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What psychiatry will be like in 1990 depends on decisions which will be made by both government agencies and decision makers in the mental health profession over the next few years. The basis for decisions about constructive, wide-ranging mental health programs should, in my view, rest upon four major criteria: the frequency distribution of psychiatric conditions in the general population, the determinants of such conditions as evaluated by available data, optimum treatment and prophylaxis.
In the now classic Midtown Manhattan Study by Rennie et al. , psychiatric data were collected from a random sample of the community. Of the group studied, the 23.4% who had significant mental health impairment were divided into three subgroups: those affected by marked symptoms, severe symptoms and incapacitation. Two thirds, or 16% of the three subgroups were diagnosed as having neuroses or personality disorders; only one-third, or 8%, were psychotic or had an organic condition. Of the total sample, another 21.8% had moderate symptoms, bringing the percentage of nonpsychotic patients in the catchment area who deserved remedial care to 37.8%—an alarming statistic. At least five times as many nonpsychotics required treatment as psychotics. Extrapolating to the current era, four or five times the funding allocated to the study and treatment of psychotics should be directed to meeting the needs of our large nonpsychotic population.
The psychotic population can be divided into three treatment categories. The first two include those who require hospitalization—acutely psychotic, depressed and suicidal patients whose stay is brief; and those whose conditions are irreversible by any known therapeutic technique and require custodial care. Institutions for this chronic group should, of course, be maintained