^- L /-?^ MINUTES OF MEETING WITH REPRESENTATIVES OF STATE MENTAL HOSPITALS ON WHAT DO WE fcnow ABOUT ALGOlioLlSk

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1 ^- L /-?^ MINUTES OF MEETING WITH REPRESENTATIVES OF STATE MENTAL HOSPITALS ON WHAT DO WE fcnow ABOUT ALGOloLlSk IN THE STATE MENTAL HOSPITALS OF MARYLAND March 13, 196l PERSONS PRESENT Eastern Shore State Hosptal - C. Van Eyk Grobler (Psychologst), Sprngfeld - Dr. Julan Abrams (Psychologst), Sprng Grove - Dr. Fernando Cabrera (Psychatrst), Dr. John W. Shaffer (Psychologst), and Dr. A. Smopoulos (Psychatrst), Crownsvlle - Dr. John A. McGee (Psychatrst), Dr. Carl B. Schlefer (Psychatrst) and Gwendolyn 0. Krkland (Psychologst). Other persons present were Dr. Isadore Tuerk (Commssoner, Department of Mental Hygene), Dr. Lous P. Gundry (Charman, Commsson on Alcoholsm), Dr. Leo Bartemeer (Member of Commsson on Alcoholsm) and Mss Lllan M. Snyder (Research Assocate). SUMMARY OF FINDINGS Mss Snyder presented a bref statement of the reason the Governor apponted the Maryland Commsson on Alcoholsm and how the Commsson has proceeded to fulfll ts charge. Although the major concern of the Commsson s the ndvdual whose alcohol pathology s hdden or the uncommttable alcoholc (about 75% of persons for whom alcohol has become a problem), before ths group can be studed and asssted attenton must be gven to the problem of the polce court nebrate (about 3 to 1% of the alcoholc populaton) and the psychatrc patent wth alcohol pathology (about 20% of the alcoholc populaton). Servces and treatment of the two latter groups should be approached smultaneously n vew of the fact that the polce

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3 - 2 - brng about 80% of the alcoholcs who are admtted to the State Mental Hosptals (also called polce patents). Whch Alcoholcs Come to the State Mental Hosptals? The General Assembly of Maryland has desgnated the Department of Mental Hygene to have "full and complete power and supervson of all matters relatng to custody, care and treatment of the nsane." In lne wth ths charge every alcoholc admtted to the State Mental Hosptals must be certfed by one or two physcans that he s nsane and n need of hosptal care. No alcoholc wth a physcan's statement has been turned away. Some patents at ther own request wthout a physcan's statement have been admtted. Alcoholc patents admtted to State Mental Hosptals are gven the followng dagnoses: Acute Bran Syndrome Assocated wth Alcohol Intoxcaton (02.1) Ths typcally refers to those persons sufferng from delrum tremens and acute alcoholc hallucnatons. Chronc Bran Syndrome Assocated wth Alcohol Intoxcaton (13.0) Ths refers to types of chronc delrum formerly called Korsakoff's psychoss and mples some degree of permanent bran damage resultng from use of alcohol. Socopathc Personalty Dsturbance wth Alcoholsm (addcton) (52.3). Under ths dagnoss are placed cases of well-establshed addcton to alcohol wthout recognzable underlyng dsorders. Patents sufferng from psychoses n whch excessve drnkng may be contrbutory are not classfed as alcoholcs n the State Mental Hosptals.

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5 A 3 '- How do Indvduals wth Alcohol Pathology Com to the State Mental Hosptals? IQ^q Type of Admsson Alcoholc Patents Voluntary 171 Two Physcans 656 Court 197 Percent All Patents Percent 17% kzk 10% 6k% % 19% % TOTAL: 102^ 100% ^2^1 100% Durng the calendar year 960, 125 nebrate court orders were ssued from the Baltmore Cty and Baltmore County Courts. Of ths number, 122 alcoholcs were asssted by the Legal Ad Bureau, Inc. These patents were sent to the followng hosptals: Crownsvlle - 'f (2 women) Sprngfeld - 7k (6 women) Sprng Grove - hh (5 women) What was the Admsson Procedure? The alcoholc, hs famly or others (ncludng polce offcers) very seldom used the State Hosptal Pre-admsson Servce. Voluntary admsson was usually used the frst tme at the suggeston of staff members at Johns Hopkns or Unversty or medcal departments the of ndustry. Few persons seemed to be aware of the exstence of/voluntary admsson. After the alcoholc has used ths type of admsson once, he usually prefers to use t agan n subsequent admssons f ths becomes necessary. Some State Hosptals permt only two voluntary admssons a year. Ths s to dscourage the alcoholc from usng the State Cental Hosptal as a free dryng-out faclty. When the patent presents hmself n the Admttng Offce, the socal worker sees hm and hs famly frst to see that hs papers are n order and to be sure he s where he thnks he s. The socal worker

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7 - k 1 prepares hm for the next twentyj-fou- houts. The admttng physcan then examnes the patent. Alcoholc patents comng to the Admttng Offce wth the famly request or communt.y request are usually accompaned by a relatve or a polce offcer. The group s frst seen by the socal worker who looks over the papers and attempts to prepare the patent and famly members for the hosptal experence. The polce offcer who accompanes the patent s seldom the one who has made the arrest or who has talked wth the famly. The Inebrate Court Order s prepared by a staff member (usually a law student) of the Legal Ad Bureau.between 9 and 10 A.M. The patent wats at the Legal Ad Offce whle a clerk takes the papers to Judge Allen's offce (Crcut Court No. 2) before 10 A.M. Judge Allen sgns the petton sometme between 10 and 12 before hs Court convenes. It s not necessary for the patent to appear at Court. As soon as the patent s gven the Court Order, he may take the streetcar to Sprng Grove or may go n a taxcab. Occasonally, he goes n a polce car. Sometmes he holds the Order untl hs money runs out or untl a week or so before t expres. The Court Orders are usually wrtten for 60 days. Through What Process s the Patent Gven the Label of an Alcoholc? As soon as possble after the patent s admtted, the examnng physcan, usually a thrd-year resdent or less, sees the patent. Hs dagnostc mpresson s based on the patent's hstory, nformaton from the referral source (often a prvate physcan or a physcan from a general hosptal), the physcan's certfcates, the observed behavor of the patent durng the examnaton and the relatves' story. The

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9 - 5 - examnng physcan may not make a fnal dagnoss untl after the acute stage has passed. Labelng s not done by a medcal specalst for the treatment of alcoholcs nor s there an admsson staff conference n whch a jont, mult-professonal study and dagnoss s made. What Therapes and Treatments are Provded? Attenton s frst gven to savng the alcoholc's lfe. There were thrty-seven deaths of alcoholcs n State Mental Hosptals durng the year endng June 30, 960 (k% of all deaths). Fve alcoholcs ded n polce lockups before they ever reached the hosptal. The next step n treatment s to provde relef of pan and dscomfort durng the acute stage. Attenton s also gven to other lls assocated wth drnkng. Ths may nclude malnutrton and lver dsfuncton among other lls. Followng recovery from the acute stage, patents who reman n the hosptal are provded a varety of therapes by many professons de- pendng upon the needs of the ndvdual. At Sprng Grove State Hosptal n the Alcoholc Rehabltaton Unt, these therapes are specfcally drected toward the alcoholc ndvdual. What Are the Goals n Treatment? Staff members state that ther goals n assstng the alcoholc patent are as follows: (1) to acheve sobrety (for lfe) (2) to assst n vocatonal rehabltaton (3) to get along wth others ncludng famly members and the boss (k) to develop self-apprecaton, self-confdence and usefulness Some staff members concentrate on one of the goals and others beleve they are all mportant.

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11 - 6 - How Effectve s the Treatment? Staff members can see mprovement n ther alcoholc patents from the tme of admsson to the tme of dscharge. Comments about the nature of the mprovement s summarzed n the Medcal Record. Staff members, however, do not know what happens to ther alcoholc patents after dscharge. Nothng s known about whether the mprovement has been mantaned at the end of one month, sx months, one year or three years. There s no follow-up bult nto the servce program ether by letter, by appontment or by home vst. There are no agreed upon crtera for evaluatng results. What Researches are beng Done to Fnd Out More About Alcoholsm? Two researches have been publshed. These studes have been made on the effcacy of drug therapy durng the acute stage at Sprngfeld State Hosptal and Sprng Grove. The results of several other studes at Sprng Grove are about to be publshed. Multvaret factors are currently beng studed among alcoholc patents at Sprng Grove. About 150 patents have completed these studes. The most urgent need s to know more about the phenomenon of alcoholsm. Is t a dsease? Psychatry says "no", that t s a symptom and yet psychatry dentfes three dsease labels. Is t a syndrome wth medcal, socal and moral components? Members of Alcoholcs Anonymous say that t s. Is t a symptom that can be used at wll by ndgent ndvduals who need a "tcket of admsson" to an nsttuton such as a jal, mental hosptal or correctve nsttuton. There s a need to classfy the dverse types of alcoholcs and to

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13 - 7 - compare the types of alcoholcs wth the types of therapes rendered and results obtaned. There s an excellent opportunty at the present tme to make classfcaton studes before more selecton s made of patents admtted to the Sprng Grove Rehabltaton Unt. There s already some natural selecton such as the economc factor. There s a need to study responsveness. Under what condtons can we expect responsveness? We must dentfy the response types. The general practcng physcan s at a loss to know how to treat hs alco- holce patents untl he knows what therapes have been proven successful. What s the purpose of buldng large rehabltaton facltes for varous alcoholcs f we do not know who the alcoholc s and what hs needs are and how responsve he wll be to the rehabltaton provded? How Many Alcoholcs were Processed n the State Mental Hosptals? The number of alcoholc patents admtted to the four State Mental Hosptals durng the calendar year 1959 was as follows: Crowns- Eastern Sprng Sprng- Admsson vlle Shore Grove Feld Total Percent Frst 212 k ^ 558 5^% Re-adms. 10k ^66 W Total ^ 100% There was a slght ncrea-je n the alcoholc admssons durng the year endng June 30, I960. Alcoholc Admssons: Frst Admsson Re-admssons % (2k% of all hosptal admssons) 552 k8% (26% of all hosptal re-admssons) Total: % (25% of all patents)

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15 * 8 - If we compare the alcoholc patents wth patents admtted for treatment of schzophrenc reactons, we observe the followng hfor^- maton: Schzophrenc Admssons; Frst Admsson 539 (21% of all frst admssons) Re-admssons 856 (kl% of all re-admssons) Total: 1395 (30% of all admssons) On any one day n the State Hosptals there are ^l^ alcoholc patents (a 15% ncrease n fve years) and 4,309 schzophrenc patents (a 2% decrease durng the last fve years). Durng the year endng June 3Q, I960, a total of 1,121 alcoholc patents were dscharged. Of ths number 621 were dscharged on completon of ther frst admsson. Study of the 621 alcoholc patents who were dscharged at the end of ther frst hosptal experence revealed the fact that these patents averaged 65 days hosptalzaton (50 days n Eastern Shore to 79 days n Sprng Grove). At an overall per dem cost of $k.69 per day, the average cost of care per patent amounted to $30^.85. About k2% of these patents were dscharged at the end of a month's hosptalzaton (as compared wth 33% for all alcoholc patents dscharged (ncludng re-admssons) and 11.6% for all hosptal patents dscharged (ncludng re-admssons). Questons for Dscusson What s the meanng of the nformaton collected? What are the gaps n the data? Why dd Crownsvlle have the lowest percent of returnees?

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17 - 9 - Why dd Sprngfeld have the hghest percent of returnees? Does Crownsvlle provde the most effectve treatment, or s the treatment program so bad that patents refuse to return? Are patents gong to Crownsvlle n a later stage of ther llness so that they de before returnng? Is the dagnoss changed on the return trp? Is there a post dscharge treatment program whch holds the treatment gans made n the hosptal? Is there greater selecton for admsson n the pre-admsson servce? Do the returnees reman longer n the hosptal? Do we really know why patents come back? Before the Chapter on the State Mental Hosptals n the Commsson's fnal report s completed, what more do staff members wsh to know? SUMMARY OF DISCUSSION The queston was asked, "What proporton of alcoholcs admtted to State Mental Hosptals are admtted n the acute stage?" Dr. Cabrera repled that from 60 to 70 out of the last koo patents admtted to Sprng Grove were admtted n the acute stage. Many ntoxcated alcoholcs sober up n jal before enterng the State Mental Hosptal. Dr. Bartemeer wondered what proporton of patents enter the State Hosptal by way of the polce lockup. Although t s estmated that approxmately S0% of alcoholc patents are "polce patents" the exact number s unknown. Dr. Bartemeer hopes that the tme s near at hand when all alcoholcs and mental patents wll be taken drectly to a medcal faclty and by-pass the polce staton. Dr. Tuerk ponted out that he hao recommended that a recevng hosptal be establshed. Ths plan has worked well n other ctes and should meet the need n Baltmore. Dr. Cabrera stated that there were 6,000 arrests last year n Baltmore

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19 due to drnkng. Most persons who de n jal have an elevaton of alcohol n the blood stream at autopsy. Dr. Smopoulos expressed the fear that f facltes for treatment are mproved that there wll be more patents. Hosptals could not handle the 6,000 ndvduals arrested for drnkng. It was ponted out that there would need to be a screenng devce so that the mentally ll patent would be classfed and routed to the approprate faclty for care. Dr. McGee crtczed the current method of classfyng the alcoholc n the State Mental Hosptals. He felt that many ndvduals were called alcoholcs who really are not true alcoholcs. He wondered f the man factor n the treatment of the alcoholc s not the psychogenc factor. He commented further that the AMA publshed a seres of artcles n 1956 advsng the general practcng physcan that alcoholsm s a dsease. Ths was an attempt to nterest the prvate physcan n the alcoholc. Dr. McGee feels that professonal ndvduals treatng the alcoholc should certanly be sympathetc and understandng toward the ndvdual wth a drnkng problem rather than consder hm as a degenerate or a crmnal. At the same tme, we should not oversmplfy the problem and class all alcoholcs n one overall category. Mr. Grobler rased the pont that f the alcoholc s treated n a mental hosptal he should be treated lke any other patent and should not be segregated. He mpled that segregaton lowers the status of the alcoholc and lessens the opportunty for all staff members to treat hm and for other patents to assocate wth hm. Dr. Abrams commented that the re-admsson of alcoholc patents s

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21 ". automatc. He mpled that alcoholcs are expected to return and that they are never turned away. Dr. Shaffer asked "Where do we go from here?" Do we buld bgger and better mental hosptals or do we apply the knowledge we know and at the same tme attempt to gan a greater knowledge about ths problem? He felt there s greater need for classfcaton of the ndvduals who become excessve drnkers; and ve must fnd a more humane way to treat them. Through the research already begun at Sprng Grove the staff beleves that t s possble to analyze all of the dfferent factors that go nto the makeup of an alcoholc. We need to determne whch type responds better to whch types of treatment. The alcoholc s defned as one who gets nto repeated trouble because of the lls assocated wth drnkng. Many of the alcoholcs are pure and smple character dsorders. Dr. Tuerk wondered f physcans n prvate practce would see hs group of patents as character dsorders. He descrbed the studes currently beng done on personalty types at the V/nter General Hosptal n Kansas. Dr. Shaffer commented about ther study of condtoned reflex whch may ndcate whch patents can use antabuse. Dr. Bartemeer wondered how many patents currently beng admtted as alcoholcs are also addcted to other drugs. Dr. Cabrera estmated that about 3% of these patents use barbturates or other drugs. It was agreed that the multple addcton makes treatment much more dffcult. Does the hope for the future le n the use of transqulzers as a substtute for all other drugs ncludng alcohol? Dr. Bartemeer commented that n hs experence many alcoholcs have told hm that whle they were n the hosptal they had no desre to drnk.

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23 Mss Snyder commented that Professor Trce has often rased ths pont that one of the dffcultes n dealng wth ths problem s that t s quescent about 90% of the tme. It s only durng the acute stages that the ndvdual gets nto trouble. The quescent stage may occur at any tme, and the factors accountng for ths are unknown. Dr. Cabrera stated that n hs opnon hs staff s workng to capacty; In comparng hs program wth the other State Mental Hosptals, the therapes used n other hosptals are not orented toward the alcoholc. He felt that hosptals should use more communty help and cooperaton such as Alcoholcs Anonymous and the psychatrc clncs. He elaborated on the dffcultes he has n carryng out a follow-up program. He would lke to see a follow-up program developed smlar to the one n Mnnesota. He also felt that the type of commtment should be changed. The alcoholc should be admtted as an alcoholc and the admsson should be a voluntary agreement for a defnte perod of tme smlar to type of commtment now n use n Florda and Mnnesota. Dr. Tuerk stated that the dfference n the varous programs n the State Mental Hosptals depends on the nterest of at least one person n every hosptal who s dedcated to the treatment of the alcoholc. He beleves that the establshment of the Central Regstry wll ad n the follow-up program. The jont program wth the Health Department wll ad n the exchange of nformaton. There has been a lag n Baltmore Cty. However, at the present tme, Doctors Schnedmuhl wth the Cty Health Department, Fedler at the Unversty Hosptal and Neustadt at Cty Hosptals are all n the process of workng out programs to assst the alcoholc.

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25 Dr. McGee stated that t s certanly necessary for a person who s dedcated to assst the alcoholc to spearhead the program at each State Mental Hosptal. Ths person, however, should have the admnstratve responsblty for the program. There are three groups whch should be asssted: the psychotc alcoholc, the alcoholc undergong a psychotc epsode durng the acute stage and the schzophrenc patent wth alcohol complcatons. The acutely medcally ll alcoholc should be treated n a general hosptal. Dr. Schlefer emphaszed the fact that there s a great deal of confuson n gatherng nformaton about alcoholc patents n makng a clear-cut dagnoss. Usually there s very lttle nformaton about the alcoholc when he s brought nto the admttng offce. If he s drunk, he s very lkely to get the label of acute bran syndrome; and f he s sober but has been drunk he may get the label of chronc bran snydrome. If he has ncpent DT's, he may be called acute. There s no logc or reason for the current labelng process. The fgures factually don't mean anythng because one patent n one hosptal may have one label whereas n another t would be somethng else. Even dfferent physcans may have a dfferent opnon or on dfferent days the patent may present dfferent symptoms. Before there s any meanng to a dagnostc label, the process s gong to have to be standardzed. Ths wll take a great deal more knowledge than we have at our dsposal. Dr. Shaffer ponted out that ths s exactly what hs group s tryng to do at Sprng Grove. At the present tme they are usng about a hundred pre-admsson varables and a hundred and ffty post-admsson varables n a study of each person who agrees to partcpate. The studes nclude psychatrc nter-

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27 vews, personalty tests, ntellgence tests, medcal studes and others. Although some of the studes may be redundant, t s hoped that n phase 2 of the research that a short cut can be found, so that there can be a Standardzed psychatrc work-up. Mss Krkland emphaszed the fact that as a frst step n any program to assst the alcoholc the professonal staff n the mental hosptals must be educated. There s very lttle nterest or understandng of the alcoholc patent. Nothng much s gong to be accomplshed untl the atttude of professonal staff members toward the alcoholc s changed; Dr. Smopoulos put n a word of cauton about devotng so much tme and energy to treatng the alcoholc patent to the neglect of other patents n the mental hosptals. The admnstrator of a mental hosptal has a bg job to do and the needs of many patents to consder. He usually tres to make nvestments of money and personnel n those projects whch wll brng the hghest return. The alcoholc s often not as well motvated n dealng wth hs llness as other patents are. We do not know f any of our efforts are actually makng more alcoholcs sober. We should be makng comparsons of treatment efforts toward a specfc segregated group of alcoholcs wth results n other treatment approaches now beng used n other hosptals n order to justfy a specalzed type of servce. Dr. Cabrera ended the dscusson by statng that the problem of the alcoholc s a very serous one n the communty. Every alcoholc who s rehabltated becomes an ndvdual who wll be a taxpayer. Tax money expended n the rehabltaton of the alcoholc wll be returned to the communty n tax ncome. Lllan M. Snyder Research Assocate Maryland Commsson on Alcoholsm

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29 TABLE I AGE ON FIRST ADMISSION OF ALCOHOLIC PATIENTS BY RACE AND SEX DISCHARGED FROM EACH STATE MENTAL HOSPITAL DURING YEAR ENDING JUNE 30, I960! Crowns-] Eastern, Sprng j Sprng-- j Grand vlle 1 t Shore Grove fe:ld j Total Total!Total Age j Negro Whte! Whte. Whte T Whte Ne'groj Group [ M F ' M F.j M F M F! M F M Ft M T Under 20 1: j ko-kk j ! Unknown Total Total , ?7, j ',38 f , j 55! ! 9' 2! 11 -f 6 20 I 8: 34! ?4! 9 j : I 59 $ 8 3 : loj 81 \2k\ ! 10! 85 jlsl 103., 9 j 14 j 2 86 llj ; 51 65! 13 1 Zl 8 L-j. 3 ; ^ j 11 ;, 42 5 I 4? J- n 25 j j 1 I !! -U 21 j ^54! 46 5l2 l09j !

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31 FIGURE I. FIRST ADMISSION ALCOHOLIC PATIENTS DISCHARGED FROM STATE MENTAL HOSPITALS DURING YEAR ENDING JUNE 30, I960 NUMBER OF 80 PATIENTS 70 BY SEX AND RACE ko t o Age Group W Male W Female N Male N Female

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33 FIGURE 2. FIFST AJT'ISSIOW EXOESrVE IF.PJKERS DISCHARGED FROM PS V CHIATPIC OUTPATIENT CLINICS DUB-D^G YEAR ENDING JUNE 30, I NUMBER OF 70 PATIENTS BY 60 SEX 50 AND RACE ho UO h5 $05$' &) Ape Group W Male W Female,._. N Male ' r~- N Femgle

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35 I FIGURE 3. ALCOHOLIC PATIENTS ADMITTED TO STATE MENTAL HOSPITALS 1959 CROWNSVILLE EASTERN SHORE SPRING GROVE SPRINGFIELD NUMBER OF PATIENTS j lao! 120 ; 100 j 8d 6o ko!. J n -*. 1 N! ^ : Krj ^ ; t a N 1 1 ^! 'x.'x 1 }. *\ t j j N X 1 r > M "" v! ^. 1 S * ^ X X, "s ; -. s K s S r h j. 1 j t 4 X v Nl S j! I 1 ; ; -C - s * v^ 20 > 1 s N I X v v V > "N '""S *>-. 1 t,.) Frst Admsson vy\v.\\l Re-admsson

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37 Fgure *f. ALCOHOLIC PATIENTS DISCHARGED FROM STATE MENTAL HOSPITALS (k) AND PSYCHIATRIC CLINICS (32) HOSPITALS June 30, I960 CLINICS June 30, NUMBER OF PATIENTS Frst Admsson NXWWH Re-admsson

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