creates a serious economic problem for the patients themselves, their families, and society in general. The details of this problem have been discussed fully elsewhere (16-18). Some pertinent facts are summarized here.

In the United States, there are 226 State, 47 county, and 324 private hospitals for mental disease, as well as the 39 Veterans Administration neuropsychiatric hospitals. The distribution of these hospitals by average daily resident patient population during 1954 is given in table 1. The median population for the State hospitals is 2,043; for the county hospitals, 267; for the Veterans Administration neuropsychiatric hospitals, 1,343; and for the private hospitals, 30.

As of June 30, 1951, there were 584,000 patients, or 3.9 per 1,000 civilian population, resident in all hospitals for the prolonged care

1930 1935 1940 1945 1950 1955

of the mentally ill in the United States. In a single year, the movement of patients in and out of these hospitals is considerable. For example, as of July 1, 1950, there were 671,000 patients on the books and in the following 12 months there were 266,000 admissions, making a total of over 937,000 patients under the care and supervision of mental hospitals during that year. Discharges in the same 12-month period number 192,000 and deaths, 48,000.

Between the years 1903 and 1951 the number of resident patients in these hospitals increased almost 4 times (from 150,000 to 584,000) whereas the general population only doubled. Thus, the number of patients per 1,000 population doubled, from 1.9 to 3.9 (fig. 1 and appendix table 1).

Figure 2 and appendix table 2 show the geographic differences in the United States in

the age-specific resident patient rates, that is, the proportion of the population in various age groups in a mental hospital as of the last decennial census in April 1950. The agespecific rates for resident patients increase quite rapidly with advancing age, from 34 per 100,000 population in the age group under 15 years to 1,726 per 100,000 in the age group 85 years and over. The rates are consistently higher in the northeastern section of the country, where they rise from a low of 72 per 100,000 population in the age group under 15 years to 1,150 per 100,000 in the age group 55-64 years to 2,282 per 100,000 in the age group 85 years and over.

Figure 3 and appendix table 3 show the first admission rates for patients admitted to State mental hospitals in the United States in the years 1933, 1940, and 1950. During 1950, the first admission rate to the State hospitals rose from a low of 2 per 100,000 for persons under

RATE PER 100,000 CIVILIAN POPULATION

SOURCE: U. S. Bureau of the Census: United States census of population: 1950, vol. IV, Special Reports, pt. 2, ch. C., Institutional population. Washington, D. C., U. S. Government Printing Office, 1953.

4534 44 54 AGE (IN YEARS)

SOURCE: Patients in hospitals for mental disease, 1933. Issued by U. S. Bureau of the Census. Patients in mental institutions. Issued by U. S. Bureau of the Census, 1938-46; by U. S. National Institute of Mental Health, 1947-51.

15 years of age to 87 in the age group 35-44 leveled off to between 85 and 90 for years, persons 45-64 years, and then climbed rapidly to a high of 205 at ages 65 years and over. Between 1933 and 1950, these rates showed no striking variations for the age groups under 65 years. However, in the population 65 years of age and over, the rate per 100,000 increased from 157 in 1933 to 170 in 1940 to 205 in 1950.

Figure 4 and appendix table 4 show the agespecific first admission rates to State hospitals in 1950, by diagnosis. In the age range 15-49 years, schizophrenia and manic-depressive psychosis predominate. During the next decade of life, the involutional, syphilitic, and alcoholic psychoses attain considerable importance. In the sixties, the cerebral arteriosclerotic and senile psychoses assume prominence, and these

mental diseases of the senium continue to rise in frequency until the end of the life span.

The characteristics of the resident patientsthat is, the population resident in State mental hospitals on any one day-are considerably different from those of the first admissions.

Although data on resident patients by age, sex, diagnosis, and length of stay are not available for the United States as a whole for 1950, such data are available for selected States.2

The resident patient curve specific for age and diagnosis yields interesting information with respect to age differences in resident patients with specified types of mental disorders (fig. 5 and appendix table 5). These differences might be highlighted by considering two important diagnostic groups, the schizophrenics and patients with mental diseases of the senium. The schizophrenics constitute a high proportion of resident patients in all age groups whereas

California, Louisiana, Michigan, Nebraska, Ohio, Pennsylvania, and Virginia, 1950.

patients with mental diseases of the senium become a major problem only in the age group 65 years and over.

Although admissions of senile cases have increased greatly in the last decade, the resident population of mental hospitals consists largely of a slowly accumulated core of schizophrenic patients, who are admitted during youth or early maturity and stay, in many cases, for the rest of their lives. The turnover of senile cases is very rapid because of their high death rate. Thus, the median duration of hospitalization for resident schizophrenics, who constitute about 46 percent of the resident population and 24 percent of first admissions, was 10.5 years. For resident patients with mental diseases of the senium, who constitute about 12 percent of the resident population and 26 percent of first admissions, the median duration of hospitalization was 2.4 years.

Although mental hospitals provide care and treatment for persons afflicted primarily with Figure 5. Resident patient rates per 100,000 civilian population for selected diagnoses, by age: State hospitals for mental disease, California, Louisiana, Michigan, Nebraska, Ohio, Pennsylvania, Virginia, 1950.

the psychoses and for a smaller proportion of patients with other disorders, it should be emphasized that the patients constitute quite a heterogeneous population group of mentally ill persons, many of whom have superimposed or concurrent physical illnesses. Of the patients under treatment, some-primarily the new admissions are in the acute stages of illness, whereas others are chronic, long-term residents. Some are quite young and others are quite old, and their diagnoses are varied. Although all socioeconomic classes are represented, the great majority of patients in the public mental hospitals are drawn from the lower strata of society.

Because of the magnitude of the problem, hospital administrators and public health, welfare, and governmental officials at the Federal, State, and local levels are interested in finding some way (a) to reduce first admission rates to these hospitals or (b) to effect a higher turnover of patients, that is, to increase release rates and to keep readmission rates low, thus eventually reducing the size of these populations. Already mental hospital administrators have mentioned that they have noticed either a stabilization of resident populations or a tendency for some populations to decrease. A recent letter from the Council of State Governments also raises this point. Although some of these trends had started some years ago, it is interesting that these questions have been raised more frequently since the tranquilizing drugs have come on the scene.

Although the tranquilizing drugs do possess some of the necessary properties of an agent that could prevent admissions to mental hospitals by making it possible to treat more patients on an outpatient basis, much more information is needed about the processes operating in society that lead to hospitalization before one can conclude that any significant proportion of a reduction in admissions to mental hospitals can be attributed to the tranquilizing drugs. The fact that reserpine can produce severe mental disorders in patients in whom these disorders were not manifest prior to the use of the drug also indicates that

3 Communication from Sidney Spector, director, Interstate Clearing House on Mental Health, Council of State Governments, 1313 East Sixtieth Street, Chicago 37, Ill.

it has a property of producing a condition which may require hospitalization. In addition, much more information is needed about the factors that contribute to improvement in patients and that lead to release from the hospital before any major portion of these differences can be attributed to the tranquilizing drugs.

The explanation of trends in admission, release, death, and resident patient rates of mental hospital populations and of differences that may be found between corresponding rates in different States, regions, and countries is no simple matter. A mental hospital is a complex population unit to study. The composition of its patient population is a resultant of medical, social, economic, and administrative factors which have determined (a) current and past rates of first admissions to the hospital, (b) current and past rates at which patients are released to the community or die, and (c) current and past rates at which patients are readmitted to the hospital (19). Furthermore, a great variety of factors must be taken into account in order to explain adequately the observed differences. The etiologies of the major mental disorders are unknown, diagnostic methods are not fully standardized, and the relative efficacy of the therapies used to treat the mentally ill lacks careful statistical evaluation.

Let us consider some of the questions raised by studies of indices of the type demonstrated.

First Admission Rates

First admission rates, long regarded as an incidence index for the psychoses, have been used to answer questions on whether there has been an increase or decrease in the incidence of specific disorders, that is, the rate at which new cases develop (20, 21). Such studies, however, no matter how carefully done, suffer from the limitation that the relationship existing between the number of persons hospitalized for a given disorder and the number

Kramer, M.: Some considerations of the population dynamics of mental hospitals with a discussion of research needed to evaluate the accomplishments of such hospitals. To be published in the Proceedings of the Research Conference on Socio-Environmental Aspects of Patient Treatment in Mental Hospitals, December 13-16, 1955, Boston Psychopathic Hospital, Boston, Mass.

of persons in the population who have the same disorder but who never reach a mental hospital is not known.

Hospitalization rates are a resultant of the incidence of mental disorder and of a series of factors that determine the number of persons who are admitted eventually to mental hospitals. These factors include availability of mental hospital beds; availability and usage of other community resources for diagnosis and treatment of mental disorder (for example,

general hospitals with psychiatric treatment services, psychiatric clinics, and private psychiatrists); and public attitudes toward hospitalization. Therefore, to understand more fully the distribution and course of mental illness in the population, it is necessary to study rates of hospitalization in mental hospitals in relation to these factors.

The following example illustrates why studies of the way the mental hospital is used by the community of which it is a part or, to borrow

States not reporting for their en

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