tation and licensure. Community based care and nondirect mental health services require specially trained personnel to meet these demands for service. And, it is a sad fact that treatment available to children, the aged, abusers of alcohol, and drugs, and poverty stricken, is limited both in available services and competently trained personnel. These programs require adequate staffing that assures the success of sound programatic and administrative planning. Yet the action taken by Secretary Weinberger eliminates all renewals, all new training grants and all supplemental clinical training grants, without any concern for the consequences of this rash act. This untenable position is taken in spite of the testimony presented before your committee for fiscal year 1973 by the Department of Health, Education, and Welfare that "to meet the Nation's needs, more than 25,000 additional mental health workers are desperately needed in our mental health facilities but are unavailable." [Part III, p. 97, hearings.]

Vigorous action on the part of Congress is necessary to prevent the further loss of trainees. The planned DHEW phase out will result in the collapse of all Federally funded training centers. (See Exhibit E) The cutback of psychiatric residency trainees is from 3,373 in fiscal year 1972 to 567 in fiscal year 1976 with no further funding beyond this year. The cutback in psychiatric nurses trainees over the same period is from 1,287 to 690. For psychiatric social work trainees it is from 1,476 to 718 and for psychologist trainees, it is from 2,241 to 1,520. This opposition by DHEW is incomprehensible in view of the catastrophic effect it would have on the care of the mentally ill.

It also is noted that the cutbacks in training stipends are uneven. This may be used to weaken the structure of the training programs which require inter-disciplinary collaboration for their success. If one discipline is phased out and receives no funding, it will cause the others to fall prey to the same fate. Therefore the coalition recommends that the proportion of trainees among psychiatrists, clinical psychologists, psychiatric social workers, and psychiatric nurses be maintained at the same ratio as projected by NIMH for manpower shortages by 1981.

IMPLEMENTATION OF CONGRESSIONAL FUNDING SHOULD NOT BE OBSTRUCTED

The Office of Management and Budget in cutting back on the resources and machinery to fund the federally-supported mental health projects has created intense frustration in these training centers in recruiting trainees and setting up programs to begin by July 1st. Therefore, the coalition recommends that Congress direct that training grants be awarded by formally chartered review groups or committees as well as by the National Advisory Mental Health Council. In the future, at least a 9-month lead time is needed to process and appoint trainees who qualify.

ECONOMIC ADVANTAGE

Any mental patient who is so handicapped that he can't keep a job or goes from one job to another or requires prolonged hospitalization is a serious burden personally and financially to everyone. Whether this country is economically prosperous or oppressed financially, the only humane approach is to keep that person in his rehabilitation. There can be no argument to have him scrounge around for relief in the market-place in good times. Nor can the argument be used that because of budgetary stringencies funds should be sought elsewhere. The mentaly ill cannot be neglected by such spurious reasoning. Effective treatment which maintains the patient's capacity to work, to take care of his home and to contribute to the life of the community is an essential goal in the care of the millions who become handicapped mentally. This is a responsibility this Nation should never avoid.

RECOMMENDATIONS

1. The Coalition recommends the appropriation of $125 million for mental health manpower training. This will support 8,500 stipends, well below the level needed to meet the projected mental health manpower requirements of this Nation.

Although the coalition strongly urges the funding of $125 million it wishes to advise that the absolute minimum recommended appropriation would be $110 million. $110 million represents the appropriation necessary to hold the line in maintaining the training programs and to provide for only 5,568 stipends in all categories of training. Anything less than this would have a devastating effect upon this program by dismantling the basic support functions.

2. To retain the resources necessary to administer these funds, it is recommended that this committee of Congress make clear its intent that allocation of awards will be based upon appropriate peer review of application (that is, formally chartered initial review groups or committees as well as by the National Advisory Mental Health Council) and that this process will be carried out in a timely manner.

3. The coalition also recommends that, at this time, the allocation of stipends for psychiatrists, clinical psychologists, psychiatric social workers, and psychiatric nurses be in ratio to the projected manpower needs as established by NIMH.

Mental health, as you know, is the most pressing of all national health problems and requires strong congressional leadership to inspire the best in this Nation to deal with it. On behalf of the mentally handicapped we present this petition for your support and ask your favorable response to our request.

EXHIBIT A.-TRENDS IN MENTAL HEALTH MANPOWER APPROPRIATIONS, ALCOHOL, DRUG ABUSE AND MENTAL HEALTH ADMINISTRATION

1 This column illustrates the deterioration of this vital program. (2-digit inflation not reflected in trend).

2 Coalition's recommended level for fiscal year 1976.

3 The figure of $110,000,000 has been cited by the National Coalition for Mental Health Manpower as the bare minimum recommended level of funding to permit the mere sustenance and continuation of this program.

Note: The Coalition was formed in 1971 in response to the Administration's attempt to phase out the mental health manpower program in the National Institute for Mental Health.

EXHIBIT B

FUNDING FOR PSYCHIATRIC RESIDENCY TRAINING: A NATIONAL DILEMMA

AMERICAN PSYCHIATRIC ASSOCIATION

Implications of elimination of NIMH support

When APA informed the Office of Management and Budget that the elimination of this program would be disastrous to the production of psychiatrists, the response was "prove it." This implied demonstrating actual losses to manpower deleterious to the mental health care delivery capacity of the Nation.

As a result, APA undertook the survey, "A Nationwide Pattern of Fiscal Support for Psychiatric Residency Training." The national roster of chairmen of departments of psychiatry and directors of residency training programs were forwarded questionnaires. The survey reported the following results: All 260 psychiatric training programs accredited by the AMA and the American Board of Psychiatry and Neurology (ABPN) were asked to provide specific data on the dollar-value of fiscal support for: (1) stipends provided to psychiatric residents, and (2) associated teaching costs of psychiatric residency training (e.g., faculty salaries, equipment and supplies to expand department capabilities for psychiatric training). Each training center was asked to indicate the dollar amounts privided for the above two purposes by source.

Some 239 out of the 260 AMA-ABPN accredited programs (92 percent) provided usable data for reporting census results. These 239 training programs can be categorized as follows:

The total nationwide fiscal support from all sources for psychiatric residency training programs during fiscal year 1971 amounted to approximately $100 million. State and local governments combined with the private sector of the economy (as represented by physician contributions, medical school aid to their own psychiatry departments, foundations, and private voluntary health agencies) contributed 61 percent of this support. The Federal Government provides 34 percent of all fiscal support for psychiatric residency training via NIMH and another 5 percent via other Federal programs (e.g. VA, DOD, HEW, etc.).

Stipend support provided directly to the 4,275 psychiatric residents in training from all sources of training_amounted to approximately $49 million while approximately $51 million were devoted to fiscal support of teaching costs. The average dollar-value of stipend support provided to each psychiatric resident in training was $11,647. An additional $12,000 per student was the average for associated teaching costs. Thus the total investment per student during fiscal year 1971 was approximately $23,600. Nevertheless, a substantial amount of this is recovered in patient services.

However, there are important differences between the various types of training programs with respect to the dependence on NIMH for fiscal support. All of the medical school based psychiatric residency programs depend upon NIMH for some or all of their fiscal support. Only about one-half of the State hospital based programs depend upon NIMH (54 percent). Further, medical-supportbased programs depend upon NIMH for about two-fifths of their total support (39 percent). State-hospital-based programs look to NIMH for about one-eighth of their total support (14 percent). Medical school based programs depend upon NIMH for about one-half of their resources for psychiatric resident stipends (49 percent). State-hospital-based programs look to NIMH for about one-eighth of their stipend support (14 percent). Medical school based programs receive one-third of their support for associated teaching costs of psychiatric residency training from NIMH (33 percent). State hospital based programs receive about one-sixth percent of their support for associated teaching costs from NIMH (16 percent).

Given the pre-eminent position of NIMH as a source of fiscal support for psychiatric training throughout the United States, it follows inexorably that if NIMH fiscal support for psychiatric residency training is to be "phased out," such action would have a catastrophic effect on psychiatric residency training throughout the country.

The concrete effects of this action on the part of the executive branch of the Federal Government would be as follows: More than one-third of all psychiatric resident positions throughout the country would be lost (35 percent). This amounts to 1,500 positions out of the current pool of 4,275 psychiatric residents in training. Nor will the results of this action be evenly distributed across all training programs. Medical school based programs will lose one-half of their psychiatric residents (46 percent) while the less well NIMH supported State hospital based programs expect to lose only 13 percent of their psychiatric residents.

Thus, the programs of highest quality in the university medical centers where the best American medical school graduates enter psychiatry as a medical specialty will be effectively dismembered while the Nation is left with the poorest training centers, remote from urban facilities, staffed predominantly by foreign medical graduates.

Clearly, psychiatry as a medical specialty will lose if the action proposed by the executive branch of the Federal Government is sustained. But in a time when the Government wants to increase the Nation's pool of licensed physicians by 50,000 (15,000 of which are supposed to be psychiatrists) ** the Nation's citizens will be the ultimate losers.

This report was circulated to the Office of Management and Budget, referred to in congressional testimony, and presented to key Congressmen and Senators. Lowered funds for teaching costs would mean that numbers of medical school professors would have to be dismissed. There would be less time for remaining faculty to devote to teaching and to public service.

Distraction of faculty from the service setting into private practice will further contribute to the two-class system of service delivery. It is estimated that elimination of the Federal support would result in a loss of from 20 to 50 percent of faculty time for education.

In some cases, residents will gravitate toward private practice in affluent areas in order to supplement stipends which will be reduced or eliminated. These computations underscore the sizable increases that may be expected in the number of persons needing mental health services and in the manpower required to deliver these services merely as a result of population increases. I might add that the population forecasts are equally significant for the planning of resources to meet problems that the expected increases are likely to produce for medical care, social, welfare, legal, correctional, and other human services.

FROM: DIVISION OF BIOMETRY, NATIONAL INSTITUTE OF MENTAL HEALTH, 1973

SUMMARY OF PUBLIC SERVICE VERSUS PRIVATE PRACTICE ACTIVITIES OF PSYCHIATRIC RESIDENTS WHO HAVE1 GRADUATED FROM 8 TRAINING PROGRAMS OVER THE PAST 5 YEARS

1 By public service is meant an average of more than 50 percent of time in spent hospital work, teaching, community mental health centers, the military, and research.

2 The director, Dr. Jack R. Ewalt, was unable to supply precise data, but he stated that all but 13 of the 135 have spent some time as full time employees in public service agencies and facilities. All of the 135 have spent some time in teaching activities. Only 2 guradates are known to be in full time private practice.

3 The director, Dr. Philip Wolcott, was unable to supply precise information but stated that most graduates are doing part time public service work. Only 18 are known to be in solo private practice.

RESIDENCY TRAINING PROGRAM, DUKE UNIVERSITY, DURHAM, N.C., EWALD W. BUSSE, M.D., DIRECTOR

Fifty-three residents have completed training at Duke University within the past 5 years. Of these, 49 were supported in whole or in part by NIMH training stipends. The 53 residents are now engaged in the following activities: