The States primarily utilize the grant funds to develop and assist in the operation of mental health services including clinics. These programs provide a wide variety of mental health services to a full range of mental health patients including the mentally retarded.

Mental health project grants. From its inception in 1958 until the end of fiscal year 1962, the NIMH supported 400 distinct projects through its programmental health project grants. These projects-ranging in duration from 1 year to 7-account for over 400 annual grants and a total of over $25 million in awards. The history of this program has been marked by a steady growth and diversification of effort-reaching a level in fiscal year 1962 of 248 grants and $10,108,959 in awards for studies in a variety of specific problem areas. Among the major substantive concerns of the Institute have been the areas of mental retardation, child health and development, juvenile delinquency, schizophrenia, alcoholism, aging, drug addiction, and psychopharmacology.

In the area of mental retardation, the total expenditure of mental health project grant funds between 1958 and 1962 was nearly $5 million; the level of support in 1962 was over $2 million. Among the major areas included here are studies of the diagnosis and treatment of the retarded; the psychological and social adjustment of the retarded and their families; and the care, management, and training of the retarded.

Effort in the area of schizophrenia has also been heavy. From the inception of the NIMH mental health project grant program in 1958 until the end of fiscal year 1962, 263 awards totaling $8,786,485 were made for projects in the area of schizophrenia. In 1962, over 50 projects, totaling nearly $2 million were devoted to studies of schizophrenia. Here, too, the emphasis of the program ranges over a broad area-including, for example, social and cultural factors; epidemiological studies; and analyses of treatment methods.

NIMH has responded to the increased public interest and concern about the problem of juvenile delinquency by increased mental health project grant support through the years. A total of 241 research grants has been awarded for the total sum of $5,766,610 between 1958 and 1962. In fiscal year 1962, 45 grants totaling $3,358,178 were awarded for juvenile delinquency studies.

Other special program areas which NIMH has supported include problems of the aging, alcoholism, and drug addiction. Twenty-six grants totaling $652,886 were awarded for studies of aging from the years 1957 through 1962. In 1962, six grants totaling $227,338 were devoted to studies of aging. Between 1957 and 1962, 30 grants totaling $1,100,311 were awarded for studies of alcoholism, while in 1962, 15 grants totaling $530,350 were devoted to this psychiatric and social problem. In fiscal year 1962, six grants totaling $191,383 were supported for studies of drug addiction.

It should be noted that a number of projects supported by NIMH are overlapping in their areas of emphasis. A single study may be relevant, for example, to both the fields of psychopharmacology and schizophrenia, or to both mental retardation and juvenile delinquincy. As a result, the figures noted above should not be interpreted as representing wholly discrete parts of the program, but rather areas of overlapping, interrelated effort.

(b) Construction: Hill-Burton program

Historically, the Hill-Burton program, under the Hospital Survey and Construction Act, has been directed toward assisting the States in the construction of adequate hospital and medical service facilities through matching grants to public or private, nonprofit applicants. There is no specific legislative provision for the construction of the various types of mental health facilities; however, the authority does allow for the construction of specialty-type facilities such as chronic disease facilities including mental illness.

As provided by law, the specific projects to be supported are based on priorities as to relative need as determined by the States and based on approval by the State agency. In point of fact, the States have identified these relative needs with the demand and need for general hospital facilities throughout the country. This demand and need has been so great that the States have been unable to direct Hill-Burton funds into the mental health category.

In the period, 1947-62, the total Federal expenditure under the Hill-Burton program was approximately $1.8 billion. Of this amount, only about percent or $59.6 million has been used for the construction of beds and facilities for the care of the mentally ill.

In terms of numbers of approved projects there were only 2.3 percent in the mental health category-146 mental hospital projects out of a total of 6,236 approved Hill-Burton projects.

In sum, then, the Hill-Burton program has been oriented primarily to general hospital facilities with only minimal support to mental health facilities; and, in large measure, most of the construction support provided has been confined to psychiatric wards in general hospitals.

A. Background

III. PROPOSED NEW PROGRAMS

By direction of the President in December 1961, the Secretary of Health, Education, and Welfare, in consultation with the Secretary of Labor and the Administrator of Veterans' Affairs, initiated a study to determine recommendations for a broadened national program in the field of mental health and illness. The findings and recommendations of this study group were reported to the President in December 1962.

The impetus of the President's request for such a study was the historic final report of the Joint Commission on Mental Illness and Health-the culmination of 5 years of the most intensive and comprehensive study of mental illness in the history of this country. To implement its program recommendations, the Joint Commission proposed that the Nation increase its total mental health outlay to a level of $3 billion by 1970, with the increase to come principally from the Federal Government.

The President, in his unprecedented special message of February 5, 1963, has now proposed a national mental health program of far-reaching dimensionsa program with the intermediate goal of reducing the resident population in public mental hospitals by some 50 percent in a decade or two and the ultimate goal of eliminating the traditional custodial mental hospital, as we know it today, from the American scene; a program designed to return mental health care to the mainstream of American medicine. The heart of this program is the concept of the community mental health center-a new concept representing a wholly new emphasis and approach to the prevention of mental illness and to the care, treatment, and rehabilitation of the mentally ill, an approach that will make it possible for most of the mentally ill to be successfully and promptly treated in their own communities and returned to a useful place in society. In marked contrast to the Joint Commission recommendation that such an expanded program be financed principally by the Federal Government, the President's program proposes that responsibility be shared by governments at every level-Federal, State, and local-and by the private sector. Under the impetus and stimulus of this program, the total national outlay would indeed meet the goal of the Joint Commission of $3 billion by 1970-but its financing would be shared by all levels of government and by the private sector. Under this program, the total national outlay would increase from its current (1962) level of $2.2 billion to an annual level of $3.2 billion by 1970. The Federal share of this increase would be approximately 30 percent; the State and local share, 63 percent; the private sector, 7 percent. It is to be expected that the private sector share will progressively increase as the community programs develop. It is also predicted that, ultimately, the availability of community mental health centers throughout the country will leave such a marked impact on the resident patient population in public mental hospitals as to make possible a significant shift of State and county expenditures from such hospitals to community use. A comparative analysis of these projections is set forth below:

Federal...

State and local..

Private sector.

C. Need for new legislation

The heart and major thrust of the President's national action program is the proposed grant program embodied in H.R. 3688 for the construction and initial staffing of community mental health centers. Existing legislative authorities under the Hill-Burton program are not adequate to implement the proposed program. They do not now provide specific categorical coverage for the field of mental health and illness and experience has clearly shown that the limited general coverage now available under Hill-Burton has been inadequate even for conventional mental health facilities. Further, the placing of additional funds in the regular Hill-Burton program would not accomplish the specific purposes set forth in H.R. 3688.

In sum, then, existing legislative authorities are not adequate for the implementation of the community mental health centers construction and initial staffing proposals set forth in H.R. 3688. Specific legislation is therefore needed and in view of the positive advantages that would accrue in terms of visibility and direct program emphasis, such legislation has been developed as a specific categorical proposal with respect to mental health and illness-H.R. 3688. D. Summary

The foregoing highlights of mental health program development in the Public Health Service provide a necessary backdrop, both in terms of historical development and current program content, to a consideration of the President's proposed national mental health program-particularly that part of the President's program requiring legislative consideration, namely H.R. 3688-the Community Mental Health Centers Act of 1963.

Based, in part, on the recommendations of the final report of the Joint Commission and, in part, on recommendations of the President's interdepartmental study group, the President in his special message proposed "a national mental health program to assist in the inauguration of a wholly new emphasis and approach to care for the mentally ill. This approach relies primarily upon the new knowledge and new drugs acquired and developed in recent years which make it possible for most of the mentally ill to be successfully and quickly treated in their own communities and returned to a useful place in society." Essentially the President's program consists of the following major points:

1. The provision of Federal assistance through planning grants for the development of comprehensive mental health programs by the States.

2. The support of expanded research in order to "push back the frontiers of knowledge in basic and applied research into the mental processes, in therapy, and in other phases of research with a bearing upon mental illness."

3. The extension of efforts to increase the supply of and improve the utilization of trained manpower.

4. The provision of special grants for demonstration projects to assist State mental hospitals to improve the quality of care, and to provide in-service training for personnel manning these institutions. This will permit the hospitals to perform a valuable transitional role, through the strengthening of their therapeutic services, by becoming open institutions serving their local communities. 5. The development of comprehensive community mental health centers through the provision of Federal support on a sharing basis for construction and early year operation (H.R. 3688).

All of the foregoing recommendations can be carried out within existing legislative authorities with the exception of the final proposal which is proposed for implementation under H.R. 3688. As indicated earlier, current construction authorities under the Hill-Burton program do not provide specific authority even for conventional mental health facilities, and, of course, provide no authority for the wholly new types of construction envisioned in the community mental health centers proposal. In the light of this fact, and the need to provide visibility and specific emphasis to and impetus for the prompt development of community mental health centers, the specific mental health legislation represented by H.R. 3688 would appear to be both desirable and necessary to effectively implement the President's recommendation in this critical area.

That the proposed program will pay off in humanitarian terms is clearly not debatable. There are some 17 million of our population with some form of mental or emotional problem; nearly 516,000 of these are in public mental institutions. Most of them are confined and crowded within an antiquated chain of State hospitals. In 1961 only 29 percent of these hospitals were approved by the Joint Commission on Accreditation of Hospitals; over one-third are more than 75 years

old; 18 percent of their beds were rated as nonacceptable on the basis of fire and health hazards. The average amount expended in them for patient care is only $4 a day. In spite of these conditions, these institutions cost the taxpayer over $1 billion in 1962.

That the program will pay off, in economic as well as humanitarian terms, can also be confidently predicted. The investments of the past have already paid off to the extent of the reversal beginning in 1956, of a 9 year upward trend (1946-55) in the resident patient population in public mental hospitals. The steady decline in resident patient population of only 1.1 percent per year during the period 1955-62 has already resulted in an accumulated saving of $700 million in maintenance costs exclusive of capital outlay-an amount in excess of the total Federal appropriations to the NIMH since its inception in 1948.

At the end of 1962, there were still some 516,000 resident patients in public mental hospitals. A reduction of 50 percent in this population-one of the goals of the President's program-would result in estimated savings in hospital maintenance costs of even greater proportions. If this 50 percent of our current resident patients were further assumed to obtain gainful employment upon release, at the average earnings for 1962 of $5,024, the national product would be increased by $1.296 billion—a significant return on the Federal, State, and local, and private investment represented by the proposals contemplated in H.R. 3688. The foregoing represent the highlights of the humanitarian and economic impact of the investment proposed by H.R. 3688. We are now on the verge of the greatest breakthrough in the history of mental health in this counrty. Our state of readiness is due in large part to the wisdom and financial support provided by the Congress over the past decade and a half which have enabled us to tool up through research, trained manpower, and the stimulation of public interest throughout the Nation.

The implementation of this legislation is critically needed; it is feasible and timely. It offers a dramatic opportunity for historic progress against mental illness together with potential economic gains of an equally historic proportion. It will provide a type of facility which by its very nature will restore mental health care to the mainstream of American medicine. Finally, its passage will ultimately affect the welfare of millions of American citizens.

APPENDIX A

LEGISLATIVE AND RELATED HISTORY-PHS MENTAL HEALTH PROGRAM

1929: Public Law 672, 70th Congress-To establish two U.S. narcotic farms for the confinement and treatment of persons addicted to the use of habitforming narcotic drugs, and for other purposes.

The act created a Narcotics Division in the Public Health Service to administer this program.

1930: Public Law 357, 71st Congress-Establishment of the Division of Mental Hygiene, Bureau of Medical Services, Public Health Service, by transfer of the authorities, powers and functions of the Narcotics Division. Provided broader scope and enlarged responsibility including narcotic addiction activities, supervision, and furnishing of medical and psychiatric services to Federal prisons, and for the study and inventory of the causes, prevalence, and means for the prevention and treatment of nervous and mental diseases.

1946: Public Law 487, 79th Congress-The National Mental Health Act, enacted July 3, 1946.

Provided for improvement of the mental health of the people of the United States through the conducting of researches, investigations, experiments, and demonstrations relating to the cause, diagnosis, and treatment of psychiatric disorders; assisting and fostering such research activities by public and private agencies, and promoting the coordination of all such researches and activities and the useful application of their results; training personnel in matters relating to mental health; and developing, and assisting States in the use of the most effective methods of prevention, diagnosis, and treatment of psychiatric disorders. The act authorized the establishment of the National Institute of Mental Health to administer this program.

1946: Public Law 725, 79th Congress-Hospital Survey and Construction Act (Hill-Burton).

Provided assistance to the States to inventory existing hospitals, survey the need for hospital construction, and to assist in the construction of public and other nonprofit hospitals.