something like 10 times that in New Mexico, which doesn't mean that the people in New Mexico are only one-tenth as crazy as the people in Delaware. In large part, it means two things: one, that there is recognition of mental illness as such. In Haiti, for instance, mental illness is regarded as demonic possession, and is treated by voodoo.

Second is the combination of an urban society, where people are forced to live fairly close together, plus the available facilities for treatment, leads to higher rates of hospitalization. Presumably, in New Mexico, if you are sheep farming or doing some outdoor activity and have personal conviction that you are a rooster and want to stop and crow 2 or 3 times a day, as long as you get your sheep farming done, no one is going to pay much attention. But if you are working on an assembly line, and this means a car is going to come out without a steering wheel, you won't last too long.

So I think a part of the increased number of patients coming for treatment is a function of the degree of sophistication in recognizing the illness.

I hope that answers your question.

Mr. BLATNIK. Thank you.

Dr. KLINE. You are welcome.

In any case, instead of the increase, there was actually a decrease of over 7,000 patients. In other words, the difference between the expected population and the actual population was almost 20,000 patients.

Note that this was almost the first time anything like this had happened since records had been available. This was not an isolated phenomenon due to an abrupt change in 1 or 2 States since in point of fact 43 of the 48 States had less patients than had been anticipated. In New York State where the anticipated increase had been between 2,000 and 2,500 patients there was an actual loss from the hospital rolls of some 500 patients—a difference of roughly 3,000. It is impossible to prove that the drugs and the drugs alone were the cause of this unique reversal, and undoubtedly the enthusiasm of hospital staffs who found for the first time they had means of treating patients on a large scale-successfully-may have entered into the picture, but the burden of proof lies with those who say that the drugs had little or no effect in bringing about this remarkable change.

It is interesting that there are still a number of people, for reasons which, as a psychiatrist, I can guess at, who find objection to the drugs doing anything.

The customary cry of the cynics is that the patients were "pushed out" of the hospitals but this argument is given the lie by the fact in New York State where discharge increased by 23 percent in the fiscal year 1955-1956, this increased rate was maintained during the fiscal year 1956-57. One might "push out" of a hospital a patient who is not ready for discharge but within a few months the community would have pushed him right back in again if the improvement existed only in the minds of the hospital staff. The fact that these patients have remained out now for 1 to 2 years is strong indication that some real change has been wrought. Another bit of contributory evidence is the fact that, again in New York State where I know the figures best, the rate of return of patients who are kept on maintenance doses of the pharmaceuticals is roughly half that of patients not on medications. I am well aware that each of these figures which I have given may

be subjected to statistical criticism on the grounds that this or that factor was not taken fully into account. On the other hand, the evidence is so one-sided and overwhelming that, even though one were to make allowance for each of the possibilities in some reasonable proportion, the weight of cases is so large that only the most unlikely of accidents could invalidate them.

To press for a congressional analogy it would be like arguing with three-quarters of the precincts reporting with a majority for one candidate so large that 90 percent of the remaining votes would have to go opposite to the first three-quarters in order for the second candidate to win; to offer all sorts of plausible explanations of why the first three-quarters of the precincts reported the way they did with the presentation of logical reasons why the remaining one-quarter would vote 90 percent in the opposite direction. As a theoretical consideration no one could say that it was beyond the realm of possibility but it reaches a point where one becomes quite frankly impatient with such caviling; with the attitude-let's wait for 20 years before we make a judgment. Reality demands that we accept the fact that the mass of evidence indicates that the drugs are useful and if one wishes to retain reservations that in the long run things may turn out differently than seems to be indicated no one could quarrel since at least one has acted in good faith on the evidence at hand.

Actually, what I might add here is that even more convincing than statistics is the experience of those of us who spend 10 or 15 years working in hospitals, some people even longer. You go to any hospital superintendent who has been in the business any length of time, or any person who has been on a hospital staff and simply ask on the basis of personal experience, "What is the predrug era as opposed to the postdrug era?" You can throw your statistics out of the windows because hospitals are just not the same places they were.

The people who feel that the drugs may not be doing very much are those who have not worked in the situation.

Mr. PLAPINGER. When you say "people," Doctor, you are referring to others in the profession, or are you?

Dr. KLINE. You mean those who object to the drugs?

Mr. PLAPINGER. Yes.

Dr. KLINE. There are some in the profession. There is also a great collection of puristic statisticians who quite truthfully say that as far as statistics go, you haven't proved your case. But statistical proof is one thing and actuality is sometimes another thing, since it is true that we can't always set up ideal controlled experiments at the present time. It hasn't been done. It would be very nice, but even without statistical proof if you give the drugs the patients calm down. If you look at the figures that come out of hospitals without personal experience, you may find all kinds of quite legitimate things that might have had an influence.

Just as I say, it may be that with even three-quarters of votes in, it has happened that at least one candidate has gone to sleep thinking he was President and waked up to find he wasn't. This is in this case so unlikely, and so much against the experience of anyone who has worked in a hospital, that I would be willing to make a considerable investment if it were a betting matter and betting were legal. The personal experience of successful results in place after place is almost universal. So the objectors are usually those who are not psychiatrists,

or, if they are psychiatrists, those who have not had experience with hospitals or with the type of patients seen in the garden variety psychiatric practice. There certainly are patients in whom the drugs don't make that much difference. But in the vast majority, they do. Another source of considerable confusion both to psychiatrists and the lay public alike is the claim that while the drugs may reduce symptoms that they do not cure the patient.

I bring this in partly because someone else may raise it subsequently, and partly because it is a personal hobbyhorse. I have heard this in so many psychiatric meetings, the argument that the drugs don't cure, but only get the patient better. There are two important points in answer to this:

1. That with 1 or 2 very rare exceptions we know so little about the causes of mental disease that it is completely impossible to talk meaningfully about cures. The need is for more extensive and intensive research and this point has been recognized fully only in recent years. The magnificent support of the United States Congress has contributed materially to investigations in this area. At the present time the commonsense definition of what is meant by cure, that is, the relief of symptoms which prevent the individual from useful social function and from enjoyment of life are far more sensible than criteria based on unproven theoretical considerations or the use of unvalidated psychological, physiological, or biochemical tests. With your permission I would like to submit as exhibit 2 a paper I published last year entitled, "Criteria for Psychiatric Improvement" which reviews this problem in more detail.

Mr. BLATNIK. Without objection, it is so ordered. (See appendix, exhibit 2, p. 171.)

Dr. KLINE. I might add that following the publication of this paper I received a letter from certainly one of the most prominent psychoanalysts in the country, in highly complimentary terms, saying he occasionally came across a paper he wished he had written and this was by far the most sensible discussion of improvement that he had seen. I was pleased to get it since, if anything, I expected objection on this score.

2. In an extremely significant, but, I am afraid, overlooked article, also published last year, Gruenberg underlines the point that, in considering the results of pharmacotherapy, one must consider not only complete and final relief of all signs and symptoms of the disease but recognize, as in the case in all other fields of medicine, that reduction of disability is of at least equal importance and that the evidence is overwhelming that here, too, the psychopharmaceuticals have a major contribution to make.

The fact that thousands upon thousands of patients are now released from mental hospitals and tens of thousands more have been spared this experience is much more significant than the fact that in a percentage of these patients there are still some residual disabilities of the illness. Suffice it to say that many former patients have been able to return to a productive social existence and are receiving a satisfactory amount of enjoyment out of the experience of living.

Even for those patients who must remain institutionalized because our ignorance is still such that we have not devised adequate treatments, a new world has also been created. No longer is the

mental hospital racked with wild and meaningless shouting, nor do we see any longer the so-called disturbed wards of only a short 5 years ago. As a result of the pharmaceuticals, a problem has actually been created, since so many patients are now amenable to psychotherapy, occupational therapy, recreational therapy, and other types that the facilities and the personnel for providing these do not exist. I might also add, anecdotally, that, in one of the New York State hospitals, the patients in what had been labeled as a chronic disturbed ward, within 6 or 7 months after the drugs had been introduced, came to the psychiatrist in charge of the ward with a complaint. They said they felt their ward should no longer be designated as a chronic disturbed ward; one, that there was no one disturbed in it any longer, and, secondly, it was not a chronic ward, since 10 or 15 percent of the patients had already gone home, and they didn't want to be designated a chronic disturbed ward, as they weren't. I think it is anecdotal contributory evidence.

It was never anticipated that so large a share of the hospital population would be capable of this type of treatment. Although reduction in mental-hospital population has been noted throughout the world wherever these pharmaceuticals were used (and in a few places, like Denmark, there are actually vacancies in some of the mental hospitals for the first time in their history), this does not mean the immediate abolition of the mental hospital as we presently know it. Because of the unfortunate overcrowding-I think this is estimated around 25 or 30 percent-it will be a considerable period before the hospitals will even return to the population for which they were originally built, and new and better treatments will have to be devised before the chronic population can be very sizably lessened. The greatest eventual hope is in the adequate treatment of acute patients in order to prevent institutionalization.

I think on this point Dr. Ayd will be particularly helpful. There have been studies done, which I have not included, which indicate that the referral from clinics or outpatient departments to mental hospitals have been very significantly reduced by the use of a drug, so that a very small percentage of patients are now referred to the hospital, compared with previously.

At the present time, a number of us, in cooperation with some of the pharmaceutical houses (Hoffman-La Roche, Schering, and Wyeth), are planning a project which will help determine if this is a feasible and economic way of handling the problems of mental illness; that is, will the use of adequate pharmaceuticals and good outpatient facilities make it unnecessary to construct large scale mental hospitals? Such a setup would utilize not only the drugs but psychotherapy and other available techniques since, despite the opinion of a few extremists, there exists no conflict between psychodynamic and pharmacodynamic treatment. In point of fact, they admirably supplement one another.

A brief mention should also be made of the side effects, since these, too, at times are apt to lead to confusion if not properly understood. Any pharmaceutical which possesses potency invariably has side effects. This is merely another way of stating that a pharmaceutical acts at multiple sites and, usually, in more than one way. Ideally, a drug would do only what was therapeutically necessary and no more, but few, if any, compounds of this type exist anywhere in na

ture or the laboratory. Let me select, as a well known example, to this committee, at least, aspirin, which has at least two major actions, (1) reduction of pain, (2) reduction of temperature. If the use of the drug is primarily for the relief of pain, then the reduction in temperature would be a side effect and, vice versa, if the drug is given for reduction of temperature then reduction of pain sensitivity would be a side effect. Sometimes, misunderstanding of this has led to unfortunate publicity. Let us imagine that aspirin was used for a year or so for its pain-reducing properties and only then was it noted that it also reduced body temperature. This might immediately lead to a hue and cry that the drug was potentially dangerous since the normal body temperature was 98.6° F. and the use of aspirin reduced this so that the individual no longer functioned in a normal manner which, since it was below what nature intended, might lead to all sorts of dangerous reactions. Similarly, if the drug were used primarily to reduce temperature and it were subsequently discovered that it also lessened pain sensitivity, a similar alarm might be sent out that since the individual did not respond to pain in a normal manner he might be subjected to all kinds of accidents and, therefore, the drug should not be used.

Mr. BLATNIK. Doctor, just to clarify, in describing side effects, you are not implying that all side effects, while they are effects in themselves, are necessarily harmful? There would be side effects that are not necessarily of any significance or importance. Could there also be side effects that are damaging?

Dr. KLINE. Yes; I'll refer to those.

Mr. BLATNIK. Excuse me.

Dr. KLINE. But I wanted to make the point that, sometimes, what are called side effects are only side effects because you happen to be looking down a particular tube. Later, what was once a side effect may be the reason you are using the drug. As with aspirin, if you are using it for pain, then the reduction in temperature is a side effect, since this is not your reason for using it. You are trying to reduce pain.

On the other hand, half an hour later, with another patient, you may be giving the drug to reduce temperature, in which case, the reduction of pain sensitivity is then called a side effect.

So, not only are the side effects not necessarily dangerous, but, at times, they become the principal reason for using the drug. It depends on what you are trying to accomplish as to whether you call this a side effect or not.

There are others, of course, which are just a bloody nuisance where at least no one knows of any possible use, although sometimes these, surprisingly, turn out to be something that later you do find medically useful. So that the term, as you indicate, makes it sound as though these are dangerous, horrible things, whereas, in point of fact, they may be either unimportant or annoying, at most, although, as I'll indicate, there are a few dangerous ones.

In the case of the psychopharmaceuticals there are similarly side effects but the vast majority of these, although they may be annoying, are not dangerous and to the best of my knowledge (except as noted below) are fully reversible when the medication is discontinued, reduced, or supplementary drugs given to correct the side effects. There