of an agent that could achieve such results. However, before any major portion of observed differences can be attributed to these drugs, much more information is needed about the processes operating in society that lead to hospitalization and about the factors in the hospital and in the community that lead to release from the hospital.

Data are presented to show that between 1940 and 1950 there had already been striking variations and, in several instances, reductions-in some age-specific first admission rates to State mental hospital systems. It is emphasized that there is a need for much careful epidemiological and social science research to illuminate the facts about "paths to the mental hospital" as well as about the "barriers" hospital administrators place between the hospital and the community before it can be determined what part the tranquilizing drugs may be playing in the reduction of admissions to mental hospitals. Data are presented to emphasize the complexities involved in interpreting release rates and also to demonstrate that, even prior to the advent of the tranquilizing drugs, there had been striking changes in the release rates of patients from mental hospitals.

Questions are raised as to whether the observed differences in release rates are due to (a) more intensive use of therapies, (b) differences in the kind of risk being admitted now as compared to years ago, (c) changes in attitude of staff toward level of improvement expected in patients prior to release, (d) administrative factors and staff and patient organization within the hospital, or (e) changes in the community's attitude and that of the patient's family toward the mental hospital and the mentally ill.

Because of the large number of variables involved, well-designed experimental studies are needed to evaluate the various therapies, singly and in combination with each other and with various ancillary programs. In such studies, there must be carefully defined diagnostic groups of patients, comparable control groups, carefully specified therapeutic plans and staffing patterns, and specific objective criteria for evaluating results of treatment and for determining condition at time of release.

The questions being raised about the importance of the tranquilizing drugs on the out

come of treatment emphasize quite sharply the need for clarification of what constitutes psychiatric treatment and of the objectives of treatment within the hospital setting. If hypotheses with respect to the effectiveness of the tranquilizing drugs in accomplishing the goals of hospital treatment are to be tested, it is also essential that experiments and studies be devised that permit assessment of the effectiveness of a treatment method without use of the drugs and the effectiveness of the method when the drugs are used. This is particularly important in psychotherapy since the many statements about the promise of the tranquilizing drugs have emphasized that these drugs make patients more accessible to this form of therapy.

The milieu now made possible in the wards of mental hospitals following the introduction of the tranquilizing agents, namely, a marked reduction in or elimination of motor excitement in patients and the reduction or elimination of the use of seclusion and restraint, raises serious questions about the retraining of existing staff and the changing of staffing patterns as well as how many additional or how many fewer personnel will be required to do the job that will need to be done. Not only have the numbers of personnel in mental hospitals been inadequate in relation to the size of the patient populations they have to treat but the turnover of personnel has also been relatively high. Much research must be done to determine the kinds of personnel needed and how to stabilize them in the new milieu that the tranquilizing drugs are treating.

The need for carefully designed followup studies is urgent to determine how relapse rates are related to diagnosis, sex, age, length of hospitalization, therapy, and relationship of socioenvironmental factors encountered by patients in the extrahospital world to relapse or successful readjustment. The tranquilizing drugs add further complications to the problem. example:

For

How should dosage levels used in the hospital be modified up to time of release?

When the patient is released, on what dosage, if any, should he be maintained?

What problems does the use of these drugs pose for the family?

What information should the family be given? What resources in the community are needed

to follow up these patients adequately to prevent serious complications from developing, to detect complications when they have developed, and to take appropriate steps to safeguard the patient, his family, and the community and to facilitate readjustment of the patient to the extrahospital world?

Effect on Outpatient Practice

The advent of the tranquilizing drugs suggests the possibility that relatively inexpensive agents are available that will make it possible to treat many types of psychiatric disorders on an outpatient basis. With the advent of the tranquilizing drugs, it has been suggested that the general practitioner can now treat some of the milder forms of mental disorders and thus reduce the need for psychiatrists.

Some of the possible problems that these drugs may create are considered in relation to the psychiatric manpower of the Nation and the availability of outpatient and other community psychiatric services. The widespread use of these drugs in our current state of knowledge concerning their immediate and short-range effects could result in situations that could tax seriously the limited psychiatric resources of the Nation.

It is also suggested that administrators of community mental health programs scrutinize carefully the current organization of psychiatric outpatient and inpatient services within their areas to determine how they must be modified and reorganized to meet the new demands that may well be placed on them by the advent of the age of pharmacotherapy in the psychiatric disorders.

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