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A VERY FEW YEARS AGO IT would have been difficult to justify the inclusion of a chapter on mental hygiene in a general treatise on preventive medicine and hygiene. The medico-legal term "insanity" was used to designate all abnormal mental states and the incorrect conception of mental and physical diseases as distinct and practically unrelated was widely accepted. These misconceptions and the hopelessness, both as to cure and prevention, which characterized the medical attitude toward mental diseases combined to disassociate mental medicine and its problems from the subjects which were engaging the attention of physicians and sanitarians generally. There seemed little likelihood that the determination to prevent diseases which was beginning to dominate the medical profession would soon extend into the domain of mental medicine. Today, however, a treatise on the prevention of disease which failed to include a chapter on mental hygiene would neglect an important field of preventive medicine. The realization that many forms of mental disease depend in a large measure upon preventable causes, the rapid growth of psychiatry and its acceptance as a department of scientific medicine, and the newly discovered opportunities for utilizing its resources in practical attempts to deal with social problems have broken down the barriers which so long and so effectually isolated mental medicine. . . .
IMPORTANCE OF THE PROBLEMS OF MENTAL HYGIENE
On the date of the last federal census, January 1, 1910, there were 187 454 persons in institutions for the insane in this country. This number exceeded the number of students in all the colleges and universities in the United States. It exceeded the number of officers and enlisted men in the United States Army, Navy, and Marine Corps, and also the population of Columbus, Ohio, our twenty-ninth city in size. This great number by no means included all persons with mental diseases in this country or even the number who would have been receiving treatment in institutions at that time had all the States supplied adequate provisions. We know that the ratio of persons with mental diseases to the whole population is about the same in different parts of the country, for wherever sufficient institutional provisions exist they are utilized to very much the same extent. If, therefore, all the States provided for the insane as adequately as do Massachusetts and New York there would have been more than 300 000 patients in institutions on January 1, 1910, instead of 187 454. The cost of caring for mental diseases in a State which makes adequate provisions exceeds any single item of expense except that for public education. The average annual cost of caring for a patient in a State hospital for the insane is about $175, making the total cost of caring for the patients under treatment in all the institutions in the country in 1910 more than $30 000 000. To this great sum should be added, if we are to state fairly the cost of mental diseases, the economic loss through the withdrawal from active life of more than 30 000 people who enter these institutions each year.
No one can state the number of the mentally defective in this country or even the number requiring institutional care. Massachusetts, the State which has supplied institutional provisions most liberally, has one bed to every 1354 of the general population for such sufferers. If this ratio existed in every State there would be 74 747 persons in such institutions at the present time [March 1, 1916]. Actually there are approximately 22 000. We know, however, that even in the State which has made the most liberal provisions there are many mentally defective persons uncared for and many who are improperly confined in correctional institutions or in almshouses. There is reason to believe that there are not less than three mentally defective persons in every thousand of the whole population. Although their cost to the communities through their own dependence, the support of their illegitimate children, and the crimes and misdemeanors which they commit, or more frequently invite, cannot be estimated, we know that it is more even than the great cost of caring for them in suitable institutions would be.
Such statistics as these serve as a convenient means for comparing the cost of mental diseases and mental deficiency with that of other diseases, but they cannot convey an adequate idea of the personal suffering and unhappiness and the social and family disasters for which mental disorders are directly responsible. It should be remembered that the same causes which bring about the commitment of many thousands of persons as "insane" each year are responsible for much mental disease which is never recognized and for many failures in adaptation which prevent people from meeting difficult situations in life and which lead to innumerable conflicts with laws and conventions. To avert some of these disasters is as much the task of mental hygiene as to control the preventable causes of mental disease and of mental deficiency. . . .
MENTAL CAUSES
Important recent additions to our knowledge concerning the psychology of mental diseases have brought about radical changes of opinion as to the part played by mental causes. The statistical tables of hospital reports have always listed as etiological factors "grief," "worry," "death of a relative," "fear," "remorse," "fright," and "disappointment in love." Large numbers of cases have been attributed to such causes as these without any knowledge of the manner in which they operated. It has been pointed out that they really represent little more than a catalogue of the untoward circumstances which, to a greater or lesser degree, shadow the life of every individual and that the proportion of persons who develop mental disease in consequence must be extremely small. This difficulty has been disposed of by the assumption that if only a few of those of us who are exposed to such adversities develop mental disease, an inherited neuropathic predisposition must determine this unfortunate outcome. Recent studies, however, especially those which have followed the enormously important discoveries of Sigmund Freud, have shown that the significance of such factors can be estimated only by understanding the part which they play in the mental lives of the individuals affected. Many factors which have been listed as causes of mental disease are now known to be merely striking circumstances attending the progress of psychoses or surface indications of deep-seated conflicts in personal life. . . .
Preventive Measures
The enormous increase of interest in the mental life of childhood is leading to the recognition at a much earlier period than formerly of those factors which endanger mental health. Education must be fundamentally altered to fit the needs of subnormal children and those with special difficulties of adaptation. So numerous and so disastrous are the results of failure to make the modifications in teaching which these children require that the whole educational system might well be examined with reference to their special needs. Constant and increasing efforts should be made to determine the individual requirements of school children and the attention of the best educators should be given to devising means for furnishing such children with an equipment which will fit the individual child to live successfully, the average child being, for the moment, forgotten. Special classes exist now only for mentally defective children. They should be provided for all kinds of atypical children, intellectual defect representing only one and not perhaps the most important cause of imperfect mental adjustment. . . .
ECONOMIC FACTORS
Unemployment, overwork, congestion of population, child labor, and the hundred economic causes which increase the stress of living for the poor are often contributing factors in the production of mental diseases. Weaknesses in constitutional make-up—defects in the armor of personality—are disclosed under the stress of such conditions, but might have remained undiscovered under happier circumstances. All that can be said of the prevention of such causes is that everything which makes for the betterment of those upon whom the stress of living falls heaviest will save many from mental disease. If the operation of these powerful causes cannot be prevented, those who are most likely to be harmed might, perhaps, be shielded a little if the special danger which they face were more generally known.
CONCLUSION
. . . It seems essential that, notwithstanding the complexity of some of the questions involved, the prevention of mental diseases and mental deficiency should be considered in the general advance which is being made against all diseases, for it is very closely related to all the other fields of preventive medicine. Recent advances in the field of psychiatry have given grounds for encouragement, for if the outlook in some directions is not bright the accuracy with which the part played by certain causes is being defined promises much. The fact that it has been definitely determined that there are certain essential causes of mental disease and mental deficiency, and that some of these essential causes are entirely controllable, makes it imperative that preventive measures should be energetically promoted. At the same time the great advantages in the promotion of mental efficiency which may result from better understanding of the nature and importance of mental conflicts and of the means by which more successful adaptations may be made, should lead to developments in the constructive phases of mental hygiene which, in the end, may prove the greatest service to mankind of this branch of hygiene.
Footnotes
Excerpted from Thomas W. Salmon, "Mental Hygiene." In: Milton J. Rosenau, ed. Preventive Medicine and Hygiene. New York: D. Appleton & Co; 1916:331–361.
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