Dr. GLASS. On the contrary, I don't think we should disregard it but now community hospitals are entering, as you know, into this program very heavily so we are not disregarding them.

We are inviting them. For example, St. Anthony's Hospital in Oklahoma City has an approved mental health center and are entering into it voluntarily. That doesn't mean that Mercy Hospital three blocks away has to do it.

Dr. DONOHUE. There ought to be some private beds in addition to the community part.

Mr. JARMAN. Mr. Brown.

Mr. BROWN. If you can properly separate treatment of mental illness in community hospitals into prevention which means outpatient care and treatment which means inpaitent care and then, incarceration, definite assignment of a mentally ill patient to a hospital because there is no hope of treatment, what kind of breakdown do you get on that basis, percentage-wise? Where is your need greatest?

Dr. GLASS. Let's say this: We can't agree with your definition because we have treatment as outpatient and treatment as inpatient and day care, but nevertheless, I understand what you mean that if you consider those cases that require prolonged care, institutional care, if you are talking about psychiatric patients and get away from the physically disabled the older patient who needs a supervised living enviroment like a nursing home, if we exclude those and talk about physically able but menatlly ill patients who have to be kept in an institution for a prolonged period, we don't feel it is more than 1 to 2 percent of admissions.

Experience indicates that 1 to 2 percent of admissions would reach such severity as to be kept for that long.

Mr. BROWN. Let me pursue this question just a step further. There is in crime control and prevention a trend away from incarceration and into treatment so to speak, the social approach and now perhaps a trend into prevention.

We are doing this in welfare to some extent. Is there a Federal involvment here in the prevention of mental illness that we are overlooking and merely spending all our funds on treatment?

Dr. DONOHUE. No, all your poverty programs-I was on the discussion of Ozarkia today which crosses some of our area and these things are being well considered. If you are going into the prevention of mental illness you get into a real complicated area, getting into poverty, education, pre-school.

Mr. BROWN. Alcoholism, drugs.

Dr. DONOHUE. You are getting into a cross structure of family relationships, sociological relationships in families and many things which under the present programs are ongoing.

I don't know whether there are letters for them but in general the poverty programs, the Appalachia-Ozarkia type things where we are really going into the redevelopment of our cities and things like this, these in the final analysis would be preventive programs in the mental health field.

You get into the outpatient and actual care and treatment to prevent the individual from getting sicker. Yes, we are doing that. In the Oklahoma Medical Association, for instance, to show you the interest in

this in the State of Oklahoma, we have had two conferences in which the medical association financed a conference to bring in the people who were interested and we had 1,000 come in who work in these various areas in Oklahoma who came in because there is this much interest. We had one for doctors and had over 200 doctors. There is a marked interest and the American Psychiatric Association working with another grant is training physicians to understand more about psychiatry. We have Thursday afternoon programs on those because when I went through medical school it was a hit and a lick. So we are shifting this whole thing. You see, there are actually 7 levels in the mental health field. You start down here with 42 percent according to the Joint Commission Report of people going to ministers before they go anywhere.

So, you start with the minister, the police officer, the schoolteacher, and another layer of counsellors, court counsellors and public health nurses and the layer of general physicians who see these people alone and mental hygienic clinics and advisory clinics.

Then you have psychiatrists and then here comes this new mental health center and then you have the State hospital. We have a compendium of service already structured. I agree we need to train the people.

For instance, in Oklahoma now we have a school for police officers. The police officers from Oklahoma City come and spend 2 days working and taking courses in the state hospital, in this area and we also have 14 hours of courses in psychology for them and things like that. The other day I was talking to them about subsequently having these in these cars that make rounds

guys

Dr. GLASS. I would like to pursue your question. That part of the community mental health center that deals with preventions, the consultation and education, is one of the essential services.

Now, the actual prevention is really indistinguishable from what goes on with all the other programs under welfare and poverty and so forth.

The consultation and education arm of the center meets with those people, police, judges, welfare workers, and others to bring the contribution of the mental health center to them.

Mr. BROWN. Thank you.

Mr. JARMAN. Thank you again, gentlemen, for being with us and for your testimony.

A roll call is in progress so that we will ask for permission to sit again at 1:30 here in this room to conclude the hearing.

The Committee will stand in recess until 1:30 p.m.

(Whereupon, at 12:40 p.m. the hearing recessed to reconvene at 1:30 p.m. the same day.)

AFTER RECESS

(The subcommittee reconvened at 1:30 p.m., Hon. John Jarman, chairman of the subcommittee, presiding.)

Mr. JARMAN. The subcommittee will please come to order.

The House is in session, but we have secured permission to continue hearings during general debate on the bills on the floor of the House

MENTAL HOSPITAL FACILITIES

There are 497 mental hospitals in the United States. They include 244 state hospitals, 45 county hospitals, 41 Veterans Administration neuropsychiatric hospitals, two other Federal hospitals, and 165 private psychiatric hospitals. Approximately 495 community general hospitals, or about 1 out of every 11, have separate units for treating psychiatric patients. About the same number more admit psychiatric patients to their regular medical facilities.

CARE AND TREATMENT OF MENTAL HOSPITAL PATIENTS

The great majority of patients in state mental hospitals receive only custodial care. Only a small percentage receive intensive psychiatric treatment, even though research has demonstrated that some patients who have been in the hospital as long as 5, 10 or 20 years do recover when they receive intensive treatment. The reason for this situation is that few state hospital systems have the necessary funds to provide adequate staff and equipment for intensive treatment. A key index of this inadequcy is the amount which the hospital spends per day for the maintenance of each patient. (Maintenance covers the salary of all personnel, treatment supplies, plus equipment, food, clothing, and overhead.) Latest figures show that the average daily expenditure for maintenance in public mental hospitals is $6.74 per patient. One state spends as little as $3.18. By contrast, short-term general hospitals spend more than $44 per patient per day, private psychiatric hospitals, $33, and VA psychiatric services, more than $16 per patient per day.

PSYCHIATRISTS: THEIR NUMBER AND DISTRIBUTION

In 1965 the number of practicing psychiatrists totaled about 14,650, providing approximately 721,000 man-hours of work activity per week. However, only 60% of work activity was devoted to direct services to patients, with the remaining time spent in consultation, teaching, administration, and research.

In a recent comprehensive government survey of psychiatrists, in which 88% reported information about themselves, only 9% reported that their major specialty is child psychiatry.

More than half of the nation's psychiatrists are located in five states: 21% in New York, 13% in California, 6% each in Pennsylvania and Massachusetts, and 5% in Illinois; 13% reside in areas which represent 35% of the population. One state has as few as 11 psychiatrists.

COST OF MENTAL ILLNESS

About 2 billion dollars is spent annually for the treatment of mental illness in state, county, Federal and private mental hospitals and in psychiatric units of community general hospitals.

Annual expenditures for community mental health programs (including outpatient clinics) total $112,122,419.

COST OF MENTAL ILLNESS TO INDUSTRY

Business authorities conservatively estimate that the annual loss to industry directly related to emotional disorders is staggering, amounting to many billions of dollars each year.

Mr. BRANDT. The record shows the need for comprehensive mental health services, and I think the fact that the need has been translated into demand for services speaks to the effectiveness of the program which the Congress inaugurated in 1963, which was expanded to include staffing grants in 1965 when the vote in the House was 389 to nothing, and which you are now considering for extension.

The great demand for funds under this program continues. We anticipate that funds presently available will fall far short of the amounts ultimately required.

HOW MANY ENTER AND LEAVE MENTAL HOSPITALS?

The latest figures show that over 1,500,000 persons are on the books of public and private mental hospitals, psychiatric services of general hospitals, and Veterans Administration psychiatric facilities. (This includes patients in hospitals at the beginning of the year, plus those admitted during the year.)

One any one of the year about 760,000 persons are under the psychiatric care of these hospitals, including about 150,000 who are not actually in the hospital but are on "trial visit" or a similar form of supervision.

Of

Currently about 800,000 perosns are admitted during the year to public and private mental hospitals and the psychiatric services of general hospitals. these, nearly 300,000 have already been hospitalized one or more times.

WHAT ARE CHANCES OF LEAVING A MENTAL HOSPITAL?

With good care and treatment, at least 7 out of 10 patients admitted to a mental hospital can leave partially or totally recovered.

Data from a number of states show that about 75% of those admitted for the first time leave the hospital within the first year.

In the case of the most prevalent mental crippler, schizophrenia, the chances of release within a year for newly admitted patients have jumped from about 20% to about 80% in the last 40 years. The higher rate occurs, however, only when proper treatment is promptly administered.

In the case of two other serious mental illnesses, involutional psychosis and manic depressive psychosis, the chances of recovery or improvement are about 65% and 75%, respectively.

In the past, readmission rates have been as high as 35% of the patients discharged within a year. Recent research has shown that this figure can be reduced to about 10% with continuing and thorough rehabilitation service, including medical, social and vocational after-care.

MENTAL ILLNESS AMONG CHILDREN AND YOUNG ADULTS

Mental illness occurs at all ages, including childhood. It is estimated that there are more than half a million mentally ill children in the United States classified as psychotic or borderline cases. Most of these children are suffering from the psychiatric disorder known as childhood schizophrenia.

Only a very small percentage of the total are receiving any kind of psychiatric treatment.

The latest annual figures show that 24,438 children and young adults were admitted to public mental hospitals for the first hospitalization for serious mental disorder. Of these, 3,247 were under 15, and 21,191 were between 15 and 24.

On any given day in that year there were 27,686 children and young adults with serious mental disorders in our public mental hospitals. Of these, 4,547 were under 15 and 23,139 were between 15 and 24.

In private mental hospitals, first admissions of children and young adults totaled 4,636, of which 243 were children under 12 and 4,393 were between 12 and 21 years of age.

Conservatively estimated, an additional 300,000 children under 18 are served in psychiatric clinics each year, for less severe mental disorders.

During a one-week period, psychiatrists in private practice saw about 49,600 children (under 12) and adolescents (12-17 years). This figure represents about 24% of all patients (207,400) seen by psychiatrists in private practice.

CLINIC FACILITIES IN THE COMMUNITY

Last year there were about 2,000 public and private outpatient clinics in the United States. Many of these are part-time, and most of them have long waiting lists.

An estimated one million children and adults are served in these clinics. Almost half of these clinics are in the northeastern states, principally in urban

areas.

The best-informed mental health professionals estimate that a full-time clinic is needed for every 50,000 people. This would mean 3,880, or twice as many as now exist.

77-607-67-10

MENTAL HOSPITAL FACILITIES

There are 497 mental hospitals in the United States. They include 244 state hospitals, 45 county hospitals, 41 Veterans Administration neuropsychiatric hospitals, two other Federal hospitals, and 165 private psychiatric hospitals. Approximately 495 community general hospitals, or about 1 out of every 11, have separate units for treating psychiatric patients. About the same number more admit psychiatric patients to their regular medical facilities.

CARE AND TREATMENT OF MENTAL HOSPITAL PATIENTS

The great majority of patients in state mental hospitals receive only custodial care. Only a small percentage receive intensive psychiatric treatment, even though research has demonstrated that some patients who have been in the hospital as long as 5, 10 or 20 years do recover when they receive intensive treatment. The reason for this situation is that few state hospital systems have the necessary funds to provide adequate staff and equipment for intensive treatment. A key index of this inadequcy is the amount which the hospital spends per day for the maintenance of each patient. (Maintenance covers the salary of all personnel, treatment supplies, plus equipment, food, clothing, and overhead.) Latest figures show that the average daily expenditure for maintenance in public mental hospitals is $6.74 per patient. One state spends as little as $3.18. By contrast, short-term general hospitals spend more than $44 per patient per day, private psychiatric hospitals, $33, and VA psychiatric services, more than $16 per patient per day.

PSYCHIATRISTS: THEIR NUMBER AND DISTRIBUTION

In 1965 the number of practicing psychiatrists totaled about 14,650, providing approximately 721,000 man-hours of work activity per week. However, only 60% of work activity was devoted to direct services to patients, with the remaining time spent in consultation, teaching, administration, and research.

In a recent comprehensive government survey of psychiatrists, in which 88% reported information about themselves, only 9% reported that their major specialty is child psychiatry,

More than half of the nation's psychiatrists are located in five states: 21% in New York, 13% in California, 6% each in Pennsylvania and Massachusetts, and 5% in Illinois; 13% reside in areas which represent 35% of the population. One state has as few as 11 psychiatrists.

COST OF MENTAL ILLNESS

About 2 billion dollars is spent annually for the treatment of mental illness in state, county, Federal and private mental hospitals and in psychiatric units of community general hospitals.

Annual expenditures for community mental health programs (including outpatient clinics) total $112,122,419.

COST OF MENTAL ILLNESS TO INDUSTRY

Business authorities conservatively estimate that the annual loss to industry directly related to emotional disorders is staggering, amounting to many billions of dollars each year.

Mr. BRANDT. The record shows the need for comprehensive mental health services, and I think the fact that the need has been translated into demand for services speaks to the effectiveness of the program which the Congress inaugurated in 1963, which was expanded to include staffing grants in 1965 when the vote in the House was 389 to nothing, and which you are now considering for extension.

The great demand for funds under this program continues. We anticipate that funds presently available will fall far short of the amounts ultimately required.