Facts of Medicine; 12; Mental Health

The Facts of Medicine presented by the Harvard Medical School and the Lowell Institute with Dr. David D. Rothstein, Professor of Preventive Medicine, Harvard University, and Mr. Parker Wheatley, General Manager of WGBH -TV. The Facts of Medicine is made possible by a grant in aid from the John Hancock Mutual Life Insurance Company and produced in the studios of WGBH -TV, Boston. Dr. Rothstein, what do you mean by mental diseases? This is a very difficult question to answer because obviously there are all kinds and degrees of mental disease and my definition would certainly include all those people who are in institutions, but going beyond that I think we can draw a pretty clear line as to where mental disease begins and the lack of it ends and that is at the point where a person's behavior interferes with his ability to do his job, to get along with his friends, his co -workers, and his family. Interfers? Interfers. How seriously?

Well, seriously enough so that the people with whom he worked would feel that they just probably couldn't carry on and where a doctor who examined him would consider on the basis of the evidence presented to him that this person really had more than just the thing we all have where we had difficulties with each other every once in a while. And the same would apply to a family situation? Exactly. Family situation, job situation, situation in the Army, there are many situations where it's obviously not a very clear line and yet you will find people on the borderline, of course, but there are many people on one side of that line unfortunately, that's why it's our very big problem. This gives sufficient latitude though for individual differences or as some people more unkindly might call peculiarities or eccentricities in behavior? Yes, I think it would allow for those, but even allowing for those, this problem is really a tremendously big problem. It has a very great extent although I must say it's very difficult to measure just how many people there are in the United States because with this kind of problem because nobody goes around knocking on doors and asking everyone how many people

are in this kind of difficulty. So we have to devise certain kind of indices to try to see if we can tell how common a disease this really is. And one of the ways we do this is to look at the total number of hospital beds in world with this particular problem in comparison with all other problems. Now here we see these two columns add up to about a million and a half beds and a little bit less than three quarters of a million beds, a little less than 50 % are concerned with mental disease. So from that point of view it's a tremendous problem you say, just a very big one. Now this doesn't mean, however, that there are as many people, that there are as many beds involved because when we look at the next chart we see that in terms of admissions of people to hospital which would be another index of the severity of this disease we see that there are relatively few admissions compared with all the other diseases, a very tiny amount. Actually there are 19 and a half

million admissions over here on this side, the 100 % side so to speak and there are only 325 ,000 admissions over in this little tiny column. These are all figures gotten from the Journal of the American Medical Association when they do their annual studies on hospitals. Dr. Rutstein, all hospitals, all types of hospitals included, private, public... That's right, all the hospitals in the United States of all sorts. Now this then raises the question, since there are as many beds involved practically with mental disease as with all other diseases then it must be that the people stay longer in mental hospitals if there aren't so many admissions and we have a chart here on this problem and this chart doesn't reveal as much as we'd like it to and for reasons which I'll explain. You see the average stay in a general hospital in the United States for other than mental disease is 9 days whereas we really can't calculate the state in mental hospitals because it keeps changing all the time because it depends on the definition in any particular

community as to what they will call mental disease, what they will admit to a mental hospital, the rules about commitment, all these various things committed in this particular situation, what facilities they have for taking care of patients outside of hospitals so that mental hospital stays are almost impossible to get a general rule on and of course they're such a widespread anyway. That is there are people that stay a very short time and there are people that stay a very long time and Dr. Ewald, the Commissioner of Mental Health in Massachusetts, gave me some figures which I think might explain this point a little bit more clearly. Now first, when people are first admitted to a mental hospital, a certain number of them of course are very ill when they're admitted, setting them up very old and within a relatively short time really within the first 60 days about almost 17 % of the admissions die. These are the acute cases but after that death is extremely rare in a mental hospital so that after the first 60 days including those who die about half are discharged from the hospital. So this gives you a big bunch on one hand you say. On the other hand, we have some individuals with diseases like schizophrenia that may stay in institutions

their whole lives. So you have this big spread and it's hard to say this is the average stay because it varies so much that there really is no word that fits this kind of a picture unless we describe as we just have this widespread and stay in a hospital. So you have then in a hospital people who come in and stay for a long time and that's why you have so many beds involved, this big backlog of people that are kept in institutions and then we have a smaller number of beds where the people keep coming in and going out or where a certain number of people die and that's about the way the picture looks. So this is three ways then of measuring how many we have. Now we have quite a different way of telling how common this problem is and that is what happened in World War II with rejections from selective service. And you can see here that the first cause of rejection, the first cause of rejection was mental disease. In other words, this was the commonest medical reason for rejection of an individual from the armed forces. Almost one -fifth were not admitted to the armed forces. One -fifth of those who were turned down for medical reasons

were turned down because of mental disease. I have heard it said, without authority, however, that a good many people should not have been admitted for the same reasons. Again, Mr. Wheatley, lines are so hard to specify that it's true, it's very difficult for doctors sometimes to tell where to draw this line, whether to a person in or not. Probably errors were made in both directions, but certainly a lot of people went in the army and cracked up eventually. But this, I do want to make one other point here. We're all concerned these days with physical fitness. And I think it's important to remember that physical fitness insofar as an individual able to be admitted to our armed forces is concerned that we can't cure this kind of disability in physical fitness by giving people more exercise when they're children. This is mental disease. This isn't a matter of building big muscles. This is quite a different question. So I do think that we have to keep this clearly in mind. Dr. Rettstein, is this

situation getting better, getting worse? We really don't know. First, the whole matter of admissions to hospitals and the matter of discharges from hospitals are increasing. But this doesn't tell us whether the problem is increasing. It may just mean that communities are becoming more enlightened and will admit milder disease to hospitals. It also may mean that management and sedation, new drugs, are a little bit more effective so we can discharge people more rapidly. But this doesn't tell us how much disease we have. And so I really can't answer your question. I really don't know, Mr. Wheatley. I really don't know. Now, the next thing I'd like to make clear is that mental diseases, the title was selected as mental diseases because there are many diseases involved. Wow, this isn't just one disease. This is a whole group of diseases, just like the heart diseases. And just to give you an example of what's been happening, we can point out that in this chart here, we can take two diseases that may

cause difficulty. As we can see here in this chart, senile disease is one and syphilitic brain disease is another. And you see, one has been going down while the other has been going up. Mental disease from syphilis has been going down because we have adequate treatment with penicillin to be able to handle people early with syphilis so they don't get brain disease from syphilis. But on the other hand, the senile diseases are going up because we're preventing the acute diseases in childhood and people are living longer and therefore there are more people who become old and there are more people who become senile and more people then who may be admitted to institutions because they become senile. Just growing old doesn't mean you become senile. No, not at all. But among people who grow old, the tendency to become senile is a function of age. That is, more common to be senile at 80 than at 40, although we do see people at 40 who are senile. The other point is, in this connection, is that

not only do we have changes going on in these individual diseases, but even in certain of the diseases because of their very nature and their natural history. The amount of time they stay in an institution differs. And we have another chart here to show this. We have a disease which we call manic depressive disease and we have another disease called schizophrenia. These are two common types of severe mental disease. And we can see here that over a period of five years, those who have manic depressive disease do better. That is about 80 % of the end of five years are discharged from the hospital, whereas when it comes to schizophrenia, only a little more than half are discharged from the hospital. So the amount and rate of admission and discharge will depend not only on the amount of disease in the community, but on the nature of that disease. This is the point, I think, which has to be clearly understood. Are we making any progress in the treatment of mental diseases, Dr. Hudson? Well, this is a difficult question to answer, Mr. Wheatley, because I guess it depends whom you talk to, what answer you get. I've looked over what information I can find, and I think that certain things are

clear. There are a few specific kinds of mental disease, particularly one due to vitamin deficiency, like pelagra, which causes a kind of dementia, so -called. And the kind due to syphilis has now almost been completely controlled, or can be completely controlled, because we can treat syphilis early and we can give adequate diets and vitamin concentrates for the treatment and the prevention of pelagra. But now we get into a large mass of mental diseases. This, these first two, are a very small amount of the total problem. Which first two, you mean? The pelagra and the syphilis, this is really a tiny amount of the whole problem. We get into the more complicated diseases, both in the psychoses, as we call them, these serious diseases, or the psychoneuroses, as some people call them, the milder diseases, but all range of them at least. Then we get into various kinds of diseases that are recommended. And one of the commonest things that's done is to have a patient go to a psychiatrist, of one kind or another, and get one kind or another treatment, depending on what that particular psychiatrist thinks is the best way to treat these mental illnesses. And I think it's perfectly clear that people get a lot of benefit out of talking to psychiatrists and having a psychiatrist trying to probe and find out

what things are bothering them so they can talk them out. On the other hand, I don't know of any evidence that this has really cured any of these diseases, although I think it's perfectly clear that a certain number of symptoms have been relieved by this process. And psychiatrists pick on certain kinds of disease for treatment better than others, because they know certain respond better than others. Dr. Rotstein, is that a distinction you would explain a little more, the difference between relieving symptoms and being cured? Well, I think when a person has mental disease, he may have all kinds of symptoms, and some may be more severe than others, some may interfere with his job, and some may not. And of course, these diseases themselves have their own natural history where they come and go, and some of them fluctuate back and forth like manic depressive disease. That's why it's called manic depressive disease. And it's very difficult to tell very often, unless you do controlled studies, and these are a little hard to do in this field, and haven't been commonly done, to determine whether the improvement in the patient has been resulted from the treatment, or whether it's been just the natural change that's gone on in the disease. Like getting over a cold? That's

right, or maybe even better, a person with arthritis who for a few days has more pain and a few days has less, that kind of thing, chronic illness. Now, you've all heard of shock treatment, giving people electric shock. This was in fashion a few years ago. It's gradually going out of fashion, except for one certain kind of depression, and I think it's usefulness is gradually becoming smaller. We've all heard about what surgery, called psychosurgery, which has to do with doing operations on the brain, some of them have been called lobotomy. I think it's generally recognized now that this probably has given a lot of useful information about mental disease, but probably hasn't really contributed anything to the cure of particular individuals. More recently, we've gotten into the question of drugs, and you've all heard now about what they could now call the tranquilizing drugs. And these keep people, when they come disturbed, it quiets them down, and they become easier to manage. And there's no question in my mind that these drugs have made it easier to manage patients in mental hospitals, or even to manage patients at home who've been in a mental hospital

before. I think this may be true. But we mustn't fool ourselves about these drugs. All we do is to sort of put a cover over the situation. We don't eradicate this difficulty. We just sort of cover it over for as long as the drugs are given. And I think tranquilizing drugs will find a usefulness in the management of patients. I see no evidence at the moment that it'll have any effect at all on the treatment of any of these diseases. I see no evidence at all at the moment on that. And of course, this brings us all back to the fact that a lot of people are put into institutions. Why? Because they cannot get along outside of an institution in society. They cause so much difficulty to their families, to their employers, and so on, that they interfere with just normal social living. And we don't like to have to use institutional treatment, but it's perfectly obvious that at the moment it's one of the only treatments for the severe forms of mental illness. What this means is then that institutionalization is something that we do in this country a lot. In some countries, they have colonies of people after discharge where they can go and work when they become milder. Perhaps as we go

along, we'll think more of treating people on an ambulatory basis and get them out of institutions. This is a tremendous problem at the moment. But of course, this is treatment now. I'd like to ask a question about treatment right here. How do you know, how does a person know when he needs some treatment of some sort? Well, I think he'll know soon enough and he ought to go to his personal physician, and if he does, his personal physician ought to be able to tell him whether he needs a psychiatrist. On the other hand, there is another problem which I should like to stress at the moment. And there is that most of the treatment now being given is sort of in the nature of an educated guess. You know when we treat patients, when I treat patients in a hospital who don't have mental illness, a certain proportion, a small proportion of what I do is backed up by objective scientific evidence. But a good deal of what I do is the best guess I can make under the circumstances because we don't have evidence on everything. And if we think back far enough in ordinary medical treatment and go back to the century ago, we find that as doctors we were bleeding people and we were purging people

and giving them purges one day and bleeding them the next to get rid of all this bad stuff. And so we thought that was good. Well, now we don't purge people much. Instead of bleeding them, we give them transfusions. We do just the opposite. But we thought it was very reasonable at that time to do this, and so in mental disease now it's considered reasonable to purge people and give people catharsis. At the same time, the wise psychiatrist is the person that recognizes that he has to treat his patient as best he can with the best guess he's got at this time. And he doesn't fool himself to believe that what he does is really backed up very often by objective scientific information. We hope we'll get objective scientific information, and there are ways of getting it in this field. At the moment, the psychiatrist and psychiatry, because this is a more complicated problem, are the same as infectious diseases were before Pasteur, before we had knowledge about germs. Does that clear that point up? It is clear, Dr. Rutzstein. I would like to know how good an educated guest may be and how you come about having one. I think history will only give us the answer to that. We don't know. can't tell. All we do is we know our educated guests as a mental disease

are probably not very good because most patients don't respond very strikingly to the kind of treatment that's given. But seriously, tell me how you arrive at an educated guest in respect to rheumatic fever. Well, what you do very simply is that you go to a patient and he presents a problem, which there's no evidence in literature. You remember you saw two or three patients that had the same problem, a couple of the doctors told you they had a few patients about the same problem. So they say, well, they thought this would work, so you try it. Sometimes it does, sometimes it doesn't. And sometimes when it works, you don't even know whether it's the thing that caused, what you did caused the benefit. Maybe it was the disease itself getting better, you see. These are difficult answers to come by in any disease. Is there any possibility that we can do a better job of preventing mental diseases? Well, prevention is the big problem, and of course we can prevent, as I pointed out, syphilis and prokologram. When it comes to preventing other diseases, we have these other diseases, we have very little information about their nature. And what we

need are studies in communities to find out under what conditions these diseases occur, to see if we can find some environmental factors that are related to the cause of these diseases. This, I think, is the big hope. But I do think one should discuss, for a moment, this whole discussion of the mental health clinic, the mental health program that's become so widely disseminated over our country. Now, the mental health clinics have certain values, and there are certain things that they just can't do. For example, if a mother brings the youngster in because he won't eat spinach, and the whole house is disturbed because Johnny won't eat spinach, there is no reason at all why the doctor shouldn't tell the mother that it isn't necessary to give Johnny spinach. There are many other things that have as much food value, and do away with this acute situation that's developed. There are many acute situations that develop in families, in institutions where this kind of problem comes along. So we can do things about that in mental health clinics. But we don't have any evidence at all, and I would stress this over and over again. We don't have any evidence at all that the

particular kind of treatment that's given in a mental health clinic will have anything to do in one way or another with preventing real mental disease in this child when Johnny grows up. And this is an important point because a lot of loose discussion is handed around because the assumption is if you can do something acutely, this automatically means that you prevent mental disease in the future. And there are some studies on this problem now, a few studies. Unfortunately, both of them are negative, but I think it's worthwhile pointing out these studies so we see what the problems are. First, out in Wisconsin, Dr. Sewell did some studies on some families of American stock on children and tested out whether the so -called Freudian theories about development of personality had any validity, whether or not they would stand a test. And so he studied two groups of children, one of whom had this kind of treatment and the other that did not. And at the end of early childhood, around five or six years, he was unable

to tell any difference. Now this doesn't mean that these theories have no validity, but it does mean that someone has tried to do an experiment and tried to find out in this limited group whether or not there is any benefit. And I would point out that this is the only kind of evidence we have at the moment which is negative evidence. We need more evidence of this sort, more studies. And we would hope that the proponents of these particular theories would work as assiduously on doing these studies as the opponents so that we could get evidence on both sides of this question. At the moment, we only have controlled evidence on the opponent side of the question. And even Dr. Sewell at the end of this study, which I have here, pointed out that there were many limitations to a study. It would have to be done over and over again. But he did point out that, he said, but despite these and other limitations, he says, the results of this study are unequivocal for the sample covered. And their generality, whether this is generally applicable to the whole situation, must be affirmed or denied by means of better design and executed studies and not by dialectic. And this is the important

point. He's asking for proof, not argument. That's right. Well, this study that was done with Sewell wasn't set up as a controlled observation the way we'd set up a study now. But what he did was to study a population group that did or did not have these factors and compared the children that had them with the children that didn't. I don't mean to point out that he set up two separate groups and followed the study through. He did what we call an epidemiological study where he went backwards after the study had been done to find which studies the children had this treatment and which children had not. Would you set the study up more tightly yourself? I think you could if you could possibly get mothers to follow the instructions. This may be a difficult problem. I think this would be a very desirable thing to do. And some of us years ago recommended just such a study. I think some of us would like to help in the development of such studies, as a matter of fact. This study isn't final. Dr. Sewell himself isn't final but it's the only kind of evidence we have which is negative. Now one other study and that is the Cambridge

Somerville study which has to do now with quite a different question but still falling in the range of mental disease and that is what about this matter of delinquency that we hear so much about? Is this tied up with mental disease? Are the mental disease approaches useful in this particular kind of thing? Well, Dr. Richard Cabot who was a very wise Boston physician set up studies back in the 30s, 1937 to be exact, in which he took a group of delinquent boys in Cambridge and Somerville or what they call really pre -delinquent boys. Boys they thought were really going to become delinquent and this was on the advice of teachers and the advice of policemen on the beat and so on. And having selected this group he divided them into two parts and one half got treated with counseling and advising and had medical social workers and so on advising on it and the other group had no treatment at all. What year was this? It was 37 to 45. Before the war and during the That's right. And this matter of fact the publication however is much more

recent. publication I think was 1953. Now what they did after this situation had been followed for all these years was to find out what happened to these boys. The first thing they did was to ask the people who had been counseling and guiding these boys and the boys themselves. And the counselors in general felt I think that somewhere around two -thirds had been benefited and about half the boys said they thought they'd been benefited. But actually when one went back and did the test of delinquency or at least one test of delinquency to tell whether or not they had had any offenses in court we have a chart right here to show this. I think it's a very revealing chart. It showed that if you took the number of boys who had court offenses in this period of 37 to 45 and these are the so -called treated group and these are the controlled group who had no treatment you see there were about the same number of boys who had court offenses during that period and in terms of whether the number of offenses they committed a little bit more on the treated side than on the untreated side. On the other hand on the untreated side

some of the offenses were a bit more severe. I think the fair thing to say about all of this is that it really didn't make any demonstrable difference all of this effort and all of this difficulty. And I would like to point out that if we could go back to this chart again to point out that it is this kind of objective of having this control here that's always so necessary because as physicians we always sort of believe that we do a lot of good for our patients and sometimes maybe it's just the fact that the disease itself takes care of itself or the condition like delinquency takes care of itself. So that then we are faced then with this whole question of being able to measure in some objective way the exact results more than just our guess as a result of exposure to our patients as to whether or not benefit has been done. And I think this study doesn't tell us very much about how to take care of mental illness but it does show us the importance of certain kinds of studies in mental illness so that we won't

fool ourselves when we look at what happens after we do something for a patient with mental disease. Is there any hope for the future in research? I think there is much hope and I think we can be very encouraged about developments in recent years. And first we are finding out a very great deal now about how the brain burns up its energy. You know the brain uses sugar just the way an engine uses coal for energy. And we are finding out now how this coal is burned so to speak, how this sugar is burned and get some idea of how in our heads perhaps in the heads of those of us who are classified as having mental disease or those of us who don't have mental disease how these differences may occur and these may give us some real leads. Also we are finding out a little bit about how the chemistry of the brain works out even beyond the question of the burning of fuel. And this is going to give us some very good leads. We are getting some very interesting information about memory as to how

our brains store up information. And this may be very helpful in the future and help unraveling problems of mental disease. And then we have got some interesting studies going in families on heredity to see where hereditary problems are. I am very encouraged about this whole question Mr. Wheatley really. I really think the answer to your question is that our whole audience although I realize if any of them have members of their families who have mental illness that they should realize at the moment that relatively little can be done in a positive way but that there is real hope in the future. think this is really important. You are not opposed Dr. Rutstein to using such ages we have now even though they are imperfect and complete perhaps not final at all. Not only am I not opposed to doing them but I would recommend strongly that they be done. I think that where we don't have specific information we are bound to use our best guess. And I have no quarrel at all. As a of fact I strongly encourage every possible kind of psychiatrist including psychoanalysts to do everything possible that they believe should be done. But on the other hand I don't want them

to attempt to say or to imply that in doing this they have the answers to these problems. This is just the most educated guess that exists at present time. If we take this humble attitude about saying how little we know about this problem it will be the surest way in which we can find out important things about this most important group of diseases that we face at the present time. Thank you very much Dr. Rutstein. The Facts of Medicine has been presented by the Harvard Medical School and the Lowell Institute with Dr. David D. Rutstein Professor of Preventive Medicine Harvard University and Mr. Parker Wheatley General Manager of WGBH -TV The Facts of Medicine is made possible by a grant in aid from a John Hancock Mutual Life Insurance Company directed by Paul Rader and produced by Dr. Rutstein and Mr. Wheatley in the studios of WGBH -TV Boston.