Mental diseases: a public health problem. James Vance May
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hundredths per cent were cases of dementia praecox; 1.7 per cent of alcoholism; 2.26 per cent of alcoholic psychoses; 2.39 per cent of epilepsy; 15.72 per cent of mental deficiency; 9.0 per cent of psychoneuroses; 2.14 per cent of manic-depressive insanity; 2.09 per cent of psychopathic personality; 1.21 per cent of general paresis; and 2.94 per cent were unclassified. Two and thirty-two hundredths per cent were diagnosed as suffering from syphilis in some form and 6.27 per cent were either delinquent, defective, subnormal, retarded or distinctly feebleminded. In 3.76 per cent no disease was found, either mental or physical. The great bulk of these cases were diagnosed either as mental deficiency, psychopathic personality or epilepsy. The ultimate disposition of 2,741 cases, covering a period of two years, serves as an index of the practical operation of such a department. In 42.03 per cent of these cases no care or observation other than that of the out-patient department was required. In 1.69 per cent of the cases commitment was recommended to hospitals for mental diseases, in 7.15 per cent, to schools for the feebleminded and in .11 per cent, to penal institutions. General or psychopathic hospital care was recommended in 11.31 per cent. In 2.74 per cent of the cases a report was made to courts; in 1.61 per cent, to schools; in 18.75 per cent, to social agencies; and in 1.13 per cent, to physicians.
The functions of the social service department in a general way may be summarized as follows:—1. The after care and supervision of patients at home; 2. Advice to families of patients in regard to their cases; 3. Advice given other members of the family; 4. Financial relief; 5. Reference to other social agencies or institutions; 6. Information obtained for case histories; 7. Inquiries relative to home conditions when discharge of a patient is under consideration, etc. The routine operation of the department is well illustrated by the annual report of the Boston State Hospital for 1920. The number under social service supervision during the year was 428. Of these, 278 were new cases. Thirty-two and thirty-seven hundredths per cent were referred by the out-patient physicians; 59.71 per cent by the ward service; 7.19 per cent by other social agencies; and .73 per cent were brought by relatives or friends. The principal reasons for their reference to the social service workers were shown as follows:—For medical history, 50.36 per cent; assistance in securing employment, 9.35 per cent; financial aid, 3.6 per cent; supervision, 7.2 per cent; advice, 19.42 per cent; convalescent care, 2.87 per cent; home care, 2.87 per cent, etc. An analysis of the cases under supervision shows the principal psychoses represented to be as follows:—Arteriosclerosis, 1.8 per cent; general paresis, 4.68 per cent; alcoholic psychoses, 1.8 per cent; manic-depressive psychoses, 4.68 per cent; dementia praecox, 16.55 per cent; paranoid conditions, 4.31 per cent; psychoneuroses, 9.35 per cent; undiagnosed psychoses, 6.84 per cent; and without psychoses, 44.24 per cent. This latter group was made up mostly of psychopathic personalities (28.45 per cent) and mental deficiency (26.29 per cent). The purely social problems presenting themselves in connection with these cases were reported as follows:—Mental disease, 75.54 per cent; physical disease, 2.16 per cent; poverty, 2.88 per cent; criminality, 3.24 per cent; juvenile delinquency, 2.52 per cent; sex offenses, 2.16 per cent; alcoholism, 2.16 per cent; family dissension, 6.12 per cent; ignorance, 2.52 per cent; and bad environment, .36 per cent. In addition to this, 299 discharged soldiers and 543 out-patient cases were reported as being under the supervision of the department, as well as 532 special cases studied in connection with the investigation of syphilis.
The Psychopathic Hospital in Boston started on a new chapter in its history on December 1, 1920, at which time it was formally separated from the Boston State Hospital and became a separate institution under the direction of Dr. C. Macfie Campbell.
The Phipps Psychiatric Clinic at the Johns Hopkins Hospital in Baltimore was established in 1913. An integral part of a large general hospital and intimately associated with a medical school, it conforms rather closely to the plan of the German psychiatric clinics. A study of its activities shows that during a period of five years (ending January 31, 1918) the admission rate averaged 403.8 per year. Fourteen and three-tenths per cent of the cases were diagnosed as dementia praecox or schizophrenic reaction and 13.7 per cent conform apparently to the classification of manic-depressive psychoses. Ten and five-tenths per cent were diagnosed as neuroses or psychoneuroses; 6.1 per cent as general paresis; fifteen per cent as agitated depressions; 2.3 per cent as alcoholic psychoses; and 6.1 per cent as constitutional inferiority or constitutional psychopathic states. Seven and nine-tenths per cent were cases of anxiety neuroses, agitated depressions or anxiety psychoses; 2.3 per cent were paranoic states or reactions; 3.5 per cent were cases of alcoholism, and 3.7 per cent of drug habits. The dispensary service of the Phipps Clinic has reported an average of 565 cases per year, representing a total of 2,260.5 visits annually.
The work of Drs. Meyer, Hoch and Kirby at the Psychiatric Institute, of Dr. Barrett at the Psychopathic Hospital at the University of Michigan, of Dr. Southard at the Psychopathic Department of the Boston State Hospital, and that of Drs. Meyer and Campbell at the Phipps Psychiatric Clinic in Baltimore has brought the subject of psychopathic hospitals very prominently before the public. Various other establishments of a similar nature have been planned and some are in process of construction, or already in operation. The State Psychopathic Institute at Chicago and the Psychopathic Hospital of the University of Iowa should be mentioned in this connection. Psychopathic hospitals have been planned for New York City and one is to be built by the State of California. The legislature of Colorado has already made an appropriation of $350,000 for the establishment of an institution of this type in the city of Denver.
The work already done in this field shows quite conclusively that general hospital methods are not inconsistent with the developments of modern psychiatric progress. The large percentage of voluntary cases received and the number of persons consulting the physicians in the out-patient departments shows an unexpected demand on the part of the public for institutions of a new type. As Dr. Adolf Meyer[36] has pointed out, "Our organized system for the care of mental disorder is in many respects forbidding. It throws together all kinds of diseases, and shocks in that way the already sensitive patient who fears the worst for himself or herself. It comes at once with an outspoken declaration of insanity in the very commitment to a hospital, an expression which carries a humiliation to the patient and adds insult to injury. It often means carrying the patient off to a remote asylum which is too widely supposed to have the inscription, 'Leave hope behind all ye that enter here.' Helpfulness rather than coercion must take the place of all this." What the psychiatric clinic may be expected to accomplish in remedying this difficulty was summarized by Dr. Meyer[37] in the following words:—"It is eminently necessary to get model institutions in which medical students and physicians can learn how to deal with the many problems of the disorders of the organ of behaviour from their inceptions into all their ramifications. The clinic must do the work for at least one limited district, with its out-patient and social service and consultation department, and with its hospital wards. Everything must be done to make help in mental disorders more acceptable and convincingly helpful. More patients must learn to look to it for help and the organization must be so as to give the patient and the physician and the public at large a conception very different from that to-day associated with insanity. It is not so much the issue of more help to the curable, but the issue of more work near where the troubles begin, and work against that which breeds trouble. For this we must learn to put the chief weight on hospitals and organizations for natural districts for intensive work rather than upon the mere economy of large hospitals far away from where the troubles develop."
Southard has raised the question as to the correct designation of institutions of the psychopathic hospital type:—"A word is again necessary as to the meaning of the term 'psychopathic hospital.' For various reasons the term has become so attractive in propaganda that a comparatively large number of institutions of whatever scope have been founded or recommended to receive the term 'psychopathic hospital,' 'institute,' 'department' or 'ward.' Thus there is developing a tendency in state hospitals to denominate the receiving ward 'psychopathic.' There can be no advantage in this designation other than that of calling old ideas by new names. The idea of the receiving ward for committed cases destined to receive the ordinary probate court group of cases is not altered or improved in any manner by the designation 'psychopathic.' The best opinion seems to be that a psychopathic hospital or institute shall be an institution in which all types of mental cases, from the probate court group on the one hand up to the most dubious and difficult cases of mental disorder on the other, may be examined; but if an institution is primarily or chiefly concerned