were regarded as persons possessed by the devil or by demons. As a consequence, they were persecuted, driven out into the countryside, and left to wander among the beggars, the poor, and the mendicants. In keeping with existing ideas about the cause of mental illness, it is readily understandable that these people suffered persecution and many were physically tortured and killed. In the 13th and 14th centuries isolated localities and communities became more humanitarian toward those who were poor and made their livelihood by begging, and established almshouses for those who were unable to care for themselves. Gradually this concept was extended to include the physically handicapped and the mentally ill. Almshouses had their origin in England, the most famous of which was located at Bethlehem which is remembered as the notorious "Bedlam." With the migrations of people from the Old World to America in the 17th century, the establishment of almshouses for the indigent people was but a natural outgrowth of the culture from which they had come. Ultimately the almshouse lead to the establishment of what are known today as the municipal hospitals. As the country grew, so grew a need for hospitals. In 1752 the Pennsylvania Hospital was established by private subscription in Philadelphia as the first institution in the colonies exclusively devoted to the care of the sick. In the case of the Pennsylvania Hospital, provision was made for the first time in the colonies to provide care for the mentally ill.

About 20 years later the first institution devoted exclusively to the care of the mentally ill was established in this country, brought about by a request to the Virginia Assembly to provide a State institution for "idiots, lunatics, and other persons of unsound mind." Thus was established the first State institution for the care of the mentally ill at Williamsburg in 1773. It is worth noting, too, that the principle of State aid was involved, for the major asylums built in this country after 1825 were to be State institutions. At this time the appeal for public support seemed logical in view of the prevailing attitude that the Government had a responsibility for poor relief since custodial institutions were likely to care for the poor. It was for this reason that by 1840 most general hospitals in the United States represented private philanthropies but that alongside them had evolved insane asylums and municipal hospitals, both of which had evolved from the concept of the almshouse. Following the example of Virginia, a list of the States providing insane asylums would include Kentucky (1824), South Carolina (1828), Virginia (second State hospital, 1828), Ohio (1830), Massachusetts (1833), New York (1836), Vermont (1836), Maine (1840), and Tennessee (1840). A few of the States continued to depend upon private hospitals for the care of the mentally ill. Generally, however, the principle was evolved by this time that it was the responsibility of the State to provide facilities for the custody, care, and treatment of the mentally ill. This pattern of governmental responsibility continues to exist to the present day. Unfortunately, the principle of providing custodial institutions for the needy poor through the almshouses persisted in the evolution of the insane asylums. Gradually this philosophy has undergone some changes so that many of the States are discarding the principle of simple custodial care and have instituted modern, up-to-date methods of treatment. The development of the intensive treatment programs, however, has been hampered by a variety of factors, including lack of facilities and personnel.

Historically the care and treatment of the mentally ill has been a public responsibility with a primary authority vested within the States and communities. The last 3 to 4 decades have seen the development of clinics for treating the less serious emotional disorders of adults and children not requiring hospitalization. A more recent development has seen the establishment of facilities in general hospitals for the early diagnosis and treatment of mental disorders. Other extraordinary changes have taken place. The mental institutions have begun to come out of their isolation-systematic after-care and supervision of patients on parole, social-work programs integrated with the treatment functions of the hospital, affiliation between mental and general hospitals and mental hospitals and medical schools for mutual advantage in the training of nurses and physicians, increasing use of clinical psychologists in hospitals and clinics, and systematic programs of inservice training for various classes of personnel.

THE MENTAL DISORDERS

By the preventive application of psychiatric knowledge, as it is acquired, mental health problems can ultimately be solved. This does not mean that mental health should operate from an ivory tower; indeed, "mental health is everybody's business." The prevention of mental disorders is a relatively new public-health field in which psychiatrists have worked in relative isolation for

too long a time. The vast amount of psychiatric morbidity is hardly recognized in the other specialties of medicine. It has been estimated that 40 percent of patients who are treated in general practice have psychiatric complications. The heart patient, who may look well but who lives under an unpredictable threat, has an important emotional life component with which he must live and his very survival may depend upon the degree of tranquility which can be brought to the problem. Any chronic disease produces conflicts and the degree of morbidity often depends more upon the individual's attitude than the disease itself. And morbidity costs money in the long run, as well as causing misery and unhappiness.

The development of new methods and techniques has already decreased morbidity in schizophrenia, manic-depression psychosis, involutional psychosis, paresis, epilepsy, and in some of the neuroses. Indeed paresis is so clearly preventable that it stands to be conquered in the foreseeable future. Like it, chronic alcoholism is preventable and there is an awakening of interest and research on the problem. One can reason with conviction that drug addiction and delinquency are also preventable.

Schizophrenia forms the hard core of chronic mental illnesses. We don't know the cause, but there are environmental factors. It strikes usually in early life and it contributes the largest group of hospitalized mental patients. Progress has been made in the treatment of schizophrenia and in providing extramural medical care, but we still cannot prevent what we don't understand.

The neurosis may be said to represent almost a way of life. Treatment methods have been improved, but it would appear that preventing the development of a neurosis should be much easier and more simple than helping an individual readjust to life after the neurosis has developed. The vast amount of neurotic illnesses and morbidity cannot be estimated, but we can recognize early signs and unhealthy environmental factors in the development of the neurotic pattern of life. Present knowledge is not being generally applied. Existing knowledge usually runs far ahead of application. Our knowledge is far from complete, and the number of trained personnel to apply present knowledge is inadequate.

Mental disorders of the senium have increased rather alarmingly, due largely to increase in longevity. There are social, environmental, and economic factors in precipitating a mental break in many of these old people, and early medical care can salvage many of them. Here again the lag in the application of existing knowledge is sometimes amazing. For example, we know that if an aged person lives alone, perhaps cloistered, prepares his own meals which he eats alone and has little or no social life, his early failure in adjustment, both physically and mentally, is predictable. Hospital utilization is on the increase in all spheres, partly because of the increase in the number of aged persons.

The group of intellectually subnormal citizens represents a most neglected field. Some States do not have special facilities for them either in public schools or in institutions. The educable should be given an opportunity to develop fully his potential abilities and the trainable should have the benefit of improved habit control. Even an idiot can learn to improve his habits which decreases the burden of the mother or of an institution. Between 1 and 2 percent of our population is mentally deficient. We know that this can be reduced by simple methods such as preventing birth injuries and other mechanical trauma, controlling rubella in the prospective mother and early attention to blood incompatibilties of mother and child. The association of convulsive disorders is common in this group; progress is being made and several large State institutions for epileptics have been discontinued.

THE PREVENTION OF MENTAL ILLNESS AND THE PROMOTION OF MENTAL HEALTH

The prevention of mental illness is a goal that is sought to reduce human suffering and national economic loss. As is true in the instance of many other medical problems such as cancer, heart disease, poliomyelitis, and others, the means of prevention are not yet at hand for all the mental illnesses. The cause and necessary understanding have been established for the prevention of general paresis and the psychosis associated with pellagra, a vitamin-deficiency disease. Certain infectious diseases frequently lead to brain damage with permanent changes in the personality and when the prevention of these diseases has been established, so will the brain damage and mental illnesses in these instances be prevented.

Mental illness that is, to the best of our present knowledge, psychological in development and origin is best prevented by early diagnosis and treatment. The greater knowledge needed to discover latent or less obvious mental illness and predict with accuracy the future development of mental illness before it is apparent awaits new discoveries that must come from research.

The prevention of the further progress of a mental illness, if unrecognized or untreated, must be met by trained professional personnel who are skilled in diagnosis and treatment. These individuals can make broader contributions by conveying their knowledge either as a consultant in research or in teaching. This leads greater recognition and prevention of mental illness by physicians, parents, teachers, workers in children's agencies, and others.

The increased emphasis on psychiatry and related fields in the teaching of all physicians prepares them to be better able to recognize early manifestations of personality disorders. They are those able to initiate corrective procedures in mental disorders and to refer to the special agencies or specialists in mental health those with more severe illnesses for early care and treatment.

Rehabilitation in the field of mental illness has only recently received attention. The concept of a comprehensive rehabilitation program, first developed in the area of physical illness, offers hope as another means to prevent further disability as a result of mental illness.

The promotion of mental health is a goal that is in part reached by the prevention and the treatment of mental illness. Through the knowledge attained from work with the mentally ill, much has ben learned of those factors that contribute to mental health. The main preoccupation of scientists in this field has been wtih the cause and treatment of illness. It is important to learn more of what contributes to the development of a healthy person (not just the absence of disease) as well as what contributes to a sick personality. Through continued research and training of professional people will come the means for advancement toward the goals of preventing mental illness and promoting mental health.

DIAGNOSIS, TREATMENT AND REHABILITATION

The principal requisite in our knowledge of mental disorders is an accurate definition and classification of the separate disease processes. It is the basis for our scientific psychiatry. Without an index there would not be a starting point for the treatment of the separate psychiatric disorders or for instituting further investigation. Diagnosis is essential before treatment procedures can be instituted. However, classification in psychiatry is still incomplete and uneven. For instance, we have an exact body of information regarding general paresis, while our information regarding schizophrenia and the manic-depressive psychoses is still incomplete. While accuracy of diagnosis is essential in the treatment of the individual mental disorder, proper classification is extremely essential to a better understanding of epidemiology-the natural history and extent of mental diseases. At the present time, aside from persons who are confined to mental institutions, our information regarding the size and extent of the problem of mental disorders is inexact and incomplete. This represents an area for exploration in the immediate future.

In the treatment of mental disorders a variety of methods and techniques are employed. These range from the chemical therapies, on the one hand, through the shock therapies and psychosurgery to psychotherapy, on the other hand. In addition, nonspecific techniques such as occupational and recreational therapy, music, and bibliotherapy are employed in the treatment of mental disorders. Play therapy is effective in the treatment of the emotional disorders of children. The patient is encouraged to be an active participant in a wide range of activities, the so-called total push therapy, designed to restore him to a useful and meaningful way of living. This is in contrast to the older methods, some of which are still too prevalent, of providing simple custodial care without any attempts at treatment. The overcrowding of our hospitals and the lack of professional personnel still prevent us from providing modern advanced methods of treatment to all persons suffering from mental disease.

It is only recently that isolated attempts to rehabilitate the mentally ill have been tried. Rehabilitation has been defined as an attempt to restore the handicapped person to the fullest mental, emotional, social, economic, and personality usefulness of which he is capable. Some hospitals have instituted programs of such a nature and continue to assist and provide support for the individual after his discharge from the hospital in order to help him in a more successful and useful adaptation in the community to which he returns. Techniques of rebabilitation also represent an area for exploration in the near future.

SIZE AND COST OF THE PROBLEM

Intelligent planning for an integrated public-health attack on mental disorders demands adequate epidemiological information. A variety of facts is needed. What is the extent of the problem-that is, how many are affected? What are the characteristics of the mentally ill as a group and as compared to the rest of the population with respect to such factors as age, sex, race, and occupation? How does mental illness develop in the individual and what factors explain its distribution in the population? What are the psychological, physiological, and socioeconomic factors that may be related to cause and course of the illness? There is a wide gap between the facts that we have now and those that we need to have. Indeed, to answer any one of the above questions requires a major research effort. Let us consider what is needed to make a statement on the prevalence of mental illness, that is, the number of mentally ill persons as of a specified interval of time. First, we need a definition of whom we are to count— who are the mentally ill? Second, we need techniques for detecting cases. For mental disorders this is not a simple matter. We are not dealing with a single entity but with a broad variety of disorders characterized generally by abnormal patterns of behavior. Some are due to known organic etiological factors, such as syphilitic infection, cerebral arteriosclerosis, alcohol intoxication, brain trauma, or convulsive disorders; others are of psychogenic origin or without clearly defined physical cause or structural change in the brain, such as the schizophrenic and manic-depressive psychoses, the psychoneuroses, the psychosomatic disorders, and a broad group of personality disorders.

Although mental disorders are sometimes considered as chronic illnesses, many have acute and reversible phases. Thus, in addition to defining the types of abnormal behavior we wish to find, we must also specify whether we are looking for individuals who have exhibited such behavior at any time in their lives, or only during some specified period of time. Even if we were to agree on whom to count, we still have the problem of devising standard methods for case finding and diagnosis needed for separating the population into those who have a mental disorder and those who do not.

Despite difficulties of definition and case finding, estimates have been made of the extent of the problem of mental disorders. As will become apparent from the statement that follows, these data have many shortcomings. Nevertheless, it will also become apparent that they all point to a single fact— mental disorders are a major cause of illness and disability in the Nation. Community surveys of prevalence

At least 6 percent of the total population, 9,000,000 people, suffer from a serious mental disorder. This estimate is based on the findings of two widely quoted surveys: One done in the eastern health district of Baltimore, Md., by Lemkau, Tietze, and Cooper,' and the other in Williamson County, Tenn.* Although these surveys are not entirely comparable, these findings make it clear that in both surveys persons with psychotic disorders-the illnesses which for the most part require mental-hospital care-constitute only 10 percent of the cases found. Disorders classified as psychoneuroses and personality disorders of adults and children accounted for the large bulk of all cases. Some idea of the distribution of various mental disorders in the population can be obtained from tables 1 and 2 which present the results of the two case-finding surveys.

Selective Service data

A second widely cited source of prevalence data is the World War II experience of the Selective Service System. Selective Service records, as is well known, show more registrants rejected for mental and personality defects than for any other cause. Of 4.8 million rejections up to August 1, 1945, 18 percent were due to these disorders. Additional data come from studies on prevalence of medical defects made on a carefully selected sample of registrants between the ages of 18 and 44 years who were examined during the period 1940-43. These studies showed mental illness as the sixth most common defect among all registrants in the sample, with a prevalence rate of 55.8 per 1,000. For

1 Lemkau, P., Tietze, C., and Cooper, M., Mental Hygiene Problems in an Urban District, Mental Hygiene, volume 25 (1941), pp. 624-646; volume 26 (1942), pp. 100-119, 275-288; volume 27 (1943), pp. 279–295.

2 Roth, W. F., and Luton, F. H., The Mental Health Program in Tennessee, I: Description of the Original Study Program: II: Statistical Report of a Psychiatric Survey in a Rural County, American Journal of Psychiatry, volume 99 (1943), pp. 662-675.

Felix, R. H., and Kramer, M., Extent of the Problem of Mental Disorders, Annals of Political and Social Science, volume 286 (1953), pp. 5-14.

a variety of reasons, Selective Service prevalence rates cannot be applied to general male population age 18-44 to determine the number of such individuals with mental disorders. However, these data emphasize the large loss of manpower to the Armed Forces for which mental disorders are responsible. Armed Forces data

Although Armed Forces experience is not applicable as a measure of mental illness prevalence in the general population, an indication of the magnitude of the problem insofar as these services are concerned is derived from the number of disability discharges because of neuropsychiatric reasons during World War II. Of 980,000 disability discharges from the Army during the period December 1941 through December 1945, 43 percent were for neuropsychiatric reasons (table 3).

Patients in mental hospitals

The most detailed data available on the mentally ill are derived from mental hospital records. These relate only to persons whose illness has been recognized and who are sufficiently ill to warrant admission into a hospital for longterm care of psychiatric disorders.

In the United States in 1950 there were 201 State, 111 county and city, 228 private hospitals for mental disease as well as the 33 VA neuropsychiatric hospitals. The persons admitted to these hospitals are those with the more serious mental diseases, primarily the psychoses. They constitute a major illness problem for the Nation because of their large numbers and the amount of care they require. The cost of their hospital care is prodigious. Combined, these hospitals spend more than $500 million annually for maintenance and care of patients.

At the end of 1950 there were 577,000 resident patients, or 3.8 per 1,000 population, in all long-term mental hospitals. About 85 percent of these patients were in State, 9 percent in Veterans' Administration, 4 percent in county and city, and about 2 percent in private hospitals.

There has been a continuous increase in the resident-patient populations of these hospitals since 1903, the earliest year for which reasonably comparable data are available, when the number of residents was only 150,000, or 1.9 per 1,000 population (table 4).

Many factors are responsible for this fourfold increase in number of patients and twofold increase in ratio of patients to general population: First, there is the possibility of a real increase in the incidence of mental illness, but this is difficult to determine; second, the fact that the population is aging means that many more people are brought into the age groups where rates of admission are the highest; third, there is a greater awareness of the problems of mental illness on the part of both the lay public and the medical profession, as well as increased public confidence in the management of these hospitals and the service they render; fourth, a considerable proportion of admissions fall into the group requiring extensive long-term care. Thus, with increasing admission rates, the absolute numbers of such patients will increase in the resident-patient population. The improvement in death rates over the years resulting from better medical care and the use of the new wonder drugs has also contributed to an increased resident population. Fifth, there has been a constant increase over the years in the availability of hospital space. However, mental hospital beds are still unequally distributed throughout the Nation, as may be seen from the variations found in the resident-patient rates of the States, ranging from about 2 per 1,000 population in New Mexico to 6 per 1,000 in New York State.

In a single year the movement of patients into and out of these hospitals is considerable. For example, as of July 1, 1949, there were 554,000 in residence and 87,000 in extramural care. In the following 12 months there were 260,000 admissions, 184,000 discharges, and 47,000 deaths. Thus, there were over 900,000 patients under the care and supervision of mental hospitals during that year. The rate of first admissions to long-term mental hospitals has long been used as an index of the incidence of the more serious mental disorders. A sizable literature exists concerning the characteristics of such admissions, especially of those entering State mental hospitals.*

Malzberg, B., Social and Biological Aspects of Mental Disease, Utica, N. Y.: State Hospitals Press, 1940; Dayton, N. A., New Facts on Mental Disorders, Springfield, Ill.: Thomas, Charles C. (1940); Census of Patients in Mental Institutions, 1923-49.

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