe Dr. Felix could give us these figures. They are available through his office and his staff.

STATEMENT OF DR. ROBERT H. FELIX, DIRECTOR, NATIONAL INSTITUTE OF MENTAL HEALTH

Dr. FELIX. Mr. Chairman, with your permission and in the interest of time, I will give one figure rather than the breakdown, but I will be glad to submit for the record the full information if you wish.

The cost of the care of patients in mental hospitals plus the cost including Veterans' Administration hospitals plus the cost for pensions of neuropsychiatric disability of veterans, Veterans' Administration pensions, comes to about $40 million over $1 billion a year at the present time. For the past several years the annual figure has increased at the rate of around $100 million a year. I will let it go at that unless you want some more information.

The CHAIRMAN. That illustrates the tremendous problem that this presents. We could continue here for a week, and nothing would illustrate more clearly and more definitely than the statement that you have just made as to the immensity of this problem.

Dr. FELIX. Mr. Chairman, I should like to mention one other figure, and I hesitate because I do not want to discourage you. May I be so bold as to mention one other figure, which I think illustrates what we have ahead of us if the situation does not change.

If the present birth rate remains constant, if the number of mentally ill who are hospitalized remains constant, and if the cost for hospitalizing the mentally ill remains constant, each year's crop of new babies will, because of the percentage of them who will go to mental hospitals, cost the taxpayers-this is just the taxpayer and not any private foundation-$800 million before they die.

The CHAIRMAN. It is time somebody began to think about this in a very serious way.

Dr. FELIX. I wish to God they would, Mr. Chairman. We have many people working in this field, but we sometimes get a little heavy hearted. Not through any fault of the Congress, because they have been most generous, but there is so little public understanding of the problem. If the whole Nation would begin to understand; if people would work for their State hospitals and mental-health clinics in their communities and assist their schools to develop better guidance programs for the students who are having problems; if we could do something in the field of marriage counseling to save homes that are breaking apart because of psychological reasons, much could be done. These things mean as much as the funds which you and those in the upper House between you appropriate for the program which I have to administer. I do not mean by this, gentlemen, that I could get along with less, but that is one aspect of the program and public understanding and support are other important aspects.

For some reason or another, gentlemen, there seems to be a feeling among many of the people in our country-the people on the highways and byways and my home in Kansas and your home wherever it may be-that if you forget about mental illness and ignore it, it will go away. There is another thing I would like to mention. And this is something that I wish someone, maybe some of you gentlemen who are experts in public life and know how to sound out the opinions of people could suggest methods of handling. If a person other than we who are professional psychiatrists, psychologists, and so forth, shows an interest in mental illness and begins to push for increased attention to the problem, immediately you will see people who will begin to look at him out of the corner of their eyes and wonder why he is so interested. They suspect something happened to him or some member of his family.

On the radio and television, in magazine articles, in newspapers you can hear or see or read articles about people who tell of their experience with a heart attack or "I was a sufferer from cancer" and tell what science did for them and what more needs to be done on the problem as a whole. I wonder if any of you have ever seen the same kind of thing in connection with mental illness. There was one program on television a short time ago, on a national hook-up, in which a well-known person stated that he had been ill. Perhaps with the exception of that individual and one or two others, have any of you ever heard a person in public life-a public figure-get up in public and say "I had a nervous breakdown" or "I had a mental illness. I have recovered." I just pose that question, gentlemen. I daresay if I were a Member of the House of Representatives and had had such

an illness-I am a part of this culture, too-I would probably be rather careful that that did not get out if I could help it, because it might hurt me every other November. Is not this a terrible situation? We hide this thing and cover it up; we alibi for it and bury our heads in the sand, gentlemen, and this is the greatest problem, the most expensive health problem, we have in this country. Excuse me. I have to live with it every day.

The CHAIRMAN. Your emphasis is excusable.

Dr. WORTIS. Mr. Chairman, Mr. Heselton asked a question before about the State governments, and I did not want that to go unanswered, since we are fortunate to have in the room Dr. Willey who has worked with that group. I wonder if Dr. Willey would say something about that in answer to Mr. Heselton's question.

The CHAIRMAN. Will you give your name, Doctor, and your position?

STATEMENT OF DR. RICHARD WILLEY, EXECUTIVE ASSISTANT FOR THE AMERICAN PSYCHOLOGICAL ASSOCIATION

Dr. WILLEY. I am Dr. Richard Willey and I am executive assistant for the American Psychological Association and also formerly research associate for the Council of State Governments, which prepared one of the two reports which have already been referred to.

Concerning the relationship of the Federal Government and the States, the States' role in mental health in the past, I believe, has been somewhat different from that of the Federal Government. The States have traditionally had responsibility for the actual care and treatment of individual patients, whereas the Federal Government's interest has more recently been centered in sponsoring research, in the program of the National Institute of Mental Health, and a more overall approach to this problem.

The States have very recently taken a great deal of interest in the promotion of mental health. The period between 1948 to 1951 or 1952 was the period of peak interest in increasing the buildings available to mental institutions, increasing building programs, and adding wings to hospitals and building new hospitals, and so on. I think that was a very successful move. It did, however, result in revealing unfortunate shortcomings in that after many of the State building programs had been completed, it became apparent that there were not adequate staffs to actually use these buildings. So that while bed space was provided, there was some doubt as to whether the actual level of care was improved as much as the building program had been. Hence the need for personnel and increased research, which has been brought into more prominence within the last 2 or 3 or 4 years.

The States are extremely active in promoting their mental health programs. A resolution of the governors conference in August was made to the effect that a conference of all State officials or representatives of the State agencies concerned with mental health be held on a national scale. In addition to that, there has been a great number of increases in budgetary allocations for mental health in some States. This, however, has been very selective, and while certain States have taken a great deal of initiative in increasing their research and training programs, others have not.

Mr. DOLLIVER. Doctor, would you comment on this situation? I think this has been going on in my home State of Iowa. There has been a trend toward removing the less seriously afflicted patients in the State hospitals to other institutions, such as county homes or nursing homes. Is there any general pattern on that which has been going on in the last 2 years?

Dr. WILLEY. That has been the subject of a great deal of discussion in the States because of the overcrowding of State institutions. I think it is generally felt-and I would defer part of this question, however, to the psychiatric representatives-that it would be a great help if particular classes of patients could be so transferred. There has been considerable reservation about actually doing it, however, because of the fact that homes for the aged usually do not have adequate medical staffs. The homes for the aged-the convalescent homes-have been a great aid, but again the number of them is limited from the standpoint of adequacy of facilities.

There has been some study made of whether certain types of patients could be more adequately cared for by the States if new types of institutions were set up, but most of those plans have not come much further than the discussion stage to my knowledge.

Mr. DOLLIVER. I have read a statement somewhere-or maybe it is a residue in my mind-that there has been a great deal of overcrowding in some of these State institutions. Has any measure been taken recently to alleviate that situation?

Dr. WORTIS. I believe Dr. Stevenson, if I may interrupt, could answer that.

Dr. STEVENSON. Yes. I think one important measure was the Hospital Construction Act, which has been taken advantage of by many States in assisting them in developing more hospital beds. I believe the situation has not in the least been alleviated, however. Population grows faster than beds, and overcrowding shoves them up into attics that were intended for that use, shoves them into buildings that were intended for the artisan; it shoves the paint shops down in the basements in buildings in which patients are located, so that the hazards of fire are great; it increases the drain on the utilities which were, let us say, constructed for 1,800 patients and now have to serve 3,000. A hospital on whose board I am a member has approximately 50 percent overcrowding. It was built for 2,100, and it has housed 3,200. My State and your State and, California, Tennessee, and Wisconsin are the only States left that retain the county system which reflects the ancestry of the State hospital which was the almshouse. Under the county system, if it gives adequate service, it is far more expensive. Burlington County, N. J., has a county hospital. If that county transferred its patients to the State hospital which serves that area, the patients would get better service and the county would save $100,000 or more, which represents the difference between what its share is in the State hospital and its full service to those patients in the county hospital.

Mr. DOLLIVER. To what do you attribute that additional or excessive expense in the case of local treatment of these people?

Dr. STEVENSON. There are a number of factors. One of them is that these institutions provide opportunities to appoint people to their staffs and it provides opportunities to contract. I think that is, frankly, the largest ill, and so the opportunity to do away with them

is greater at a time when the labor market is tight and demands for jobs are not so great. I would except from that statement several county hospitals that are just as good and some better, but I do not know whether they are more expensive or not. They are hospitals that range from 1,500 to 2,000 patients-along in there. There are several others, but I am talking about the small ones.

Mr. DOLLIVER. Those are in the larger cities?

Dr. STEVENSON. They are located in Milwaukee, Detroit, Newark, N. J., and so on.

Mr. HESELTON. In view of the report which has been made about the interest of State groups in this problem, I am wondering what the general attitude of the State legislatures has been. Have they been cooperating, or have they not been cooperating?

Dr. STEVENSON. There is just one thing that I would like to say about that. I would say they have been, in general, exceptionally cooperative in the sense that they have been willing to stick their necks out beyond what public support would warrant, but we know they cannot keep on sticking their necks out unless there is more public backing. And unless more public backing is developed soon, their necks will have to be pulled back. When a State advances on the basis of what I think of as polite blackmail-putting the bee on the legislature and nothing is done to follow up and support it, we can be almost certain that there will be a recession.

Mr. SCHLAIFER. May I speak to that, too?

The CHAIRMAN. Yes. We shall be glad to hear from you.

Mr. SCHLAIFER. The honored chairman of our National Mental Health Committee is the one who is responsible for that resolution being introduced to the Council of State Governors and for its being put into effect. Now there will be some hearings and some continuing meetings in regard to it. Several of the members here have worked on that plan, but what has happened in the States I think is a very interesting thing.

I think there has been, generally speaking, in this entire field what I would term "a great deal of 'buck passing'." The State legislatures have these hospitals on their hands, and the tremendous cost of them has already been pointed out. As you gentlemen know, in your own States close to one-third of the operating budget is for the care and treatment of patients in the hospitals, and the funds have never kept pace with the needs. When one of the governors in one of these States who is very much interested in this whole problem-one of the leaders in the field-wanted to do something about it, his State legislature said "Why should we appropriate a great deal of money for research and training when it will benefit New York State? Let New York State do it." New York State has done the biggest project that is going on. There has been the general idea that this is something which has been pushed back-the idea of mental illness and care and treatment has been pushed in the background, and the information in regard to the tremendous sums of money the taxpayers pay for it, but they do not pay for it in the sense that they are getting an end result. I think this is a very serious problem that the States have to work out.

Mr. HESELTON. That leads me to ask another question. Has the fact that the Federal Government has gone into this field and appropriated what possibly some people may think are inadequate funds but still