to physicians, who have the required background, in treatment of the neuroses. The establishment of special clinical services for treatment of neuroses would provide the organization and cases for training. A special training course for those psychiatrists whose experience has been limited to in-patient work with the hospitalized mentally ill could be a quick and effective means of making qualified personnel available for treatment of the neuroses. III. THE EFFECTIVE USE OF CLINICAL SERVICES Merely increasing the capacity of psychiatric clinics as they are now operating is not the entire solution to the problem of providing psychiatric treatment for those who need it. In studying the experince of psychiatric clinics accepting rejectees and dischargees, it was discovered that there were expensive wastes of clinical time, particularly in those clinics whose primary function was conceived as treatment. Most clinics are operated on an appointment schedule and broken appointments cannot easily be filled by other patients. Of 1,185 rejectees and dischargees reported by 11 clinics: 13 percent failed to keep the original clinic appointment. Of those who came to clinic: 19 percent failed to return after 3 or less visits; 16 percent failed to keep appointments after four or more visits; 25 percent were re-referred to other community resources; 28 percent were continuing under care; and 8 percent were discharged as completed service cases. The effectiveness of the clinics' treatment work could be said to be effective in only 36 percent of the number of cases referred (28 percent continued and 8 percent discharged by clinic). This represents too great a waste of clinic time. Responsibility for improper referrals and for men who go to the clinic not understanding the nature of the clinic or of psychiatric help are clearly placed on the referral sources. Proper preparation for referral includes the determination of suitability for out-patient psychiatric care, the preparation of the patient for the services at the clinic and the preparation of pertinent history or diagnostic material for the use of the clinic. Agencies and individuals referring patients to clinics should be meticulous in the screening and preparation of patients for clinic referrals so that the inadequate time available may be used effectively. Clinic procedures, too, must be reexamined in view of the necessity to use each clinic hour in effective service. The following points should be considered by each clinic: (1) Clarification of policies for accepting patients so that other community agencies will refer only acceptable cases. (2) A plan for screening cases prior to acceptance for treatment so that only the cases with treatment possibilities will be given psychiatric treatment time. Such screening procedures could conceivably be made available at central referral points such as the Army induction station, veterans' service center and Veterans' Administration. A centralized screening and referral source which represented all clinical services could do much to eliminate the present system which places responsibility on the patient or the referring agency to find a clinic which can serve the patient. As one means of effecting such a coordination of service, the New York City Committee on Mental Hygiene in 1945 made a psychiatric social worker available to the Veterans' Administration to help in the referral of cases to appropriate clinical services. Such a service might effectively be expanded to other sources of referrals to psychiatric clinics. (3) Clinical procedures: For many of the men in this study, the procedures involved in being admitted to a psychiatric clinic through admitting officers, general medical clinics, social work interviews or other persons, so delay the psychiatric treatment that the man gives up the effort to get help. Modification of procedures within clinics may well result in a lowering of the 42 percent of men who do not return after one clinic visit. IV. PSYCHIATRIC ORIENTATION FOR ALLIED PROFESSIONAL PERSONNEL The data of the study show that of the men who needed and wanted but were not receiving psychiatric help, 85 percent had been in contact with one or more community services (including the family physician). That there had not been recognition of the psychiatric problem or referral to appropriate psychiatric treatment services by the professional staff of the social and health agencies or by the doctor is indication of a real need for more understanding of handicapping psychiatric conditions by the professions who work with troubled people. Perhaps some cases might have been referred to psychiatric services had such services been more available to meet the needs of the population, but there is general experience in this field which indicates that psychiatric problems are too frequently not recognized by the family physician, the employment counselor, or the public welfare worker. The following recommendations are made for psychiatric orientation of professional personnel in social and health services: (1) Social agencies.-In-service courses on psychiatric problems as they appear in the services rendered by an agency for all professional staff members, and especially courses for employment and vocational counseling services and agencies working with veterans. The better the understanding between agencies referring patients and the psychiatric clinics, the more effective the service that can be rendered by both. Therefore, orientation courses given by clinic staff which would include the purpose and policy of the clinic would be mutually helpful. (2) Physicians.—The general practitioners and the physicians in hospitals and clinics have the largest number of contacts with people who are psychiatrically handicapped. They treat the men for their physical ills and for their emotional problems, yet they have, with rare exceptions, little training for the latter responsibility. It is impossible to provide psychiatric treatment for all men having psychiatric handicaps and it is also probably unnecessary. The family physician can often handle most effectively some of the less acute psychiatric problems. To do so, however, he should have some knowledge and training in selection of cases which are proper for him to treat and which require the more specialized training in psychiatry. A program of psychiatric orientation for medicine is contained in a recent publication of a conference held under the auspices of the National Committee for Mental Hygiene, entitled "Medicine and the Neuroses." The findings of the conference which are reported in that publication and its recommendations are endorsed. V. THE DEVELOPMENT OF A PUBLIC PROGRAM OF MENTAL HEALTH CONSULTATION SERVICES Permeating the data in this study is a basic unfamiliarity, on the part of the men with psychiatric problems and the people with whom they have been in contact, with fundamental mental health principles and with knowledge of the possibilities for help with their problems. The concepts they had were that they should get over their difficulties through "will power" or "character," or that their problems were only related to physical conditions. In the psychoneurotic, these falacious ideas often aggravate the condition and rarely is the individual able to bring himself back to a state of healthy functioning through such efforts. That more resources for giving help to people with mental health problems at early stages in their development are urgently needed is again emphasized by this study. Of the men who wanted help but were without it, only 7 percent had ever had contact with a psychiatrist. Most of the men had sought some help from medical or social services but few had been in contact with a service equipped to aid them on their psychiatric problems. The educational as well as therapeutic value of easily available diagnostic and treatment services has been demonstrated in tuberculosis, venereal disease, and cancer. Treatment services in the field of mental hygiene could be of great value in both the early detection and treatment of personality problems and in providing an additional opportunity for people to learn more about behavior. The development of mental health consultation services in New York City's health centers is recommended as an essential part of an adequate preventive and treatment program in mental hygiene. The consultation service here recommended is one in which the services of the full psychotherapeutic team (psychiatrist, psychologist, and psychiatric social worker) would be available. Persons with any type of psychiatric or mentalhealth problem could come for advice. Prolonged, intensive treatment would not be given in the consultation center but cases requiring this type of care would be referred to the psychiatric services specializing in treatment. Such a service could be an effective means of screening cases for the treatment services. The consultation service would give short service to the great number of people who need advice and help on minor problems. Mothers would be given help with their children, young people would have a resource for help with their many problems and professional workers in the area might seek the psychiatric advice of the service on the problems which confront them. The health centers of the health department are recommended as the proper location for such consultation services in New York City for two reasons. First, because the correlation of frequency and type of identified psychiatric problems with socioeconomic conditions makes their prevention and treatment a proper concern of public health and, second, such services should be easily available to all persons in the city and the health centers offer the best setting for their becoming so. Mr. PRIEST. Is Dr. Victor Vogel present? STATEMENT OF DR. VICTOR H. VOGEL, OFFICE OF VOCATIONAL REHABILITATION Dr. VOGEL. My name is Victor H. Vogel, United States Public Health Service, assigned as psychiatric consultant to the Office of Vocational Rehabilitation. Mr. Chairman, Mr. Brown has asked me to add a little additional information on the efforts that New York State is making to meet its mental hygiene needs. I have just come this week from a conference with the commissioner of State department of mental hygiene, Dr. MacCurdy, in Albany, and I know he has extensive plans for setting up a postwar system of mental-hygiene clinics to serve the citizens of New York. These plans are being delayed now because of the unavailability of psychiatrists whom he hopes to get released from the armed services. He also has plans for training psychiatrists for these additional staff physicians in the nucleus of mental hygiene clinics now existing in the mental hygiene program in the State hos-pitals of New York. Mr. PRIEST. We certainly thank you for that explanation. Dr. VOGEL. I think what a State like New York will require from a Federal program such as this bill would create would be a knowledge of increased research and the proper techniques for the treatment of mental disorders. Mr. PRIEST. This concludes the hearing of witnesses. The Chair, without objection, would like to insert in the record at this point a letter written by Mr. Sanford Bates to Congressman Wolverton some time ago. Mr. Bates had hoped to appear here today, but was unable to do so, and his views with reference to this legislation are contained in that letter to Mr. Wolverton. (The letter referred to is as follows:) STATE OF NEW JERSEY, DEPARTMENT INSTITUTIONS AND AGENCIES, Trenton, June 26, 1945. Hon. CHARLES A. WOLVERTON, Member of Congress, Washington, D. C. MY DEAR CONGRESSMAN: I note that you are a ranking member of the Committee on Interstate and Foreign Commerce. There has been referred to your committee a bill, H. R. 2550, which in section 7 in its present form contains provision which will cause a serious conflict in the administration of this department and, in fact, of the work of supervising mental hospitals and mental hygiene in most of the States of the country. As you know, this department of institutions and agencies was established in 1918 and ever since then, under the expert and humanitarian guidance of Commissioner William J. Ellis, has developed a mental hygiene service which has brought great credit to this State. The health department in this State has had nothing to do with the control and administration of mental hospitals or the development of preventive mental hygiene programs. This is true in New York, Massachusetts, and many other places. The matter came before the mental hygiene committee of the department of institutions and agencies yesterday and they voted unanimously to protest against the present wording of section 7 and to ask that that provision of the bill be amended by striking out the reference to "health authorities" and substituting the phrase "authority having control of the administration of mental hygiene activities." I am enclosing herewith an attested copy of the minutes of this committee. I have talked with Dr. MacCurdy, commissioner of mental hygiene in New York City, and also I have gotten in touch with Dr. Perkins, commissioner of mental diseases for Massachusetts, and they both are strongly of the opinion that the bill should not pass with this section as it now is. I feel sure we can count on you to see that this change is made in order that the work of practically all the States in the country might not be upset or an unfortunate conflict develop in this important activity. Very truly yours, SANFORD BATES, Commissioner. Mr. PRIEST. Without objection, we will also insert in the record a letter from the Illinois Society for Mental Hygiene; a letter from Dr. Karl M. Bowman, president, American Psychiatric Association; a letter from Margaret Clark Lefevre, executive secretary of the Minnesota Mental Hygiene Society. (The letters referred to are as follows:) Hon. JAMES PERCY PRIEST, ILLINOIS SOCIETY FOR MENTAL HYGIENE, House Office Building, Washington, D. C. DEAR CONGRESSMAN PRIEST: It has come to my attention that the House will soon consider a bill to provide for and aid in coordinating research relating to neuropsychiatric disorders; to provide for more effective methods of prevention, diagnosis, and treatment of such disorders; to establish a National Neuropsychiatric Institute; and for other purposes. This, I believe, is H. R. 2550. The members of the board of directors of the Illinois Society for Mental Hygiene at its last meeting has carefully studied the provisions of this bill and would urge that you do everything within your power to secure passage of such legislation. As a mental hygiene society we have kept in close touch with the mental health of the Nation in general, and our State in particular. We are well cognizant of the deficiencies that exist, and we are firmly of the opinion that the passage of this legislation will be a great help to meet some of the existing deficiencies. Sincerely yours, Hon. J. PERCY PRIEST, V RUDOLPH G. NOVICK, M. D., AMERICAN PSYCHIATRIC ASSOCIATION, House of Representatives, Washington, D. C. HONORABLE SIR: I have read through H. R. 2550 which you have presented. In my opinion H. R. 2550 is a definite step forward in the attempt to solve the problem of mental disease and mental defect. The provision for a central research hospital under United States Public Health Service will develop further study of this problem by the Public Health Service and will result in the Government's taking greater interest and more intelligent interest in this matter. The provision for grants-in-aid for research under other than the United States Public Health Service auspices will enable various medical schools, universities, and hospitals throughout the country to carry on studies which are clearly needed and will offer them financial assistance without which this would be impossible. The provisions for training and instruction will enable us to secure more and better psychiatrists. These are badly needed at the present time. There are only two points of a somewhat technical nature that I wish to raise: First, I believe that the term "neuropsychiatric' is a misnomer and that what should be established is a National Psychiatric Institute. Psychiatry is that specialty of medicine which deals with the problems of mental health and mental disease. Since the bill provides for establishing the National Advisory Mental Health Council, it would seem to be more appropriate to use the word "psychiatric" than "neuropsychiatric" throughout the wording of this bill. Second, it is not clear to me whether the use of the term "State health authority" would limit the grant to the State department of public health or whether the State departments of mental hygiene or of mental health, or by what other term they are called, would be eligible to receive grants. It seems that most study and research concerning the problem of mental health would be carried out by the State department that has charge of mental health no matter what its exact title is. I wish to state, therefore, that I regard this bill of great importance for the future health of this Nation and hope that it will be passed. Sincerely yours, Hon. J. PERCY PRIEST, KARL M. BOWMAN, M. D., President. MINNESOTA MENTAL HYGIENE SOCIETY, INC., House of Representatives, Washington, D. C. DEAR MR. REPRESENTATIVE: Shortly after the introduction of the National Neuropsychiatric Institute bill, H. R. 2550, the Minnesota Mental Hygiene Society wrote to our Representatives in Congress, enclosing the following page that we issued to our members, and urging their support of the bill. At that time we called to the attention of Dr. Walter Judd certain safeguards which we would like to see incorporated in the bill if it could be done without jeopardizing its passage. May we take this opportunity to call them to your attention, too? It would seem to us that the legislation should be written to provide for adequate representation on the National Advisory Health Council of competent men from each of the several fields included in the broad term "neuropsychiatry" so that while one field might from time to time receive more attention on the basis of over-all needs, decisions will not be made because of the special interests of the men serving at the time on the Council; that similarly, there should be adequate geographical representation on the Council, to assure that funds will be equitably distributed on the basis of the value of the projects concerned, and not concentrated in one area of the country. Briefly, it is our opinion that the legislation should be written in such terms that its intentions would be mandatory upon any administrator, and that we should foresee the possibility of a man in that position who would not merit the confidence we can justly place in our present Surgeon General. We want to assure you of our full support of the bill and of the needs in the State of Minnesota for such funds as it will make available. Respectfully yours, MARGARET CLARK LEFEVRE, Mr. PRIEST. The Chair would like to state also that Dr. I. E. Reagan, who is State public health officer of the State of Virginia, and also is president of the Association of State and Territorial Public Health Officials, is preparing a statement for the record. He had hoped to be here but could not come. Dr. C. B. Winslow, professor of public health, of Yale University, also had hoped to be here but could not come, and he also is preparing a statement, and without objection his statement, when received, will be printed in the record. The Chair will state that up to this minute there has been only one voice raised in opposition to this legislation. It came in a letter this morning from the Citizens Medical Reference Bureau, Inc., an organization which is against compulsory medicine or surgery for children or adults. Without objection, that voice of opposition will also be entered in the record at this point, and without objection a brief editorial under the caption "New leadership in mental hygiene," from the American Journal of Public Health, June issue, 1945, will be entered in the record. (The papers referred to are as follows:) |