A4368

CONGRESSIONAL RECORD -—~ APPENDIX May 23

Economics, Ethics, and Mental Illness

EXTENSION OF REMARES

or

HON. JOHN E. FOGARTY

OF RHODE ISLAND
IN THE HOUSE OF REPRESENTATIVES
Monday, May 23, 1960

Mr, FOGARTY. Mr. Speaker, under
leave to extend my remarks I include an
address which I delivered at the lith
Mental Hospital Institute, Buffalo, N.Y.,
on October 20, 1959: :

Economics, ETHics, aND Menta ILLNESS

{Address of the Honorable Joun E. Fogarty,
Member of Congress, second district,
Rhode Island, at the lith Mental Hospital
Institute, at the Hotel Statler in Buffalo,
N.Y., on Octover 20, 1959)

Distinguished guests, ladies and gentle-
men, I am greatly honored by your invitation
to present the academic lecture at this 11th
Annual Mental Hospital Institute. I have a
sense of some temerity, however, in address-
ing a group such as this on the subject of
ethics and mental illness. All of you have,
in the most practically real and effective way,
dedicated yourselves to improving the condi-
tion of the mentally ill, The staffs of the
outstanding hospitals that have received the
Mental Hospital Service Achievement Awards
here tonight are in the front echelons of an
army of many thousands who work against
tremendous odds. These people, despite the
magnitude and seeming hopelessness of the
task, have made substantial gains in the
campaign to improve care and treatment for
the mentally ill, to help them recover more .
rapidly and more fully. As a layman, I can
add.to your great effort only my indirect help,
my understand.ng, and my support for your
work.

I have been closely concerned for-a long
time, as many of you may know, with the

. problems of mental and emotional disorders.

The prevalence of these illnesses, and the
regularity with which they afflict a large
proportion of our people in every class and
condition of society put them in a critical
category all by themselves. If mental ill-
ness were acutely contagious instead of
causing chronic invalidism and disability,
our country and all the countries of the
civilized world would long ago have declared
& state of emergency against this epidemic.

As a nation, we are painfully aware of the
economic costs of mental illness; we have
deep sympathy for the misery of those who
suffer from mental iliness and the hardships
endured by their families; we want to do
as much.as we can to alleviate this suffer~
1960

ing—but we are not sure how much we can
afford .to do; what limits we should set to
our efforts in the light to what we know at
present; in what directions. we should exert
our efforts most vigorously.

The dilemma was posed most succinctly in
the recent report on the economics of men-
tal illness. This report is the second in @
series being issued by the Joint. Commission
on Mental Illness and Health as part of &@
national mental. health survey initiated by
Congress. The purpose of the survey is to
bring together a comprehensive body of
findings and recommendations that will
serve as the basis for planning a stepped up,
comprehensive national mental health
program.

Dr. Rashi Fein, the economist who worked
out methods for estimating the direct and
indirect costs of mexital illness in the United
States, estimates them conservatively at a
minimum of $3 billion each. year. This fig~

“ure obviously does not represent the full
cost of mental illness. It includes direct
costs of caring for the mentally ill expended
by public and private agencies, by the pa-
tients and their families, by public institu-
tions and private foundations. It includes

estimates of such indirect costs as loss of

production and loss of earnings. It does
not include the costs of private care outside
the hospital, of public assistance to the
mentally ill or the handiing of the mentally
ill by police, court, penal, social welfare and
other public institutions. Nor does it in-
clude the costs of related problems such as
drug addiction, alcoholism, juvenile delin-
quency, and mental retardation.

The $3 billion figure includes $100 million
as an estimated minimum direct cost of care
provided by psychiatrists in full-time prac-
tice. It does not include the cost of pay-
ments to psychiatrists in part-time practice,
to general practitioners, or to internists for
the care of the mentally ill. Iam sure that
you who work in the field are well aware of
the difficulty of gathering accurate statistics
on this subject. It has been estimated that
perhaps 50 percent of the patients consult-
ing general practitioners are suffering from
complaints of an emotional origin. If this
cost were included, we would have to add
another $1 billion to our $3 billion annual
total.

We all are, of course, painfully aware that
even though we pay out $3 billion annually,
we are not providing our mentally ill with
anything like the best care presently pos-
sible. The average expenditure per patient
in a public mental hospital is just a little
better than $4 a day. This compares with
a daily cost of approximately $25 in a gen«
eral hospital. The staff of the Joint Com-
mission raise some very provocative ques-
tions in their preface to Dr. Fein’s report.
They ask: “How much would it cost to pro-
vide the highest possible standard of care
for the mentally i11? Can we afford these
costs? . More exactly, which can we better
afford—the cost in-human misery caused by
mental illness or the cost in dollars to pro-
vide the best care we know how to give?”

AS a people, we Americans are committed
morally and ethically to the proposition that
each man and woman is entitled to the op-
portunity to realize his best capabilities.
This includes the opportunity to receive
proper medical care, regardless of income,
social class, or the nature of-the illness. We
subscribe to the statement in the constitu~
tion of the World Health Organization that
“the enjoyment of the highest attainable
standard of health is one of the fundamental
rights of every human being without distinc-
tion of race, religion, political belief, eco-
nomic or social condition.” However, we are
a practical people. We also want to know
whether large increases in the money spent
to. treat mental iliness would be justified
from an economic as well as a humanitarian
viewpoint. Will increased expenditures tend

CONGRESSIONAL RECORD — APPENDIX

to reduce the extent of the problem in the
future? Where will the money come from?

“Should available increased funds be spent

to step up research that hopefully will re-
duce the problem drastically at some future
date—and, in the meantime, limp along with
inadequate care for those who how are men-
tally. ill or who become mentally ill in the

_ hear future?

From an ethical point of view, I do not
believe that we have any choice. We can-
not abandon one iota of the available po-
tential for uncovering useful new knowledge
through research. Equally, we cannot
abandon the mentally ill. We are morally
obliged to strive, to the limit of our abili-
ties and resources, to improve the lot of the
mentally ill, to make treatment more effec-
tive, to increase our efforts at cure and reha-
bilitation. Certainly people suffering from
this illness are entitled to the same con-
sideration as those with physical illness. As
you know any person with acute appendi-
citis, can obtain a good surgeon to remove it
regardless of his ability to pay. We do not
provide similar services for the mentally ill.

But because our resources are far from
unlimited, we must make choices. What
Kinds of expanded services for the mentally
ill are likely. to be the most profitable?
Where will our efforts be apt to bring the
greatest payoff in terms of patient recovery?
. Until fairly recently these were questions
which could be answered almost solely. on
empirical evidence. And as a glance back
over history will remind you, the answers
that were accepted and applied in treatment
were colored more often by the intellectual
attitudes of the times than by. detached
analysis. Thus, little of constructive value
was done to help the mentally ill in Western
Europe until the age of enlightment at the
end of the 18th century. Paradoxically, the
period of the Renaissance, during which new
emphasis was placed on the dignity and
worth of the individual, was characterized
by cruel and repressive treatment for the
mentally il.

As you Know, it was not until the 1800’s
that a systematic approach to mental illness
was predicated on the belief that the men-
tally ill are entitled to the humane treat-
ment that. is the inalienable right of all
human beings. This era of moral treatment,
based on principles advocated by Pinel and
Tuke, stressed the importance of attempting
to influence the mentally ill by appealing to
them with kindness and understanding
rather than by regimenting them. Although
it was believed that mental illness was
caused by some unknown pathological proc-
ess in the brain, the advocates of this type
of treatment felt that their approach would
do much to help -their patients.

In that era, there were so few mental
hospitals in the United States that only a
small fraction of the people who needed hos-
pital care would be admitted, but the hos-
pitals that did exist were operated along ex~
cellent principles. They were small. The
superintendents were highly intelligent and
well motivated. The atmosphere was
friendly, -comfortable, hopeful, and the
superintendent was able to talk to each
patient daily. Despite the paucity of treat-
ment methods, the number of discharges and
recoveries in these hospitals was substantial.

Further advances in care and treatment
were made in the big mental hospitals that
were established during the latter half of
the 19th century. New discoveries made
during the first half of the present century
enabled us to conquer the psychoses due to
pellagra and general paresis. The use of
shock therapy changed the entire picture
with respect to involutional melancholia.
The various psychotherapies were developed,
and much was learned about the anatomy,
physiology; and pathology of the nervous
system.

A4369

In our own day, we have witnessed a pe~
riod of remarkable progress which began
shortly after World War II. Stimulated by
the realization that mental and emotional
disorders were a dangerous hazard to our
safety as a nation, Congress, at that time,
initiated our present ongoing program of
support for research, training, and service in
the field of mental health. In the short span
of years since then, this activity has grown
manyfold. Equally important, new work in
the field of mental iliness has been begun
and stimulated by State and local govern-
ment agencies, institutions, private founda-
tions, citizens’ organizations, universities
and medical schools, training centers, and
groups of all types throughout the couniry.

I have watched this campaign grow and
spread, as you ail have, and I must say the
results have been impressive. New research
findings have emerged—the tranquilizers
and other psychoactive drugs have come into
general use—we have developed new ways
of training personnel and using people now
available to treat patients—-we have set up
new kinds of treatment facilities and
changed our uses of present facilities. The
growth in treatment resources and know-
how has been little short of phenomenal.
Though we are still far from our goal, we
have, I believe, what no previous period had.
We have a handle with which to grasp the
problem of mental iliness. We have some
tools that can help us decide, on a scientific
basis, where our expanded efforts are most
likely to bring results in terms of patient
recovery.

Among the more useful tools, it seems to
me are the epidemiological studies of mental
illness. These studies have provided new
knowledge about who becomes ill, how long
they remain ill, what happens to the mental
patient both in and out of the hospital, and
the effects of new therapies and new kinds
of domiciliary and outpatient care. This
kind of information, obviously, is of first im-
portance in long-range planning and in make-
ing critical decisions which will affect the
patterns of caring for the mentally ill for
decades to come. A great deal of this in«
formation has come from the many statis«
tical studies of mental hospital populations
sponsored and conducted by the States in
the Model Reporting Area for Mental Hos-
pital Statistics, with the guidance, coopera=
tion, and assistance of the National Institute
of Mental Health. Experts in this field have
charted new ways of analyzing the problems
of mental illness. :

To me, one of the most significant changes
that has taken place in recent years is that
communities are assuming more responsi-
bility for the care of the mentally ill. Serve
ices and facilities that make it possible to
keep people out of mental hospitals and still
give them adequate care ate being estab-
lished throughout the Nation.

Of particular importance has been the in+-
crease of psychiatric facilities in general hos-
pitals. The numbers of these hospitals ace
cepting psychiatric patients rose from 43 in
1939 to almost 1,000 in 1958.

The increase in the number of outpatient
clinics and the extent of their services has
been equally phenomenal.

New types of outpatient facilities and day-
eare and night-care centers have been
opened. .

Emergency psychiatric services are being
developed which hopefully will obviate the
need for hospitalization in some instances.

Nursing homes and chronic-disease hos-
pitals are being used more and more for care
of such groups as the aged mentally ill.

There has also been an increase in after-
care facilities in the community so that
patients who have been released are less
likely to relapse.

Within the mental hospitals, there have
also been significant changes. In fact, from
what I have read I would say that there has
A4370

been a virtual revolution in the way in which
the hospital views and handles the mental
patient, a revolution that has been reflected

in the more hopeful attitude toward mental

illness prevalent throughout our society to»
‘Gay. The use of total push programs, begun
about 10 years. ago, have demonstrated that
many backward patients—the ones for whom
hope had long since been abandoned-——could
improve to the point where they can be ree
turned to the community. :

The open hospital has been another major
step forward in the attempt to prevent long~

term hospitalization and its associated ill.

effects. The healthy activity and sense of
purpose that characterize the modern mental
hospital are a far cry from the atmosphere
that surrounded the mental hospital even as
recently as 25 years ago. The idea of the
open hospital has come to our shores in
recent years from England where it has
worked out very successfully in a number of
hospitals. As yet it is not so generally ac-
cepted here as abroad.

A number of commentators have pointed
out an apparent difference in the amount of
violence among British and American pa-~
tients and have suggested that something in.
the British personality or the more uniform
culture in Great Britain may make the open
hospital more feasible there than here. But
the precedent for patient freedom in this
country existed long ago. In 1849, Charles
Dickens described, in his “American Notes,”
scenes in the Boston Lunatic Asylum that
would do justice to the more enlightened of
our present-day institutions, “Every patient
in this asylum,” Dickens wrote, “sits down
to dinner every day with.a knife and fork:
5 * * At every meal, moral influence alone
restrains the more violent among them—
but the effect of that influence—is found,
even as a means of restraint, to say nothing
of it as a means of cure, a hundred times
more efficacious than all the strait-waisccts,
fetters, and handcuffs. * *:*

One might logically conclude, therefore,
that the success of the “open door’ is de-

pendent upon a real change in attitude to-"
Opening locked doors -

ward the mentally ill.
and giving patients. the social freedom that
is rightfully theirs is not enough. There
must be real conviction on the part of the
entire hospital staff that the patient can im-
prove. Patients must be given treatment;
all the available therapies—chemotherapy,
psychotherapy, physical therapies and so
on—must be marshalled and organized on
an individual basis so that each patient is
given the benefit of all that is now known
about treating mental illness.

More and more the hospital must take its
place as part of a network of mental health
services in the community. The treatment
and rehabilitation programs of the hospital
need to become more closely integrated with
community health and social services, so
that the patient can receive continuous psy~
chiatric and social assistance that will change
as his needs change—and so that he will
be able to maintain his links to the com-~
munity and to his family throughout the
course of his illness.

Dr, Robert Felix, Director of the National
Institute of Mental Health. and president-
elect of your American Psychiatric Associa=-
tion, pointed out this need at your meeting
2 years ago when he said: “I would envision
the time when we would consider the hospi-
tal period not as a separate entity, but as
an entity in the total therapeutic program
of the individual.” The hospital also must
share its responsibilities in the total com~
munity forces available for fostering pre-
yentive programs and positive mental health
activities. Dr, Felix has also said: “* * *
members of our hospital staffs are going to
be much more effective as a total therapeutic
instrument in hospital programs if there are
devices set up whereby they must spend

CONGRESSIONAL RECORD — APPENDIX

some of their time in consultation with other.
agencies in the community.”

This means that hospital staff would be-

come involved in a: whole array of commu-
nity activities—such as industrial mental
health, school mental health, the mental
health aspects of law enforcement programs,
and various community mental health activi-
ties in cooperation with civic. leaders. Al-
though these activities would, of course, bur-
den the already overcrowded schedule of hos-
pital staff, the benefits would far outweigh
the difficulties—and the advantages would
probably spur renewed and successful efforts
at expanding hospital staff. Closer contact
with the community would give the hospital
physician, nurse, social worker, and psychol-
ogist a clearer understanding of the problems
confronting the patient when he leaves the
hospital. Such contacts would also stimu-
late professional personnel and other people
working and living in the community to pro-
vide services within the hospital and help
the hospital staff.

Ideally, if we are to make the mental hos-
pital an effective therapeutic instrument, it
must be set within a larger community
which itself is a healing cormmunity—in
which the general climate and the available
services tend to minimize the unhealthy
stresses which contribute to mental illness,
and tend to promote mental health in a
positive way. Recent research leaves no
doubt that an individual’s social environ-
ment has a tremendous influence on his
mental health. In the hospital,.a thera-
peutic environment means a climate in
which the entire staff brings help to the
patients and the patients help one another—-
in which there is increased emphasis on
patient self-government and the patient is
given more responsibility for managing his
own, affairs—in which treatment and help
and rehabilitation are dominant. In the
community a situation conducive to mental

health means ready and adequate heip for.

families in trouble, before one of thelr mem-~-
bers breaks down—it means helping families
recognize the early signs of mental illness
and seek the proper kind of help as soon as
possible—it means halfway houses, sheltered
workshops and social-therapeutic clubs for
discharged patients—it means the establish-
ment of mental health centers to serve as
screening and referral agencies—it means
psychiatric emergency services and foster-
home care and other measures to avoid long=
term mental hospitalization.

The problem of avoiding long-term men-
tal hospitalization is perhaps most acute
with the aging—the group who are the par-
ticular focus of this. Mental Hospital In-
stitute. The problem represented by the dis-
proportionately large number of persons 65
years and over being admitted to public
mental hospitals will become an even more
critical one in the years ahead. It is esti-
ynated that by 1980 the number of people
65 years and over in the general population
will double. If the current trend remains
fixed, the increased numbers cf older people
in: our mental hospitals will be tremendous.
This will pose additional problems, because
older patients require a great deal of phy-=
sical and medical care and special staff
attention. :

This emerging problem suggests increased
emphasis on research in many directions.
For example, we need to know more about
the aging process itself, about the cause of
mental iliness in the aged, and about the
cultural and economic factors that deter=
mine choice of the hospital for needed care.
Not all patients with mental diseases of
the senium are cared for in mental hos-
pitals. There are a variety of other facilities
available—homes for the aged, nursing
homes, chronic disease hospitals. We need
more facts before we can decide which fa-
cility can furnish the most appropriate care.

May 23

Perhaps we should give more thought to
foster home care of the aged patient whose
condition does not necessitate hospitaliza-
tion but who does not have a family able or
willing to give him the help he needs. In
thinking of such foster care, we should not
ignore the contributions that might be made
by the increasing numbers of healthy and
active older people in our population—peo-
ple for whom the responsibility of providing
a foster home for aged patients. would mean
the difference between aimlessness and @
sense of purpose and being needed that are
essential to everyone’s mental health. Pay=
ments for providing such foster care might
mean. the difference between self-respecting
independence for thousands of healthy eld-
erly people and the economic dependency
on, others that in itself can breed. psycho-
logical problems for the aged. Perhaps this
approach could heip the older people to help
themselves.

But the question of institutional or com-
munity or home care of the aged mentally
ill, as of other types of mental patients, is
only one aspect of the problem. The choice
of treatment and treatment facility will
change with constantly changing medical
knowledge about prevention, treatment, and
rehabilitation. It will change as attitudes
of the community toward mental illness keep
changing, It will change as we learn more
about the complex interactions of biological,
psychological, economic, and social forces
that influence mental health and mental ill-
hess. The mental hospital is in a strategic
position to contribute to the accumulation
of that knowledge as well as to test it out
with patients. It can be a living laboratory
for the study of mental illness. The estab-
Ushment of research activity within the hos-
pital itself would heip to strengthen its ties
with university and other research centers,
and would make the hospital more attrac~-
tive as a place to work and learn. In thus
branching out into other activities, the men-
tal hospital may help to solve the chronic
problems of insufficient staff that has tended
to keep it ingrown and isolated in the past.

Tam aware that most of these thoughts

‘have occurred to all of you, perhaps many

times. IT am also aware of the numerous
practical problems and obstacles that daily
frustrate your attempts to move ahead, But,
as you carry on your deliberations at this
Tustitute, and as you work in your respective
hospitals throughout the coming year, you
should know that there is broad and gen-
erous public support for your efforts. I be-
lieve I express the feelings of the vast ma-
jority of our people when I say that our
country is committed to a full program of
activity in the field of mental illmess, up to
the limit of our economic, and scientific
abilities, :

en arr OTRAS