FOR RELEASE

UPON DELIVERY

WHICH FLEMMING DO YOU READ?

TESTIMONY BEFORE
SENATE APPROPRIATIONS SUBCOMMITTEE ON LABOR-H.E.W,
ON FISCAL 1960 BUDGET (SEN, LISTER HILL, CHAIRMAN)
10:00 A.M, Tuesday, May 26, 1959,
Room F-82, Senate Wing, Capitol Building
by
MIKE GORMAN - Washington, D. C.

Executive Director, NATIONAL COMMITTEE AGAINST MENTAL ILLNESS

Mr, Chairman and Members of the Committee:

On April 21st the New York Times ran a headline, "Flemming
Pleads for Mentally I11," over a story covering a press conference
held the previous day by Secretary of Health, Education and Welfare
Arthur S, Flemming.

"Tens of thousands of mentally ill patients in our nation
today are receiving disgracefully inadequate care and treatment,"
Mr, Flemming stated at his press conference, "While there has been
some encouraging progress against mental illness in recent years,
the situation as a whole is one that I believe the American people
would find genuinely shocking if they knew the facts".

Mr. Flemming cont?»»ed with a biting criticism of our present
financial support of efforts to fight mental illness, Here are the
Secretary*s own words in all their eloquent simplicity:

“One thing, however, is clear: the resources we are devoting
-2-

to mental illness today fall dreadfully short of meeting the problem.
We have not yet mounted an effective attack on mental illness in this
country. The fact is, we are barely holding the line... . Many
of the 277 state and county mental hospitals in this country are still
little more than custodial institutions with wholly inadequate funds,
personnel and facilities for even the simplest methods of treatment",

The above is a bold and challenging summation of the nation's
number one health problem, To the seventeen million Americans suffer-
ing from mental illness, and to their distraught families, it offers
promise of a sizeable investment of funds to fight this raging epidem-
ic, But I am sorry to report that the Secretary’s words were just
words, and that his gallant crusade was upended by the Bureau of the
Budget.

On April 30th the same New York Times headlined another story:
"Flemming Fights Rise In His Budget", Among other things, Mr. Flemming
was reported as fighting a small $8 million increase appropriated by
the House of Representatives for the National Institute of Mental
Health,

In appropriating approximately $60 million for the Institute for
the coming year, the House Appropriations Committee noted that this
sum was many times less than the annual money savings which have
already resulted during the past three years as a result of the in-
tensive application of the new drugs and other medical research dis-
coveries to the problem of mental illness, I quote from the House
Report:

“Recent figures presented to the committee indicate that
-3-

mental illness costs this country a minimum of $3 billion a year.

“Despite the staggering economic losses, the committee re-
ceived heartening evidence of remarkable progress against mental
illness, Over the past three years, there has been a drop of
13,000 patients in State mental hospitals, At the end of 1958
there were 52,000 fewer mental patients in all mental institutions
than might have been expected on the basis of the rising curve from
1945 to 1955,

“Just the annual money savings resulting from this reduction
amount to much more than this entire appropriation if calculated
on the most conservative basis, It costs an average of $1,500 a
year to provide little more than custodial care for each patient
in a mental hospital and in institutions where good care and service
is given the costs are much higher, Restored to a useful life this
same person is earning his own living and paying taxes.

"Medical research that can increase our ability to prevent
chronic mental illness is the only way of eventually cutting down
on the Nation*s multi-billion dollar annual bill for care of the
mentally ill."

In essence, Mr. Chairman, the Administration budget for the
National Institute of Mental Health for fiscal 1960 is a backward
step in our fight against mental illness, For example, it allows
only $3 million to finance new research applications despite con-
servative projections which estimate a minimum of $6 million in new
applications just at the present rate of growth. In the face of
desperate shortages of psychiatrists and allied personnel, it cuts
the number of vitally needed traineeships from 2,533 to 1,775, De-

spite approved applications for general practitioner training far in
-4-
excess of the $1,300,000 voted last year, it cuts that program back
to last year's level,

Despite the important inroads we are making against mental
illness, the problem is far from solved. By making a phone call
to Bethesda, the Administration budget makers could have learned
that admissions to state mental hospitals alone have risen 25,000
in just the past two years, Furthermore, psychiatric admissions
to general and private hospitals have set new records, while clinics
in all parts of the country have waiting lists of from six months
to two years,

We are therefore requesting $79,986,000 for the operations of
the National Institute of Mental Health during fiscal 1960, We
predicate this requested increase on the premise that now is the
time to invest heavily in psychiatric research and training programs
designed to accelerate the breakthroughs already achieved.

State government is following this wise course. in just the
past two years, appropriations for state mental hospitals have gone
up from approximately $663,000,000 in 1956 to $813,000,000 in 1958,
Our requested figure for the Institute is less than ten percent of
what the states are currently spending on this grave problem.

The following are the specific budget recommendations of the
National Committee Against Mental Illness:

RESEARCH:

We are proposing $30,000,000 for the research grants program
of the National Institute of Mental Health for the coming year,

Of this total sum, approximately $15,000,000 should be allo-

cated for general research grants. While presenting no detailed
-5-

breakdown of various areas where research support should be in-
creased, we want to make a special plea for an increase in the

sums allocated to research on alcoholism, This is a staggering
problem--it is estimated that there are five million alcoholics

in this country today. We know shamefully little about physiological
addiction to alcohol beyond the general suspicion that the metahbo-
lisms of many individuals are so constituted that alcohol seems to
answer a physiological craving similar to the craving for food in

an under-nourished person,

Through the action of the Congress last year, a modest $300,000
research program on alcoholism is now getting under way. We think
the research phase of this program should be lifted to a minimum of
about $1,000,000 during the coming year.

The Title V program of the Institute has become one of the
most exciting developments in the entire field of psychiatry. The
purpose of this program is to support new ways of handling mental
illness other than in the traditional mental hospital setting. If
time permitted, I could detail a number of the imaginative projects
now under way--the use of emergency psychiatric teams in Boston;
support for the work of doctors in private practice here in the
District of Columbia in treating mental illness in the community;
extramural care for older people with mental illness; day and night
hospitals and a host of additional developments,

One area of Title V work is of enormous interest to our com-
mittee, As the House report notes, juvenile delinquency is a prob-
lem "of great magnitude in terms of parental distress, economic

burden and loss of potentially useful citizens . . . . But there
-6-
seems to be no coordinated effort to do anything about it, and no
one group accepts responsibility for giving leadership in efforts
to prevent or ameliorate the problem."

Our committee is deeply impressed with the few attempts which
have been made to attack juvenile delinquency on a saturated, com-
munity-wide basis, The Henry Street Settlement group of New York
City outlined before the House committee a well-designed protocol
for a research study of the effectiveness of an all-out community
attack on juvenile delinquency, and we think that the time is now
to begin support of that kind of study.

The Title V program, currently running at about $2,800,000 a
year, has already accumulated a sizeable backlog of worthwhile
project applications which cannot be granted because of insufficient
funds, It is therefore suggested that this program be at least
doubled during the coming year,

The psychopharmacology program is just beginning to achieve its
real potential, In addition to supporting vital drug research at
hospitals, medical schools and research laboratories throughout the
country, the Psychopharmacology Service Center has initiated a number
of pilot arrangements with the pharmaceutical industry which are in-
dications of what can be done in the years to come. After a period
of initial confusion and some healthy controversy, a general concensus
has developed that industry's role in the psychopharmacology program
should be confined to basic research, with particular emphasis upon
the mode of action of the drugs and the development of better screening
techniques for testing and evaluating the many promising compounds de-

veloped in the laboratories each year,
-7-

The problem of the screening and evaluation of new drugs is a
most critical one, I am happy to note that the Psychopharmacology
Service Center is deeply aware of this problem, although it does not
yet have the sizeable funds to accomplish the task, The initial
problem is one of more effective screening of compounds in animals,
In its report to the Congress, the Psychopharmacology Service Center
notes that its staff "has been actively discussing with industrial
scientists research needs in the area of pre-clinical drug screening
which could best be met by grants or contracts to non-profit organ-
izations, and three meetings of industrial and university scientists
have been held in the last two months to discuss the specific needs
in three special areas of screening".

Of even more importance is a need for quicker and more accurate
screenings in human beings of promising compounds, During the past
year, it is estimated that over 300 drugs were developed which were
deemed of sufficient interest to warrant testing in patients, This
involves a staggering evaluation task at the human level, as the
Psychopharmacology Service Center notes in the following words in
its report to the Congress:

“It is also apparent that there is a major need for better early
clinical studies on promising new drugs . .. . Several competent
investigators are now carrying out new-drug evaluation studies,
but the number of clinical units able to do effective work of this
sort falls short of the need for this type of research,”

In connection with the difficult job of screening promising
new compounds, the NCAMI proposes that the Institute support eight

pilot screening centers during the coming year. Each of these
-8-

centers might cost in the neighborhood of $250,000, We regard this

as a very important proposal, since the present state mental hospitals
and university teaching hospitals are far too overburdened with patient
care and related problems to finance elaborate screening programs,

Dr. Nathan Kline will present this proposal in more detail in his
testimony.

A second need in the field of psychopharmacology is the training
of research workers in psychopharmacology. The pharmaceutical in-
dustry has enormous laboratory and other resources far beyond the
financial capacity of our medical schools and research foundations.

I have talked to a number of leaders in the pharmaceutical industry

about this problem, and they agree that industry could play a vital

role in the training of research fellows in psychopharmacology. In

fact, there are several informal training arrangements now in exist-
ence between universities and pharmaceutical companies,

Commenting with favor upon this development, the Psychopharma-
cology Service Center had this to say in its official report to
Congress:

"Considerable interest has been expressed in the use of the
well equipped interdisciplinary groups now available in some company
laboratories for the training of research workers in pharmacology and
psychology at both the pre-and post-doctoral levels through coopera-
tive relationships with graduate departments in nearby universities
and medical schools,”

We propose that approximately $1,000,000 be allocated to this
psychopharmacology training program during the first year, We leave

it to the wisdom of the Psychopharmacology Service Center to determine
-9-
how much of this training can be done within industry and how much
can be done in academic institutions, Our major concern is with
the problem, not with the mechanism used to solve it, We are deeply
concerned with testimony received by the House of Representatives
that the critical shortage of clinical pharmacologists in the United
States is the major bottleneck in the discovery and application of
better drugs for mental illness, Numerous positions currently bud-
geted for psychopharmacologists and neuropharmacologists in medical
schools, pharmaceutical laboratories and private research institutions
are vacant today because of the lack of an aggressive training pro-
gram in this field,

In sum, we are proposing $10,000,000 for the psychopharmacology
program during the coming year--a modest increase of $1,000,000 in
the basic drug research program, including additional projects with
industry; $2,000,000 for the establishment of screening centers, and
$1,000,000 for training.

Just one observation on the aforementioned proposals. We
respectfully suggest that these sums be not considered inflexible.
Availability of manpower and many other considerations frequently
determine the speed with which a program can get off the ground. If
one part of the program is held back because of any one of a number
of obstacles, we hope that the appropriation can be transferred to
another area in the broad field of psychopharmacology.

The important thing is strong continuing support for drug re-
search, We feel that we are proposing a modest and realistic increase
in the psychopharmacology program until it moves out of the pilot

stage, AS you well know, the cancer chemotherapy program has moved
- 10 -

forward much more rapidly during the past five years--from approxi-
mately $1,000,000 in fiscal 1954 to $23,000,000 in fiscal 1959,

We hope to achieve a like momentum in the next several years in the
field of psychopharmacology.

RESEARCH FELLOWSHIPS:

The current appropriation for research fellowships is only
$1,396,000. Despite the fact that this is roughly double the
previous year*s appropriation, applications on hand already far ex-
ceed the money available. Considering the current critical short-
age of competent research workers, it is nothing short of tragic
that this research fellowship program has been starved over the
past few years,

We propose that this program be increased by $1,000,000 in
the coming year, with at least one-half of the increase being de-
voted to research fellowships in the biology of mental illness,
TRAINING:

"The great need today is for more professionally trained
personne] in all fields of mental health," Secretary Flemming stated
on April 21st. “The American Psychiatric Association in December
1957 published results of a study of professional staff in public
mental hospitals as of 1956, This study shows that the number of
physicians, psychiatrists, registered nurses and other nurses and
attendants was grossly inadequate . . . . Because of the shortages,
I am told that the potentials inherent in the new tranquilizing drugs
are as yet largely unrealized.”

Despite these fine words, the present Administration has rec-

ommended a sum for training which will cut the number of available
-ll -

traineeships one-third under last year’s figure. Shocked at this
cut, Representative Fogarty asked Dr, Robert Felix if it meant there
were enough psychiatrists and other personnel to handle the problem
of mental illness, Here is Dr, Felix’? answer:

“No sir, there are not enough psychiatrists or other personnel,
We do not have enough. We could use additional funds next year.
In fact, if we do not get additional funds next year, we will go
back,"

We are asking an increase of about $8,000,000 in these general
training programs, At least $2,000,000 of this increase should go
to the excellent program designed to train potential research workers
in a broad variety of biological and psychological disciplines, As
we have pointed out for the past several years, only two medical
schools are currently receiving money to support this program, and
there are only 85 fellows in the entire national program, We under-
stand that there are scores of applications from various university
departments indicating their willingness to participate in this program.

We cannot understand the Administration*s position on this issue,
On the one hand, it continually protests that it cannot support more
research grants because there aren*t enough competent research workers
in the country. On the other hand, it refuses to recommend the money
to train these needed research workers and, in effect, slams the door
on scores of institutions which are willing to provide this training.

For the training of the general practitioner, the Administration
recommends the same sum as last year--$1,300,000, Although this pro-
gram only got under way last fall, the demand for it has far exceeded
the fondest expectations of those of us who testified for its creation,

For the two phases of the program-- the support of general practitioners
- ]2-
taking a three-year psychiatric residency, and the support of pilot
projects in methods of training general practitioners who want to
remain family physicians but increase their psychiatric skills--
there are on hand many more applications than can be granted under
the present inadequate appropriation,

Noting that this program had just gotten under way during the
past year, the House Appropriations Committee reported that "it has
been received with unprecedented enthusiasm by the medical profession
despite the newness of the program, The Institute has been unable to
finance many of the applications from all parts of the country. Since
the family physician is dispensing the greatest quantity of the new
drugs, it is absolutely vital that he receive the psychiatric educa-
tion he so avidly seeks, It will be expected that this program be
expanded in 1960,"

We are therefore requesting $5,000,000 for this program during

fiscal 1960, This increase is mandated, in part, by the nature of
the program, For example, all the general practitioners who have
begun the first year of psychiatric residency must take a minimum of
two more years of training before being eligible for certification,
By holding the program to last year*s level, the Administration closes
the door on any new applications for the coming year, Since the
average Stipend under this program runs about $10,000 a year, adding
only 100 new fellows costs $1,000,000 the first year, We are hopeful
that at least 200 new fellows can be started; this will cost about
$2,000,000 during fiscal 1960.

The short-term training of general practitioners who want to

increase their psychiatric skills is just as important. A recent
-13-

survey by the General Practitioner Education Project of the American
Psychiatric Association pointed up the scarcity of psychiatric train-
ing opportunities open to the average family physician, In many
parts of the country, there is absolutely no place where the general
practitioner can go for advanced psychiatric training.

Again, in the interest of flexibility and because the program
is SO new, we suggest that the Institute be permitted to relate its
support to the level of applications and to the availability of
training manpower,

GRANTS FOR CLINICS:

We suggest an increase of $1,000,000 over the sum of $4,000,000
recommended by the Administration, The big need here is federal
matching support for clinics and other preventive services in the
poorer and less populous states, In the larger states, state and
local contributions for clinics and other community mental health ser-
vices frequently run ten and even twenty times the size of the federal
contribution, However, in a number of the poorer states, the basic
federal grant of $25,000 is far from adequate, With the additional
funds proposed, we suggest that the minimum matching allocation to a
state for expansion of clinical services be raised from $25,000 to
$50,000,

DIRECT OPERATIONS
RESEARCH:

We recommend that the intramural research program of the Institute

be lifted to a level of about $8,000,000--an increase of a little over

a million dollars more than the Administration recommendation, This
-~14-

modest increase would allow additional money for drug addiction studies

at Lexington, some increase in the intramural program in psychopharmacology,
an expansion of the vitally important collaborative research project
recently inaugurated at St. Elizabeths, greater support for studies

at the Clinical Center, and a well-deserved boost for the excellent
statistical and evaluation work of the Biometrics branch of the Institute.

We would also like to see a modest expansion of the various tech-
nical assistance staffs of the Institute, As the various grant pro-
grams have grown over the past few years, the demands upon the Institute
staff have far exceeded its present capacity, Again the Administration
has been derelict in not asking the Congress for additional appropria-
tions with which to employ more technical staff for the Institute. We
would remind the Administration, which is constantly celebrating the
virtues of local community effort, that the Institute hasbeen unable
for the past several years to supply all the technical help and assist -
ance requested by the states and by scores of local communities, We
therefore suggest the following increases in Institute staff programs:
REVIEW AND APPROVAL:

An increase from the current $863,000 to $1,250,000 in 1960, The
basis for this increase is an obvious one--each year more and more
research and training grant applications have to be considered, and
it is important that they receive both prompt and careful technical
scrutiny. It has come to our attention that, in some areas, con-
sideration and support of worthwhile projects have been held up for
long periods of time because of a shortage of the technical manpower

needed to review the applications,
-15-

PROFESSIONAL AND TECGHNICAL ASSISTANCE:

We recommend an increase in this area from the current $1,730,000
to $2,000,000 in the coming year, The major justification for this
increase has been discussed previously, but it is important to note
that this technical assistance to state, local and private effort is
particularly needed in psychopharmacology, drug addiction, alcoholism,
mental retardation, and the general practitioner training program.
ADMINISTRATION:

We recommend an increase of about $280,000 above the $362,000
appropriated for fiscal 1959,

Here again it is obvious you need more central staff positions
to carry out the ever-widening responsibilities of the Institute, A
great number of major programs have been added these last few years--
psychopharmacology, Title V, general practitioner, training of re-
search workers, etc. The Institute has had no comparable increase
in the professional manpower required to plan and direct these pro-
grams, We understand that this shortage of key administrative per-
sonnel has reached critical proportions, and we strongly urge this
committee to rectify this growing imbalance between expanding grant
programs and a limited technical staff responsible for their success
or failure,

There is a related preblem which does not fall directly within
the purview of this committee, but it is one of great importance.

Put very simply, the salary scales at the Institute are much too
low, In obtaining qualified professional staff, the Institute must

now compete with much higher salaries paid by state mental health
- 16 -

departments, and even, in some cases, local community mental health
boards. If the Institute is to continue its position of leadership
as the major psychiatric arm of our national government, the salaries
it can pay to its professional and administrative personnel must be
increased all along the line,

Appended to this statement is the detailed budget request of
the National Committee Against Mental Illness for the fiscal 1960

operations of the National Institute of Mental Health,
NATIONAL INSTITUTE OF MENTAL HEALTH

FISCAL 1959 Appropr.

 

GRANTS

Research Grants $18 ,834,000
Title V (2,800 ,000)*
Psychopharmacology (6 ,000 ,000)*

Research Fellowships 1,396 ,000

Training 18,213,000
General Practitioner (1,300 ,000)*

Grants for Clinics and

other Preventive Services $4,000 ,000

 

DIRECT OPERATIONS

Research 6,921,000
Review & Approval . 863,000
Training Activities 100 ,000

Professional and

 

Technical Assistance 1,730,000
Administration 362 ,000
TOTAL 52,419,000

* Items in parentheses are subdivision
breakdowns of particular program totals.

Citizens Request - FISCAL 1960

$30 ,600 ,000
(5,600 ,000)*

(10,000 ,000)*
2,396 ,000
30 ,000 , 000

(5,000 ,000)*

5,000 ,000

8,000 ,000
1,250,000

100 ,000

2,000 ,000

640 ,000

79, 986 ,000