mality either in circulation or total oxygen consumption of the brain in schizophrenia.

A major area of research in the Institute deals with family relations in schizophrenia. Perhaps the single point on which there has been the greatest agreement, at least at the level of clinical impression among workers in this field, is that there is some sort of gross defect or abnormality of a psychosocial nature in the families of schizophrenic patients.

Progress during 1958 in work on family studies included: (1) enlargement of the number of families of schizophrenics studies; (2) beginning of clinical comparison studies with the families of nonschizophrenics; and (3) development of new clinical methods, such as family therapy, in which parents, the patient, and siblings are seen together and their transactions are observed directly and studied diagnostically through a psychotherapeutic approach.

In addition to the kinds of research projects and investigations described above, the Institute is curently supporting, under its mental health project grants program, a large number of experiments, demonstrations, and studies designed to develop improved methods of diagnosis, care, treatment, and rehabilitation of schizophrenic patients.

TRAINING

Although progress has been made in increasing the number of persons trained in a variety of mental health disciplines, we are still faced with serious shortage areas. Since its inception, the Institute's training program has been dedicated to stimulating an increase in both the quality and quantity of professional personnel in the mental health disciplines. Until 1958 emphasis was primarily on training clinical personnel. This is an area where the needs remain immediate and critical. We are therefore continuing to strengthen this program. Beginning in 1958, the training program entered into a new phase of its development with the expansion of research training and the inauguration of two new programs.

Research training

The research fellowship program was markedly expanded in the current fiscal year. In line with congressional recommendations, a substantial share of the increased funds has been awarded for research fellowships in the field of physiology.

Currently available support for research training includes: grants to four medical schools for the development of interdisciplinary training, particularly the research aspects of training for biologic and social scientists in the field of mental illness so that there will be a broader approach to the solution of the problems of mental health and mental illness; medical student stipends for extracurricular clinical or research activities in psychiatry; research training on a graduate level in psychology. In this latter program 23 new grants were awarded during 1959 in 9 areas of psychology.

Other new programs

As early as 1947, the Institute recognized the need for sufficient psychiatric training to enable physicians to deal more effectively with the emotional problems of health and illness. By 1950, grant support in the undergraduate training program was provided to expand psychiatric curriculum in nearly half of the medical schools. At present all medical schools provide this training. Since no provision was made for the physician who graduated prior to 1950, a few grants were awarded during the last 10 years for postgraduate institutes and workshops for groups of general practitioners and other physicians in practice. Those pilot efforts have been most successful.

Public interest in psychiatric training for general practitioners and congressional support have made it possible for us to move forward in this area. The present program provides two types of training for the practicing physicianthe residency training program under which grant support may be provided which enables the practicing physician to leave his practice and take training which will make him a full fledged psychiatrist; the other is for postgraduate courses for the practicing physician who intends to continue his practice but who wishes to have a better understanding of the psychological factors in health and illness.

Under the program, support is offered medical schools, hospitals, clinics, and national and local medical and psychiatric societies to develop and conduct

postgraduate courses, institutes, and seminars. The response to this program to date is concrete evidence that this type of training is fulfilling a hitherto unmet need. Four grants (two residency, two postgraduate) have been awarded. Thirteen additional applications (10 residency, 3 postgraduate) have been approved by the National Advisory Mental Health Council and funds will be awarded shortly.

State activities

COMMUNITY SERVICES PROGRAM

It takes many strands to weave a pattern but the pattern in State community mental health programs is emerging perhaps faster than any of us would have dared to dream 10 years ago. In State mental health programs there has been a trend toward more interagency collaboration. One finds increasing participation of community mental health and hospital programs in the training programs of professional schools. Federal, State, and local funds budgeted in 1958 by State mental health authorities increased sharply for training of community mental health people.

The technical assistance projects program has been an exceedingly fruitful avenue for strengthening community mental health programs, coordinating mental health activities in a State, and bringing to people working on State problems expert knowledge on specific subjects. At the invitation of the State mental health authority the Institute helps plan and supports workshops or conferences on a particular subject of concern to the State. Top experts in the field are invited to attend and join with the State personnel in a concentrated study of specific problems. Last year 17 such projects were completed. Subjects ranged from mental retardation to alcoholism as a mental health problem in industry. The impact of these technical assistance projects is not limited to the originating State since reports of the project are published and distributed widely to people in other States.

Regional activities

States are cooperating to attack problems of mental illness and to promote mental health in a number of ways. We have discussed, in other years, the importance of the work of the Southern Regional Education Board, the North East State Governments Conference, and the Western Interstate Commission for Higher Education. This last year as a result of the 11-State survey of mental health needs conducted by Western Interstate Commission on Higher Education, a Western Council for Mental Health Training and Research was established. This organization has a 4-year grant from the Institute. Their goals include the development of programs in the Western States in mental health training and research which cross not only State lines but institutional and professional lines as well. Some very practical approaches include the development of psychiatric residency programs between universities and State hospitals on an interstate basis, specific research and training programs which Would include summer placement programs for high school students, and summer training programs for graduate students.

The year 1958 witnessed the growth of cooperation through interstate compacts. Two States, Kentucky and Louisiana, passed legislation ratifying the interstate compact on mental health. This brings the total to 12 States now participating in this interstate agreement. Under this program State residency requirements may be waived if to do so is for the best interests of the sick person.

Developing mental health services in rural areas continues to be a major problem. Most mental health services are concentrated in cities, especially in metropolitan areas which have professional training centers. The most recent data available indicate that only 9 percent of professional man-hours of all outpatient psychiatric clinics were in rural areas which contained 41 percent of the population of the Nation. Several States are experimenting with regional or multicounty administrative units for providing mental health services.

In 1939, only 43 general hospitals in the United States accepted psychiatric patients: in 1959, almost 1,000 general hospitals accepted these patients. The availability of coverage for mental illness in Blue Cross and other health insurance plans has been an important factor in this development in many States. Despite this encouraging progress, however, the majority of general hospitals still do not provide care for psychiatric patients.

Alcoholism

Last year, as a result of the stimulus of this committee's action and the appropriation of funds for work in the field of alcoholism, the Institute took steps to expand and strengthen its work with the States. To accelerate joint efforts of key people on this problem in different parts of the country, two nationallevel conferences were held. In January, staff members of the National Institute of Mental Health and Public Health Service Bureau of State Services met with the executive committee of the North American Association of Alcoholism Programs. In April, in conjunction with the Bureau of State Services, an ad hoc planning committee met with representatives of a variety of official and voluntary agencies with an active interest in alcoholism. Present knowledge and programs in the field were reviewed in conjunction with future planning.

The Institute has increased its consultative and technical assistance services to States and communities with respect to alcoholism programs. Consultation was provided on such problems as developing more effective treatment and rehabilitation measures in hospitals and clinics, alcoholism in industry, alcoholism among the Indians, and alcoholism in relation to such chronic diseases as tuberculosis.

CARE OF MENTALLY ILL

We are in a period of changing concepts with regard to treatment of the mentally ill. Traditional ideas of treatment are being challenged. There is a growing recognition of the concept that long periods of hospitalization are not necessarily the best treatment for every person who is mentally ill. More and more in Europe and in this country the role of the mental hospital is being studied in relation to other community facilities for the treatment and rehabilitation of the mentally ill.

Mapperly Hospital, Nottingham, England has developed in that community a mental health service which provides for use of the resources of the home, domicilary services, and community activities in the treatment and rehabilitation of the mentally ill. Outpatient services with short-term admission to hospitals, as required for treatment or rehabilitation are part of this program. With the development of hospital-community cooperation, Mapperly is also an open hospital-there are no locked wards.

This program, as well as many others, raised interesting questions about hospital management and the best ways to reduce disability from mental illness. which are reflected in a variety of new approaches being explored in this country. Establishment of day and night hospitals, "open" hospitals, emergency care and outpatient treatment servces, as well as followup and aftercare programs are in operation in many areas of the United States.

Many of the mental health project grants being supported by the Institute under the provisions of title V of the Health Amendments Act (Public Law 911) are designed to explore improved methods of care, treatment, and rehabilitation of the mentally ill. One State hospital, for example, has established an emergency psychiatric team who vists the patient in his home and provides intensive emergency treatment there. The study will eventually determine the effectiveness of this type of treatment as compared with hospitalization. This is somewhat similar to the program initiated in Amsterdam, Holland, a number of years ago by Dr. Querido. He found it an effective method. Among the 71 mental health project grants presently being supported are experiments and demonstrations which will provide new knowledge on effective methods of care, treatment, and rehabilitation of the mentally ill. In addition, this program stimulates the use of knowledge already available but not widely used.

BIOMETRICS

As more new therapeutics programs (drugs, use of day and night hospitals, halfway houses, and open hospitals) and treatment facilities are introduced into hospital and community programs, the task of obtaining data on people under treatment becomes increasingly difficult to interpret. Yet it is imperative to have data which tells us what is happening to the people we are treating. Eleven States in the model reporting area have completed cohort studies which illustrate these points. These studies determine probabilities of release, death, and retention in the hospital. Groups of first admissions, matched as to age, sex, and diagnosis, were followed for the first 12 months of hospitalization.

These studies demonstrated that there is considerable variation among the mental hospital systems of these States and the probability of retention, re

lease, and death during the first 12 months following first admission. A large variety of factors were responsible for the differences. These included characteristics of patients admitted, the severity of the illness, the characteristics of the communities from which the patients were drawn and to which they returned, the presence or absence of other facilities for the care and treatment of the mentally ill, hospital policies which affect the admission or release of patients, staffing patterns of treatment programs, and the philosophy of the hospital with respect to the degree of improvement expected in patients prior to their return to the community.

The interaction of factors operating in these hospitals and the communities they serve raises the question of how we are going to use the mental hospital in the future. For example, public mental hospitals in areas where there are large psychiatric units in general hospitals may receive a higher proportion of patients with poorer prognosis than in areas where the mental hospital is the only or primary treatment resource. The facts in these studies not only demonstrate the significance of this type of information but also open new horizons in our concepts of hospital management and the role of the mental hospital of the future. What is the optimal size of a mental hospital? What is the best relation between acute and continued treatment services? How should the mental and emotional problems of special groups, such as alcoholics or the aged, best be managed? Certainly the mental hospital will be different from that of the past. This is as it should be, because as man has learned he has moved ahead.

PROGRESS IN 1959

Dr. FELIX. Mr. Chairman and members of the committee, during 1959 every program of the Institute expanded and in some areas new programs were developed.

In the research grants program there was a substantial increase in the number of studies on problems of schizophrenia, alcoholism, mental retardation, and psychopharmacology.

Support of projects in psychopharmacology has increased from about $2 million to approximately $4 million.

A new energizer developed during the past year appears to be a promising specific treatment for mental depression, and studies are being made which may lead to its use in this type of mental illness.

A large number of projects were concerned with various phases of the problems presented by schizophrenia. Twenty-seven studies were devoted to evaluating the use of drug therapy in this disease. Many other projects dealt with basic physiological, psychological, and sociological aspects of schizophrenia.

Mental health project grants (title V, Public Law 911, 84th Cong.) number 71 and show great promise in developing new concepts in the care of the mentally ill, as well as encouraging the utilization of existing knowledge.

DEVELOPMENTS IN FIELD OF SCHIZOPHRENIA

Senator HILL. Insofar as schizophrenia is concerned, it affects a large number, a relatively large number of people; is that not true? Dr. FELIX. That is correct.

Senator HILL. And up to recently there has not been too much that could be done about it; is that right?

Dr. FELIX. That is true. This is the most serious, generally speaking, the most malignant of the mental illnesses, and on any day sufferers from this disease occupy more beds in mental hospitals than any other category of disease.

Senator HILL. Most of them really have become lost souls, so to speak, have they not?

Dr. FELIX. To a large extent, this is so. We feel there are some developments which may change this picture. Some of the new drugs give promise of moving these patients toward health with the assistance of other types of therapy, which may change this picture one of these days, we hope.

SPECIAL REPORT

If the chairman and the committee would wish, I have a special report on program developments in schizophrenia which I could submit for the record.

Senator HILL. We will be very happy to have it. (The report referred to follows:)

PROGRAM DEVELOPMENTS RELATING TO SCHIZOPHRENIA, 1959

In appropriating funds for fiscal year 1959, the Congress recommended that $1,300,000 should be spent in the area of schizophrenia, over and above amounts spent the previous year. Consonant with the gravity and the extent of schizophrenic disorders among the mentally ill, the NIMH has channeled approximately half of its research funds into studies directly or indirectly related to schizophrenia. The total allocation for research grants and intramural programs combined in fiscal year 1959 is $28,810,000. Thus an estimated $14,400,000 may be regarded as being applied to activities relevant to schizophrenia.

Such activities include a wide range of studies in basic research, in clinical research, and the testing of promising therapeutic measures, in the collection and interpretation of trends in mental hospital populations, as well as programs for the advanced training of personnel in techniques of therapy and rehabilitation, and projects in the development of hospital, clinic, and community services for the diagnosis, treatment, and rehabilitation of the mentally ill.

Although it is possible to distinguish activities specifically related to schizophrenia fairly clearly in certain types of clinical research, it is less meaningful to attempt to pinpoint the specific effort in schizophrenia within the areas of basic research, training, and community service. In basic research, developments in many fields may be potentially relevant to schizophrenia. Training and community service activities, on the other hand, maintain a broad strategy in preparing personnel to utilize all effective procedures, as they develop, in the treatment of the mentally ill.

The following report indicates the current support and conduct of research under NIMH auspices which pertains fairly directly to schizophrenia, and gives a view of the main directions taken by the program.

THE RESEARCH GRANT PROGRAM

The Institute's fiscal year 1959 estimate for the support of research on schizophrenia, carried out in hospitals, clinics, universities, and other institutions throughout the Nation by NIMH grantees, was $4,324,000-an amount larger by $680,000 than the research grant expenditure in schizophrenia for fiscal year 1958.

It is anticipated that, by the close of fiscal year 1959, a total of 200 basic and clinical research projects directly related to schizophrenia, in the amount of $5,708,000, will be supported in fiscal year 1959 through the grant program.

The size of the Institute's research grant program reflects the steadily growing interest of research investigators in probing the many unsolved questions concerning the etiology and treatment of schizophrenia. No one "cause" of schizophrenia has been identified. Scientists today believe that this condition of profound mental and emotional disorder probably results from the interplay of multiple biological, psychological, and social factors-the specific importance of which may vary from patient to patient. As a consequence, a wide range of research projects in many disciplines, including a variety of collaborative studies, is underway.

In view of the importance of the problem and the urgent demands for research results, the Institute has attempted to follow all possible scientific leads in its