CLINICAL-STATISTICAL ANALYSIS OF POPULATION CHANGES IN NEW YORK STATE MENTAL HOSPITALS SINCE INTRODUCTION OF PSYCHOTROPIC DRUGS

1. Fall of population in the New York State mental hospitals has continued through its sixth year. The rate of overall decrease has been about 1½% per year. Several elements in the total population can be identified as most affected by the change and with the exceptions of paresis and psychoses of the senium noted above, the decreases mostly involve those groups where drug therapy has the greatest clinical advantage over previous methods, this effect subsequently having been intensified by stepped-up total programs.

(a) In general, the decrease is most marked in the younger age groups and in the 2- and 3-year cases and there is an actual increase of the very long term older cases (Figures 6 and 7). Releases have risen in cases of all durations of hospital life (Figure 4).

(b) The 5-year fall (1955-60) of schizophrenic cases is the most impressive of all diagnostic groups and amounted to 3,376. This began abruptly after the introduction of large-scale drug therapy in January 1955 and has continued ever since. In this same period (1955-60) there was a marked increase of 2,064 in schizophrenic admissions. Within the schizophrenic group, the decrease was most marked in the 1- to 4-year cases (Figure 10) and the age group 24-44.

(c) In sharp contrast, the number of resident cases of alcoholic psychosis has actually risen (Figure 8).

(d) There has been a diminution of cases of other functional psychoses although of less significance than that seen in schizophrenia (Figure 8).

2. The relationship of the foregoing changes to the introduction of large-scale drug therapy remains no less open to debate than it was in May 1957 when we outlined our reasons for seeing a positive relation. We still find no other explanation for a change of such magnitude which has involved hospitals across the country and abroad and which, in its larger aspects, began quite abruptly in 1956, the year when psychiatric drug therapy first began to be applied on a large scale. There is no doubt that population reduction may be and has been brought about by many other means. However, the fact is that it was never before accomplished on a scale remotely approaching the national and international level reported since 1956.

3. However, the question as to the significance of drug therapy in this entire situation has taken on another meaning and implication. For the first few years the issue which seemed to hang in the balance was whether drug therapy should really be accepted and come into general use. It now seems that further debate on this point has lost its significance because regardless of the formal opinions which may be expressed, the fact is that hospitals throughout the world are using this method. It appears from various communications that practice varies much less than theory and that the established norm probably runs at about 60% of the population of the various mental hospitals; at least this is the impression which one gets from informal communications.

The question of drug use thus seems to be settled in a practical sense but the original problem retains its importance because insofar as the mental hospital improvements are due to drug therapy, they may be limited by the limitations of drug therapy, both as to the proportion of cases relieved and the pattern of individual improvement and its conditions. If, for example, release is due in a significant degree to such therapy, drugs may have to be maintained indefinitely afterward. In practice this is gradually being accepted and here, as often occurs, practice seems to precede theory since many psychiatrists are still dubious about this entire subject.

4. If drugs play a large role, we shall have to accept another limitation. Up to the present time they have proved much more effective in reducing active positive symptoms than in controlling negative ones, such as occupational inertia, vocational incapacity, and lack of initiative for constructive occupation—long a prime problem in the care and treatment of the mentally ill. Much effort will have to be expended in social and vocational rehabilitation, but perhaps we have not given due recognition to the fact that defects in this area are not an accidental and secondary problem but a primary and central one directly related to mental illness and especially schizophrenia, and it may be expected to become more prominent because of the differential effect of drugs on mental symptoms.

5. Perhaps most important of all is the recognition of the fact that striking and valuable as the recent improvements in hospital results have been, it is also possible to exaggerate them. The recent decreases of hospital population have continued at the rate of 1%-1½% per year in our state, and careful review of the data indicates that this rate may be expected to continue. There are some indications that a degree of acceleration will take place in the next few years to be followed by a possible plateau formation in the course of time, but chronic cases are still accumulating in our hospitals in numbers only 22% below those which had filled some 53,000 beds with long term cases in New York by 1955. In 5 years the rate has fallen from 27 per year per 100,000 of the state population to 20 per year and the mean age of such cases has risen from 50 to 56 years (Table 3). All this has implications for future decrease of the number of long term mental hospital beds which will be needed. However, the number of beds required for short term cases (less than one year) has apparently reached a plateau at about 12,000, and there is also some indication that the number of beds for intermediate care (1-4 years) will reach a plateau at about 16,000 beds, and the fall of chronicity rate is to some extent being counterbalanced by increase of state population.

6. Table 9 gives our projection of the resident patient population of the New York State mental hospitals in 1970. We believe, as a matter of judgment on the basis of the evidence given above, that in the 10 years from 1960 to 1970 there will be a continued reduction which will leave a mental hospital population of between 72,000 and 83,000 resident patients. This would be a reduction amounting to between 6% and 19%. We believe this to be a reasonable degree of [See TABLE 8 and TABLE 9 in Source PDF] precision for program planning.

7. Finally, statistical evidence is lacking for a massive acceleration of the process of shrinkage. Much of the limitation appears to be inherent in the drug therapy with which the process was begun. Any advance beyond the present rate seems to require either a newer and better technology or a newer administrative and organizational approach and it is to be hoped that no type of innovation will be applied on a large scale without provision for critical and adequate evaluation.