WHAT ARE THE FACTS ABOUT

 

MENTAL ILLNESS IN THE UNITED STATES?
WHAT ARE THE FACTS ABOUT MENTAL ILLNESS IN THE UNITED STATES?

I. HOW MANY PEOPLE IN THE UNITED STATES ARE SUFFERING FROM
SOME FORM OF MENTAL ILLNESS?
1. An estimated 19, 000, 000 people in the United States are suffering from
some form of mental or emotional illness, from mild to severe, that
needs psychiatric treatment. (1)

a. This means that about one in every 10 persons is now suffering from

 

some form of mental illness of varying degrees of severity.
2. Mental illness or other personality disturbances are usually significant

factors in criminal behavior, delinquency, suicide, alcoholism, nar-

 

cotics addiction, and very often, in cases of divorce. (2)

a. About 60, 000 persons in the U.S. are drug addicts. (2)

b. An estimated 20, 510 people committed suicide in 1964. (3)
Suicide is now the tenth leading cause of death in this country.

3. Mental illness is known to be an important factor in many physical

 

illnesses, even heart disease and tuberculosis. (1)

4, At least 50% of all the millions of medical and surgical cases treated

 

by private doctors and hospitals have a mental illness complication. (1)

 

5. An estimated 500,000 mentally ill children in the U.S. are

 

classified as psychiatric or borderline cases. Most of these children

 

are suffering from the psychiatric disorder known as childhood
schizophrenia. (1)

a. Only a very small percentage of the total are receiving any kind of
psychiatric treatment. (1)
6. Emotional disturbances and mental illness are an important factor in

the cause of 75% of all accidents. (1)

II. HOW MANY ALCOHOLICS ARE THERE IN THE UNITED STATES TODAY?
1, About 5,000,000 people in the U.S. are alcoholics, affecting 20 million
family members. An estimated 200, 000 new cases develop each year.(5)
a. FBI reports showed 1.5 million arrests for "drunkenness" in 1963,

and an additional 215,000 arrests for "driving while intoxicated. ''(5)

 

b. One out of every 7 admissions to state and county mental hospitals
is an alcoholic. (5)

c. Losses to industry from absenteeism, and other occupational problems,
associated with alcoholism are about $1 billion annually. An additional
$1.25 billion is spent each year to provide care, financial support

and treatment for alcoholics and their families. (5)
d. A recent study of cases of Aid to Families with Dependent Children
found alcoholism as a major factor in 14% of the families receiving tax
monies under this program. (5)

e. Anational public opinion survey in 1965 found that 1 in every 5 adults

questioned admitted constant worry because they "drink too much for

their own good." (5)

lil. HOW MANY PEOPLE ARE BEING TREATED FOR MENTAL ILLNESS?
1. An estimated 3,921,000 Americans were treated for mental illness in
1965. (7)
2. There is an increasing trend away from the state mental hospital as the
primary source of treatment. Twenty years ago, state institutions
handled 3 out of every 4 mental patients; in 1965, they cared for only

1 in every 5 persons receiving psychiatric treatment. (7)

 

 

1945 1965
3 out of 4 went to a State Hospital 1 out of 5 went to a State Hospital
1965 of patients treated in mental health clinics
© O O or by psychiatrists in private practice only

1 out of 3 has to be hospitalized
There is a parallel trend increasingly emphasizing outpatient care and

partial hospitalization as an alternative to 24-hour hospitalization. In
1965, almost 2 in every 3 patients were not hospitalized; they received
private office psychiatric care or were treated in one of the 2, 000
mental health clinics in the U.S. (7)

3. The following table lists where the 3.9 million mental patients re-

ceived treatment in 1965: (7)

State & county mental hospitals 807, 000
Private mental hospitals 110, 000
General hospitals 600, 000
Outpatient clinics 950, 000
Psychiatric day-night units 14, 000
V.A. hospitals 140, 000
Private office care 1, 300, 000

3, 921, 000

IV. WHAT IS THE EXTENT OF MENTAL ILLNESS AMONG CHILDREN?

 

1, An estimated 4 million children under the age or 14 are in need of
some kind of psychiatric help because of emotional difficulties. Of
these, between 500, 000 and 1, 000, 000 children are so seriously dis-
turbed that they require immediate psychiatric help. (8)

2. An amazingly high percentage of the long-term residents of state
institutions were first admitted as children or young adults. (8)

a. An analysis of a 5, 000 bed hospital at Tuscaloosa, Alabama, re-
veals that more than half of the male schizophrenic group who have
been in that hospital 20 years or more were first admitted between

the ages of 14 and 29.
. Many young children are so emotionally disturbed that they cannot

be reached by educational programs. (8)

a. A preliminary analysis of reports from Operation Head Start, a
pre-kindergarten program which served 600, 000 children last
summer, indicates that at least 10% of the children were in deep
emotional trouble so severe that it had already crippled their devel-

opment by the age of 4. (8)

ARE EMOTIONALLY DISTURBED CHILDREN RECEIVING ADEQUATE

CARE? NO!

. According to the Joint Commission on Mental Illness and Health there
is not a single community in this country which provides an acceptable
standard of services for its mentally ill children, running the spectrum
from early therapeutic intervention to social restoration in the home,
the school and the community.

. Although close to 300, 000 children were seen in outpatient psychiatric
clinics in 1963, in most cases the ''treatment" consisted of one or two
diagnostic interviews followed by the admission that there were no
facilities in the particular area for prolon:ed treatment. Because of
staff shortages, especially of psychiatric time, many clinics tell
parents seeking aid for deeply troubled children to come back in

6 months or even a year. (8)
VI, WHAT LEGISLATIVE AND OTHER DEVELOPMENTS ARE MOVING

TOWARD INCREASED TREATMENT OF CHILDREN IN THE HEART OF

THE COMMUNITY ?

 

1, Legislation passed by Congress in 1965 authorizes $120 million over a
4-year period for the training of teachers of the handicapped, with

particular emphasis upon teachers for emotionally disturbed children.

a. 100, 000 of these specialized teachers are needed right now to staff
classes, of not more than 10 children each, for the approximately
1 million children, estimated to need these individual psychological
and educational services. At present, there are less than 3, 000
teachers specially qualified to handle emotionally disturbed
children. (8)
2. This legislation also authorizes $41 million over a 4-year period in

support of research and demonstration projects designed to produce

 
more effective methods of teaching and re-educating the handicapped

and the emotionally disturbed. (8)

. Over the past few years, the National Institute of Mental Health has
joined in the support of a number of pilot projects designed to prevent
institutionalization of children by developing alternative treatment

services in specialized schools or in the community. (8)

. Legislation has also been enacted authorizing federal support for a
non-governmental study of the extent of mental illness among children

directed toward specific proposals to combat it. A Joint Commission

 

on Mental Health of Children, representing more than a score of

 

organizations active in the field, has been formed and is already under

way with a number of task force studies.

. A companion legislative effort, the Elementary and Pre-school Child

 

Development Bill of 1965, introduced last September by Rep. Sam

 

Gibbons of Florida, would provide funds over a 10-year period to
train child development specialists to work with children in the pre-
school years and in the first three grades of elementary school.
Hearings on the bill, which also provides grants to state educational
agencies to employ these child development specialists, have been
completed in the House. A groundswell of support for its imagina-
tive attack upon the current shortage of child mental health

workers is increasing. (8)
vil. HOW MANY PEOPLE ARE HOSPITALIZED FOR MENTAL ILLNESS?

1, Slightly more than one out of every two hospital beds in the United

 

States is occupied by a mental patient. (10)

2. 712,174 or 51% of the 1, 406, 818 patients comprising the average daily

 

hospital census in 1962 in all hospitals were patients in psychiatric

 

hospitals (public and private). (10)

a. The average daily resident patient population in public mental

 

hospitals (state and county hospitals) in 1965 totaled 488, 400. (13)

3. A large percentage of all State mental hospitals are still over-

 

crowded. (32)

4, Admissions to psychiatric hospitals (Federal and non- Federal) totaled

 

511, 262 in 1964, (10)
9. There are more people in hospitals for mental illness than for polio,

cancer, heart disease, tuberculosis and all other diseases combined. (1)

 

HOSPITAL BEDS
FOR

 

CANCER,

HEART,

MENTAL ILLNESSES
TUBERCULOSIS, AND

ALL OTHER DISEASES.

 

 

 

 

VIII. HOW MANY PEOPLE ARE IN ALL TYPES OF PUBLIC MENTAL

HOSPITALS ?

1, Of the hospitalized mentally ill, 98% are in public hospitals (state,

 

county, city, Veterans Administration and other federal hospitals). (10)
Only about 2% of mental patients are cared for in private and

voluntary hospitals. (10)

WHICH MENTAL ILLNESSES AFFECT THE GREATEST NUMBER OF

PEOPLE?

1, About 20% of first admissions to state and county mental hospitals in

 

1963 were patients with schizophrenia. (14)

a. Because of the relative youth of schizophrenic patients on ad-

 

mission to hospitals and their relatively low death raie, those
schizophrenic patients who are not discharged tend to accumulate

from year to year and to make up half of the resident populations

 

of these hospitals (14)

2, About 20% of first admissions to state and county mental hospitals in

 

1963 were patients with cerebral arteriosclerosis, other circulatory

 

disturbances, and senile brain disease. (14)

 

a. Patients with cerebral arteriosclerosis, other circulatory dis-
turbances and senile psychosis, because of their high death rate,

made up only about 13% of the resident population of these mental

 

hospitals in 1963. (14)
3. Other causes of first admissions to public non-federal mental hospitals
in 1963 included: (14)

Alcoholism including
alcohol intoxication - about 15. 3% of all new admissions

Personality disorders exclud-
ing alcoholism addiction - about 11.1% of all new admissions
Psychoneurotic reactions - about 10.8% of all new admissions

Psychotic disorders other
than schizophrenia - about 7.1% of all new admissions

Mental deficiency - about 2.8% of all new admissions
4, The remaining 13% include a variety of other disorders no one of

which alone has a very high incidence. (14)

PERCENTAGE OF FIRST ADMISSIONS TO PUBLIC MENTAL

 

HOSPITALS BY CAUSE -- 1963

 

Cerebral Arteriosclerosis, Other Cir-
20% ; culatory Disturbances, and Senile Brain
Disease
15.3% Alcoholism
11.1% Personality disorders, excluding

alcoholism addiction

10.8% Psychoneurotic reactions

 

Psychotic disorders other than
schizophrenia

VA

2.8% Mental Deficiency

13.% Miscellaneous

10,
X. IN WHAT AGE GROUPS DO VARIOUS TYPES OF MENTAL DISORDERS

 

TAKE THEIR GREATEST TOLL?

 

1. Very few cases of psychosis occur before the age of 15. (14)
a. Of all first admissions in 1963 to state and county mental hospitals:
(14)
(a) 2.6% were under 15 years of age
(b) 33.4% were between 15 and 34
(c) 42.9% were between 35 and 64
(d) 21.1% were 65 and older.

2. In the age range 15-44 years, schizophrenia and personality disorders

 

predominate. (14)

3. During the next decade of life (40-50), the involutional psychoses and

 

alcoholic psychoses attain considerable importance. (14)

 

4. In the sixties, psychoses with cerebral arteriosclerosis and senile

 

psychoses assume prominence, and these mental diseases of the

 

senium continue to rise until the end of the life span. (14)

FIRST ADMISSIONS INTO MENTAL INSTITUTIONS 35 - 64

 

IN THE FOLLOWING

 

65 and
OVER

AGE GROUP

15-34

PERCENTAGES - 1963

 

15and

UNDER
a

2.6% 33.4% 42.9% 21.1%

   

11.
XI, WHAT IS THE COST OF CARE AND MAINTENANCE OF THE MENTALLY

XI.

 

ILL IN PUBLIC MENTAL HOSPITALS?

 

Estimated total maintenance expenditures of state and county mental

hospitals in 1965 were $1, 201,979, 234. (13)

WHAT IS THE COST OF MENTAL ILLNESS TO THE VETERANS AD-

 

MINI STRA TION?

Mental illnesses presently cost the Veterans Administration over

$1 billion annually.

1. The estimated operating costs in fiscal 1966 for VA psychiatric hos-

 

pitals was $314, 284, 000. This does not include the costs for care of

 

psychiatric patients in general hospitals. (21)
The estimated average daily patient load in VA psychiatric hospitals
for fiscal 1966 was 52,470. This is 48% of the average daily patient

load in all VA hospitals. (21)

. The net operating cost in fiscal 1963 for VA outpatient mental hygiene

 

clinics was $7, 761,146. (9)

 

. As of June 1965, 601,367 veterans were receiving compensation and

pension payments whose major disability involved a psychiatric or
neurologic condition. The annual value of these awards was

$744,977, 004. (15)

XII, HOW MUCH IS BEING SPENT BY PUBLIC INSTITUTIONS FOR CARE

OF THE MENTALLY RETARDED?

 

1, There were an estimated 188, 332 resident patients in all public

12,
institutions for mentally retarded at the end of 1965. (16) First
admissions totaled 15, 033 and net releases during the same period
(1965) were 9,385. (16)

a, During 1965, maintenance expenditures of public institutions

caring for the mentally retarded totaled $439, 349,514. (16)

XIV. WHAT IS THE ESTIMATED COST OF PUBLIC ASSISTANCE TO MEN-

XV,

13.

 

TALLY ILL AND MENTALLY RETARDED PERSONS?

 

According to the Bureau of Public Assistance of the Social Security
Administration, a 1951 study of aid to the permanently and totally dis-
abled disclosed that 11% of the cases were mentally ill and mentally
retarded persons. Assuming the estimated 1966 case load of 581, 500 is
similar in composition, 63,965 persons with mental illness or mental
retardation receive public assistance from the Federal, state and local

government amounting to $66, 165, 000 per year. (21)

WHAT IS THE LOSS OF EARNINGS OF THOSE PEOPLE ADMITTED TO

 

 

MENTAL HOSPITALS?

 

1, The income loss in 1964 of resident patients in State and county mental
hospitals is estimated to total $1.7 billion. (19).
2. Income losses during the first year for first admissions (1964) total

an estimated $424 million. (19)
XVI. IN SUMMARY, WHAT IS THE OVER-ALL ANNUAL COST OF MENTAL

 

ILLNESS IN THE UNITED STATES TODAY?

It is estimated that mental illness costs annually approximately

a.

Total maintenance expenditures of public
mental hospitals for 1965 (13)

. Proprietary & non-profit voluntary mental

hospitals' expenses (1964) (10)

. Estimated payments for private psychiatric

care (22)

. Estimated annual cost of care of neuro -

psychiatric patients in Veterans Admin-
istration hospitals and out-patient care

for veterans with neuropsychiatric con-
ditions. (9) (21)

. Veterans Administration compensation

& pension payments to veterans with
neuropsychiatric conditions - 1965 (15)

Expenditures of Federal agencies other than
the Veterans Administration for mental
patients 1964 (U.S, Public Health Service
hospitals, Depts. of Defense, Justice
Bureau of Prisons, Interior) (10)

1965 expenditures of public institutions for
mentally retarded (16)

Cost of public assistance to mentally ill
and mentally retarded persons (21)

Estimated income loss of 1964 resident
patients in mental hospitals (19)

Estimated earnings losses in 1964, of
first admissions to mental hospitals in
that one year alone (19)

$1, 201, 979, 234.
107, 829, 000.

100, 000, 000.

$ 322,045,146.

744,977, 004.

36, 178, 000.
439, 349,514.
66, 165, 000.

1, 676, 188, 800.

423, 786, 000.

$5, 018, 497, 698.

14,
XVII. HOW MANY PUBLIC AND PRIVATE HOSPITALS FOR MENTAL DISEASE

ARE THERE IN THE UNITED STATES ?

 

1, About 531 hospitals. The average daily hospital census of mental
patients in all psychiatric hospitals, public and private, in 1964 was

695,087. (10)

 

a. Of these 531 public and private psychiatric hospitals, 326 are state

and local governmental mental hospitals. (10)

 

73 are voluntary psychiatric hospitals

88 are proprietary psychiatric hospitals

44 are Federal government psychiatric hospitals (includes Veterans
Administration and Public Health hospitals)

XVIII. HOW MANY PSYCHIATRIC CLINICS ARE THERE IN THE U.S. ?

15.

 

1. There are 2,000 psychiatric clinics in the U.S. as of the end of

1965. (7)

. Half the clinics are located in the northeastern portion of the

country which contains only 25% of the population. The south and
west have fewer clinic resources than other areas of the nation.
Only 4% of the clinics are located in rural areas where 30% of the

population live. (7)

. At least one clinic for every 50,000 in the population - or about

4,000 full-time clinics - are needed.

. Because of severe mental health personnel shortages, many clinics

operate at a level far below full-time capacity. 2/3 of the clinics in

the country are unable to obtain the services of a full-time
psychiatrist. (7)

3. A total of 950,000 persons were treated in outpatient clinics in 1965.
This is a 42% increase over the 669, 000 treated in 1961, and 89%
over the 502, 000 treated in 1959. (7)

6. Children and young adults form an increasing percentage of the
treatment load of these clinics. Between 1961 and 1963, there were
the following increases in numbers of children and young adults
handled: (7)

5 to 9 years 19% increase
10to14 years 22% increase
15tol7 years 38% increase
18to19 years 38% increase
20to 24 years 47% increase
7. In recent years, emergency walk-in clinics which offer around-

the-clock services to troubled people have been opened in a number

of cities, such as New York, Boston, Los Angeles, Berkeley,

Detroit, etc. (7)

One of the three
neighborhood
centers run by
the Department
of Psychiatry,
Albert Einstein
College of Med-
icine, serving
the psychiatric
and social needs
of the community.

 

16.
XIX. HOW MUCH IS THE UNITED STATES PUBLIC HEALTH SERVICE

17.

SPENDING FOR ESTABLISHMENT OF MENTAL HEALTH CLINICS

 

AND SERVICES THROUGH THE NATIONAL MENTAL HEALTH

 

INSTITUTE?

1, 36, 790, 000 has been allotted in fiscal 1966 in federal matching grants
to the states for the support of psychiatric clinics and related mental
health services.

2. In addition, $50 million has been appropriated in fiscal 1967 for the

third year of a program of grants for the construction of public and

other non-profit community mental health centers.

HOW MUCH IS BEING SPENT FOR RESEARCH ON MENTAL HEALTH

 

BY THE STATES AND BY THE MAJOR FEDERAL AND NATIONAL

 

VOLUNTARY AGENCIES INTERESTED IN MENTAL HEALTH?

 

1. Approximately $141.7 million is spent, as follows:

Federal funds - $113, 770, 000:

 

1) Nat'l Institute of Mental Health, U.S.
Public Health Service, fiscal 1965:

Intra-mural research $12,149, 000

Research grants 85, 230, 000
Research fellowships 8, 364, 000
Collaborative studies 3, 702, 000 $109, 445, 000 (25)

2) Out of fiscal 1965 medical research
appropriations totaling $37 million,
the Veterans Administration spent
for research in mental illness an
estimated. ........... 2... . 4,325,000 (27)
Fiscal 1966 appropriations for medical
research to the VA totaled $40. 8
million, although how much will be
spent specifically for research in
mental illness is not known.

Total Federal Funds

 

Non-federal funds - $27, 994, 188

 

1) National Association for Mental Health -

 

1964 |

2) The Foundations' Fund for Research

in Psychiatry (New Haven, Conn. )
total grant expenditures,
July 1, 1964 - June 30, 1965

 

3) Other estimated annual research
support from private national grant-
ing agencies (18)

4) Estimated annual state expendi-
tures for mental health research

Total Non- Federal Funds

 

Total Funds.

$113, 770, 000.

$ 336,014 (28)

458,174 (29)

3, 200, 000 (18)

24, 000, 000 (30)

27,994,188

. $141, 764, 188.

2. On the basis of 695, 087 (10) patients in psychiatric hospitals in 1964,

this would indicate that the amount spent for research per individual

 

hospital case, employing Federal, State, national voluntary health

agency, and other private funds, is only approximately $204.

 

3. In contrast to the approximate total of $141.7 million currently being

 

spent for research against mental illness:

a. The Nation spent $12.6 billion - OVER 93 TIMES AS MUCH - for

alcoholic beverages alone in 1964 (31), an average of $66 annually

 

for each man, woman and child. We are spending about 70¢

 

18.
XXI,

19.

annually per each man, woman and child in the United States for

research against mental illness.

 

 

b, Mental illness is costing the Nation over $5 billion annually.

Yet our annual research investment to combat this toll is less

 

 

than 3% of this cost.

 

HAS MEDICAL RESEARCH PAID OFF IN THE FIELD OF MENTAL

ILLNESS? YES!

1, The tranquilizing drugs (reserpine, chlorpromazine) and many

of the new drugs, including the psychic energizers have, over the
past 10 years, revolutionized the care of state mental hospital
patients and brought about an unprecedented, sustained annual

reduction in state hospital populations.

 

At the end of 1955, there were 558, 922 resident patients in

state and county public mental hospitals. During that same year

 

there were 178,000 admissions to, and 126,500 net releases from,
these hospitals. (13)
At the end of 1965, even though admissions had soared approx-

imately 136, 000 to a total of 314,443, there were 83,161 less

 

patients in these same hospitals in 1965 as compared to 1955. (13)
(Up until 1955, before the general use of the drugs, the mental
hospital patient populations increased each year. )

This is a remarkable reduction of 15% in the total number of
patients in these hospitals over the short span of 10 years. Even
more remarkable, this downward trend in hospital populations has
accelerated over the past five years, reaching a record

reduction of 15,000 patients in 1965. The total drop of 52, 000
patients since 1961 is more than double the average rate of drop
during the preceding six years (1955-1961).

The key to this spectacular reduction is the 126% increase in

 

number of patients released each year -- from 126,500 in 1955

 

to 287,000 in 1965.

This total reduction in institutionalized patients over the past

 

10 years is roughly equivalent to the combined mental hospital

 

populations of 19 states: Alabama, Arizona, Arkansas, Colorado,

 

Connecticut, Delaware, District of Columbia, Florida, Idaho,

 

REDUCTION IN STATE HOSPITAL POPULATION EQUIVALENT TO THE COMBINED MENTAL
HOSPITAL POPULATION OF 19 STATES

 

20,
21.

Kansas, Kentucky, Maine, Mississippi, Missouri, North and South

Dakota, Minnesota, Vermont, and Washington,

. This dramatic reduction in hospitalized patients has resulted in

enormous Savings to the states. In the decade following the close of

 

World War II, the over-all rise in number of patients in our state
mental hospitals averaged 13, 000 a year. If this trend had continued
during the past 10 years, the states would have been forced to
construct 130,000 additional beds. Instead of an increase, this

reduction of 83,000 patients resulted in an aggregate saving of

approximately 213,000 beds over the 10-year period. (32)

 

Figured at the estimated cost of $20, 000 a bed, this is a saving

of $4.3 billion in construction costs alone! (32)

 

. This steady reduction in state mental hospital populations has been

achieved in spite of the fact that each year since 1955 has witnessed

a record increase in admissions to these hospitals. The following

 

are the admission figures for the past 10 years: (13)

1955 - 178, 003 1959 - 222,791 1963 - 283,591
1956 - 185,597 1960 - 234, 791 1964 - 302,946
1957 - 194,497 1961 - 252, 742 1965 - 314,443
1958 - 209, 823 1962 - 269,854

. Of particular importance is the fact that an increasing number of

states are sharing in these significant population reductions.
In 1965, 40 states reported decreases, as against only 30 during

1959, (13)
PERCENTAGE DECLINE IN NUMBER OF PATIENTS RESIDING

 

IN PUBLIC MENTAL HOSPITALS AT END OF YEAR

 

EXCLUSIVE OF VETERANS ADMINISTRATION:

 

Number of Resident Patients

 

 

Decline Percent
State 1955 1965 1955-65 Decline
lowa 5, 374 2,222 3,152 58.6%
Utah 1, 337 592 745 55.7%
Washington 7, 361 3,851 3,510 47.6%
Colorado 5, 786 3,138 2,648 45.8%
Arkansas 5, 086 2,779 2,307 45.4%
Minnesota 11, 449 6, 592 4,857 42.4%
Oregon 4, 886 2, 845 2, 041 41.7%
Kansas 4,420 2, 622 1, 798 40.7%
Idaho 1, 221 740 481 39.4%
Kentucky 7, 700 4, 887 2, 813 36.5%
Oklahoma 8, 014 5, 454 2, 560 31.9%
Nebraska 4, 826 3,398 1,428 29.5%
Massachusetts 23, 302 17, 253 6, 049 25.9%
North Dakota 1,993 1,479 514 25.8%
Ohio 28, 662 21,830 6,832 23.4%
North Carolina 12,125 9,335 2, 790 23.0%
Louisiana 8,271 6,448 1, 823 22.0%
Illinois 38, 883 30, 818 8, 065 20.7%
Montana 1,919 1,518 401 20.4%
California 37, 277 30,349 6,928 18.6%
New Hampshire 2, 733 2, 239 494 18.1%
District of Columbia 7, 318 6,131 1,187 16.2%
Missouri 12, 021 10,316 1,705 14, 2%
Michigan 21,798 18,711 3,087 14, 2%
New Jersey 22, 262 19, 428 2, 834 12.7%
Pennsylvania 40, 920 35, 958 4, 962 12.1%
Wisconsin 15, 008 13, 315 1, 693 11.2%
Maryland 9, 273 8, 346 927 10.0%
West Virginia 5, 619 5, 060 559 9.9%
Rhode Island 3,442 3,114 328 9.5%
New York 96, 729 87,661 9,068 9.4%
Connecticut 8, 668 7,908 760 8.7%
Maine 2,996 2, 768 228 7.6%
Vermont 1, 294 1, 207 87 6.7%
New Mexico 950 890 60 6.3%
Indiana 11,342 11,048 294 2.6%
Delaware 1, 694 1, 667 27 1.6%
Texas (1959) 15, 857 15, 652 205 1.3%
Wyoming 655 648 7 1.1%
Arizona 1, 690 1, 684 6 less than 1%

PERCENTAGE INCREASE IN NUMBER OF PATIENTS RESIDING IN
PUBLIC MENTAL HOSPITALS AT END OF YEAR,

EXCLUSIVE OF VETERANS ADMINISTRATION:

Number of Resident Patients

 

Increase —- Percent
State 1955 1965 1955-65 Increase
Florida 8, 026 9,992 1,966 24.5%
Nevada 440 523 83 18.9%
Alabama 7,197 7,691 494 6.9%
South Carolina 6, 042 6, 406 364 6.0%
South Dakota 1, 603 1, 648 45 2.8%
Virginia 11, 303 11, 544 241 2.1%
Mississippi 5, 295 5, 367 72 1.3%
Georgia 11, 710 11, 823 113 1.0%
Tennessee 7, 730 7, 767 37 less than 1%

Sources:

1955 Patients in Mental Institutions, Part II]. Tables 1 & 2.

Provisional Patient Movement and Administrative Data, State and County
Mental Hospitals United States 1965, Mental Health Statistics. Current
Reports, January 1965. National Institute of Mental Health, Bethesda,
Maryland,

9. In some of the states where more intensive application of the drugs

 

has occurred, patient population reductions have far exceeded the

 

national average.
6. A recent study reported in the Archives of General Psychiatry on
the use of powerful tranquilizers to help acute schizophrenia
patients quickly states the following: (32)

a. The patients in the study were young schizophrenics averaging
28 years of age, usually suffering either their first psychotic
breakdown or their first hospitalization. All were judged
markedly ill.

b. In six weeks 95% of the patients on the drugs improved. The
improvement in 75% of the cases was classified "marked to

moderate improvement."

XXII, WHAT HAS CAUSED THIS REDUCTION IN THE NUMBER OF RESIDENT

 

PATIENTS IN OUR STATE MENTAL HOSPITALS?

1. Extensive statistical documentation shows that increased state

 

tranquilizing drugs, and anti-depressant drugs, and more medical

 

personnel to provide treatment, have now begun to pay off in

 

dramatic fashion, and have finally achieved the cumulative force
needed to reverse the seemingly inevitable annual rise in mental
hospital populations:

a. In 1945, the average daily expenditure on each resident mental

patient was $1.06, ten years later (1955) it had risen slowly to

24,
25.

 

$3.06 per day. In 1965, this had risen to $6.74, more than
six times the 1945 figure and a considerable increase even when
the rising cost of living is taken into account, (13) although by

any hospital standard a per diem expenditure of $6.74 is grossly

 

inadequate.

. In 1945, there was one full-time employee for every 6.8 patients

in mental hospitals - an impossibly low treatment personnel-to-
patient ratio. A decade later, considerable improvement was
achieved when the ratio rose to approximately one employee for
for every four patients (146, 392 full-time employees for 558, 922

patients). (7)

PATIENTS
1945 1955 1965

© ° Oo oO 0 ' € 060
7 EMPLOYEES

By 1965, a ratio of almost one full-time employee for every

o 60 ©

      

2 patients was achieved (230, 564 full-time employees for
475,761 patients). The biggest yearly jump occurred in 1965,
when 31, 000 employees were added to the staffs of state
mental hospitals. Much of this significant increase in 1965
reflects the impact of the Nat'l Institute of Mental Health's

Hospital Improvement Grant program - over the past 3 years,
$36 million has been awarded to mental institutions to improve
their treatment potential; 80% of the funds awarded in this
exciting program are being used to employ additional and new
kinds of psychiatric personnel. (7)

. However, the personnel shortage in state mental hospitals is
still critical. For example, 25% of budgeted positions for staff
psychiatrists remain unfilled. Many of the filled positions are
held by foreign doctors - in a number of states, as high as 50%
of the total physician complement is made up of foreign-born
doctors.

According to a recent survey published by the Nat'l Institute of

Mental Health, 21 state hospitals are without a single psychia-

 

trist, and 91 state hospitals have only one to four psychiatrists. (8)
. In spite of the tremendous shortages which still exist, there

have been the following increases in psychiatric personnel during

 

the past decade, largely the result of increased salaries and a
great expansion of budgeted positions. They are probably the most
significant evidence of how many state legislatures have given
to the state mental hospitals the increased treatment potential

needed to step up discharge rates: (12) (14)

Superintendents & Physicians (including psychiatrists,
residents and interns)

 

1945 - 1,458 1963 - 5,214

Psychologists & psychometrists

 

1945 - 69 1963 - 1,161

26,
27.

Social Workers

 

1945 - 410 1963 - 2,659

Graduate Nurses

 

1945 - 2,583 1963 - 10,644

Other Nurses & Attendants

 

1945 - 33,147 1963 - 103,109

. All of the foregoing factors led to a steady rise in discharge rates--

a rise so gradual that it was frequently obscured by the increasing
flood of admissions. In 1945, the net release rate per 1,000 average
resident patients was only 153; in 1965, it had almost quadrupled to
a level of 592 patients discharged for every thousand still resident

in the hospital. (12) (13)

HOSPITALS

912 NET RELEASES FOR
EVERY 1000 ADMISSIONS

An even more Significant barometer of progress is the ratio of

 

 

 

 

net releases to the total number of hospital admissions. In 1965,

this soared to the record level of 912 net releases for every one

thousand admissions. (12) (13)
XXIII. WHAT NEW LEGISLATIVE DEVELOPMENTS HOLD OUT PROMISE

 

FOR A FURTHER REDUCTION IN OUR STATE MENTAL HOSPITAL

 

POPULATIONS?

1. In October, 1963, the Congress passed the landmark Community
Mental Health and Mental Retardation Centers bill (P.L. 88-164.)
This bill provides $150 million through 1967 in federal matching
money to the states for the construction, expansion or remodeling
of community centers for the mentally ill. (20)

In order to qualify for this matching federal aid, each state is
required to submit a construction plan describing its comprehen-
Sive blueprint for the location and priority assignment of all
mental health centers in the state. Despite the extraordinary diffi-
culty of this task, and the fact that Congress did not vote the first
monies for the centers until the fall of 1964, the states responded
so enthusiastically that as of July 15, 1966, federal matching grants
totalling close to $60 million were awarded for the construction
and/or staffing of 128 new community mental health centers in
42 states, Puerto Rico and the District of Columbia.

As a result of this first year funding, mental health services will
soon be available to approximately 22 million Americans in their
home communities. Assuming that states and communities apply
with the same enthusiasm for the matching funds that will be avail-
able during the remaining period of the present authorization, the
National Institute of Mental Health estimates that over a third of the

nation’s 200 million people will have access to community mental

28.
29,

health center services by 1970.

. In order to strengthen the state and local capability in supporting

these centers, the Congress last year amended the basic 1963 act by
providing a seven-year authorization of approximately $224 million

in federal matching monies in support of the personnel and other

 

operating costs of the centers, The federal staffing grant for any

 

one center may not exceed 51 months, and it drops from 75 percent
of total operating costs during the first 15 months to 30 percent

during the last year. (23)

. Because of the enthusiastic acceptance of the new program, com-

bined with a widespread feeling among public officials that the

unprecedented citizen demand for these centers would soon exceed
available monies, the 1965 National Governors' Conference unani-
mously passed a resolution requesting the Council of State Govern-
ments to convene a conference ''for a thorough consideration of the

future role of each level of government in multiple-source financing

 

of community mental health programs."

At the three-day conference, held in Chicago in December, 1965
and co-chaired by Governor Otto Kerner of Illinois and Senator
A.M, Spradling of Missouri, scores of state legislators and county
commissioners hammered home the point that the federal contribu-
tion to community mental health services, even with the inclusion
of the 1963 and 1965 legislation, fell far below that made by most
states and many local communities. Arguing for a renewal and

broad expansion of the Community Mental Health Centers Act of
1963, the major resolution of the conference -- unanimously
adopted by the delegates -- stated:

"Of the total annual public mental health expenditures of

$2 billion in this country, only $115 million, less than four
percent, is available for ongoing local community mental
health services, The share of the Federal Government in
this funding is less than ten percent... It is therefore
imperative that the Federal Government, which receives
the largest share of the tax dollar from our people, pro-
vide critically needed additional seed money for these
programs,

"It is the consensus of the conference that the national
goal of 2,000 new community mental health centers to

be established by 1975, as envisioned by the landmark
1963 and 1965 Federal legislation, will not be realized

without expanded Federal, State and local support."'

XXIV, CAN THE AMERICAN PEOPLE AFFORD ADDITIONAL EXPENDI-

 

TURES FOR MENTAL HEALTH SERVICES?

 

1, Proponents of additional appropriations for mental health services
are frequently told that state taxes have reached a confiscatory

level, and that the individual citizen is "groaning under a tax

30.
31.

burden which he is increasingly unable to handle."

What are the facts? How much of our personal income do we
spend on state taxes?

In 1963 we spent, measured in constant dollars, 4% of our
personal incomes for state taxes as against 3.7% in 1948. In
other words, in a period of 15 years there was a rise of only

three tenths of one percent in the portion of our individual incomes

which went to state government in the form of taxes. (50)

In 1964, total general state expenditures -- including federal
grants and other sources of revenue -- averaged out to $195.47
per person, as compared to $115.37 in 1956. But per capita
personal income increased at a record rate in that same span

of time -- from $1, 767 in 1956 to $2, 550 in 1964. (50)

. How about state mental hospital operating expenditures as a

percentage of total general state expenditures?

Only 2.7% of general state funds went to mental hospitals in
1964, a significant drop from three and a third percent which
was budgeted for these facilities in 1956. (50)

Is this a fair proportion of state expenditures? By way of

contrast, state governments in 1963 devoted 28% of their funds

 

to highways. (50)

In that year, as a nation, we spent $10 billion for highways. (50)

 

Furthermore, the Department of Commerce recently estimated

that the accelerated national highway program inaugurated in 1957
would, upon completion in 1972, cost the American people $55

billion.

100% - Total General State
Expenditures

 
  
    
 
   
 

 

1963 State Mental Hospital

Operating Expenditures As a
Percentage Of Total General
State Operating Expenditures

 

 

 

28% - For Highways

Less Than
2.7% - For operation of state
mental hospitals

 

When we consider the needs created by the explosive rise in
our population, -- a record growth of 50 million people in the last
16 years, -- added to an unprecedented, sustained rise in individual
income, we cannot but conclude that the so-called heavy burden of
increased taxes for public services is an undocumented myth.
3. What about federal, state and local expenditures for community

mental health services?

32.
In 1955 -- before the big push for community services -- the

per capita expenditure for clinics and other community facilities

 

was only nine cents per year. In 1964, it had increased appreciably

to 59 cents per person per year -- hardly an excessive drain on

 

the solvency of the individual taxpayer. Furthermore, in 1965,
less than four percent of the $2 billion spent by all levels of
government for mental health expenditures was budgeted for

community mental health services. (50)

XXV, WHAT ARE WE SPENDING OUR MONEY ON THESE DAYS?

33.

 

In 1964, we spent for:

Recreation - $22.7 billion (11)

Alcoholic Beverages - $12.6 billion (31)

 

Tobacco Products - $7 billion (31)

Foreign travel and remittances - $3.5 billion (11)

 

We also managed in that same affluent year to spend $359 million
for chewing gum! (31) This compares with a total of approximately

$141.7 million spent by all sources -- federal, state and local

 

governments, voluntary health organizations and private founda-
tions -- for psychiatric research to get Americans out of state

mental hospitals which are mostly "human warehouses". (51)

 
XXVI. WHAT ROLE WILL THE PSYCHIATRIC UNIT IN THE GENERAL

 

HOSPITAL PLAY IN THE EXPANSION OF EARLY, INTENSIVE

 

TREATMENT SERVICES DURING THE YEARS AHEAD?

 

1. Over the past few years, the general hospital has assumed a tre-

mendously increased role in the care of mental patients. A

 

 

1964 AVERAGE DAILY
COST* PER RESIDENT
PATIENT IN PUBLIC
MENTAL INSTITUTIONS,
VETERANS, PROPRI-
ETARY PSYCHIATRIC
AND SHORT-TERM
GENERAL OR SPECIAL

HOSPITALS.

 

NON - FEDERAL
GENERAL &
SPECIAL
SHORT-TERM
HOSPITALS

$41.58 *

 

 

PRIVATE
PSYCHIATRIC
HOSPITALS

$21.99 *

 

 

VETERANS
PSYCHIATRIC
HOSPITALS

$15.47 *

 

 

 

* Cost to hospital of patient maintenance

 

 

STATE
MENTAL
INSTITUTIONS
1965

$6.74 *

 

 
35,

recently completed nationwide survey reveals that general hospitals
treated and discharged almost 600, 000 psychiatric patients in the
12-month reporting period ending in April, 1965. This represents
a 40 percent increase in psychiatric services rendered by general
hospitals during the past decade. The survey also highlights the
fact that the public mental hospital is no longer the major locus

for in-patient treatment of mental illness -- in 1965, general

hospitals discharged more than twice as many mental patients

 

as did state and county mental hospitals. (26)

 

. There are 3,183 general hospitals that now admit psychiatric

patients. Of this total, 1,046 either have separate psychiatric
units or regularly and routinely treat psychiatric patients on the
general wards of the hospital. The other 2,137 hospitals admit
mentally ill patients on an emergency basis for diagnosis,
treatment or for retention pending admission to other facilities.

(26)

. The 467 general hospitals which maintain separate psychiatric

units are by far the most active in terms of patients treated. In
the 1964-65 reporting year, they accounted for 54 percent of all
discharges from general hospitals (321,144) and for 81 percent

of all psychotic discharges (72,079). (26)

. Under the impetus of the 1963 and 1965 Community Mental Health

Center legislation, the general hospital of the future will become

an even more important community resource. More than 50 per-
cent of the new community mental health centers being con-
structed with federal aid have a general hospital psychiatric

unit as the key facility.

5. The average length of stay of a patient in the psychiatric unit
of a general hospital varies from 23 to 33 days in such represent-
ative cities as Sacramento, Louisville, Hartford, Ann Arbor,
Philadelphia, Chicago, New York, Dallas and Washington,
D.C. (24)

In Illinois, the average stay in psychiatric units in general

hospitals is 16 days, Although the per diem cost of some of
these units has run as high as $35 per patient, the total cost

per patient has been approximately 50% of the total cost per

 

patient treated in the state mental hospitals in Illinois. (24)

 

6. A number of states and cities are subsidizing psychiatric beds

 

in general hospitals for patients unable to afford them. Since

 

1960, Georgia has supported psychiatric units in general hos-
pitals in its major cities. Although the daily cost to the state
has been high -- $30 to $35 - the approximate cost per patient

treated has been only about $1,000, considerably less than the

 

cost of long-term treatment in the 12,000 bed state hospital

 

at Milledgeville. (32)
More than half of the states which have passed Community
Mental Health Services laws over the past decade, providing state

and local matching monies for these services, use a percentage

36.
of the funds for the support of psychiatric beds in general
hospitals. (32)

7. Part-time hospitalization through the use of either day or night
hospitals has increased remarkably over the past decade.
175 day-night hospital programs in operation in all parts of

the land. (26)

XXVII. WHAT ARE WE DOING TO INCREASE THE PSYCHIATRIC SKILLS

37,

 

OF THE GENERAL PRACTITIONER AND THE NON-PSYCHIATRIC

 

SPECIALIST?

1. In 1958, Congress allocated the first monies for a national program

devoted to training the general practitioner in psychiatric skills.

 

The program was divided into two parts: (34)

a. Provision of stipends at a level sufficient to permit non-psychia-
tric physicians to give up their practice and undertake three
years of residency training withthe objective of becoming full-
time psychiatrists.

In fiscal 1959, the first year of the program, 94 non-psychia-

tric physicians were enrolled in this program. In the current

 

 

 

year, 676 physicians are in residency training programs leading
to certification as psychiatrists.

Since the inception of the program, 800 fully qualified psychia-
trists have been added to the manpower pool. They are serving

in many facilities which have been critically short of psychiatrists
for years; for example, a significant percentage are directing
mental health clinics which now, for the first time, have acquired
psychiatric leadership for their programs. However, this number

is still inadequate for the needs.

b. Grants to institutions qualified to offer postgraduate courses
designed to enable the general practitioner, internist, pediatri-
cian or other non-psychiatric specialist to function more effec-
tively in a therapeutic, referral or preventive role in dealing
with problems of mental illness.

Since the inauguration of this program, close to 10, 000 physi-

cians have been reached in formal courses, and many additional

 

thousands have attended refresher courses sponsored by local
and state medical societies and by university medical centers.
Physicians taking these postgraduate courses receive no stipend
whatsoever for the period of training -~ the individual grants
cover only the faculty costs of the training institutions, Physi-
cians enrolled in these programs range in age from 23 years to

93 years, with a median age of 46.

2. In fiscal year 1961, a third type of training was offered under this
program. Intensive, full-time psychiatric training for periods of
not less than six months nor more than one year was offered to

non-psychiatric physicians, residents and interns who intend to

38.
39,

practice, or continue practicing, in a field other than psychiatry.
In the first five years of this program, 242 special residency sti-

pends were awarded for training at 55 different institutions. (34)

. In the eight years since the activation of the General Practioner

Training Program, (fiscal 1959 through 1966) the Congress has
appropriated $51 million for the three basic training programs.
For the fiscal year beginning July 1, 1966, President Johnson has
recommended $11 million for a continuation of this highly success-

ful effort. (34)

. In addition to the federal program, many of the country's leading

medical organizations are intensifying their activities in training

the general practitioner in psychiatric skills.

Since 1957, the American Psychiatric Association has had a full-
time psychiatrist heading its General Practitioner Education
Project. The APA, in conjunction with the Western Interstate Com-
mission on Higher Education, The Southern Regional Education
Board and a number of national medical organizations, has spon-
sored a series of regional seminars for general practitioners,

In addition, the director of its GP project travels across the
country each year speaking to many state and local medical asso-
ciations and academies of general practice. The APA also publishes
a newsletter covering developments in this field. (37)

The American Academy of General Practice gives official credit
to those of its members who take approved postgraduate courses in

psychiatry. (37)
As a result of all of these efforts, more postgraduate courses
are now offered in psychiatry than in any other medical specialty.
The August 11, 1965 issue of ''The Journal of the American Medical
Association" noted that 253 formal postgraduate courses in psychia-

try were conducted in 1965, as against 114 only three years ago.

XXVIII, WHAT ARE THE STATES AND LOCALITIES SPENDING ON COMMUN-

 

ITY MENTAL HEALTH SERVICES?

 

1. In 1965, state and local governments spent approximately $115

million for community mental health services. (4)

This compares with $6 million spent by state and local govern-

ments for these services in 1952, and $37 million in 1959.

 

2. As of December, 1965 twenty-six states had enacted legislation
which provides matching money on a formula basis to local govern-
ments for the provision of community mental health services. (4)

These twenty-six states are:

California (1957) Michigan (1963) Oregon (1961)
Colorado (1963 Minnesota (1957) Rhode Island (1962)
Connecticut (1955) Nevada (1965) South Carolina (1961)
Idaho (1965) New Hampshire (1965) Texas (1965)

Illinois (1961) New Jersey (1957) Utah (1961)

Indiana (1955) New York (1954) Vermont (1957)

Kentucky (1964) North Carolina (1963) Wisconsin (1959)
Louisiana (1964) North Dakota (1965) Wyoming (1961)
Maine (1959)

Maryland (1966)

40.
41,

3. The typical state matching provision is 50 percent of eligible expen-

ditures, but several states have moved up to 75 percent matching for
augmented services or for areas with low incomes. Only seven
states have per capita limitations (50 cents per capita is typical) on
state expenditures. (4)

Typical eligible expenditures include operating costs for out-
patient, consultation, prevention, information and education and
rehabilitation services, with at least ten states also sharing in the
support of in-patient services in general hospitals. (4)

Heretofore, the Acts have usually specifically excluded capital
outlay as an eligible expenditure. However, following the passage
of the federal Community Mental Health Centers Act in 1963, several
states have begun to reconsider this item. For example, New York
has already amended its program by authorizing State participation
of one-third the total cost of community mental health facility

construction. (4)

. Even before the enactment of the federal legislation, a number of

states had pioneered in the opening of comprehensive centers

designed to provide early, intensive treatment on a flexible basis.

a. AS a result of the passage of a bond issue in 1961, TWinois will
eventually have six small regional centers covering designated
mental health zones in various parts of the state. All of the

centers will have inpatient facilities in addition to a host of

additional community services.
b. In 1962, Colorado opened a 125-bed comprehensive mental health
center near Denver. During the past two years, it has added
separate geriatric and children's units. The Fort Logan Center
provides day and night hospitalization, outpatient services, a
half-way house and psychiatric home-treatment teams which
work out of regional clinics set up in the city of Denver. (6)

Although it takes patients from a population area of close to
a million people, it hospitalizes only a small proportion of those
it screens. For example, as of July 31, 1963, there were 399
patients in its Psychiatric Division, distributed as follows: (6)
24-hour. ..... 69 Halfway House...... 6
Day Hospital . . 173 Follow-up ........ 93
Night Hospital. . 20 Family Care....... 38
The scale of fees at the Fort Logan Mental Health Center indi-

cates how considerable the savings can be through a reduction in

 

The State Hospital at Pueblo, The Fort Logan Mental Health
Colorado. Center near Denver.

42,
expensive, 24-hours hospitalization. For example, the average
cost per day for inpatient care is about $20. For day patient care,

it is only $8, and for outpatient follow-up care it is $8 per week. (6)

c. The Massachusetts Mental Health Center in Boston, the oldest
community mental health center in the country, has approximately
150 beds. With a full-time staff of 14 psychiatrists, plus 59 psychia-
tric residents and a number of Harvard medical students on rotation,
it handles 4, 000 patients a year. It operates a 24-hour hospital, day
and night hospitals, and an emergency walk-in clinic which alone
handled more than 2, 000 patients in 1963. (32)

d. The Boston State Hospital operates a home-treatment service for
the Dorchester area, which has 180,000 residents. Working out of

the state hospital, the psychiatric team collaborates closely with

 

family physicians in visiting homes and preventing hospitalization.

 

The Boston State Hospital also runs five day-hospitals and a half-

way house for patients about to be discharged to the community. (32)

XXIX, WHAT PERCENTAGE OF THE STATES' MENTAL HEALTH BUDGETS

43.

 

IS BEING DEVOTED TO RESEARCH IN MENTAL ILLNESS?

 

While the States were spending in 1965 over $1 billion 201 million in

 

total maintenance expenditures for patients in public non-federal

 

mental hospitals (13), they were spending only about 1.9% of this

 

amount for research in mental illness.
XXX, HOW MUCH DOES THE COUNCIL OF STATE GOVERNMENTS REC-

 

OMMEND THE STATES SHOULD SPEND FOR RESEARCH & TRAIN-

 

a

1,

It was the general consensus of the National Governors' Conference
on Mental Health held in Detroit, Michigan, in February 1954, that

10% of each state's mental health budget should be allocated for

 

research and training.

. The average percentage of the States' total mental health budget

which the state mental health officials feel should be devoted to

research is 4% - some even suggest 7%. (40)

 

XXXI. DO THE PATIENTS IN STATE MENTAL HOSPITALS RECEIVE

 

ADEQUATE CARE?

mental hospitals in the United States per resident patient was only
$2,461. 05 per year (13), or $6.74 per day. In the same year,
Alaska was high with $23.02 per day. Mississippi was low with

only about $3.18 per day. (13)

. In contrast, the average expense per patient day in Veterans

Administration psychiatric hospitals was $15.47 in 1964, and
the total expenses per patient day in proprietary mental

hospitals was $21.99 in the same year. (10)

. In 1964, the expenses per patient day in non-federal short-term

general and other special hospitals in the United States, where

44,
research and surgery have brought new treatments and cure for
patients, were $41.58. (10) This contrasts with $6.74 per day
per capita maintenance expenditure in public mental hospitals
in 1965. (13)

(a) The average length of stay in short-term general and special

hospitals in 1964 was 7.6 days (10)

AXXII, WHAT ARE THE STANDARDS FOR CARE OF MENTAL PATIENTS?

45.

 

1. The latest approved American Psychiatric Association minimum

standards for care are: (41)

a.

For clinical psychologists: admission and intensive treatment

 

service, 1 clinical psychologist to each 100 patients; continued
treatment service, 1 - 500 patients.

For physicians: admission and intensive treatment service,

1 physician to each 30 patients; continued treatment service,

1 - 150 patients; geriatric service, 1 - 150 patients.

. For registered nurses: admission and intensive treatment serv-

ice, 1 registered nurse to each 5 patients; continued treatment

service, 1 - 40 patients; geriatric service, 1 - 20 patients.

. For attendants: admission and intensive treatment service,

1 attendant to each 4 patients; continued treatment service,
1 - 6 patients; geriatric service, 1 - 4 patients. ("Attendants"
means practical nurses, barbers, beauticians, domestics,

orderlies, janitors and mess attendants. )
XXXII, WHAT ARE THE ACTUAL CONDITIONS OF CARE IN MENTAL

 

HOSPITALS COMPARED WITH APPROVED STANDARDS?

 

1. The actual average ratio in state mental hospitals in 1964 was one

physician for each 103 patients; one professional staff member

 

(includes physicians, psychologists, psychometrists, psychiatric
and other social workers, registered nurses, occupational and

other therapists) for each 20 patients; and one full-time employee

 

(includes attendants, maintenance employees, kitchen employees
as well as medical record librarians, teachers, business office

employees, dentists) for each 3 patients. (50)

XXXIV. HOW MANY DOCTORS AND OTHER MEDICAL PERSONNEL SPE-

 

CIALIZE IN THE CARE OF MENTAL PATIENTS?

1. In 1965 there were approximately 14, 200 psychiatrists in the
United States who were members of the American Psychiatric
Association. Of these, about 600 (4%) are administrators, super-
intendents or commissioners (some of these undoubtedly practice
part time). (44)

2. In 1965, there were 8,468 diplomates of the American Board of

Psychiatry and Neurology. Of these: (45)

6, 802 were certified in psychiatry only

674 were certified in neurology only

992 were certified in psychiatry and neurology both
8, 468

3. There were approximately 10, 644 graduate nurses employed full-

 

46.
time in public mental hospitals in the United States in 1963 (14);

 

103, 109 other nurses and attendants (14). An estimated 7, 500 social
workers were employed in mental health hospitals, clinics and
institutions in 1963 (46); however, only 2,048 were employed full-

time in public mental hospitals (14)

. There were 1,734 members of the American Psychological Asso-

ciation who are diplomates of the American Board of Examiners in
Professional Psychology in 1965, This is the highest rating obtain-
able in psychology, and the number includes persons who have
specialized in clinical, counseling, or industrial psychology. The
1965 membership of the American Psychological Association is

23,561; anticipated 1966 membership, roughly 24,500. (47)

XXXV. WHAT ARE THE SHORTAGES IN PSYCHIATRIC PERSONNEL?

47.

 

1. It is conservatively estimated that we need an additional 10, 000

 

psychiatrists to fill present and projected positions in state mental

hospitals, general hospitals, clinics and community mental health
centers, (17)

a. About one in every four budgeted positions for staff psychiatrists

 

is unfilled in Veterans Administration hospitals and in state

 

hospitals for the mentally ill and the mentally retarded. (33)

 

b, According to a recent survey published by the National Institute

 

of Mental Health, 21 state hospitals are without a single

 
21 STATE HOSPITALS WITHOUT A SINGLE PSYCHIATRIST

[i

 

 

 

 

 

 

 

  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

e
|
"
@ aa 4
e a
see 8
O

 

 

 

 

 

 

 

 

 

 

psychiatrist, and 91 state hospitals have only one to four

 

psychiatrists. (35)

c. Many of the filled positions are held by foreign born physicians.
Nationally, approximately 40 percent of the psychiatrists and
psychiatric residents working in state hospitals come from
other countries and, in a number of states, more than half of
the total psychiatric complement is made up of foreign born
physicians. (35)

2, The shortage of clinical psychologists is equally grave. The most
recent figures provided by the American Psychological Association
Placement Office show that, in 1963, there were seven positions
offered for every three applicants. (36)

3. One out of every four budgeted positions for professional registered

48.
nurses in state mental hospitals and institutions for the mentally

retarded was unfilled as of September 30, 1963. (38)

4. The ratio of mental health professionals to patients in state mental

hospitals in 1964 falls far below the minimum personnel standards

recommended by the American Psychiatric Association, as illus-

trated in the following table: (39)

 

American Psychiatric Association

 

 

 

 

 

 

 

 

 

 

Bate Recommended Minimum Standards
Average Admission &
Daily Pts. Intensive Continued
Resident under Treatment | Treatment | Geriatric
No. Pts. Treatment Service Service Service
4096 All physicians
including
psychiatrists 110:1 180:1 30:1 150:1 150:1
1086 Psychologists
and
Psychometrists 416:1 678:1 100:1 500:1 (None)
(The APA Standards relate only to
clinical psychologists)
10,089 Registered
Nurses 45:1 73:1 5:1 40:1 20:1
1787 Psychiatric
social
workers 253:1 412:1 APA standards state: ''One to 80

new admissions per year. One to
60 patients on convalescent
status or on family care. One
Supervisor to every 5 case

workers,"

XXXVI, ARE WE MAKING ANY HEADWAY IN REDUCING SHORTAGES OF

 

PSYCHIATRIC PERSONNEL? YES!

 

1. In 1965, the number of psychiatrists, psychologists, social workers

49,
and psychiatric nurses working in the field of mental health totaled

about 65, 000 as compared to 23, 000 only fifteen years ago. (36)

 

The National Institute of Mental Health has played the major role

 

in this dramatic expansion of psychiatric personnel. From 1948 to

 

1965, the annual number of NIMH training stipends rose from 219
to over 9,000. In this span of time, the Institute provided training
for approximately 30, 000 individuals in the four core disciplines

in the mental health field. (36)

In 1963, approximately 11% of all medical specialty residencies
were .the field of psychiatry, as against only 6% in 1950. Further-
more, psychiatrists in 1963 comprised 7% of all medical specialists,

as against 3% of all medical specialists in 1953. (42)

. Despite these remarkable increases, the burgeoning demand for

mental health services has required personnel in the mental
health field to divide their working hours among a number of
facilities. For example, a 1963 Survey covering outpatient clinics,
public and private hospitals for the mentally ill and public and
private institutions for the retarded noted that 30% of the psychi-
atrists and 16% of the psychologists were providing services in
more than one institution. Even more striking were the number of
professionals in outpatient clinics who had multiple employment —
46% of the psychiatrists, 23% of the psychologists, 22% of the

nurses and 13% of the social workers. (43)

50,
 

5. It is estimated we will need between 120, 000 and 125, 000 profes-

 

sionals in the four core disciplines by 1975 to overcome existing

 

shortages and to meet anticipated demands generated by the new
community mental health centers, the Medicare legislation, ex-
panded psychiatric benefits for workers achieved through the bar-

gaining process, the rapid growth of psychiatric units in general

hospitals, etc. (36)

An adolescent patient is
interviewed at the
Philadelphia Psychiatric
Center.

XXXVI, ARE WE MAKING PROGRESS TOWARD FULLER HEALTH INSUR-

51.

 

ANCE COVERAGE OF MENTAL ILLNESS?

 

1. Under increasing pressure from subscribers, from public officials

at the federal and state level, and from labor's increasing mili-
tancy at the bargaining table, the commercial insurance companies

and Blue Cross- Blue Shield are slowly increasing their coverage

 

of mental illness.
However, a comprehensive 1965 Blue Cross Association study of
the economic aspects of mental illness, while noting appreciable

improvement in coverage of psychiatric illness by its member
plans, is frank to admit that insurance benefits for mental illness

are Still far more limited than for physical illness. Quoting from

 

the Blue Cross report:

"Restrictions on these benefits are common and among
those covered for mental illness the proportion with full
coverage (the same benefits as any other illness) was
somewhb~+ less than one-third of those covered."

 

. The commercial and non-profit insurance companies, while more
willing to cover full, 24-hour hospitalization of mental patients,

are quite resistant to efforts to get them to cover partial

hospitalization and out-patient treatment in community facilities
and in the doctors' office. (6)

The 24-hour bed is no longer a venerated receptacle for the mental
patient. In fact, there is an increasing recognition that continuous
hospitalization is frequently an anti-treatment device, making it
all the more difficult for the mental patient to resume his duties
in society. (6)

Day hospital coverage is much more economical for the insurance
companies. For example, in January of 1964, Colorado Blue Cross
began covering 30 days of day hospital care at the Colorado General
Hospital, Figures on the first year of coverage show an average
treatment period of 12 days, at a cost of $18 per day. This day
care cost compares with $34 per day for 24-hour hospital
treatment at Colorado General. At the Fort Logan Mental Health
Center in Denver — a public facility - inpatient care is $20 per

day, while day hospitalization is only $8 per day. (6)

o2,
53.

3. The importance of adequate insurance coverage of mental illness,
particularly for short term community-based care, was heavily
stressed in President Kennedy's historic 1963 message on mental
illness and mental retardation when he told the Congress:
"Mental health services should be financed in the same way
as other medical and hospital costs. At one time, this was
not feasible in the case of mental illness, where prognosis
almost invariably called for long and often permanent
courses of treatment. But tranquilizers and new therapeutic
methods now permit mental illness to be treated success-
fully within relatively short periods of time — weeks or
months, rather than years."'

President Kennedy directed the Department of Health, Education

and Welfare to set up a task force on insurance to meet with the

major carriers and develop a minimum set of standards for psy-

chiatric insurance, Late in 1964, the Task Force on Insurance

 

released a set of principles designed to promote broader coverage
of mental ilIness. The major principles are:

a. Emphasis should be placed on early referral and short-term

 

intensive therapy. With regard to out-patient benefits, this
would indicate low deductible features and low co-insurance to
encourage early care.

b. In-hospital benefits should be increased and partial hospitali-
zation should be included in all benefits. Included within the
definition of "allowable hospital expenses" should be those in-
curred within day and night hospital programs,

c. Increased coverage should be given to all the professional skills

essential to treatment and rehabilitation of the mentally ill -
not only psychiatrists and other doctors, but clinical psycholo-
gists, psychiatric social workers, psychiatric nurses, etc.

. Comparable coverage should be provided for all accepted types
of treatment. The objective should be continuity of care, so
that the patient receives the most appropriate treatment at
each stage of his illness. When deemed necessary, treatment
visits by members of the patient's family (collateral visits)
should be covered in addition to the patient's visits.

. Prescribed drugs should be covered for ambulatory as well as

for hospitalized patients. Drugs are a vital resource for the

 

treatment of mental illness, whether the patient is ambulatory

or hospitalized; moreover, drugs may be the very factor keeping

some patients ambulatory instead of having to be hospitalized.

 

54,
XXXVHOI. WHAT ARE SOME OF THE BREAKTHROUGHS IN RECENT YEARS

55.

IN INCREASED COVERAGE OF PSYCHIATRIC ILLNESS? (48)

 

1,

The Federal Employees Health Benefits Program, enacted by the
Congress in 1959, covers more than two million federal employees
and their four million family members for both basic psychiatric
hospitalization and, under an optional major medical plan, for
out-patient care including a limited number of visits to a private
psychiatrist. A survey of the first three years experience with

the plan reports one annual admission for psychiatric illness for
every 500 members, and an average hospital stay of only 11 days
per admission. This is much less than the admission rate for

most other illnesses — for example, there are ten times as many

admissions under the federal plan for respiratory diseases.

Retail Clerks Local 770 of Los Angeles has pioneered in providing
psychiatric services for its members since 1960. The employers
contribute two and a half cents an hour in fringe benefits for the
psychiatric program, This generates about $600, 000 a year and,
for this amount of money, the Southern California Permanente
Medical Group provides psychiatric hospitalization and unlimited
out-patient care. Any clerk or his dependent can, in the course of
a year, come in for any kind of program: a long, chronic problem,
an educational program, a problem concerning the speech diffi-
culty of a child, parent-child guidance, diagnostic evaluation,

marital and pre-marital counselling - in other words, the whole
spectrum of psychiatric services as we know them today.

Only a small number of retail clerks — one for every thousand
eligible members — is hospitalized; the median hospital stay is
less than 20 days. Family therapy accounts for the bulk of the
case load — at present, about 40 percent of the total service

provided.

: MANY MILUONS OF WORKERS
pa ARE COVERED FOR
a =6PSYCHIATRIC ILLNESSES
UNDER EMPLOYEE INSURANCE
PLANS

 

3. The biggest breakthrough in coverage of psychiatric illness for
workers was the landmark United Auto Workers Contract of 1964,
covering two and a half million workers and their dependents in
77 major American cities. The plan, which went into effect on

September 1, 1966, not only provides generous inpatient benefits,

06,
57,

but it allows each worker $400 per year in out-patient benefits.

Its emphasis upon out-patient treatment either in the doctor's
office or in day hospitals, community mental health centers and
clinics; its coverage of drugs dispensed by a hospital or commun-
ity mental health facility; its use of group psychotherapy and family
counselling, and its coverage of services, including psychological
testing, provided by various members of the mental health team
embody the most enlightened principles of progressive psychi-

atric coverage.

Furthermore, and this may be its most important contribution, it
encourages the worker to seek treatment by providing the first
five visits for therapy at no cost, and then slowly increasing the
co-insurance contribution over the duration of the period of treat-
ment. This is the obverse of most existing plans, which insist
upon a high deductible and heavy early co-insurance to deter

utilization.

Dr. Daniel Blain, President of the American Psychiatric Asso-
ciation, when the UAW contract was negotiated, and now an active
participant in its implementation, recently hailed the UAW plan
as establishing "a prototype which, if emulated in future bargain-
ing contracts throughout American industry will, for the first
time in history, make adequate psychiatric care available to

millions of Americans who have been deprived of it."
XXXIX, HOW DOES THE 1965 MEDICARE LEGISLATION INCREASE BENE-

 

FITS FOR THOSE OVER 65 AND FOR MEDICAL INDIGENTS

 

GENERALLY? (49)

1, Under the basic Social Security provision (Part A of Title 18),
persons over 65 with a diagnosed mental illness are entitled to up
to 90 days of care in a general hospital or community mental
health center for each spell of illness, with the patient paying a
$40 deductible for the first 60 days, plus $10 a day for the 61st
and subsequent days. The mental patient is also entitled to up to
100 days of post-hospital extended care per duration of illness in
a nursing home, or other facility which is not primarily for mental
patients. He is also entitled to 100 home visits by health workers
representing agencies not primarily engaged in the treatment of

mental illness.

If the patient is placed in a public or private institution solely en-

 

gaged in the treatment of mental patients, there is a lifetime limit

of 190 days on such coverage.

2. Under the voluntary section of the Medicare legislation (Part B of
Title 18), the individual who elects to enter the plan pays $3 a
month and the federal government matches this sum. Subject to a
$50 deductible, the plan covers 80 percent of the patient's bill for
physicians’ services in and out of the hospital, home health

services, drugs, diagnostic tests, etc. The only restriction on

58,
59.

psychiatric benefits relates to out-patient care ~— during any
calendar year, the limit is $250 or 50 percent of the expenses,

whichever is smaller.

Under the revised Kerr-Mills program, as outlined in Title 19 of
the Medicare legislation, medical services are extended to in-
clude larger categories of-the medically indigent (as opposed to
aged on public assistance rolls); dependent children ; and rela-
tives responsible for their care, under the Aid to Families of
Dependent Children; the permanently and totally disabled, the
blind, etc.

With regard to mental illness, state plans which qualify for in-
creased federal matching monies may include psychiatric in-
patient services in a public or private mental institution for
patients over 65 years of age, and in a general hospital for those
patients who are under 65. After July 1, 1967, states planning to

qualify for matching monies must provide a minimum medical

 

assistance program also including outpatient hospital services,

laboratory and X-ray services, skilled nursing home services and
physicians' services regardless of where they are provided. On an
optional basis, states may provide a broad range of additional

Services such as prescribed drugs, ‘lental services, eyeglasses, etc.

- Under another section of the Medica.'e legislation, covering public

assistance recipients, federal funds to the states are authorized for

the first time to share in meeting the costs of patients over 65 years
of age in mental institutions. This provision, which went into effect
on January 1, 1966, will give the states an estimated $75 million a
year in additional monies for the care of aged patients. However, in
order to qualify for these funds, states must submit evidence that
this additional money is being used for improved services.

Patients on public assistance under 65 years of age in general
hospitals who have a diagnosis of mental illness are now eligible —

again for the first time - for federal matching payments. However,

 

states wishing to qualify for this additional federal money must
submit plans, including provisions designed to insure the best
possible care for each mental patient covered. The state plan must
stress alternatives to institutional care, with particular emphasis
upon the development of community mental health center treatment

facilities for these individuals.

. During the first year of implementation of the Medicare legislation,
it is estimated that about $200 million in additional federal monies
will be provided for better treatment of the mentally ill. This figure
does not include the large sums which will go into the Health Insur-
ance Trust Fund for coverage of psychiatric hospitalization under
Part A of Title 18, nor does it include the additional state expendi-
tures required as matching funds for expanded coverage of the
medically indigent and recipients of public assistance who require

psychiatric care.

60.
REFERENCE LIST

(1) Data from Nat'l Association for Mental Health. "Facts About Mental
Iilness'' 1965 Fact Sheet.

(2) Community Research and Services Branch Report, Nat'l Institute of Mental
Health. October 6, 1965.

(3) National Vital Statistics Division, U.S. Public Health Service, Washington,
D, on

(4) A Summary Description of Community Mental Health Services Acts. Posi-
tion Paper, National Conference on Community Mental Health Programs.
December 13-15, 1965.

(5) "A Plan for a Center on Alcoholism and Drug Abuse," October 1965.
National Institute of Mental Health, Bethesda, Maryland 20014.

(6) "The Need for Improved Insurance Coverage of Mental Illness"', speech by
Mike Gorman, Executive Director, National Committee Against Mental
Olness, Seattle, Washington, April 27, 1965.

(7) December 1965 Report. Office of Biometry, National Institute of Mental
Health, Bethesda, Maryland.

(8) Information obtained from National Committee Against Mental Llness,
Washington, D.C.

(9) Department of Medicine and Surgery, Veterans Administration, Washington,
D.C., per letter dated September 30, 1964 from Arthur J. Klippen, M.D.,
Controller, Department of Medicine and Surgery.

(10) "Hospitals", August 1, 1965, Guide Issue, published by the American
Hospital Association, Chicago.

(11) Statistical Abstract of the United States, 1965, Published by U.S. Depart-
ment of Commerce, Washington, D.C.

(12) Biometrics Branch, National Institute of Mental Health, Bethesda,
Maryland, 20014.

(13) Provisional Patient Movement and Administrative Data, Public Mental
Hospitals, United States, 1965. Mental Health Statistics, Current Reports,
Series MHB-H-10 and MHB-I-10. Nat'l Institute of Mental Health, Bethesda,
Maryland.

(14) Patients in Mental Institutions 1963, Part Il, Biometrics Branch, Nat'l
Institute of Mental Health, Bethesda, Maryland.

(15) Letter dated September 28, 1965 from Edward R. Silberman, Controller,

Department of Veterans Benefits, Veterans Administration, Washington,
D.C.

61.
(16) Provisional Patient Movement and Administrative Data: United States, 1965.
Public Institutions for the Mentally Retarded. To be published in the Mental
Health Statistics, Current Reports Series, MHB-H-10 and MHB-I-10.
Office of Biometry, Nat'l Institute of Mental Health, Bethesda, Maryland.

(17) Daniel Blain, M.D., Chairman, American Psychiatric Association Com-
mission on Manpower in Hearings before U.S. House of Representatives,
Appropriations Subcommittee for Labor-HEW, Fiscal 1967 budget.

(18) "Private Support for Mental Health", Jeanne L. Brand, Ph.D. Nat'l
Institute of Mental Health. Public Health Service, Publication #638. (1964)

(19) Of the total noninstitutional population of the U.S. 14 years of age and over
in 1964 of 134,143,000, 70,357,000 or 52% were actually employed
(Statistical Abstract of the U.S., 1965). Assuming the same percentage of
employed would prevail among the average daily resident patient population
in public mental hospitals in 1965 of 488,400, 253,968 people would have
earned in one year (1964) about $1, 676, 188, 800 ($6, 600 median family
income in U.S, in 1964, according to Current Population Reports, Series
P-60, No. 44, May 27, 1965, Consumer Income, Bureau of the Census,
U.S. Department of Commerce, Washington, D.C.)

Assuming 52% of first admissions in 1964 to public mental hospitals had
been able to be employed and each earned the $6,600 median family income
for that year, some 64, 210 could have earned in that one year $423, 786, 000
in income,

(20) Community Mental Health Facilities Branch, Nat'l Institute of Mental
Health, Bethesda, Maryland.

(21) Budget of the U.S. Government 1966. p. 509. 1966 estimated average
number of recipients per month of aid to the permanently and totally dis-
abled: 581,500, the estimated average monthly payment in 1966: $86. 20.

(22) "Economics of Mental Illness" by Rashi Fein, Ph.D. » Monograph Series
No. 2, Joint Commission on Mental Illness and Health.

(23) Public Law 89-105, 89th Congress. Signed into Law, August 4, 1965.

(24) Hearings before U.S, House of Representatives, Appropriations Subcom-
mittee for Departments of Labor, Health, Education and Welfare, Fiscal
1964 Budget.

(25) National Institute of Mental Health, Bethesda, Maryland 20014.

(26) Report of Survey Conducted Jointly by American Hospital Association and
Office of Biometry, Nat'l Institute of Mental Health. December 1965.

(27) Edward Dunner, M.D., Director, Research Service, Department of
Medicine and Surgery, Veterans Administration, Washington, D.C.

62,
(28) National Association for Mental Health, New York.

(29) Foundations' Fund for Research in Psychiatry, New Haven, Connecticut
Annual Report 1964-1965.

(30) "Action in the States in the Fields of Mental Health, Mental Retardation,
and Related Areas" Interstate Clearing House on Mental Health, Council of
State Governments, Chicago, Dlinois, April 1963; February 1965.

(31) From a survey compiled and published annually by "Drug Topics, "' Topics
Publishing Co., Inc., New York, N.Y.

(32) Mike Gorman, Executive Director, National Committee Against Mental
Illness, Inc., Washington, D.C.

(33) Psychiatric Studies and Projects No. 10, September, 1963. Mental Hospital
Service, American Psychiatric Association.

(34) Program Analysis Section, Training & Manpower Resources Branch, Nat'l
Institute of Mental Health. Communication dated March 9, 1966.

(35) Survey of Mental Health Establishments - Staffing Patterns and Survey
Methodology, October, 1965. National Institute of Mental Health, Bethesda,
Maryland.

(36) Mental Health Manpower Needs, 1965-1970."' Training and Manpower

Resources Branch, Nat'l Institute of Mental Health, Bethesda, Maryland,
November 29, 1965.

(37) General Practitioner Education Project, American Psychiatric Association.
December 1965.

(38) "Facts About Nursing" American Nurses Association, 1963.

(39) Joint Information Service of the American Psychiatric Association and the
National Association for Mental Health, 1965.

(40) "Training and Research in State Mental Health Programs, " published in
1953 by the Council of State Governments, Chicago, Illinois.

(41) "Standards for Psychiatric Hospitals & Clinics" 1965 Edition (Revised 1958)
American Psychiatric Association.

(42) "The Crisis in Mental Health Manpower and How to Meet It'' White Paper
prepared by Commission on Manpower, American Psychiatric Association,
March, 1966.

(43) Survey of Mental Health Establishments Staffing Patterns. Office of Biometry,
National Institute of Mental Health, Bethesda, Maryland. 1963.

63.
(44) Personal communication, August 3, 1965 from Austin M. Davies,
Executive Assistant, American Psychiatric Association, New York.

(45) Personal communication, August 11, 1965 from David A. Boyd, Jr., M.D.,
Executive Secretary Treasurer, American Board of Psychiatry and
Neurology, Inc., Rochester, Minnesota.

(46) Mental Health Manpower, May 1965, No. 6. Nat'l Institute of Mental
Health, Bethesda, Maryland 20014.

(47) Personal communication, August 5, 1965, from Mrs. H.M. Hildreth,
American Psychological Association Membership Committee, Washington,
D.C.

(48) "Improving Mental Health Insurance Coverage." Public Information Section,
National Institute of Mental Health, August, 1965.

(49) Social Security Amendments of 1965: Summary of Mental Health Care
Provisions, Program Analysis Section, Community Research and Services
Branch, Nat'l Institute of Mental Health, September 14, 1965.

(50) Fifteen Indices, 1966 Edition. Publication of the Joint Information Service
of the American Psychiatric Association and the National Association for
Mental Health, Washington, D.C.

(51) "The New Mental Health Challenge for All Americans", speech by Mike
Gorman, Executive Director, Nat'l Committee Against Mental Illness, to
First Legislative Conference, Massachusetts Association for Mental
Health, February 3, 1964,

(52) Article in Los Angeles Times, March 1964, by Robert C. Toth —
"Mentally Ill Helped by Tranquilizers ~ 95% Improve".

CREDITS

P. 6 Photograph by Rudolph Janu, New York, N.Y. Reprinted by permission of
"Mental Hospitals", The Journal of Hospital and Community Psychiatry, pub-
lished by the American Psychiatric Assoc.

P. 16 Photograph courtesy Albert Einstein College of Medicine

P, 42 Photographs courtesy of the Denver Post

P. 51 Photograph courtesy of Dr. Schulman

64.