State Care
For almost a century, the responsibility of providing care and treatment for our nation’s mentally ill has fallen to the state. The programs followed in the state hospitals and clinics of New York are here described by DR. PAUL H. HOCH, commissioner of mental hygiene for the state of New York since 1955. Dr. Hoch, who is professor of clinical psychiatry at Columbia, was born in Hungary and came to the United States in 1933 after serving as physician in charge of brain research at the University of Goettingen in Germany. In this country he has continued his research and practiced psychiatry.
PAUL H. HOCH, M.D.
THE statistical facts about the incidence and the prevalence of mental illness have been so widely publicized in the last decade that they have been synthesized in a series of cliches: “Half the hospital beds in the country are occupied by mental patients.” “One person in ten is sufficiently sick mentally or emotionally to require professional help.” “One family in three will at some time place one of its members in a mental hospital.” “Mental illness is the country’s number-one health problem.” Unfortunately, these are not exaggerations or slogans but the simple truth. At the present time there are 500,000 patients in mental hospitals throughout the country; possibly one million are under treatment in clinics or other outpatient facilities; and countless thousands who need psychiatric help are receiving no treatment of any kind.
For almost a century the responsibility of providing care and treatment for the mentally ill has fallen to the state. During most of this period there was little treatment available, and the function of the state hospitals was largely custodial. With rapidly rising admissions and a constant accretion of patients who did not improve or recover, the population of these institutions expanded at an alarming rate. By 1955 the rate of increase in New York state was sufficient to require a new institution every year. Since it was impossible to keep up with this growth by constant construction of new hospitals, the result was that the existing hospitals became seriously overcrowded and the outlook for the future was bleak.
At this time our efforts were concentrated on three major areas: intensive research to develop new effective treatments; training of badly needed specialists in the various psychiatric professions; and development of a construction program to reduce overcrowding, replace obsolete facilities, and provide for inevitable future expansion.
What happened in 1955 is now history. Research paid off. The tranquilizing drugs and other new therapies were introduced. There was a sudden substantial increase in the number of patients who improved sufficiently to leave the hospital. For the first time in the history of the mental hospitals the inexorable rise in patient census was stemmed, and hospital populations began to decline.
Another revolutionary change was taking place at the same time. With the passage of New York state’s pioneer Community Mental Health Services Act in 1954, the concept of community care became a reality. This law established the principle that local governments should share the responsibility for care of the mentally ill and that treatment should be provided in the community as close to the patient’s home as possible. Under the act the state pays half the cost of local mental health services operating in a county or city program. New York state reimbursed local governments for such services last year in the amount of $15,758,728.
Last year, for the first time, the federal government, having confined its interest to research and training, recognized its responsibility in the area of psychiatric care and established a program of aid to states for the development of mental health services in the community and the improvement of mental hospitals. Thus, three levels of government are now involved in the staggering public problem of providing care and treatment for the mentally ill, and the principle of joint responsibility is accepted. Financially, however, the sharing at the present time by local governments and the federal government in the total cost is quite limited. In New York state, for the current year, city and county governments are investing some $21 million, the federal government is contributing $4 to $5 million, while the state’s mental hygiene budget is $363 million, about 30 percent of the total budget for state operations.
NEW YORK state’s mental hygiene program represents perhaps the largest and most complex state government operation in the world, requiring the services of some 44,000 persons — more than a third of the state’s employees. The magnitude of its operation is a reflection of the extent of the health and social problems represented by mental illness and mental retardation.
The Department of Mental Hygiene operates twenty-nine institutions, including nineteen hospitals for the mentally ill, seven schools for the retarded, a hospital for epileptics, a research and training institute, and a hospital for short-term treatment and training. In these institutions there were 112,000 patients as of March 31, 1964. Another 21,000 were convalescing in the community, receiving follow-up care through state-operated clinics.
Of the resident patients, 85,000 were under treatment in the state hospitals. During the year, 32,000 patients were admitted, 10 percent more than in the previous year and 48 percent more than in 1954. The continuing growth in admissions is due not to any rise in the incidence of mental illness but to increasing longevity, increasing general population, increasing demand for psychiatric care, and increasing public confidence in state hospitals and the effectiveness of their therapeutic programs. In the last few years our hospitals have treated more patients than ever before in their history.
Despite this tremendous increase in admissions, we have been able to achieve a steady diminution of total hospital census through an even greater increase in releases. During the fiscal year, 30,000 patients were released to the community, 100 percent more than in 1954. In this same period the average length of hospitalization was reduced from eight months to four months. Thus, with modern treatment methods the hospitals are able to hold their own against an overwhelming influx of patients by getting more patients out of the hospital and by getting them out faster. Since 1955 there has been an average decrease of one percent in total hospital population each year.
The treatment program that has made this achievement possible includes a variety of tranquilizing or energizing drugs; electric shock therapy, and for some patients, insulin; group therapy, and in selected cases individual psychotherapy; rehabilitative techniques such as occupational and recreational therapy and especially vocational rehabilitation; and in many hospitals the subtle influence of milieu therapy, which involves the interpersonal relationship between patients and hospital staff. Preferences vary, of course, as to which treatment should be emphasized, and no therapy or combination of therapies constitutes a panacea, but the significant fact is that, for the acute patient at least, effective treatment is a reality. The improvement in speed and rate of recovery is directly attributable to the intensive treatment program operating in an open hospital setting.
There are in the New York state hospitals about 30,000 patients who require long-term care. Many of these chronic patients entered the hospitals before the advent of the newer therapies. Others, although exposed to modern treatment methods, failed to respond. Experience has shown that as many as 10 percent of these chronic patients will respond to retreatment sufficiently to leave the hospital. We have provided for intensive treatment units for chronic patients at all state hospitals. Thirteen are now in operation, and the rest will be set up this year.
There are several groups of patients with extraordinary handicaps requiring highly specialized services. Among these are mentally ill and emotionally disturbed children, the mentally ill blind, the mentally ill deaf, and the aged who require psychiatric care. Special units are provided for all of these groups in the state hospitals. The demand for such special services is increasing rapidly, and more units are needed, particularly for children. There are now special facilities for children in ten hospitals, and additional ones will be established wherever the need exists. In each of them full educational and recreational opportunities are provided, as well as treatment.
New programs have recently been established for the treatment of narcotics addicts and alcoholics. A Division of Alcoholism was created in the Department of Mental Hygiene in 1961, and a Division of Narcotics Addiction in 1962. These represent two new groups of patients which the state hospitals were unable to accommodate in the past.
At present there are two units for the treatment of alcoholics located in state hospitals. An aftercare clinic is also in operation in the New York City metropolitan area. In addition, contracts have been signed for two state-supported alcoholism clinics to provide treatment on a community basis. Under the state-aided program, the counties also are beginning to develop alcoholism clinics and other services in the community.
The state’s comprehensive three-pronged program on narcotics addiction provides for treatment, aftercare, and research. Six narcotics inpatient units have been established in state hospitals, providing a total of 555 beds. Aftercare is provided in a special clinic, soon to be augmented by a second installation, and intensive research is being carried on at Manhattan State Hospital, including both clinical and laboratory studies.
Under the Metcalf-Volker Act, a pioneering law which established the program in 1962, arrested narcotics addicts who are not hardened criminals may elect to be hospitalized for treatment rather than stand trial for their violations. Charges against them subsequently may be dropped upon successful conclusion of the hospital treatment program, including aftercare.
IN ADDITION to the many programs which involve the state hospitals and the various categories of mental illness, the Department of Mental Hygiene conducts a broad program of care and training for the mentally retarded. Here again we are dealing with a problem of major dimensions. Of every hundred children born, three will be retarded. While most of these can remain at home, particularly with recent expansion in community facilities, a certain proportion will eventually require institutional care. An increasing percentage of those entering institutions are severely retarded, with physical as well as mental disabilities. These people need intensive nursing care and are less likely to return to the community.
New York state operates seven residential schools for the retarded, in which at the present time there are 25,000 patients. This number has been increasing at the rate of 500 to 600 patients annually, resulting in a serious problem of overcrowding despite an active building program. The recently created Mental Hygiene Facilities Improvement Fund is working closely with the Department of Mental Hygiene to accelerate urgently needed construction of state school facilities as well as other aspects of the building program. Four new state schools for approximately 6000 patients are in various stages of planning and construction.
The program for the retarded is administered by the department’s Division of Mental Retardation under an associate commissioner. Its objective is to provide the best possible medical care, education, and training for patients in the state schools, in order to raise these patients to the maximum level of self-sufficiency. For those who are able to return to the community, programs of vocational preparation are conducted, as well as special training in homemaking, grooming, and other requirements of daily living.
Today there is increasing emphasis on the development of community services for retarded children and adults, including special classes, training centers, day occupational centers, and sheltered workshops. Interest in such services is now being stimulated under the state-aided community mental health program.
The community program, now ten years old, provides a working basis for comprehensive, coordinated services throughout the state in which state hospitals are an integral part of the total community operation. Planning now under way at both the state and local levels aims to strengthen this integration and fill existing gaps in service. At the present time New York City and thirty-three counties, representing 94 percent of the state’s population, are participating in the program and receiving state aid. Local services for which state aid is available include psychiatric units in general hospitals, psychiatric clinics, rehabilitation services, and consultant or educational services to related agencies such as schools, courts, and health or welfare agencies.
Another area of acute need for psychiatric services which received scant attention in the past is the correctional institutions. In recent years the Department of Mental Hygiene has developed a staff of more than fifty psychiatrists and thirty psychologists plus psychiatric nurses and psychiatric social workers, who are assigned full or part time to prisons, reformatories, and other installations of the Department of Correction. These services are under the direction of an assistant commissioner for forensic psychiatry.
Personnel required to operate mental health facilities and conduct a comprehensive psychiatric service include a formidable range of professional and subprofessional specialties, in virtually all of which there are grave national shortages — psychiatrists, psychologists, nurses, social workers, occupational and recreational therapists, physical therapists, psychiatric aides, teachers of the handicapped, and others. In addition, there is in every institution a vast array of business, service, and maintenance employees essential to the daily life of a self-sufficient community. For all categories there must be continuous training, both in preparation for a profession and on an in-service level. Providing such training is a major responsibility of a state mental health department. New York’s program includes a graduate school of psychiatry, psychiatric residencies in all hospitals, and eighteen schools of nursing which provide 75 percent of our own psychiatric nurses and in addition give affiliate training in psychiatric nursing to students of nearly all other schools of nursing in the state. There is also a school of practical nursing specializing in the care of the retarded.
In-service education offers stipends and scholarships for academic training at colleges and universities as well as regular seminars conducted within the system. There are internship programs in a number of professions and a central school for foodservice personnel. The twofold objective of the program is to produce new professionals and skilled specialists and to keep all employees, particularly those dealing directly with patients, abreast of new developments in their respective fields.
Keeping the public informed about mental illness and mental health is another important obligation of a state mental health agency. Through its office of public relations the department conducts a broad educational program designed to reach all segments of the public and utilizing all available media.
In psychiatry, as in any other field of scientific endeavor, research is the lifeblood of progress. The spectacular advances of the last few years, the development of new effective treatments which have transformed the mental hospital and made possible a whole new philosophy of community-centered care, are direct and dramatic results of intensive research. Some of the most significant research in recent history was conducted in New York state hospitals when mass trials of the new tranquilizing drugs demonstrated their effectiveness beyond all question. The decision to use them on a large scale was made late in 1954, and by the middle of 1955 the impact of this new therapy had changed the entire mental health picture, first in New York state and shortly after in the rest of the country.
This was not the first major contribution of New York’s research program to the care and treatment of the mentally ill, nor will it be the last. Along with other agencies throughout the country, we are concentrating on many new avenues of investigation and intensifying our efforts in more familiar areas of study.
Since 1954 the comprehensive drug research program has tested over 330 different drugs and has made much progress during the past few years in the study of new tranquilizing compounds, as well as the recently developed antidepressant drugs. Major areas of research today are in the nature and etiology of schizophrenia, arteriosclerosis and other disorders associated with aging, mental retardation, addiction, and mental diseases of children.
Until research produces the solution to this tremendous problem of mental disorder, until we have at our disposal specific cures and effective preventives, the major emphasis of today’s multifaceted mental health program must continue to be the care and treatment of the mentally disabled. While the program is broad, comprehensive, and inevitably costly, there are many areas in which it has only scratched the surface. There are certain aspects of our operation in which the success we are now achieving is only an indication of what could be achieved if adequate resources were available.
Perhaps the most pressing problem of all stems from the financial straitjacket placed upon the mental hospitals, which are expected to operate a modern medical facility with a full program of psychiatric treatment on a fiscal pattern designed for a nineteenth-century poorhouse. Psychiatric care in a general hospital today costs from $25 to $40 a day. Yet, throughout the country, state hospitals are struggling to provide the same kind of care on an average of less than $5 a patient per diem. New York allows about $6 a day, and we feel that our hospitals rank among the best. But there is a limit to what can be done within these stringent provisions. Treatment suffers from restricted personnel and the deleterious effects of overcrowded, antiquated housing, and the standard of living for patients is geared to a painfully frugal economy.
Plans that are emerging today will bring to bear upon this staggering human problem the best that modern medicine and all of the related service professions have to offer. But these plans can be implemented only to the degree that they are supported by cold cash. The state can no longer bear this burden alone. The only feasible approach to future mental health care in this country is through multiple financing on a large scale. Federal, state, and local governments must combine resources, and their contribution must be supplemented by private and voluntary financing plus insurance.
The time has come to repudiate the long shadow of the nineteenth century and bring the problem of mental illness out into the light of a new day. We must deal with it as realistically and as wholeheartedly as we do with any other medical problem. Until we do, we are just as guilty as our ancestors of rejecting and neglecting America’s mentally ill.