Open Collections

UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

Change in prevalence and retention of patients in Canadian psychiatric institutions, 1955-1960. Kennedy, Margaret Josephine 1963

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
831-UBC_1963_A8 K3 C4.pdf [ 6.67MB ]
Metadata
JSON: 831-1.0105740.json
JSON-LD: 831-1.0105740-ld.json
RDF/XML (Pretty): 831-1.0105740-rdf.xml
RDF/JSON: 831-1.0105740-rdf.json
Turtle: 831-1.0105740-turtle.txt
N-Triples: 831-1.0105740-rdf-ntriples.txt
Original Record: 831-1.0105740-source.json
Full Text
831-1.0105740-fulltext.txt
Citation
831-1.0105740.ris

Full Text

i . CHANGES IN PREVALENCE AND RETENTION OP PATIENTS IN CANADIAN PSYCHIATRIC INSTITUTIONS 1955-1960 by MARGARET JOSEPHINE KENNEDY A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS i n the Department of PSYCHOLOGY We accept t h i s thes i s as conforming to the standard required from candidates f o r the degree of MASTER OF ARTS Members of the Department of Psychology THE UNIVERSITY OF BRITISH COLUMBIA May, 1963 In presenting t h i s thes is i n p a r t i a l f u l f i l m e n t of the requirements for an advanced degree at the Univers i ty of B r i t i s h Columbia, I agree that the L i b r a r y s h a l l make i t f r e e l y ava i lab le for reference and study. I further agree that permission for extensive copying of t h i s thes is f o r scholar ly purposes may be granted by the Head of my Department or by h i s representatives. I t i s understood that copying or p u b l i c a t i o n of t h i s thes is for f i n a n c i a l gain s h a l l not be allowed without my w r i t t e n permission. Department of Psychology  The U n i v e r s i t y of B r i t i s h Columbia, Vancouver 8, Canada. Date M a y . 1963 ABSTRACT i i . The 75>000 patients i n mental institutions are only a fraction of the mentally i l l i n Canada. A l l of these hospitalized patients have passed through several phases of a complicated selective process. Interpersonal relations, group and community attitudes, and hospital policy, are some of the interacting factors i n this process. The hospitalized population i s a conglomerate of recent admissions and patients remaining from the admissions of many previous years. Changes i n various hospital and societal factors affect the nature of these cohorts. For these reasons, the composition of. the .hospital population merits consideration of i t s e l f , 'rather than as an index of the amount of mental i l l n e s s i n the total population. The purpose of this thesis was (a) to review the characteristics of psychiatric patients under in s t i t u t i o n a l care i n Canada i n 1960 and compare them with those of other populations reported i n the literature, (b) to assess the changes which have taken place in this population between 1955 and 1960, and (c). to elucidate some of the reasons for this change and to suggest areas of further enquiry. The results show that, i n 1960, seventy per cent of the 75>000 patients had been under continuous hospital care for over two years. The proportion of the population under hospital care increased with age. Schizophrenia was the most frequent diagnosis for patients over 2 0 , and mental deficiency the most frequent for those under 2 0 . S t a t i s t i c a l l y significant changes occurred between 1955 and i 9 6 0 i n the number and characteristics of patients under hospital care. The following variables were affected: (a) Age groups; there were fewer patients between the ages of 20 and 59 > and more younger and older patients. (b) Diagnostic categories: Schizophrenia decreased and mental deficiency increased. Xc) Length of stay: there were more recently-admitted i i i . p a t i e n t s , and a decrease i n the number of patients hospitalized-f o r from two to f i v e years. Although a smaller proportion of the patients admitted i n 1958 was retained continuously than of those admitted i n 1955, there were s t i l l approximately 4,000 patients remaining f o r more than two years from the cohorts of each of these years. Changes i n the r e t e n t i o n r a t i o s are associated with changes i n the composition of the patient population between 1955 and 19^0. Some suggestions from other studies regarding the causes of current changes were r e j e c t e d . These suggestions included (a) the changing age d i s t r i b u t i o n of the population, (b) separation of a large cohort of patients who were admitted between 1933 and 1937, and (c) a decline i n s y p h i l i t i c b r a i n syndrome, and (d) increased use of t r a n q u i l l i z e r s . Publications of the Dominion Bureau of S t a t i s t i c s were discussed, and suggestions made f o r a d d i t i o n a l tabulations. Implications f o r other studies on h o s p i t a l i z e d patients were presented. The w r i t e r would l i k e to express her thanks to her f a c u l t y a d v i s e r s , D r . E . S i g n o r i and D r . D . L . G . Sampson, f o r t h e i r he lp and encouragement. E s p e c i a l thanks i s due D r . A . Hichman, of the Department of Medic ine , f o r h i s advice and c r i t i c i s m . H i s i n t e r e s t and experience i n the f i e l d of epidemiology made t h i s thes i s p o s s i b l e . V . . • TABLE OP CONTENTS Chapter I PROBLEM 1 H o s p i t a l i z a t i o n 3 Epidemiology D e f i n i t i o n 7 Indices 8 D e f i n i n g a case 9 L o c a t i n g the cases 12 Choice of index 14 Some ep idemio log i ca l s tudies of mental i l l n e s s Preva lence , s tudies 16 Variables , of prevalence , s tudies Age 19 Age and d iagnos i s 19 Sex 19 Sex and d iagnos i s 19 Diagnos is 20 Length of stay 21 Other f a c t o r s 21 Problem of present study 25 Hypothesis 26 I I METHOD Design Pat i en t s on books as an index of prevalence 27 Choice of v a r i a b l e s Age 29 Sex 3© Diagnos is 31 Length of stay 36 Type of i n s t i t u t i o n 37 Techniques of measurement Sources of data 38 R a t i o 39 Standardized r a t i o s 40 I I I RESULTS Prevalence — Pat i en t s under care a r Dec. 31, 1960 , T o t a l 44 Age 44 Sex 45 v i D i a g n o s t i c group 4 5 Length of s tay 46 Age and sex 47 Age and d iagnos i s 4 8 Age and l eng th of s tay 51 Sex and d iagnos t i c group 52 Sex and l ength of stay 54 Diagnos t i c group and l ength of stay 55 Prevalence — changes, 1955-1960 Age 57 Sex 57 Diagnos t i c group 58 l ength of s tay 59 Age and sex 59 Age and "continued-long-stay" pa t i en t s 60 Age, sex, and l ength of stay 60 Age and d iagnos t i c group 61 Age and l eng th of stay 64 Sex and d i a g n o s t i c group 6 5 Sex and l ength of stay 66 Diggnost ic group and l ength of s tay 67 Sex, d i a g n o s t i c group, and l eng th of s tay 6 8 Retent ion Retent ion of 1 9 5 5 cohort 70 A c t u a r i a l estimate of r e t e n t i o n 72 Comparison of 1 9 5 5 and 1 9 5 8 cohorts 74 IV. DISCUSSION Pat i en t s under care at December 3 1 , 1 9 6 0 Prevalence 82 Sex 82 Sex and d iagnos t i c group 83 Diagnos is 83 Changes 84 Uses and l i m i t a t i o n s of data Source data 9 0 Findings 9 2 V . SUMMARY 9 5 REFERENCES 96 APPENDIX A : Canada. Pa t i en t s i n i n s t i t u t i o n s December 3 1 . 101 v i i . APPENDIX B: APPENDIX C : APPENDIX D: APPENDIX E : APPENDIX P: APPENDIX G: APPENDIX H : APPENDIX I : APPENDIX J : United S t a t e s . Resident pa t i en t s i n mental h o s p i t a l s . ; Number and r a t i o per 100,000 102 England and Wales. Mental h o s p i t a l s . Trends i n estimated rates per 100,000 home p o p u l a t i o n on December 31, 1951-1956 103 D i r e c t o r y of p s y c h i a t r i c f a c i l i t i e s , 1960 104 Diagnos t i c categor ies used i n the present t h e s i s . D e f i n i t i o n s and common a l t e r n a t i v e terms. 109 Canada. P o p u l a t i o n , i n thousands, by sex and age group. 125 O n t a r i o . Pa t i en t s i n res idence i n h o s p i t a l s and h o s p i t a l s choo l s , 1937-1960. Number and r a t i o p e r . 100,000 126 Canada. Pa t i en t s on books, by age, sex and d iagnos t i c group. Age- and s e x - s p e c i f i c f r e q u e n c i e s . 127 Canada. P a t i e n t s on books, by age, sex and l eng th of s t a y . Age- and s e x - s p e c i f i c frequencies 128 Canada. P a t i e n t s on books, by sex, d iagnos t i c group, and l e n g t h of s tay . S e x - s p e c i f i c f r e q u e n c i e s . 129 v i i i . TABLES Table, Page 1 Canada. Pat i ent s on books. Number repor ted , and percentage of sehedule^reported f o r whom morbid i ty cards rece ived 39 2 Canada. Pa t i en t s on books, by age. Number and age- and s e x - s p e c i f i c r a t i o per 100,000 40 3. Canada. Pa t i en t s oh books, by age. Standard-i z e d age- and s e x - s p e c i f i c frequencies 43 4 Canada. Pa t i en t s on books, 1960, by age. Number and a g e - s p e c i f i c r a t i o per 100 ,000 45 5 Canada. P a t i e n t s on books, i 9 6 0 , by sex. Number and s e x - s p e c i f i c r a t i o per 100,000 45 6 Canada. Pa t i en t s on books, i 9 6 0 , by d i a g -n o s t i c group: Number and r a t i o per 100,000 46 7 Canada. Pa t i en t s on books, 1960, by l ength of s t a y . Number and a g e - s p e c i f i c r a t i o per 100,000 47 8 Canada. Pa t i en t s on books, 1960, by age and sex. Number, s e x - s p e c i f i c r a t i o per 1 0 0 , 0 0 0 , and r a t i o of male to female ra te s 48 9 Canada. Pat i ent s on books, i 9 6 0 , by age and d i a g n o s t i c group. Number and age - spee i f i e r a t i o per 100,000 49 1 10 Canada. Pa t i en t s on books, 1960, by age and se lec ted d iagnos i s (psychoses o n l y ) . Number and a g e - s p e c i f i c r a t i o per 100,000 50 11 Canada. Pa t i en t s on books, 196O, by age and l e n g t h of s t a y . Number and a g e - s p e c i f i c r a t i o per 100,000 51 . i ' " 12 Canada. Pa t i en t s on books, 1960, by sex and d i a g n o s t i c group. Number and s e x - s p e c i f i c r a t i o per 100,000 52 13 Canada., Pa t i en t s on books, i 9 6 0 , by sex and se lec ted d iagnos i s (psychoses o n l y ) . Number and s e x - s p e c i f i c afratio per 100,000 53 i x . 14 Canada. Pa t i en t s on books, i960, by sex and l ength of s t a y . Number and s e x - s p e c i f i c r a t i o per 100,000 54 15 Canada. Pa t i en t s on books, i960 , by d iagnos t i c group and l ength of s tay . Number and r a t i o per 100,000 55 16 Canada. Pa t i en t s on books, 1960, by se lec ted d iagnos i s (psychoses o n l y ) , and l ength of s t a y . Number and r a t i o per 100,000 56 17 Canada. P a t i e n t s on books, by sex. Standard-i z e d age- and s e x - s p e c i f i c frequencies 58 18 Canada. Pa t i en t s on books, by d iagnos t i c group. Standardized age- and s e x - s p e c i f i c frequencies 58 19 Canada. Pa t i en t s on books, by l ength of s t a y . Standardized age- and s e x - s p e c i f i c frequencies 59 20 Canada. Pa t i en t s on books, by age and sex. Standardized age- and s e x - s p e c i f i c frequencies 60 21 Canada. Pat i ent s on books, by age and d i a g -n o s t i c group. Standardized age- and sex-s p e c i f i c frequencies 62 22 Canada. Pat i ent s on books, by age and se lec ted d iagnos i s (psychoses o n l y ) . Standardized age-and s e x - s p e c i f i c frequencies 63 23 Canada. Pat i ent s on books, by age and l ength of s t a y . Standardized age- and s e x - s p e c i f i c frequencies 64 24 Canada. Pa t i en t s on books, by sex and d i a g -n o s t i c group. Standardized age- and sex-s p e c i f i c frequencies 65 25 Canada. Pa t i en t s on books, by sex and l eng th of s t a y . Standardized age- and s e x - s p e c i f i c f requenc ies 66 26 Canada. Pa t i en t s on books, by d iagnos t i c group and l ength of s t a y . Standardized age-and s e x - s p e c i f i c frequencies 67 X 27 Canada. Pat i ent s on books, by sex, d i a g -n o s t i c group, and l eng th of s t a y . Standardized a g e - s p e c i f i c frequencies 69 28 Canada. Pa t i en t s on books Dec. 3 1 , 1955» by se l ec ted diagnoses . D i s p o s i t i o n at Dee. 3 1 , i960 71 29 Canada. P r o p o r t i o n of pat i ent s remaining on books at end of var ious i n t e r v a l s 73 30 Canada. Pat i ent s admitted i n 1955 and 1958 and remaining pn books 2 and 3 years a f t e r admiss ion, by d iagnos t i c group. Number and percentage 75 31 Canada. Pat i ent s admitted i n 1955 and 1958 and remaining on books 2 and 3 years a f t e r admiss ion , by age. Number and percentage 77 32 Median and mean d u r a t i o n of stay i n h y p o t h e t i c a l i n s t i t u t i o n s wi th d i f f e r e n t re l ease pat terns 88 x i . FIGURES F i g . Page 1 A g e - s p e c i f i c f i r s t admission and r e s i d e n t p a t i e n t ra tes per 100,000 c i v i l i a n p o p u l a t i o n , p u b l i c prolonged-care h o s p i t a l s f o r mental d i seases , s e l ec ted mental d i s o r d e r s , both sexes, United S ta te s , 1955 10 2 Canada. P o p u l a t i o n , i n thousands, by age group 42 3 Pa t i en t s admitted dur ing p a r t i c u l a r years and cont inuous ly h o s p i t a l i z e d to end of success ive years 79 4 Canada. D i s p o s i t i o n of pat i ent s admitted d u r i n g 1955 80 1. I P R O B L E M P a t i e n t s i n m e n t a l i n s t i t u t i o n s a r e a s e l e c t e d s a m p l e o f t h e m e n t a l l y i l l i n t h e p o p u l a t i o n . T h e . . d y n a m i c s o f t h e i r " b e c o m i n g i l l , o f t h e i r i d e n t i f i c a t i o n a s - p a t i e n t s , t h e i r c a r e a n d r e c o v e r y , o r c o n t i n u e d c a r e , a r e o f v i t a l c o n c e r n t o t h e s o c i a l s c i e n t i s t . F o r t h e p s y c h o l o g i s t , c l i n i c a l , t h e o r e t i c a l , a n d s o c i a l a s p e c t s o f h o s p i t a l i z a t i o n o f t h e m e n t a l l y i l l a r e o f i n t e r e s t . B o t h n o m o t h e t i c a n d I d e o g r a p h i c m e t h o d o l o g i e s a r e a p p l i c a b l e i n a n i n s t i t u t i o n a l s e t t i n g . I n v e s t i -g a t i o n o f t h e b e h a v i o u r . o f t h o s e p e r s o n s c l a s s e d a s m e n t a l l y i l l a d d s t o k n o w l e d g e o f h u m a n b e h a v i o u r a s a w h o l e , w h i l e a k n o w l e d g e o f p s y c h o l o g i c a l f a c t s a n d t h e o r i e s f a c i l i t a t e s t h e u n d e r s t a n d i n g o f a n i n d i v i d u a l a n d t h e c h a r a c t e r i s t i c s o f h i s p a r t i c u l a r i l l n e s s . T h e s o c i a l p s y c h o l o g i s t i s c o n c e r n e d w i t h J t h e i n t e r a c t i o n o f t h e i n d i v i d u a l w i t h t h e g r o u p a n d o t h e r s o c i a l a s p e c t s o f h i s e n v i r o n m e n t . T h e r e c i p r o c a l e f f e c t s o f t h e c o m m u n i t y , f r i e n d s , a n d f a m i l y , u p o n t h e p a t h o g e n e s i s o f m e n t a l i l l n e s s , a n d t h e e f f e c t o f t h e i n d i v i d u a l ' s m e n t a l i l l n e s s u p o n o t h e r p e o p l e , a r e f a c t o r s r e l e v a n t t o h o s p i t a l i z a t i o n . T h e r e a r e a h o s t o f m e n t a l i l l n e s s e s o f d i f f e r e n t k i n d s a n d d e g r e e s , and a corresponding v a r i e t y of causes and pathogeneses. S o c i a l f a c t o r s w i t h i n the i n s t i t u t i o n i t s e l f have an impact on the p a t i e n t . Relationships between h o s p i t a l personnel, of s t a f f with patients, and of both s t a f f and patients to the community, are relevant to the course of the i l l n e s s and the nature of therapy. The questions of who becomes a patient i n a mental i n s t i t u t i o n , and the prognosis of the i n d i v i d u a l p a t i e n t , have a d i r e c t bearing on the composition of the population of p s y c h i a t r i c i n s t i t u t i o n s . This population i s not a s t a t i c one — due to many f a c t o r s , i t has undergone considerable change i n recent years. HOSPITALIZATION 3. There i s no single cause f o r h o s p i t a l i z a t i o n i n a p s y c h i a t r i c i n s t i t u t i o n . Rather i t i s the r e s u l t of the i n t e r a c t i o n of a multitude of f a c t o r s . F i r s t , some type of mental i l l n e s s must exist,) and secondly, there must he some reco g n i t i o n that the i l l n e s s i s present, and that treatment i s needed. This implies a c e r t a i n amount of knowledge about p s y c h i a t r i c i l l n e s s , i t s symptoms and what should be done about i t . Also necess'ary i s a standard of evaluation; • d i f f e r e n t sub-groups i n the population have d i f f e r e n t degrees of, tolerance f o r the same symptoms. Except i n extreme cases where the i n d i v i d u a l ' s behaviour renders him a danger to the community, some motivation to seek help i s involved on the part of the prospective patient, h i s family, or others concerned. Even at t h i s point, the question of whether he enters a mental i n s t i t u t i o n i s influenced by extraneous f a c t o r s , such as the existence of a l t e r n a t i v e f a c i l i t i e s and the a c c e s s i b i l i t y of these a l t e r n a t i v e s , and the a c c e s s i b i l i t y of the i n s t i t u t i o n i t s e l f . Overcrowding of mental i n s t i t u t i o n s may be so extreme as to preclude admission of other than the most severe cases. The type and s e v e r i t y of i l l n e s s i s a f a c t o r i n determining the kind of i n s t i t u t i o n he might enter or the kind of a l t e r n a t i v e help he might receive. In l i e u of h o s p i t a l i z a t i o n , he may receive treatment from a priv a t e p s y c h i a t r i s t or psychologist, c l i n i c , out-patient department, family doctor, clergyman, or other advisors, or none at a l l . Once admitted to the h o s p i t a l , the question of how long he w i l l remain under h o s p i t a l care i s likewise determined by a m u l t i p l i c i t y of v a r i a b l e s such as c h a r a c t e r i s t i c s of the h o s p i t a l , the patient, and the community. The h o s p i t a l ' s treatment and discharge p o l i c i e s are important f a c t o r s . Type and s e v e r i t y of the patient's i l l n e s s , h i s p h y s i c a l condition, i n t e l l i g e n c e , and previous l e v e l of functioning, a l l have a bearing on recovery. The after-care or a l t e r n a t i v e f a c i l i t i e s offered by the community, and the degree to which i t i d e n t i f i e s and t o l e r a t e s divergence from the normal, are as important i n release of patients as i n admission. For these and s t i l l other reasons, the number of patients Under the care of i n s t i t u t i o n s i s not d i r e c t l y r e l a t e d to the extent of i l l n e s s i n the population. "The t o t a l resident population on any one day i s a c o l l e c t i o n of the residues of various 5-groups of patients admitted over long period of time (indeed from the date the h o s p i t a l opened u n t i l the present day). These residues have resulted from the depl e t i o n of groups of admissions through release and death at d i f f e r e n t i a l rates s p e c i f i c f o r age, sex, diagnosis, and a v a r i e t y of medical, s o c i a l , economic, and administrative factors'*(Kramer, Pollack, and Redick, 1 9 6 1, p. 7 9 ) • Mental i n s t i t u t i o n s are co n s i s t e n t l y overcrowded. Dominion Bureau of S t a t i s t i c s (DBS) fig u r e s showed 1 0 6 $ occupancy i n i 9 6 0 (Canada, DBS, 1 9 6 0 a ) . Therefore the number of admissions i s affected by the number of deaths and discharges. Of each year's admissions, a c e r t a i n number become long-stay patients destined to remain under h o s p i t a l care u n t i l they d i e . U n t i l now, t h i s annual-increment of long-stay patients has continued so that with each succeeding year a d d i t i o n a l accommodation has been needed f o r an increasing number of admissions. The increasing load of patients has implications concerning the type of care and treatment provided by the h o s p i t a l , and the att i t u d e of the community toward the i n s t i t u t i o n . I f the mental h o s p i t a l comes to be regarded as an i n s t i t u t i o n p r i m a r i l y f o r casis with l i t t l e hope of eventual discharge, people become 6 more reluctant to seek admission to i t . At the present time, considerable a t t e n t i o n i s being paid to changes i n the number and composition of patients i n p s y c h i a t r i c i n s t i t u t i o n s . There i s evidence of an actual d e c l i n e , both i n absolute number of patients, and i n the proportion of the population who are confined to i n s t i t u t i o n s . I f patients of d i f f e r e n t age, sex, and diagnostic categories are affected i n d i f f e r e n t ways by these changes, a s h i f t i n the composition of the mental h o s p i t a l population i s to be expected. A d e t a i l e d examination of the si z e and composition of patients i n p s y c h i a t r i c i n s t i t u t i o n s i n Canada i n 1 9 5 5 and 1 9 6 0 was undertaken to determine what changes have occurred i n the-age, sex, diagnostic, and length of stay c h a r a c t e r i s t i c s of patients, and to seek possible reasons f o r the changes. In order to compare the r e s u l t s of t h i s study with those of other epidemiological i n v e s t i g a t i o n s , techniques and indices used i n epidemiology, and data obtained i n other studies, were examined. EPIDEMIOLOGY D e f i n i t i o n Epidemiology has been defined as "the study of the d i s t r i b u t i o n and determinants of disease prevalence i n man"(McMahon, Pugh and Ipsen, i 9 6 0 ) . Although o r i g i n a l l y only i n f e c t i o u s diseases were considered to be of epidemic concern, the use and d e f i n i t i o n of the term were broadened to include the study of f a c t o r s " i n i t i a t i n g and c o n t r o l l i n g the appearance of (any) disease i n populations" (Plunkett and Gordon, 1 9 5 7 ) . Hospital s t a t i s t i c s themselves are not a new innovation. O r i g i n a l l y " s t a t i s t i c s " ( r e l a t i n g to the state) included the number of patients i n mental h o s p i t a l s . Epidemiological methods were adapted to the study of mental disease as an-adjunct to the more t r a d i t i o n a l c l i n i c a l procedures, and even preceded the development of laboratory i n v e s t i g a t i o n . Laboratory techniques are used to investigate b i o l o g i c a l and chemical f a c t o r s associated with disease, and c l i n i c a l procedures are concerned with the i n d i v i d u a l patient, while epidemiology i s concerned with the occurrence of i l l n e s s i n a population. The ultimate concern of epidemiology i s with the natural h i s t o r y of disease. Investigations i n t o 8. the r e l a t i o n s h i p of s o c i a l , p sychological, and p h y s i o l o g i c a l f a c t o r s associated with mental disorders usually have as t h e i r aim the development and t e s t i n g of hypotheses concerning predisposing f a c t o r s , causes, and pathogenesis of mental i l l n e s s . Indices In studying prevalence of h o s p i t a l i z e d i l l n e s s , i t i s necessary to understand what i s meant by prevalence, and i t s r e l a t i o n s h i p to other i n d i c e s , namely incidence and duration. Incidence i s the r a t i o of new cases to the population at r i s k , or, f o r the purposes of t h i s study, the frequency of f i r s t admissions to p s y c h i a t r i c i n s t i t u t i o n s . Prevalence i s the r a t i o of e x i s t i n g cases to the population at a given time. The measure of prevalence used i n t h i s study was the number of h o s p i t a l i z e d patients being cared f o r by Canadian p s y c h i a t r i c i n s t i t u t i o n s at December 31 of each year. Prevalence i s a fu n c t i o n of incidence and duration, since the number of people who become i l l , and the length of time they remain i l l , determines the number of cases at a given time. Prevalence and incidence rates f o r the same disease can be quite divergent. For example, Kramer et a l (1961) showed ( F i g . 1) that the a g e - d i s t r i b u t i o n frequencies of admissions and resident patients f o r schizophrenia have decidedly d i f f e r e n t configurations, since the high residence r a t e , p a r t i c u l a r l y i n the older age group, resulted p r i m a r i l y from the aging of cases admitted many years previously. On the other hand, f i r s t admission and residence rates f o r patients with mental disorders of the senium showed "a d i f f e r e n t phenomenon, where both r i s e r a p i d l y with age. In t h i s instance, the high residence rates are accounted f o r by high admission r a t e s , rather than long duration of stay"(p.78). Point prevalence i s the frequency of a condition i n the population at a given moment. Lifetime prevalence i s the proportion of the population who have, or have ever had i n t h e i r l i f e t i m e , the condition under study. .In employing these i n d i c e s , the i n v e s t i g a t o r i s f i r s t of a l l faced with three major and i n e v i t a b l e problems; namely: how to define a case, how to f i n d a l l the cases i n a given population, and which index to use. Defining: a case Case-finding s u f f e r s from what Morris (1957) terms /=*/ Gr. / A g e - s p e c i f i c f i r s t admission and res ident pat i ent ra tes per 1 0 0 , 0 0 0 c i v i l i a n p o p u l a t i o n , p u b l i c prolonged-care h o s p i t a l s f o r mental d i s ease , s e l ec ted mental d i s o r d e r s , both sexes, United S ta te s , 1 9 5 5 . ( M t e r Kramer et a l , 1 9 6 1 , p . 7 7 ) . 2.000 ISOO i4oo — o o" o a. K / 000 — BOO 400 — Zoo /ViiBNTAL OiSo&D&ftS. Of* THESSAJJOM : *KBSi DB.fil'T~~P#TTB~/<J-rS ' -• f=/RST AGM ISSI OKJS Fit* ST A b W / S S I ONS O </$• /S-S4- 35-3*. 35-44 *S-S<- G5-7A- 85+ OS1 I5T-24- 45-S4- 35 - 6 4 - < S S v » . 7 S - S 4 _ 11. the "ice-berg phenomenon", or the great volume of s u b c l i n i c a l or p r e c l i n i c a l disease i n . r e l a t i o n to c l i n i c a l cases. The boundaries of the i l l - d e f i n e d zone where the s u b c l i n i c a l meets the c l i n i c a l , furthermore, may well be s h i f t i n g with changes i n the philosophic aspect of what i s health and disease, and knowledge regarding the spectrum of a b i l i t y and d i s a b i l i t y . Jahoda (1958) appraised several d e f i n i t i o n s of mental health. Conceptually, mental health may be regarded e i t h e r as a l i f e - l o n g a t t r i b u t e of a person, or as a momentary a t t r i b u t e of f u n c t i o n i n g . Some of the c r i t e r i a used have been "absence of mental i l l n e s s " j "normality", "happiness and content", " s e l f - a c t u a l i z a t i o n " , and various psychological f u n c t i o n s . Jahoda h e r s e l f suggested the c r i t e r i a of active adjustment, i n t e g r a t i o n , r e s i l i e n c e , and need-free perception. While such t h e o r e t i c a l c r i t e r i a are important, a more p r a c t i c a l d e f i n i t i o n i s necessary to separate from the general population those people who are to be c a l l e d cases. Most researchers have had to manufacture and explain t h e i r own p a r t i c u l a r operational d e f i n i t i o n s of a case. In the present study, by defining a case as a patient under i n s t i t u t i o n a l care, i t was possible to draw an unambiguous l i n e between cases and non-cases. Locating the cases Case-finding methods are c l o s e l y l i n k e d to, and vary with, d e f i n i t i o n s of a case; or, conversely, the d e f i n i t i o n evolved f o r p r a c t i c a l purposes of the study i s often determined hy the case-finding methods a v a i l a b l e to the i n v e s t i g a t o r . In general, case-finding methods f a l l into two main categories, record-searching and f i e l d surveys. Routine morbidity and mortality reports are included i n the f i r s t . Some more comprehensive studies include c l i n i c and p s y c h i a t r i s t s ' f i l e s , and s o c i a l s e r v i c e , court, and school records. Others involve searching a l l physicians' records f o r r i l l n e s s e s which may be psychogenic. A drawback of t h i s type of research i s that the eases are not representative — t h e y - a r e selected i n some manner. They are the mentally i l l whose condition has come to the a t t e n t i o n of the a u t h o r i t i e s . Blum ( 1 9 6 2 ) states that "most research to date, and treatment methods as w e l l , have been using s p e c i a l l y selected populations, where the c r u c i a l t o o l i n case f i n d i n g has been s e l f , family, or community diagnosis based on f o l k notions and f i l t e r e d medical ones about : what constitutes p s y c h i a t r i c i l l n e s s and what should, be done about i t " (p.272). 1 3 . The f i e l d survey usually e n t a i l s s e l e c t i n g a sample from the population, and making inferences about the mental status of the general population from interview or questionnaire assessment of the sample. Research of t h i s type i s l i m i t e d by the lack of a s a t i s f a c t o r y method f o r the r a p i d , r e l i a b l e , and v a l i d assessment of the i n d i v i d u a l ' s mental health, present or past. Of^en the i n v e s t i g a t o r r e l i e s on a questionnaire, i n which the subject indicates symptoms he may have, or has had at some time i n the past. Data obtained i n t h i s manner are affected by subject error as w e l l as by examiner e r r o r . Even i f accurate, a l i s t of symptoms does not convey an accurate picture of a person's state of health. The same symptoms can be produced i n many d i f f e r e n t ways; i n d i v i d u a l s d i f f e r i n t h e i r tolerance of the same symptoms; and there i s no way of assessing the severity of the symptom. Lewis (1961), i n discussing t h i s method, sees i t as "humiliating...for us to be obliged, i n many p s y c h i a t r i c surveys, to depend not on diagnosis, but on symptoms. The interviewed person o f f e r s a complaint and on the strength of i t he i s included i n a class....The method, when we have recourse to i t , takes only summary notice of the a l t e r n a t i v e h e i r a r c h i e s within which the symptoms 1 4 . "belong. The whole process i s reversive and promiscuous" (pp 228-229). The persons designated as cases i n the present study were those under care of psychiatric, i n s t i t u t i o n s at December 31 of. the years i n question. This population i s d i s t i n c t from the population of persons r e q u i r i n g treatment or those who are i l l . The v a r i a b l e s under study r e l a t e d , not to i l l n e s s or treatment needs, but to h o s p i t a l i z a t i o n . Choice of index Incidence "depends on the balance between resistance of the population and those forces or stresses — b i o l o g i c a l , c u l t u r a l , psychologic — that produce mental illness"(Kramer, 1957). In studies of h o s p i t a l i z e d patients, f i r s t admissions are not l i k e l y to coincide with onset of i l l n e s s . There i s a time l a g between the two events which v a r i e s considerably between p a t i e n t s . However, f i r s t admission rates could be used to predict the p r o b a b i l i t y of becoming h o s p i t a l i z e d . Incidence rates are used f o r p r e d i c t i n g p r o b a b i l i t i e s , and,, i n e t i o l o g i c a l studies, assessing the r e l a t i o n s h i p between various f a c t o r s and mental i l l n e s s . P r e v a l e n c e r a t e s a r e " e x t r e m e l y u s e f u l i n d e t e r m i n i n g t h e c o m p l e t e p i c t u r e o f t h e d i s e a s e d p o p u l a t i o n " ( J a c o , 1960). P r e v a l e n c e r a t i o s a r e u s e d "by i n v e s t i g a t o r s who w i s h t o g i v e a p i c t u r e o f t h e e x t e n t o f i l l n e s s i n t h e p o p u l a t i o n . I n t h i s s t u d y , the i n d e x u s e d was a p o i n t p r e v a l e n c e r a t i o o f p a t i e n t s u n d e r i n s t i t u t i o n a l c a r e . 16. SOME EPIDEMIOLOGICAL STUDIES OP MENTAL ILLNESS Prevalence, studies Investigators have arrived at estimates of prevalence using widely divergent methods and c r i t e r i a . Por t h i s reason i t i s d i f f i c u l t to compare the r e s u l t s d i r e c t l y . "The range of rates i s so great as to defy g e n e r a l i z a t i o n . Obviously the recorded values are affec t e d strongly by differences i n study design, by study d e f i n i t i o n s , and by c l a s s i f i c a t i o n systems. These v a r i a b l e s preclude p r o j e c t i o n of r e s u l t s to other s i m i l a r populations or to a broader universe. Neither can the rates be interpreted as r e f l e c t i n g d i f f e r e n c e s i n the frequency of mental i l l n e s s i n the several communities. Such d i f f e r e n c e s doubtless e x i s t , but t h e i r extent cannot be determined from studies made thus f a r " (Plunkett and Gordon, 1960, p.91). Study designs range from drawing inferences from se l f - r e p o r t e d symptoms, through observations of small populations, to use of h o s p i t a l s t a t i s t i c s and other records. Each type of study i s designed to measure a d i f f e r e n t aspect of the problem of mental i l l n e s s . Examples of these various types of studies are given below. Because of differences i n scope and objectives, the r e s u l t s are n a t u r a l l y d i s s i m i l a r . ) • ) 1 7 . Srole, Langner, Michael, Gpler, and Rennie (1962) estimated l i f e t i m e prevalence from a questionnaire survey of a sample of the general population of Mid-town Manhatten. A f t e r evaluating reports of current and past symptoms, they described 239 persons per 1,000 population as "disturbed". Leighton (1956) estimated l i f e t i m e prevalence from a questionnaire survey of residents of a small town i n Canada who had been r e f e r r e d to the i n v e s t i g a t o r s as having symptoms suggestive of mental disturbance. The sample ranges from a l l persons ever admitted to a mental h o s p i t a l to those with p h y s i c a l complaints of poss i b l e p s y c h i a t r i c s i g n i f i c a n c e . She reported a l i f e t i m e prevalence rate of 650 per 1,000, of whom 370 per 1,000 were "severely impaired" and " i n need of treatment". ; Bremer (1951) estimated the f i v e - y e a r prevalence rate of mental i l l n e s s i n a small i s o l a t e d v i l l a g e i n northern Norway. As the only doctor i n the community, he was able to carry out an intensive i n v e s t i g a t i o n of the whole population of 1,080 adults, from h i s personal knowledge,and evaluation, and information from others i n the community. He found a f i v e - y e a r prevalence rate of persons with " p s y c h i c a l l y exceptional symptoms" of 233 per 1,000, def i n i n g a "psychic 1.8. exceptional" as "anyone who showed symptoms of neurosis, psychosis, oligophrenia, psychopathy, or epilepsy". Llewellyn-Thomas (i960), as general p r a c t i t i o n e r and port physician i n a small Canadian v i l l a g e of 274 adults, c a r r i e d out a s i m i l a r intensive morbidity survey as part of the S t i r l i n g County Study. He estimated, on the basis, of p s y c h i a t r i c symptoms,'a l i f e t i m e prevalence of 64O per 1 ,000 of- the adult population. Hollingshead and Redlich (1958) estimated the six-month treated prevalence rate f o r New Haven residents, based on records of public and p r i v a t e , in - p a t i e n t and out-patient f a c i l i t i e s i n the community. They reported a prevalence rate of 8.08 per 1,000. Lemkau, Tietze, and Cooper (1942) searched records of various health, education, welfare, and f o r e n s i c agencies and p s y c h i a t r i c treatment f a c i l i t i e s i n the Eastern Health D i s t r i c t of Baltimore, and reported a one-year prevalence rate of 28.86 per 1,000 population. Pasamanick, Roberts, Lemkau and Krueger (1959) conducted a household canvass of a sample of 1,200 Baltimore residents, followed by a c l i n i c a l evaluation of a 10$ sample. Case h i s t o r i e s i n d i c a t i v e of p s y c h i a t r i c disorder were then evaluated by a p s y c h i a t r i s t . ~':-5,y They found the one-day prevalence rate i n t h i s population to be 93.4 per 1,000. 1 9 . V a r i a b l e s o f p r e v a l e n c e , s t u d i e s  A g e M a n y i n v e s t i g a t o r s h a v e f o u n d t h a t p r e v a l e n c e r a t e s f o r m e n t a l i l l n e s s r i s e w i t h i n c r e a s i n g . a g e ( L e m k a u e t a l , 1942) . A g e a n d d i a g n o s i s P a s a m a n i c k e t a l (1959) f o u n d p r e v a l e n c e o f p s y c h o s e s t o b e g r e a t e r w i t h i n c r e a s i n g a g e . P s y c h o n e u r o s e s w e r e a l m o s t u n i f o r m l y d i s t r i b u t e d i n a l l a g e g r o u p s o v e r 15, b u t r a r e i n t h e y o u n g e r g r o u p . T h e r e w e r e n o c a s e s o f p s y c h o p h y s i o l o g i c a l d i s o r d e r s f o r s u b j e c t s u n d e r 15 o r o v e r 6 5 . S e x V a r i o u s s t u d i e s r e p o r t d i f f e r e n c e s b e t w e e n m a l e s a n d f e m a l e s i n o v e r a l l r a t e s o f m e n t a l i l l n e s s , a l s o i n s p e c i f i c d i a g n o s e s , a n d i n a g e g r o u p s a f f e c t e d b y v a r i o u s d i s o r d e r s . R o s e (1955) r e p o r t e d m o r e m a l e s t h a n f e m a l e s i n s t a t e m e n t a l h o s p i t a l s i n t h e U n i t e d S t a t e s i n 1933. S e x a n d d i a g n o s i s L e m k a u e t a l (1942) f o u n d a p p r o x i m a t e l y e q u a l o v e r a l l p r e v a l e n c e r a t e s f o r m e n a n d w o m e n , a l t h o u g h t w i c e a s m a n y m e n ' s a s w o m e n ' s c a s e s w e r e d u e t o 20. exogenous causes (alcoholism, s y p h i l i s , and e p i l e p s y ) , and twice as many females as males were diagnosed as manic depressive. Diagnosis I t i s d i f f i c u l t to compare d i f f e r e n t studies on the "basis of diagnosis, since there i s such a v a r i e t y of methods of categorizing mental i l l n e s s or the sev e r i t y of the d i s a b i l i t y . For example, Srole et a l (1962) rated t h e i r subjects on a continuum from "well" to "incapacitated" without f u r t h e r d i f f e r e n t i a t i o n as to the type of mental i l l n e s s responsible f o r the i n c a p a c i -t a t i o n , and Roth and Luton (1942/43) used " s o c i a l diagnoses" based on the i n d i v i d u a l ' s s o c i a l and personal adjustment. Lemkau et a l (1942) c l a s s i f i e d t h e i r material into ten major diagnostic groupings, some c l i n i c a l and some interpersonal. They found a r a t i o of 6.66 psychotics . per 1 ,000 population, of whom 43$ were diagnosed as schizophrenic. On the basis of t h e i r New Haven data, Hollingshead and Redlich (1958) ranked schizophrenia as the most prevalent diagnosis i n a l l s o c i a l c l a s s e s , followed i n order.by character and personality disorders, a f f e c t i v e psychoses, various neurotic disorders, psychoses.of the senium, and, l a s t l y , organic psychoses. Norris (1959) compiled rates f o r resident patients 21. aged 116 and over i n mental h o s p i t a l s i n England and Wales. In t h i s population also, schizophrenia was the most frequent diagnosis, followed by manic-depressive psychosis, then s e n i l e psychoses. Rates found by Pasamanick et a l ( 1959) f o r the most frequently occurring diagnostic categories were: neuroses, 52.67 per 1 , 0 0 0 population; psychophysiological disorders, 36.50 per 1 , 0 0 0 ; mental de f i c i e n c y , 1 5 . 0 0 per 1 P 0 0 ; and psychoses, 8 .81 per 1,0.00. Length of stay Very few studies use duration of i l l n e s s as a V a r i a b l e , possibly because i t i s d i f f i c u l t to determine. In the present study, i t was possible to use the length of time a patient had been under the care of a mental i n s t i t u t i o n as an index of duration of h o s p i t a l i z a t i o n v / Norris ( 1 9 5 9 ) reported that length of stay i n London hospitals was highest f o r schizophrenia, followed i n order by se n i l e psychoses and manic depressive psychosis. Other f a c t o r s Epidemiological studies have examined other ^The'time', spent by a patient as a resident of a mental i n s t i t u t i o n is' not n e c e s s a r i l y equal to;the time spent under I n s t i t u t i o n a l care, since i n s t i t u t i o n s are" responsible''for patients i n boarding and'approved homes under 'their supervision,, or temporarily .absent .patients. 22. c h a r a c t e r i s t i c s of p a t i e n t s and of the p o p u l a t i o n s and subgroups to which they b e l o n g . Many have been concerned w i t h the r e l a t i o n s h i p of s o c i a l and economic v a r i a b l e s to mental i l l n e s s . Such a r e l a t i o n s h i p had been p o s t u l a t e d on a t h e o r e t i c a l b a s i s l o n g before these s t u d i e s were undertaken. E s q u i r o l ( 1838) b e l i e v e d "que l e s i d e e s dominantes de chaque s i e c l e , que l ' e t a t de l a s o c i e t e , que l e s commotions p o l i t i q u e s exerce une grande a c t i o n s u r l a frequence et l e c a r a c t e r e de l a f o l i e " ( p . 6 8 6 ) . P a r i s and Dunham ( 1939) showed t h a t cases of mental i l l n e s s admitted to p u b l i c and p r i v a t e h o s p i t a l s , as p l o t t e d .by r e s i d e n c e of p a t i e n t s , showed a r e g u l a r decrease from the c e n t e r to the p e r i p h e r y o f the c i t y , a l s o a h i g h degree of a s s o c i a t i o n between d i s t r i b u t i o n of d i f f e r e n t psychoses and c e r t a i n community c o n d i t i o n s , s c h i z o p h r e n i a b e i n g c o n c e n t r a t e d i n communities of extreme s o c i a l d i s o r g a n i z a t i o n , w h i l e the p a t t e r n formed by the manic d e p r e s s i v e s t a t e s was a random one. T h e i r d a t a , compiled from h o s p i t a l a d m i s s i o n r e c o r d s , measured i n c i d e n c e . Other s t u d i e s o f i n c i d e n c e show a s s o c i a t i o n s between socio-economic s t a t u s and mental i l l n e s s (Lemkau e t a l , 1 9 4 2 ; Gruenberg, 1953; Prumkin, 1955; Jaeo, 1960). Pugh and McMahon ( 1 9 6 2 ) r e p o r t e d an i n c r e a s e i n 23. mental h o s p i t a l patients during the economic depression of the . 193.0.'s ,. and an increase, f o r males., of m i l i t a r y service age during the Second World War, but the data a v a i l a b l e .were.not s u f f i c i e n t l y d e t a i l e d to implicate a s p e c i f i c diagnosis. The f i n d i n g of Srole et a l (1962) were that the "prevalence of psychopathology v a r i e s inversely with socio-economic status, and a c c e s s i b i l i t y of psycho-therapy varies d i r e c t l y " . R a c i a l and sub-cultural background (Eaton and Weil, 1955)» m a r i t a l status, area of residence ( C a r s t a i r s and Brown, 1948), and s o c i a l and geographic m o b i l i t y , are other v a r i a b l e s that have been implicated as having a bearing on the prevalence of mental i l l n e s s . I nvestigation of such v a r i a b l e s constitute important areas of research, but they are beyond the scope of t h i s study. Trends Various reports indicate that there was a great increase i n the number of h o s p i t a l i z e d patients during the :present century up to 1955, followed by. a marked r e v e r s a l of t h i s trend i n 1955 and the years f o l l o w i n g . Appendix A shows the t o t a l number. ofi patients i n p s y c h i a t r i c i n s t i t u t i o n s i n Canada,,and i n each province, 24. from. 1932 t o i960; A p p e n d i x B shows changes w h i c h o c c u r r e d i n U n i t e d S t a t e s m e n t a l h o s p i t a l s i n , t h e p r e s e n t c e n t u r y ; and Appendix. C s h o w s . t r e n d s i n e s t i m a t e d r e s i d e n c e r a t e s f o r E n g l a n d and Wales f o r the y e a r s 1951 t o 195.6, i n d i c a t i n g t h a t t h e s e changes, were widespread,. G-oldhamer and M a r s h a l l (1949) undertook* a h i s t o r i c a l study, i n o r d e r t o answer the q u e s t i o n 'JHas m e n t a l i l l n e s s i n c r e a s e d i n the p a s t , ; h a l f - c e n t u r y ? " S i n c e the i n d e x t h e y used was h o s p i t a l a d m i s s i o n s , t h e i r answer was i n terms of i n c i d e n c e . . They f o u n d l i t t l e change i n i n c i d e n c e o f p s y c h o s i s , o r o f a l l d i a g n o s e s combined f o r the age g r o u p s twenty t o s i x t y , a l t h o u g h t h e r e were i n c r e a s e s i n the y o u n g e r and o l d e r age g r o u p s . I n 1938, L a n d i s and Page n o t e d a s l o w c o n s t a n t , i n c r e a s e , i n ,the r e s i d e n t p o p u l a t i o n of...New Y o r k S t a t e m e n t a l h o s p i t a l s . . A g a i n i n New Y o r k S t a t e , t h e m e n t a l h o s p i t a l p o p u l a t i o n d o u b l e d between the y e a r s 1929 and 1955,. but t h i s t r e n d was r e v e r s e d i n 1955, and a c o n s i s t e n t d e c l i n e c o n t i n u e d f o r t h e n e x t f o u r c o n s e c u t i v e y e a r s ( B r i l l and P a t t e r n , 1959). B o t h Kramer and P o l l a c k , (1958), and Pugh and McMahon (1962) r e p o r t e d a d e c l i n i n g number o f p a t i e n t s i n p u b l i c .^mental h o s p i t a l s i n t h e U n i t e d S t a t e s i n t h e y e a r s f o l l o w i n g 1955,. 25 PROBLEM OP PRESENT. STUDY Various studies have investigated the r e l a t i o n s h i p of age, sex, diagnosis, and length of h o s p i t a l stay to h o s p i t a l i z e d mental i l l n e s s . Other i n v e s t i g a t o r s report s i g n i f i c a n t changes i n the number and composition of patients in. p s y c h i a t r i c i n s t i t u t i o n s i n recent years, p a r t i c u l a r l y since 1 9 5 5 . Are the c h a r a c t e r i s t i c s of.patients under care . of Canadian mental i n s t i t u t i o n s s i m i l a r to. those of other populations studied? Has the number and compo-s i t i o n of t h i s population undergone changes i n recent years? What are the possible reasons f o r such changes? 2 6 . v .HYPOTHESIS The hypothesis investigated was: that there was no s t a t i s t i c a l l y s i g n i f i c a n t change (p<.05) i n the age, sex, diagnostic, and length-of-stay c h a r a c t e r i s t i c s of patients under care of Canadian mental i n s t i t u t i o n s between the years 1955 and i 9 6 0 . 27 II METHOD DESIGN Patients on books as an index of prevalence H o s p i t a l i z a t i o n i s not a complete count of those with p s y c h i a t r i c i l l n e s s . Many writers f e e l , however, that h o s p i t a l i z a t i o n i s a v a l i d index of the amount of i l l n e s s i n the population. Dunham (1953), wrote that " s o c i a l judgments of persons i n the community, as to who i s s i c k represents a measure of the incidence, of, the disorder", ( p .568). In t h i s a r t i c l e , Dunham defined mental i l l n e s s as a p e r s o n a l i t y change,., the extent of which is.. judged by family and f r i e n d s . Using such an i n t e r p r e t a t i o n , he regarded.differing rates as a measure of differences between communities tin c r i t e r i a f o r mental i l l n e s s . Pugh and.McMahon (1962) based t h e i r study on the e s s e n t i a l premise that "the. amount and use of mental h o s p i t a l beds by a population or a subgroup i s r e l a t e d to the amount or s e v e r i t y of mental i l l n e s s i n that population or subgroup" (p.3). This premise might be v a l i d i f (a) a l l such persons sought admission to 2 8 . h o s p i t a l , ( b ) t h e r e w e r e s u f f i c i e n t "beds a v a i l a b l e i n m e n t a l i n s t i t u t i o n s t o accommodate a l l p e r s o n s who become m e n t a l l y i l l and ( c ) i f no a l t e r n a t i v e t y p e o f t r e a t m e n t were a v a i l a b l e . C l e a r l y none o f t h e s e c o n d i t i o n s o b t a i n . The s e l e c t i o n o f a p o i n t p r e v a l e n c e i n d e x o f • h o s p i t a l i z a t i o n , p a t i e n t s u n d e r c a r e a t December 31? h a s t h e a d v a n t a g e o f b e i n g a c l e a r c u t o p e r a t i o n a l d e f i n i t i o n o f a c a s e . I t i s . n o t i n t e n d e d as a m e a s u r e o f t h e p r e v a l e n c e o f m e n t a l i l l n e s s i n C a n a d a . C a n a d a ' s r e p o r t i n g s y s t e m i s a c o m p r e h e n s i v e o n e . A n n u a l r e p o r t s a r e r e c e i v e d by t h e DBS f r o m a l l p s y c h i a t r i c i n s t i t u t i o n s . . These i n c l u d e p u b l i c , f e d e r a l and p r i v a t e m e n t a l h o s p i t a l s ; p u b l i c and p r i v a t e p s y c h i a t r i c h o s p i t a l s ; t r a i n i n g s c h o o l s ; aged and s e n i l e homes; e p i l e p s y h o s p i t a l s ; and p u b l i c and f e d e r a l p s y c h i a t r i c u n i t s . A l i s t o f i n s t i t u t i o n s r e p o r t i n g c a n be f o u n d i n A p p e n d i x D . " P a t i e n t s on b o o k s " , as r e p o r t e d by t h e D B S , r e f e r s t o a l l p a t i e n t s u n d e r h o s p i t a l c a r e , i n c l u d i n g p a t i e n t s a c t u a l l y i n h o s p i t a l , a n d a l l t h o s e who c a n be r e t u r n e d w i t h o u t f u r t h e r l e g a l . . f o r m a l i t i e s . These i n c l u d e r e s i d e n t p a t i e n t s , p a t i e n t s i n b o a r d i n g homes, u n d e r s u p e r v i s i o n o f a p s y c h i a t r i c i n s t i t u t i o n , . p a t i e n t s o n • p r o b a t i o n ( c o m m i t t e d p a t i e n t s n o t d i s c h a r g e d i n f u l l ) 2 9 . and.otherwise absent patients whose return i s intended (such as those on v i s i t s and t r i a l weekends). However, patients r e c e i v i n g day or night h o s p i t a l care are excluded. The date chosen, .December 31 of. each year, i s one. prone to seasonal, v a r i a t i o n , since many ho s p i t a l s discharge patients .who go home f o r the holiday season and readmit, t^em on t h e i r r eturn. An average of 52,194 resident patients was. .reported f o r 1960, but there were only 50,,742 resident patients reported on December 3 1 of that year. Choice of v a r i a b l e s The choice, of. v a r i a b l e s was l i m i t e d by the data a v a i l a b l e concerning patients under h o s p i t a l care. Age, sex, diagnosis, and. length of stay have a l l been . reported c o n s i s t e n t l y . s i n c e 1955. Age i s a , " s i g n i f i c a n t index of accumulation of l i f e , experience., .the a t t r i t i o n .of the human organism, i t s l i k e l i h o o d of exposure to disease agents;, and the amount of weathering of disease processes" (Jaco., 1 9 6 0 ) Landis and Page ( 1 9 3 8 ) consider age "the. most important s i n g l e determining f a c t that we can know . 30. about mental disease, e i t h e r with, respect to. a s i n g l e patient or a group of patients....The care,., treatment, and prognosis f o r . any., patient w i l l "be determined l a r g e l y by the. age of that p a t i e n t . I f we were t o l d the age d i s t r i b u t i o n of a group of, say,., 1 ,000 ;mental,hospital, patients selected at random, we could with considerable accuracy p r e d i c t the number of each sex, the number i n each diagnostic group,, the probable' outcome, of the cases with respect to recovery, length of h o s p i t a l residence, and years,of expected l i f e " (p.21) . They also note that "each s p e c i f i c psychosis seems to be l i m i t e d to a c e r t a i n age span; each has i t s e a r l i e s t age onset, age of maximum s u s c e p t i b i l i t y , and a l i m i t i n g upper age" (p.36). In t h i s study, ages have been combined into three . groups: under 20, 20 to 59, and 60 and over. This i s to condense tabulations and because i t has,been shown that these broad groups are affected d i f f e r e n t l y by various types of p s y c h i a t r i c i l l n e s s . Sex s T h e . d i f f e r e n t i a l impact of m e n t a l . i l l n e s s upon males and females makes sex a basic v a r i a b l e of research,, whether due to d i f f e r e n t biogenetic, psychological, or s o c i o l o g i c a l , s i t u a t i o n s . 3 1 . Diagnosis There has. "been a great deal of discussion and cr i t i c a l . e x a m i n a t i o n of diagnostic categorizations of mental i l l n e s s . •. Eysenck ( i 9 6 0 ) a t t r i b u t e d deficiencies..in the. present diagnostic c l a s s i f i c a t i o n s to.the f a c t that " i n psychiatry,knowledge,of causes i s almost .completely l a c k i n g -- diagnosis i s based l a r g e l y on symptoms and syndromes" (p.2), or, quoting Cameron (1944),. "current p s y c h i a t r i c c l a s s i f i c a t i o n i s not based on f i n a l and convincing evidence — they are c h i l d r e n of p r a c t i c a l n e c e s s i t i e s " . S' • •.•...•>-•• • • • -... . . ,x louflids (1.9,55).,.; points out, that " p s y c h i a t r i c diagnosis has suffered a steady decline i n pr e s t i g e " (p.581 ), while Roe.(1959). submits, that "using techniques which are not too p r e c i s e l y v a l i d a t e d at a l l . t o place patients i n p s y c h i a t r i c categories, the inadequacy of wuich i s admitted by a l l concerned... i s a tr e a d m i l l procedure" (p.3.6). However,, low r e l i a b i l i t y i s . often taken,for granted without consulting the evidence. Ash's (1949) study i s frequently quoted as .proving u n r e l i a b i l i t y of p s y c h i a t r i c diagnoses without reference to the actu a l f i n d i n g s . The three .psychiatrists participating,, i n ..the study agreed 31 to 43$ of the time of s p e c i f i c diagnoses, 32. and 58 to 67$ .of the time on s p e c i f i c diagnoses. I t must, be pointed put,, a l s o , that the, diagnostic interviews were c a r r i e d put under a t y p i c a l conditions. The psy-c h i a t r i s t s interviewed .the subjects j o i n t l y , and were unable to ask questions which might convey.to t h e i r colleagues what diagnosis they had i n mind.. Of,: the 139 patients interviewed,,only 35 had clear-cut pathology, which.made evaluation of the cases d i f f i c u l t . With these l i m i t a t i o n s , the agreements, were, s t i l l y w e l l i n excess of change, even i n d e t a i l e d diagnostic categories. Kreitman (1961 ). pointed, out that, in.studies on inter-pbserver r e l i a b i l i t y , a c e r t a i n amount of variance i s "non-error", variance, r e s u l t i n g from actual f l u c t u a t i o n s i n the patient's s t a t e . Hunt, Wi.t.tspn, and Hunt. (.19,53) .compared .diagnoses of 794 naval enlisted,men made by a .pre-commissioning s t a t i o n p s y c h i a t r i c unit and a naval h o s p i t a l . The main question to be resolved was. that .of the men's, s u i t a b i l i t y f o r continued naval s e r v i c e . On t h i s question, agreement between the p s y c h i a t r i c unit.and hospital, was 9 3 . 7 $ . Agreement w i t h i n ..broad .diagnostic categories was,54$,. and on s p e c i f i c diagnoses, ,32.5$.,. In analysing the shifts.between the p s y c h i a t r i c .unit and hospital,. Hunt, et a l show that these were " a l l •neighbourly', changes, which do not involve much 33. c l i n i c a l displacement, and ra i s e the question as.to whether the ' p r a c t i c a l ' r e l i a b i l i t y of the diagnosis ( i n terms; of care, treatment, and d i s p o s i t i o n of the cases) i s not l a r g e r than our 'pure' s t a t i s t i c s would i n d i c a t e " (p.64). In other words, the v a l i d i t y of • diagnosis, i n terms of i t s implications f o r treatment and prognosis, was high, even though the r e l i a b i l i t y , e s p e c i a l l y on s p e c i f i c diagnoses,, was modest. Meehl (1959) agrees that "there i s enough e t i o l o g i c a l and prognostic homogeneity among patients i n a given diagnostic group so that h i s assignment to that group has p r o b a b i l i t y implications which i t i s c l i n i c a l l y unsound to ignore" (p. . 103). No adequate c l a s s i f i c a t i o n system has been advanced supported by experimental evidence, and,until something more adequate than the present system can be substituted there i s no reason f o r abandoning i t — and many reasons not to. It i s always necessary to compare cases, and with comparison comes c l a s s i f i c a t i o n . I t at l e a s t eliminates those considerations "which would be l e a s t useful i n understanding the. patient and d i r e c t s a t t e n t i o n to those which are l i k e l y to be relevant" (Poulds, 1955, P>'85.) • Norris (1959) found ;high r e l i a b i l i t y of broad diagnostic categories compared to more detailed ones. 34. Prom her experience i n using mental h o s p i t a l data, she concluded that " p s y c h i a t r i c c l a s s i f i c a t i o n based on that evolved,by the World Health Organization (1948) can be confidently used to present mental h o s p i t a l s t a t i s t i c s , ; i f r e f i n e d subdivisions of the major categories i s not attempted". Besides being useful c l i n i c a l l y , a c l a s s i f i c a t i o n system,is necessary s t a t i s t i c a l l y . The system used by the Dominion Bureau of S t a t i s t i c s i s that described i n Section V of.the. International S t a t i s t i c a l C l a s s i f i c a t i o n pf Diseases, I n j u r i e s and Pauses, of Death (World Health Organization, 1957) . Although i t s use, has been recommended by a l l Member States of the WHO, i t has been adopted by only a few countries (Stengel, 1959). Section V of the ISC,, e n t i t l e d Mental, psychoneurotic, and personality, disorders, contains 26 categories which are used to c l a s s i f y most of the diagnoses reported by. mental i n s t i t u t i o n s . The DBS booklet No. 9005-520, which describes and l i s t s terms used to report Canadian s t a t i s t i c s , d i f f e r e n t i a t e s between a c l a s s i f i c a t i o n and a nomenclature. "A nomenclature consists of a s p e c i f i c l i s t of terms f o r every,condition which i s c l i n i c a l l y recognizable. A s t a t i s t i c a l c l a s s i f i c a t i o n , , on the other hand, while containing the f u l l range of conditions, 35/ groups them i n order to f a c i l i t a t e s t a t i s t i c a l s t udies" (p.5 ) . . The DBS a c t u a l l y uses a shortened vers i o n of Section V.of the ISC. They have combined the categories f o r s e n i l e and a r t e r i o s c l e r o t i c psychoses, dropped, one of the miscellaneous categories of psychosis, combined some of the neuroses, and grouped together two of the p e r s o n a l i t y disorders; they have also.added a category f o r epilepsy and associated psychiatric., conditions.. In the present report, the number of categories i s f u r t h e r reduced, both to make the tabulations c l e a r e r and to add to the r e l i a b i l i t y of the diagnostic groups. The diagnostic categories used>in t h i s study were: 1. Schizophrenia 2 . A f f e c t i v e psychoses 3 . Senile psychoses 4 . A l c o h o l i c psychosis 5 . Other psychoses 6 . Neuroses 7. Alcoholism 8 - Mental d e f i c i e n c y 9 . Other character and behaviour disorders 1 0 . Other diagnoses. D e t a i l e d d e f i n i t i o n s of these and the categories which they subsume, as w e l l as some common diagnostic terms 36. which they supplant, are to be found i n Appendix E . In most of the tables and f i g u r e s used to i l l u s t r a t e the text, these categories were reduced s t i l l f u r t h e r i n order to c l a r i f y the trends and r e l a t i o n s h i p s . In some tabulations, i t was necessary to combine categories because the o r i g i n a l data did not give d e t a i l e d diagnoses. Length of stay Duration of h o s p i t a l i z a t i o n i s one of the determinants of h o s p i t a l i z e d prevalence. The data presented i n t h i s paper are f o r "patients on books", which includes patients other than resident patients, as discussed above. Pour length of stay categories were used; l e s s than one year; between one and tv/o years; between two and f i v e years; and over f i v e years. These categories are d i s c r e t e enough to d i f f e r e n t i a t e between short-stay patients (those under care f o r l e s s than a year), long-stay p a t i e n t s ( u s u a l l y considered to be those under care f o r two years or more), and "continued-long-stay" patients (those under care f o r f i v e years or longer). Further sub-categorization would not help to discriminate between these types of p a t i e n t s . Type of i n s t i t u t i o n The types of i n s t i t u t i o n from which data f o r t h i s 3 7 . study were obtained are defined as follows by DBS: "Mental h o s p i t a l — I n s t i t u t i o n s that provide treatment f o r a l l types o f % p s y c h i a t r i c conditions. " P s y c h i a t r i c h o s p i t a l — I n s t i t u t i o n s that provide short-term, intensive p s y c h i a t r i c treatment. "Hospital f o r mentally defectives — I n s t i t u t i o n s that provide care f o r mentally defective patients, i n c l u d i n g t r a i n i n g schools f o r the mentally d e f e c t i v e s . "Aged and s e n i l e home — I n s t i t u t i o n s f o r the care and treatment of patients s u f f e r i n g from psychoses of old age or from s e n i l i t y without psychosis. "Epilepsy h o s p i t a l — I n s t i t u t i o n s f o r e p i l e p t i c p a t i e n t s . " P s y c h i a t r i c unit — Units wi t h i n h o s p i t a l s that are organized f o r the treatment of patients with p s y c h i a t r i c d i s o r d e r s " (DBS, 1960a, P-9). 38 , TECHNIQUES OF MEASUREMENT Sources of data Main sources of data were the DBS annual pu b l i c a t i o n s Mental Health S t a t i s t i c s and i t s Supplement; Patients i n I n s t i t u t i o n s . These pub l i c a t i o n s are compiled from two types of report sent i n to the DBS by the i n s t i t u t i o n s concerned. The annual schedule i s a summary report of c h a r a c t e r i s -t i c s of the i n s t i t u t i o n such as personnel, bed capacity, patient load, and aggregate patient movement. C h a r a c t e r i s t i c s of each patient are reported on i n d i v i d u a l morbidity cards. Most i n s t i t u t i o n s report on the annual schedule, but some do not send in. patient cards. Tables of patient c h a r a c t e r i s t i c s are, of necessity, based on only those i n s t i t u t i o n s which send i n morbidity cards. Table 1 shows the discrepancy between these two sets of f i g u r e s . 3 9 . Table 1 Canada. Patients on books. Number reported, and  percentage of schedule-reported f o r whom  morbidity cards received. Year Method of reporting io of schedule-reported patients f o r whom cards received Annual Schedule Morbidity Cards 1955 70,080 67,525 96.4$ 1956 71,851 69,066 9.6.1 1957 73,041 70,311 96.3 1958 74,103 71,252 9.6.2 1959 75,617 73,047 96.6 1960 76,587 75,442. 98.5 General population f i g u r e s were obtained from annual DBS population estimates by sex and age group, up to i960. Figures f o r 1961 were obtained from the 1961 Census of Canada. A f t e r completion of the 1961 census, the DBS revised the estimates f o r the years 1957 to 1960, but the revised estimates are not yet a v a i l a b l e by age and sex; a t o t a l revised population estimate only i s obtainable f o r these years. These revised t o t a l were used where a p p l i c a b l e , otherwise c a l c u l a t i o n s were based on the o r i g i n a l estimates. Ratio To determine prevalence i t i s necessary to 40, compare the number of cases to the number i n the population. The r a t i o per 100,000 population was estimated, using the formula: Point prevalence . * 0 ° ^ ^ at * 1 0 0 , 0 0 0 . This provided a.v basis f o r comparing populations of d i f f e r e n t s i z e s . For example, Table 2 shows that, although between 1955 and'i960 the actual number of patients under i n s t i t u t i o n a l care increased, the r a t i o of patients to population declined f o r the age group 20 to 59. Table 2 Canada. Patients oh books, by age. Number and  age- and s e x - s p e c i f i c r a t i o per 100,000.' Year Age group Under 20 20 to 59 60 and over Number 1955 7,620 42,524 17,271 1960 9,852 45,271 19,888 Ratio 1955 123.4 546.3 994.4 • per 100,000 1960 134.0 529.0 1044.2 Standardized r a t i o s The d i f f e r i n g age and sex d i s t r i b u t i o n of the major mental disorders complicates the comparison of prevalence rates of two populations whose age and sex structure d i f f e r . Age and sex d i s t r i b u t i o n of the 1955 and 1960 populations of Canada d i f f e r r e d considerably (Figure 2), so that rates used to compare the two populations must take these d i f f e r e n c e s into consideration. To do t h i s , the number of cases i n each age-sex group are compared with the number of persons i n the general population with the same age and sex c h a r a c t e r i s t i c s , f o r example: Age- and s e x - s p e c i f i c r a t i o f o r males, aged 20 to 59, 1955 _ N of cases, male, 20-59, at Dec.31, 1955 Y i n n n n n ~ population, male, 20-59, at June 1, 1955 l u u » u u u -While the age- and s e x - s p e c i f i c r a t i o s are adequate to show changes within each age-sex grouping, they obscure the r e l a t i o n s h i p between the various groups i n one population and the change i n these r e l a t i o n s h i p s from one population to another. For purposes of-comparison, the rates f o r d i f f e r e n t times, or areas are usu a l l y applied to some standard population. , ' The standard population to which the; 1955 and 196O r a t i o s were applied i n t h i s study was the' 1961 population of Canada. Age- and s e x - s p e c i f i c standard frequencies: were obtained by mu l t i p l y i n g the 1955 and i960 age-and s e x - s p e c i f i c rates by the population i n the same age-sex category according to the 1961 census. .,.These sfrequeh'eiesl are an estimate of the expected number of patients under care i n 1955 and 196O i f both years had had the same population c h a r a c t e r i s t i c s . U At ois tz Z.O 2.0 To SQ — (SO ANO 4 3 . Por example, Table 3, i n which standardized frequencies are used, shows the difference between the two years as well as the relationships of the age groups to one another. Table 3 Canada. Patients on books, by age.. Stan- dardized age- and sex-specific frequencies . Year Age group Under 20 ; 20 to 59 60 and over: 1955. 1960 9:, 5.19 10,661 T ! 46,665 . " 45,363 . 19,439 ; 20,341 Due to demographic changes, the totals of age- and sex-standardized population-based rates are not equal to rates calculated on the total number of patients. Pig. 2 shows the' rel a t i v e l y greater increase i n the younger and older age groups during this period. 44. I l l RESULTS PREVALENCE — PATIENTS UNDER CARE AT DECEMBER 3 1 , 19^0 Tables i n t h i s s e c t i o n represent the actual number of patients under .care of .psychiatric i n s t i t u t i o n s at December 31 , 1 9 6 0 , and r a t i o s per. 1 0 0 , 0 0 0 population. Where the Supplement: Patients -in I n s t i t u t i o n s has:- given r a t i o s , t h e i r f i g u r e s were used. . For the r e s t of the tables, age- and s e x - s p e c i f i c r a t i o s were c a l c u l a t e d . These tables make possible a comparison of the c h a r a c t e r i s t i c s of the h o s p i t a l population i n Canada with other h o s p i t a l populations described i n the l i t e r a t u r e . T o t a l The t o t a l number of patients under i n s t i t u t i o n a l care was 7 5 , 4 4 3 , or 442.2 per 1 0 0 , 0 0 0 population. M e Table 4 shows that prevalence rates increased with increasing age. 45 Table 4 Canada. Patients on books, 1 9 6 0 , by age.  Number and age-specific r a t i o per 1 0 0 , 0 0 0 Age group Number Ratio per 100,000 <20 9,852 134 20--59 45,271 529 60+ 19,888 104 A l l ages 75,443 418 Sex . Males exceeded females both i n gross numbers and i n r a t i o per 1 0 0 , 0 0 0 (Table 5 ) . Table 5 Canada. Patients on books, 1 9 ^ 0 , by sex.  Number and s e x - s p e c i f i c r a t i o per 1 0 0 , 0 0 0 Sex Number Ratio per 1 0 0 , 0 0 0 Male Female 40 , 4 2 3 3 5 , 0 2 0 442 394 Both 7 5 , 4 4 3 418 Diagnostic groups The diagnostic category schizophrenia g r e a t l y 46, exceeded any other, "both i n number and r a t i o . Mental d e f i c i e n c y was next highest (Table 6). Table 6 Canada. Patients on books, I960, by diag-n o s t i c group. Number and r a t i o per' 100,000 Diagnostic group Number Ratio per 100,000 Schizophrenia : Affective•Psych. ": Senile Psychoses Other psychoses 28,690. 5,884 4,858 7,502 160.6 "' 32.9 27.2 42.0 A l l psychoses 46,934 262.6 Neuroses Mental Defie. Other Diagnoses 2,098 19,590 6,821 11 .7 109.6 38.6 Length of stay Table 7 shows that over h a l f the patients had been under care f o r f i v e y e a r s or longer,-and approximately 70% could be c a l l e d long-stay patients, that i s , had been under care "for 'over two years. 47. 1 Table 7 Canada. Patients on books, I960, by length of  stay. Number and age-specific r a t i o per 100,000 Length of. stay, ( i n years) Number Ratio per 1 0 0 , 0 0 0 , <1 • ... ,. 1 7 , 0 3 9 . 9 5 . 3 • 1 - 2 5,873 3 2 . 9 - 2 - 5 . 9 , 8 7 1 • 5 5 . 2 5 + 42,660 2 3 8 . 7 Age and sex . Table 8 shows a higher proportion of men i n each age group. The r a t i o ' o f men to women i s highest f o r the under-20 group, lower f o r the middle group, and nearly equal f o r the 60-and-over group. Although there are numerically more men than women ages 60 and over, the s e x - s p e c i f i c r a t i o i s s l i g h t l y smaller f o r females. 48. Table 8 Canada. Patients on books, I960, by age and  sex. Number and s e x - s p e c i f i c r a t i o per  100,000, and r a t i o of male to female r a t e s . Number Ratio per 100.000 Sex Age grou P' Under 20 20-59 60+ Male Female 5,871 4,330 24,731 20,520: 9,773 10,115 Male Female 156.4 120.3 570.0 . 486.6 1047.4 1041 .0 Ratio M/P (rates) 1 .3 1 .2 1 .0 Age and diagnosis Psychosis was the most prevalent diagnostic category i n the middle and older age groups, while mental d e f i c i e n c y was by f a r the most frequent diagnosis i n the under-20 group (Table 9). Table 9 Canada* Patients on books, I960, by age and  diagnostic group. Number and age-specific  r a t i o . p e r 100.000 Number Ratio per 100,000 Diagnostic Age group Group '. <20 20-59 60+ A l l psychoses 648 29,150 17,0.77 Neuroses 70 1 ,533 4^ 93 Mental d e f i c . '"" .8,447' 11,234 " 1 ,345 Other diag. 1 ,036 3,354 973 A l l psychoses' ;9 341 ' - 89.7 Neuroses . .. - .... '1 - . 18 • • 26 Mental d e f i c . 115 1 31 71 Other diag. 14 39 51 ._ 50. Of the psychoses, schizophrenia was the most frequent diagnosis i n a l l age groups, hut was e s p e c i a l l y high f o r patients aged, 20 to 59 (Table 1 0 ) . , •• •-<, • Table 10 ' ";';'!'" ' '•" Canada. Patients on-books, I 9 6 0 , by age and  selected,diagnosis (psychoses only). Number and ag e - s p e c i f i c r a t i o per 100,000 Number . Ratio - per 1 0 0 , 0 0 0 Diagnostic Age group , Group- . <20 2 0 - 5 9 '• 60+ Schizophrenia .488 2 0 , 8 0 1 7 , 3 6 3 A f f e c t , psych. 42 3 , 2 2 3 2 , 6 1 3 Senile psych. • — 115 4 , 7 3 9 Ale. psych. 1 517 345 Other psych. 1 1 7 , 4 , 4 9 4 2 , 0 1 8 Schizophrenia 2 . 7 1 1 6 . 4 41 . 2 A f f e c t , psych. 0 . 2 1 8 . 0 1 4 . 6 Senile psych. — 0 . 6 26 .5 Ale. psych. — 2 . 9 1 .9 Other psych. 0 . 6 25.1 1 1 . 3 5 1 . Age and length of stay . The greatest number of patients i n a l l age groups f e l l into the five-years-and-over length of stay category. This e f f e c t was not so marked f o r the youngest age group, but was exceptionally so f o r patients aged 60 and over (Table 11). Table 11 Canada. Patients on books., 1.96Q,by age and length  of stay. Number and •age-specific r a t i o per 100,000 Length of stay ( i n years) Age group < 20 I 2 0 - 5 9 60+ Number <1 2,327 I 1 0 , 9 9 5 : 3,717. 1-2 1,51&' 2 , 8 7 5 1 ,480 ; ..2-5 -"• • • ; -2 ,582 : 4 , 8 6 1 2,414 5+ 3 , 7 7 3 26,540 12,276 Ratio-per 1 0 0 . 0 0 0 1 1- 2 2 - 5 32 21 35 128 34 57 195-78 "1 27 :• . 5+-. 51 310 655 5 2 . Sex and diagnostic group Male rates were greater than female f o r a l l diagnoses except neuroses (Table 12). Table 12 Canada. Patients on books, 1960, by sex and di a g -n o s t i c group. Number and s e x - s p e c i f i c r a t i o per 100,000 , „ ; ', ,\ Sex Diagnostic group A l l Psychoses Neuroses .Mental D e f i c . Other Diag. Number Male Female 24,829 ' 22,105 722 "1 ,376 10,967 8,623 3,905 2,916 Ratio per 100,000 Male Female 275.0 251 .6 . 8.0 115.7 121.5 98.1 43.3 33.2 53 Table 13.shows that, of the psychoses, female rates f o r a f f e c t i v e and s e n i l e psychoses exceeded male rates (the di f f e r e n c e i n s e n i l e psychoses was a r e s u l t of differences i n mo r t a l i t y r a t e s ) , "but more males were given diagnoses of schizophrenia and "other" psychoses. Table 13 Canada. Patients on books, 196Q, by sex and  selected diagnosis (psychoses only). "Number  and s e x - s p e c i f i c r a t i o ' p e r 100,000 Sex 1 ,. Diagnostic group, .. . ' Schiz. A f f e c . Psych. Senile Psych. Other Psych. Number Male 1 5 , 8 2 1 2,359 2 , 1 9 3 4,456 Pemale 12 ,869 3,525 2,665 3,046 Ratio- Male 1 7 5 . 3 26.1 24.3 49.4 per 100,000 Pemale 146.5 40.1 30.3 34.6 54. Sex and length of stay Male rates exceeded female i n every length of stay category except the under-one-year group, where the female r a t i o was s l i g h t l y higher. Male rates were g r e a t l y i n excess i n the five-years-and-over category (Table 14). Table 14 Canada. Patients on books, I960,.by sex and length  of stay. Number and s e x - s p e c i f i c r a t i o per 100,000 Number Ratio. per 100,000 Sex Time since admission ( i n years) <1 1-2 2-5 5+ Male Female 8,563 8,476 3,049 2,824 . ;5,224" •4,647 2-3,587 19,0.73 Male Female 94.9 96.5 33.8 32.1 57.8 52.8 '261.3 217.1 55. Diagnosis and length of stay The preponderance of patients i n the five-years-and-over length of stay category was e s p e c i a l l y marked f o r patients with diagnoses of psychosis and mental d e f i c i e n c y (Table 15). Table 15 Canada. Patients on books, 1960, by diagnostic group  and length of stay-. Number and r a t i o per 100,000 Time since adm. (in) years) .Diagnostic. group A l l „ Psychoses •Neuroses Mental' D e f i c / Other Diag. Number < i 11 ,151 1 ,334 2,255 • 2,299 1-2 3,524 .184 1»371. \ 79 4 • - : 2^5 • 5,664 ' 184 ' 2,851 1 ,172 '5+ 26,595 •396 * 13,113 2,556 Ratio .1 -. .. .. 62;. 4 ..... , 7.5 : 1 2.6 ... ; 12.9 per 1-2 19.7 1 .0 7.7 4,4 100,000 2-5 31 .7 1.0 16.0 6.6 5+ 148.8 2.2 73.4 14.3 Table 16 gives numbers and rates f o r the psychoses separately, and shows that t h i s e f f e c t i s p a r t i c u l a r l y accentuated i n the diagnostic category schizophrenia. Table 16 Canada. Patients on -books, 1 9 6 0 , by selected  diagnostic groups (psychoses only), and length  of stay. Number and r a t i o per 1 0 0 , 0 0 0 . Time since adm.(in years) " " Diagnostic G r o u p " Schiz.- • Affec.. Psych. Senile-* Psych. .. other > Psych Number <1 6,035- •2,113 1 ,676 - 1 , 3 2 T - i . . . . . • - 1-2 1 ,724 486 - 857 457 2-5 2 , 8 4 2 660 1 ,254 908 5+ 1 8 , 0 8 9 1 , 6 2 5 1,071 * 4 , 8 1 0 Ratio 1 . . . . 3 3 . 8 . .. , . 11 .8 .. 9 . 4 - * - 7.-4-.. . per . 1-2 9 . 6 . 2 . 7 4 . 8 • 2.6 1 0 0 , 0 0 0 2 - 5 1 5 . 9 3 . 7 7.0 5.1 5+ 1 0 1 . 2 1 4 . 7 I 6 . 0 26 .9 57 PREVALENCE — CHANGES, 1955-1960 The number and composition of patients i n h o s p i t a l changed considerably i n the years 1955 to 1960. E s p e c i a l l y marked were: (a) increases i n the younger and older age groups, and decreases i n the middle age group, (b) a decrease i n psychoses and an increase i n mental d e f i c i e n c y , and (c) an increase i n the proportion of patients under care f o r : l e s s than one-year-. Tables i n t h i s / s e c t i o n . g i v e standardized /frequencies, obtained' by applying 1955 and 1960 r a t i o s , t o the 1961 .population f i g u r e s . 1.955 and 1960 r a t i o s from DBS . , tabulations. were used where a v a i l a b l e , otherwise age- and; s e x - s p e c i f i c r a t i o s were c a l c u l a t e d . Gross changes i n the v a r i a b l e s studied are shown •• i n the following four tables. -' ' ; Age • ' •" ". ' " There were r e l a t i v e l y more patients under i n s t i t u t i o n a l care i n the under-20 and 60-and-oyer age groups i n 196O than i n 1955, .and fewer patients aged 20 to 59 (Table 3, .p. 42.). Sex D i f f e r e n t patterns emerged, f o r the two sexes, 58. although the overall,, changes were quite small. There was an increase i n malq. patients, and a decrease i n female patients (Table 17)-Table .1.7 Canada., Patients on books, by sex. Standardized. age-,, and, sex-specific, frequencies Year Sex Male Female .1955 ' 1960 39,993 40,891 35,630 35,474 Diagnostic groups Psychoses decreased, while a l l other diagnostic categories increased (Table.18). Table 18 Canada. Patients on books by . diagnostic..group.. Standardized... age- and s e x - s p e c i f i c frequencies Year Diagnostic group A l l ' Psychoses ,Neuroses Mental D e f i c . Other Diag. 1 955 1960 . 50,324 47,466 1,621 2,125 19,894 21,401 3,784 5,373 5 9 . Length of stay The large increase i n patients under care for less than one year contrasted with the large decrease i n the two-to-five-year category, and slight decreases i n the one-to-two year and five-years-and-over groups (Table 1 9 ) . Table 19 Canada. ^Patients on books, by length of stay. Standardized age- and sex-specific frequencies Year \ Length ot stay (in years) > -... < y - 2-5 5 and over 1955 13,171 6,205 12,501 44,891 1960 17 ,370 6 , 0 1 0 9 , 807 4 3 , 4 9 3 The variables age, sex, diagnosis, and length of stay are closely interrelated, and fluctuations i n one of them affects a l l the others. To examine these interrelationships, changes i n each variable were considered i n conjunction with each of the others. Age and sex ,. . .. , As shown i n Table 20, the increase i n the age groups under 20 and 6o rand-pver was greater f o r males tnan f o r females, while -the. decrease i n patients aged 60. 20 to 59 was more marked f o r females. Table 20 Canada. Patients on books, by age and sex.  Standardized age- and sex-specific frequencies Sex Year Age group < 20 20-59 60+ Male 1955 1960 5,467 6,154 25,102 . 24,713 9,424 10,024 Pemale 1955 1960 4,052 4 ,507 21,563 20,650 10,015 10,317 Age and ^continued-long-stay" patients A chi square test was used to test the n u l l hypothesis that there was no difference i n the age-sex distribution of patients on books f o r over five years i n 1955 and I960. A significant difference was found between the age-sex distribution of the two populations CX 2 > 2 0 , 5 1 7 , df = 5 , P< . 0 0 1 ) . Age, sex, and length of stay A chi square test was used to determine whether, within the various age-sex groups, the duration of stay interval was the same i n 1955 and 1960. Following are 61 the six categories tested f o r sim i l a r i t y of duration of stay characteristics: (a) (b) (c) (d) (e) (f) Sex Male Female Age group under 20 20 to 59 60 and over under 20 20 to 59 60 and over. Significant differences i n length of stay distribution was found between each of the 1955 and 1960 groups CX 2 > 1 6 . 2 6 8 , df = 3 , P < . 0 0 1 ) . Age and diagnostic group Table 21 i l l u s t r a t e s further differences between age groups. Increases occurred i n a l l age-diagnostic categories except the age 20-to-59 psychotic group, i n which a considerable decline occurred. In the oldest and youngest age groups, increases i n psychosis were not so great as i n other diagnoses. 62. Table 21 Canada. Patients on books, by age and diagnostic group. Standardized age- and sex-specific frequencies Age Group Year Diagnostic group Psy^ciioses Neuroses Mental Defic. Other Diag. < 20 1955 1960 510 664 AB 65 8,349 8,838 611 1,094 20-59 1955 1960 32,503 29,341 .1,228 1,553 10,254 11,184 2,680 3,285 60+ 1955 1960 17,311 17,461 344 507 1,291 1,379 493 994 63. Table 22 shows a decrease i n the diagnostic groups schizophrenia and affective affective psychoses. The increase i n psychoses i n the 60-and-over group i s due, not to an increase i n senile psychoses, as might be expected, but to the aging of "continued-lqng-stay n patients with diagnosis of schizophrenia. Table 22 Canada. Patients on books, by age and selected diagnosis  (psychoses only). Standardized age- and sex-specifio frequency Age Group Diagnostic group Year Schlz. Affec. Psych. Senile Psych. Ale. Psych. Other Psych. < 20 1955 329 33 — — 132 1960 526 33 — 99 20-59 1955 22,869 3,820 178 454 5,635 1960 20,964 3,238 115 531 4,538 60+ 1955 7 ,313 2,654 5,047 261 2,001 1960 7,524 2,664 4,870 358 2,066 64. Age and length of stay Table 23 shows that the decreases noted i n patients aged 20 to 59 occurred among those who had been under care for over one year, mostly from two to five years. There was a decline i n the two-to-five-year length of stay group for patients aged under-20 and 60-and-over, and increased i n a l l other length of stay categories f o r these two age groups. These gains we&e largest for patients under 20 who had been under care for five years or more, and f o r patients 60 and over who had been under care .for from one to, two years. . ; 5 = :> Table 23 Canada. Patients on books by age and length of stay. Standardized age- and sex-specific frequencies Age Group Year Length of stay (in years) 1-2 2-5 5+ < 20 1955 1960 2 ,095 2,414 1,560 1,573 2,992 2,397 2,758 3,918 20-59 1955 1960 8,246 11,103 3,263 2 ,903 6,787 4 , 9 0 8 29,428 26 ,848 60+ 1955 1960 2,830 3 ,853 1,382 1,534 2,722 2,502 12,705 12,727 1 65. Sex and diagnostic group Changes i n the "broad diagnostic groups shown i n Table 24 were i n the same direction f or both males and females, but there was a greater decline i n psychosis f o r females, and a greater increase i n mental deficiency f o r males. Table 24 Canada. Patients on books, by sex and diagnostic  group. Standardized age- and sex-specific frequencies Sex Year Diagnostic group . A l l Psychoses Neuroses Mental Defic. Other Diag. Male 1955 1960 26,273 25,084 592 723 10,993 11,911 2 ,135 3,173 Pemale . 1955 1960 24,051 . 22,382 1,029 1,402 8,901.. ;9,490 1,649 2,200 66. Sex and length of stay Table 26 shows that, for patients under care f o r from one to two years, there was a decrease i n males and a slight increase i n females. In other length of stay categories, changes were i n the same direction f o r both sexes. A greater decrease f o r females than f o r males occurred i n the five-years-and-over group. Table 25 Canada. Patients on books, by sex and length of  stay. Standardized age- and sex-specific frequencies Sex Year Length of stay (in years) < 1 1-2 2-5 5+ Male 1 9 5 5 1960 6,534 8,696 3,324 3,111 6,685 5,411 2 3 , 9 8 4 2 3 , 9 6 6 Pemale 1 9 5 5 1 9 6 0 6,628 8,674 2,881 2,899 5,816 4,396 20,907 19,527 6 7 . Diagnostic group and length of stay Table 26 shows that a l l diagnostic categories i n the under-one-year group increased. In the one-to-two-year and two-to-five-year groups, both psychosis and mental deficiency decreased, while other diagnoses increased. In the over-five-year group, there was a decline i n psychosis and neuroses and an increase i n -mental deficiency and "other1? diagnoses. Table 26 Canada. Patients on books, by diagnostic group and  length of stay. Standardized age-and-sex-speoifie rates Diagn. Group Length of stay (in years) < 1 \ 1-2 ': 2-5 5+ A l l Psychoses 1955 1960 9,356 : 11,325 3,922 3,608 -7,830 5,798 31,349 27,219 Neuroses 1955 1960 943 , 1,366 134 187 202 186 422 404 Mental Defie. 1955 1960 1 ,818 2,307 1,616 1,402 3,698 2,917 12,043 13,420 Other Diag. 1955 1960 1,371 2,352 628 811 971 1,197 2,123 2,615 Sex, diagnostic class, and length of stay 68. Within the various sex-diagnostic groups, the length of stay distribution changed considerably. A chi square test was applied to each of the groups whon i n Table 27 to determine i f these differences were s t a t i s t i c a l l y in-significant. Except for senile psychoses, differences were highly significant. * P .Goi ! ** p .01 "Table 27 Panada. Patients on books, by sex, diagnostic group, and length of stay. Standardized age-specific frequencies Sex Male Pemale Length of stay (in years) 1 1=2 2-5 5+ 1 1-2 2-5 5+ Diag. Group Year 2,304 3,113 1,088 865 2,182 1,623 11,631 # 10,554 2,252 3,065 8 9 8 900 1,918 1,284 9,442 # 7,959 Scfriz. 1 9 5 5 1960 Affec. Psych. 1955 1 9 6 0 711 781 226 192 434 282 1,373 • 1,151 1,246 1,384 282 306 570 392 1,913 * 1,535 Senile Psych. 1 9 5 5 1 9 6 0 797 807 426 392 650 563 4 9 5 4 7 5 8 7 0 909 4 5 6 4 8 6 796 7 1 9 661 620 Other Psych. 1 9 5 5 1 9 6 0 655 7 8 0 327 267 799 554 3,535 # 2,946 518 577 2 1 6 1 9 9 466 372 2,294 1,974 A l l Psych. 1 9 5 5 1960 4,468 5,389 2,069 1,717 4,067 3,027 17,037 * 15,129 4,888 5,396 1,853 1,891 3,763 2,771 14,312 # 12,090 Heuroses 1 9 5 5 1960 347 450 50 62 66 66 160 * 157 596 916 84 1 2 5 136 120 262 * 2 4 7 Mental Befic. 1 9 5 5 i960 1,053 1,357 932 8 6 3 2,142 1,571 5 6 4 4 5 0 * 7,406 7 6 5 9 5 0 6 8 4 539 1,556 1,346 5,593 *« 6,014 Other Biag, 1 9 5 5 1960 860 1,455 339 471 543 667 1,115 * 1,391 511 897 2 8 9 3 4 0 428 530 1,008 * 1,224 A l l Biag. 1 9 5 5 1960 6,730 8,744 3,389 3,113 6,820 5,333 24,767 , 24,086 * 6,761 8,700 2,911 2,899 5,887 4,769 21,170 „ 19,577 R E T E N T I O N 70. R e t e n t i o n i s t h e p r o p o r t i o n o f p a t i e n t s a t a : c e r t a i n t i m e r e m a i n i n g c o n t i n u o u s l y u n d e r h o s p i t a l c a r e f o r a s p e c i f i e d t i m e i n t e r v a l . I n t h i s s t u d y , d i s p o s i t i o n i s i n t e r m s o f t w o . a l t e r n a t i v e s o n l y : s t i l l u n d e r c a r e , o r n o l o n g e r u n d e r c a r e . T h e d a t a d o n o t g i v e a n y f u r t h e r i n f o r - , m a t i o n c o n c e r n i n g ' t h e p a t i e n t s " n o " l o n g e r ' o n b o o k ' s . T h e y m a y h a v e d i e d , b e e n d i s c h a r g e d a n d r e m a i n e d ' o u t o f h o s p i t a l , , o r b e e n d i s c h a r g e d a n d r e a d m i t t e d . . , . . . R e t e n t i o n o f 1 9 5 5 c o h o r t R e t e n t i o n r a t e s f o r a l l p a t i e n t s , w h o . w e r e , , u n d e r , c a r e o f a p s y c h i a t r i c i n s t i t u t i o n a t t h e e n d o f 1 9 5 5 w e r e e s t i m a t e d ( T a b l e 28). T h o s e p a t i e n t s w h o h a d b e e n u n d e r c a r e f o r f r o m f i v e t o t e n y e a r s i n I 9 6 0 ' w e r e t h e s a m e p a t i e n t s w h o h a d b e e n u n d e r c a r e f o r l e s s t h a n f i v e y e a r s i n 195,5•., T h e r e f o r e , t h e r e t e n t i o n r a t e o f t h i s g r o u p o f p a t i e n t s w a s c a l c u l a t e d b y u s i n g a s t h e n u m e r a t o r a l l p a t i e n t s o n b o o k s f o r f r o m f i v e t o t e n y e a r s i n I 9 6 0 , a n d a s t h e d e n o m i n a t o r a l l p a t i e n t s o n b o o k s f o r u n d e r f i v e y e a r s i n 1 9 5 5 , a n d m u l t i p l y i n g b y 1 0 0 t o g i v e t h e p e r c e n t a g e o f . p a t i e n t s c o n t i n u o u s l y o n t h e b o o k s f r o m t h e t i m e o f t h e i r a d m i s s i o n t o D e c . 31, I 9 6 0 . S i m i l a r l y , t h e p a t i e n t s 71. T a b l e 2 8 C a n a d a . P a t i e n t s o n b o o k s D e c . 3 1 , 1955, b y s e l e c t e d  d i a g n o s i s . D i s p o s i t i o n a t D e c . 3 1 , 1 9 6 , 0 D i a g . A t . D e c . 3 1 / 5 5 A t . D e c . 3 1 / 6 0 io o f p t s . c o n t i n u o u s l y o n b o o k s L e n g t h o f s t a y ( y e a r s ) F L e n g t h o f s t a y ( y e a r s ) N S c h i z . * 5 5 - 1 0 1 0 + 9 , 1 7 3 4 , 3 2 5 1 3 , 8 2 0 5 - 1 0 1 0 - 1 5 .15 + 3 , 8 3 3 3 , 2 8 6 1 0 , 9 7 0 .41 .8 7 6 . 0 7 9 . 4 A l l 2 7 , 3 1 8 5+ 1 8 , 0 8 9 66.2 A f f e c . P s y c h . < 5 5 - 1 0 1 0 + 2 , 9 8 9 8 9 0 1 , 9 3 8 5 - 1 0 1 0 - 1 5 1 5 + 7 3 4 5 6 3 1 , 3 2 8 2 4 . 6 6 3 . 3 6 8 . 5 A l l 5 , 8 1 7 5+ 2 , 6 2 5 4 5 . 1 S e n i l e P s y c h . < 5 5 - 1 0 1 0 + 3 , 4 3 8 6 2 8 3 6 8 5 - 1 0 1 0 - 1 5 1 5 + 7 0 8 1 9 3 1 7 0 20.6 3 0 . 7 46.2 A l l 4 , 4 3 4 5+ 1 , 0 7 1 2 4 . 2 • O t h e r P s y c h . < 5 5 - 1 0 1 0 + 2 , 5 7 0 1,664 3 , 3 5 9 5 - 1 0 1 0 - 1 5 1 5 + 1 , 1 9 7 1,154 2 , 4 5 9 46.6 6 9 . 4 7 3 . 2 A l l 7 , 5 9 3 5+ 4 , 8 1 0 6 3 . 3 A l l P s y c h . < 5 5 - 1 0 1 0 + 46,147 1 8 , 9 2 2 4 7 , 6 1 8 5 - 1 0 10-15 • 1 5 + 1 8 , 8 2 6 1 3 , 5 4 8 3 6 , 8 8 1 40.8 - 7 1 . 6 7 7 . 5 A l l 1 1 2 , 6 8 7 5+ 6 9 , 2 5 5 6I.5 M e n t a l D e f i c . < 5 5 - 1 0 1 0 + 6,143 3 , 1 3 6 7 , 2 0 0 5 - 1 0 1 0 - 1 5 15+ 4 , 6 9 9 2 , 5 7 6 5 , 8 3 8 ' 7 6 . 5 8I.4 8 1 . 2 A l l 1 6 , 5 0 6 5+ 1 3 , 1 1 3 7 9 . 4 A l l D i a g . < 5 5 - 1 0 1 0 + 2 7 , 9 7 7 11,415 2 8 , 1 3 3 5 - 1 0 10-15 1 5 + 1 2 , 3 5 4 8 , 3 5 2 2 1 , 9 5 4 4 4 . 2 7 3 . 2 7 8 . 0 A l l 6 7 , 5 2 5 5+ 42 ,660 6 3 . 2 72. under care f o r from ten to f i f t e e n years i n 1960"were the same patients who had been under care f o r from f i v e to ten years i n 1955. Table 28'shows that' 63$ of a l l patients on books of mental i n s t i t u t i o n s at December 31, 1955,' were;' s t i l l on books f i v e years l a t e r , at December 31, I960. The patients who had been under care- f o r over f i v e years i n 1955 constituted a much l a r g e r proportion of those s t i l l under., care f i v e years l a t e r than, did' those who had been'under care f o r l e s s than f i v e years. Rate of r e t e n t i o n f o r a f u r t h e r f i v e years was much"the same f o r f i v e to ten year patients as f o r the ten year and over patients, e s p e c i a l l y the mentally d e f i c i e n t s . Patients diagnosed.as mentally.deficient-had..the ... l a r g e s t proportion remaining continuously, and those • with a diagnosis of s e n i l e psychosis the smallest. ' • i. ' ' . . . . . . . . . . . . . . A c t u a r i a l estimate of r e t e n t i o n of patients at various  elapsed lengths .of h o s p i t a l care Table 29 i s an estimate of the p r o b a b i l i t y of-a patient's remaining under care f o r a given length of time, assuming he has already been under-care f o r a-designated period. 7 3 . Table 29 was calculated from data on patient movement and patients under care of psychiatric i n s t i -tutions using a method outlined by Fisher and Clarke (1955, pp 27-29) f o r deriving absolute rates of separation from a mental hospital, using the census type of data. Table 29 Canada. Proportion of patients remaining P E L books at end of various intervals Pt. re-maining on bks. at end of: Proportion remaining of patients who were s t i l l on books at end of: 0 mo. 1 mo. 4 mo. 1 yr. 2 yr. 3 yr. G mo. 100.0$ 1 mo. 56.3 100.0$ 4 mo. 20.5 36.4 100.0$ 1 yr. 12.6 22.3 61.3 100.0$ 2 yr. 10.0 17.7 48.7 79.5 100.0$ 3 yr. 8.9 15.8 43.3 70.1 88.8 100.0$ 5 yr. 7.8 13.9 38.1 62.1 7.8.2 88.0 10 yr. 6.1 10.8 29.8 48.5 61.1 68.8 7 4 . T h e p r o b a b i l i t y o f r e m a i n i n g i n h o s p i t a l i n c r e a s e d i n d i r e c t p r o p o r t i o n t o t h e l e n g t h o f t i m e a l r e a d y s p e n t u n d e r h o s p i t a l c a r e . P r o m T a b l e 29 i t c a n b e e s t i m a t e d t h a t , o f 1 , 0 0 0 a d m i s s i o n s , 1 2 6 w o u l d s t i l l b e i n h o s -p i t a l a t t h e e n d o f o n e y e a r , a n d o n l y 6 1 w o u l d r e m a i n a t t h e e n d o f t e n y e a r s . B u t , o f 1 , 0 0 0 p a t i e n t s w h o h a d a l r e a d y b e e n o n t h e b o o k s f o r o n e m o n t h , 2 2 3 w o u l d s t i l l b e o n t h e b o o k s a t - ' t h e e n d o f o n e y e a r , a n d 1 0 8 a t t h e e n d o f t e n y e a r s - . T h e n u m b e r r e m a i n i n g p e r 1 , 0 0 0 i n c r e a s e s f o r l o n g e r s t a y p a t i e n t s . A p a t i e n t w h o , h a s - b e e n h o s p i t a l i z e d f o r t w o y e a r s i s m o r e l i k e l y t h a n n o t t o r e m a i n i n h o s p i t a l a t l e a s t t e n - y e a r s , l o n g e r . C o m p a r i s o n d'f 2.955 a n d 1 9 5 8 c o h o r t s T h e 1955 c o h o r t u n d e r s t u d y c o n s i s t e d o f a l l p a t i e n t s a d m i t t e d d u r i n g 1955 w h o w e r e s t i l l - u n d e r c a r e a t t h e ' e n d o f t h a t " y e a r . T h e 1958 c o h o r t , s i m i l a r l y , c o n s i s t e d o f a l l 1958 a d m i s s i o n s w h o w e r e s t i l l u n d e r c a r e a t t h e e n d o f 1958. I n o r d e r t o c o m p a r e 1955 a n d 1958 r e t e n t i o n r a t e s , t h e p e r c e n t a g e o f t h e s e c o h o r t s w h o w e r e s t i l l o n t h e b o o k s o n e a n d t w o y e a r s l a t e r w a s c a l c u l a t e d . Table 30 Canada. Patients admitted i n 1955 and 1958 and remaining on books 2 and 3 years after admission, by diagnostic group. Number and percentage. Date Time since adm. of ! 5 5 cohort Diagnostic grou p Schiz. Affec. Psych. Senile Psyeh. Other Psyeh. A l l Psych. Neur. Ment. Defic. Other Diagn. A l l Diagn. Dec.31/55 <1 yr. N 3,922 100.0 1,683 100.0 1,436 100.0 1,011 100.0 8,052 100.0 8 1 2 100.0 1,566 100.0. 1,182 100.0 1 1 , 6 1 2 100.0 Dec.31/56 1-2 yr. N $ 1,710 43.6 437 26.0 833 58.0 500 49.5 3,480 43.2 139 17.1 1.376 87.9 421 35.6 5,416 4 6 . 6 Dec.31/57 2-3 yr. $ 1,225 31.2 269 16.0 577 40.2 395 39.1 2,466 30.4 70 8.6 1,265 80.8 318 26.9 4,119 35.5 $ of 1 9 5 5 cohort on bk Dec.31/56 who were s t i l l on bk. Dec.31/57 71.6 61.6 69.3 7 9 . 0 70.9 50.4 9 1 . 9 75.5 76.1 Dec.31/58 Time since adm. of f58 cohort 4,754 100.0 1,942 100.0 1,541 100.0 1,053 100.0 9,290 100.0 1,060 100,0 1,486 100.0 1,735 100.0 13,571 1 0 0 . 0 <1 yr. N $ Dec.31/59 1-2 yr. N 1,766 37.1 527 27.1 845 54.8 429 40.7 3,567 38.4 1 6 5 15.6 1,148 77.3 733 42.2 5,613 40.8 Dec.3l/60 2-3 yr. H 1,097 23.1 278 14.3 574 37.2 320 30.4 2,269 24.4 82 7.7 1,062 71.5 550 31.7 3,963 28.8 $ of 1958 cohort on bk Dec.3v50 who were S t i l l on bk. Dec.31/60 62.1 52.8 67.9 74.6 63.6 49.7 92.5 75.0 70.6 76. The r a t i o of t h o s e s t i l l on hooks two y e a r s a f t e r t o t h o s e 1 s t i l l on hooks one y e a r a f t e r was a l s o e s t i m a t e d . R e t e n t i o n r a t e s were l o w e r f o r t h e 1958 c o h o r t • t h a n f o r t h e 1955 i n a l l d i a g n o s e s e x c e p t i n g " m i s c e l l a n e o u s " , and i n a l l age groups. ( T a b l e 3.0),.. . . ... There was a wide- d i s c r e p a n c y among the d i a g n o s t i c g r o u p s i n p e r c e n t a g e o f t h e o r i g i n a l number ' s t i l l u n der c a r e a t t h e - end of one and two y e a r s , m e n t a l d e f i c i e n c y h a v i n g t h e h i g h e s t r e t e n t i o n r a t e s and n e u r o s e s and a f f e c t i v e 'psychoses t h e l o w e s t . I t was a p p a r e n t t h a t , , once a p a t i e n t had been on t h e books f o r o v e r a y e a r , h i s chances o f r e m a i n i n g ; f o r a n o t h e r y e a r were much the same r e g a r d l e s s of. -d i a g n o s i s . T h i s phenomenon was a p p a r e n t f o r b o t h the. 1955 and I960 c o h o r t s . . : P r o p o r t i o n o f p a t i e n t s under c a r e f r o m one to-, two y e a r s a f t e r a d m i s s i o n who were s t i l l u nder Pare" .two .to t h r e e y e a r s , a f t e r a d m i s s i o n .dropped f o r a l l . d i a g n o s e s e x c e p t m e n t a l d e f i c i e n c y , i n w h i c h c a t e g o r y t h e r e was a s l i g h t i n c r e a s e . T a b l e 31 shows t h a t p a t i e n t s under 20 have t h e g r e a t e s t l i k e l i h o o d o f r e m a i n i n g under .care a t t h e end o f b o t h t h e one-year and t w o - y e a r p e r i o d s . .-Compared w i t h . a l l o t h e r p a t i e n t s r e m a i n i n g on books 7 7 . Table 31 Canada. Patients admitted i n 1955 and 1958 and remaining  ofl books 2 and 3 years after admission, "by age. Number and percentage. late Time since adm. of *55 cohort Age <20 20-59 60+ Bee.31/55 <1 yr N .* 1,698 100.0 7 ,413 1 0 0 . 0 2,486 100.0 Bee.31/56 1-2 yr. N * 1,245 .7.3.3 2,856 3 8 . 5 1,303 52.4 Dec.31/57 2-3 yr. N 1,105 65.1 2,066 27.9 942 37.9 -# of 1955 cohort on bk Dee.31/56 who were s t i l l on bk. Dec.31/57 * 8 8 . 8 72 .3 72 .3 Deo.31/58 Time since adm. of •58 cohort <1 yr. N * 1,771 100.0 8,791 100.0 2,987 100.0 Dec.31/59 1-2 yr. 1,216 . 6 8 . 7 2 ,948 3 3 . 5 1,443 4 8 . 3 Dec.31/60 2-3 yr. 951 53 .7 1,880 21 .4 1,036 34.7 $> of 1958 cohort on bk Dec.31/59 who were s t i l l on bk. Dec .3l/60 * 78 .2 6 3 . 8 71 .8 78. f o r ' f r o m o n e t o t w o y e a r s , t h e y o u n g e r p a t i e n t s a l s o -h a v e a g r e a t e r p r o b a b i l i t y o f r e m a i n i n g f o r a n a d d i t i o n a l y e a r . R e t e n t i o n . r a t e s d e c r e a s e d f o r a l l a g e g r o u p s , b u t t h e e f f e c t i s l e s s m a r k e d f o r p a t i e n t s a g e d s i x t y a n d o v e r . O n c e a p a t i e n t i n t h i s a g e g r o u p h a d b e e n u n d e r c a r e f o r o n e y e a r o r m o r e , t h e - e s t i m a t e d p r o b a b i l i t y o f h i s r e m a i n i n g f o r a n a d d i t i o n a l y e a r w a s ' • (2) • '' v i r t u a l l y t h e s a m e f o r b o t h c o h o r t s . .-P i g . 3 s h o w s t h a t r e t e n t i o n o f m a l e p a t i e n t s w a s ' . h i g h e r t h a n t h a t o f f e m a l e p a t i e n t s i n b o t h c o h o r t s , b u t t h a t ' t h e r e w a s a d e c r e a s e i n r e t e n t i o n r a t e f o r b o t h s e x e s . • < ' P i g . 4 s h o w s t h e d i s p o s i t i o n o f a l l 1955' a d m i s s i o n s . ( p) . •. . • •• •' v y T h e p a t i e n t s a g e d 2 0 t o 59 a t t h e e n d o f 19-57 w e r e n o t e x a c t l y t h e s a m e i n d i v i d u a l s w h o w e r e a g e d , 2 0 t o 39,in 195' t* s i n c e p a t i e n t s w e r e - a d d e d t o t h i s g r o u p " 'by o u t g r o w -i n g t h e u n d e r - 2 0 a g e c a t e g o r y , a n d o t h e r s h a d g r a d u a t e d t o t h e o v e r - 6 0 g r o u p . I n t h e s a m e w a y , t h e u n d e r - 2 0 g r o u p w a s d e c r e a s e d b y a g i n g o f t h e p a t i e n t , a g e s 18 , . t o 2 0 , a n d ' t h e ' o v e r - 6 0 g r o u p i n c r e a s e d b y t h e a g i n g o f p a t i e n t s w h o w e r e a g e d 57 t o 59 i n 1955. I t w a s n o t p o s s i b l e . t o c o r r e c t f o r t h i s e f f e c t , s i n c e t h e r e a r e n o t a b l e s g i v i n g l e n g t h o f s t a y b e i n d i v i d u a l a g e s . l l Q % m 5 S Q K •HI: 5 Ml > (ft o u U. o Q 0 y o VJ <0 in ill 79. 5 /=/Gr. 4- 80. 81. . I n c r e a s e i n t h e y o u n g e r age g r o u p was m a i n l y due t o a d m i s s i o n o f m e n t a l l y d e f e c t i v e s and t o t h e r e t e n t i o n of p a t i e n t s i n t h i s c a t e g o r y f o r ' f i v e y e a r s and l o n g e r . R e t e n t i o n r a t e s d e c r e a s e d between 1955 and 1958. E s t i m a t e d rate's i n d i c a t e t h a t t h e p r o b a b i l i t y o f r e m a i n i n g on books f o r a l o n g e r p e r i o d of t i m e i n c r e a s e s w i t h t h e l e n g t h o f t i m e a l r e a d y s p e n t i n an i n s t i t u t i o n . IV DISCUSSION 8 2 PATIENTS UNDER CARE AT DECEMBER 31, I960 Data on patients on books i n I960 were compared with other f i n d i n g s reported i n the l i t e r a t u r e . Prevalence The o v e r a l l prevalence rate was 4.22 per 1,000 as compared with 8.07 per 1,000 reported by Hollingishead and Redlieh (1958), and the one-year prevalence rate of 28.86 per 1,000 obtained by Lemkau et a l (1942). Differences are due to differences i n d e f i n i t i o n s and indi c e s used. The higher rate obtained by H o l l i n g s -head and Redlieh was due to the f a c t that they included a l l patients i n New Haven and surrounding areas under i n - and out-patient p s y c h i a t r i c care, during a six-month period. Lemkau et a l defined a case as any patient who appeared on a s o c i a l agency case record at any time throughout the year. This one-year prevalence rate and and Hollingshead and Redlieh's six month rate cannot be compared with the point prevalence rate obtained i n the present study. Sex The prevalence rate of 4*42 per 1,000 f o r males and 3-94 f o r females agreed with Rose's (1955) report 8 3 . o f m o r e m a l e s t h a n f e m a l e s i n s t a t e m e n t a l h o s p i t a l s i n t h e U n i t e d S t a t e s i n 1 9 3 3 . S e x a n d d i a g n o s i s T h e f i n d i n g s a r e s i m i l a r t o t h o s e o f L e m k a u e t a l , w h o f o u n d t w i c e a s m a n y m a l e a s f e m a l e c a s e s d u e t o e x o g e n o u s c a u s e s ( a l c h o l i s m , s y p h i l i s , a n d e p i l e p s y ) , a n d t w i c e a s m a n y f e m a l e c a s e s a s m a l e d u e t o m a n i c d e p r e s s i v e p s y c h o s i s . • T h e p r e s e n t s t u d y s h o v / s a l m o s t o n e a n d o n e h a l f t i m e s a s m a n y m a l e s a s f e m a l e s i n t h e f i r s t c a t e g o r y , a n d j u s t o v e r o n e a n d o n e h a l f t i m e s a s m a n y f e m a l e s a s m a l e s i n t h e s e c o n d . D i a g n o s i s I n a g r e e m e n t w i t h m a n y i n v e s t i g a t o r s . ( H o l l i n g s h e a d a n d R e d l i e h , 1 9 5 8 ; L e m k a u e t a l , 1 9 4 2 ; N o r r i s , 1 9 5 2 ) , s c h i z o p h r e n i a w a s h y f a r t h e m o s t p r e v a l e n t d i a g n o s i s . 84. C H A N G E S T h e d a t a c o n f i r m t h e h y p o t h e s i s t h a t t h e r e w a s a s i g n i f i c a n t c h a n g e i n t h e a g e , s e x , d i a g n o s t i c , a n d l e n g t h - o f - s t a y c h a r a c t e r i s t i c s o f p a t i e n t s u n d e r c a r e o f C a n a d i a n p s y c h i a t r i c i n s t i t u t i o n s b e t w e e n t h e y e a r s 1 9 5 5 a n d I 9 6 0 . T h e y a l s o i n d i c a t e r e a s o n s f o r t h i s c h a n g e . T h e . r e d u c e d ' r e t e n t i o n o f n e w p a t i e n t s h a s l e d t o a r e d u c -t i o n i n t h e n u m b e r o f p a t i e n t s w h o h a v e b e e n u n d e r c a r e f o r f r o m t w o t o f i v e y e a r s , v / h i c h h a s i n t u r n m a d e a c -c o m m o d a t i o n a v a i l a b l e f o r a g r e a t e r n u m b e r o f s h o r t -t e r m p a t i e n t s . T h e i n c r e a s e d n u m b e r o f p a t i e n t s u n d e r 2 0 i s d u e t o . . t h e l a r g e n u m b e r o f m e n t a l d e f e c t i v e s b e i n g p l a c e d i n i n s t i t u t i o n s . I n c r e a s e i n t h e n u m b e r o f o l d e r p a t i e n t s i s d u e t o t h e a g i n g o f o l d e r s c h i z o p h r e n i c s r a t h e r t h a n t o t h e a d m i s s i o n o f s e n i l e p s y c h o t i c s . P a t i e n t s a g e d 2 0 t o 5 9 d i a g n o s e d a s p s y c h o t i c , w h o h a v e b e e n u n d e r c a r e f o r t w o t o f i v e y e a r s a r e r e s p o n s i b l e f o r m o s t o f t h e d e c l i n e i n p r e v a l e n c e . T h i s d e c r e a s e i n d i c a t e s t h a t r e d u c e d r e t e n t i o n o f n e w l y -a d m i t t e d p s y c h o t i c p a t i e n t s h a s r e d u c e d t h e n e c e s s i t y f o r c o n t i n u o u s l o n g - t e r m h o s p i t a l i z a t i o n f o r p s y c h o s e s . H o w e v e r , t h i s w a s b a l a n c e d b y a n i n c r e a s e i n p a t i e n t s w i t h o t h e r d i a g n o s e s , p a r t i c u l a r l y m e n t a l d e f i c i e n c y , 85. m a n y , o f w h o m b e c o m e " c o n t i n u o u s - l o n g - s t a y " p a t i e n t s . B r i l l a n d P a t o n ( 1 9 5 9 ) c o n c l u d e d t h a t t h e u s e o f t r a n q u i l l i z e r s w a s t h e m a j o r i n f l u e n c e i n r e d u c i n g t h e p o p u l a t i o n o f m e n t a l i n s t i t u t i o n s " b e t w e e n 1955 a n d 1958, e s p e c i a l l y i n t h e f u n c t i o n a l p s y c h o s e s , " s c h i z o p h r e n i a i n p a r t i c u l a r . O t h e r f a c t o r s m u s t "be a l s o i m p l i c a t e d i n t h i s d e c l i n e , s i n c e , i n O n t a r i o ( O n t a r i o D e p a r t m e n t o f H e a l t h , I 9 6 0 ) a n d M a s s a c h u s s e t s ( P u g h a n d M c M a h b n , 1962), t h i s d e c r e a s e " b e g a n i n 1954» w i t h o u t " b e n e f i t o f e x t e n s i v e p h a r m a c o t h e r a p y . A p p e n d i x G- s h o w s t h a t i n O n t a r i o , a d e c l i n e i n r a t e s o f m e n t a l i l l n e s s " b e g a n i n 1948, a n d h a s c o n t i n u e d e v e r y y e a r s i n c e t h e n . P u g h a n d M e M a h o n (1962) r e l a t e d t h e - c u r r e n t . d e c l i n e i n p r e v a l e n c e t o t w o g r o u p s o f f a c t o r s ; t h o s e w h i c h d o n o t r e q u i r e c h a n g e s i n h o s p i t a l p r a c t i c e , a n d t h o s e w h i c h a r e d e p e n d e n t o n h o s p i t a l p r a c t i c e . I n t h e f i r s t g r o u p t h e y i n c l u d e ( a ) r e d u c e d r a t e o f u r b a n i z a t i o n , (t>) c h a n g i n g a g e d i s t r i b u t i o n ( r e l a t i n g t h e l o w b i r t h r a t e i n t h e 1930's to t h e r e d u c t i o n o f s c h i z o p h r e n i a ) , ( c ) d e c l i n e i n t h e f o r e i g n - b o r n p o p u l a t i o n , ( d ) s e p a r a t i o n f r o m h o s p i t a l o f t h e l a r g e c o h o r t w h i c h e n t e r e d i n t h e p e r i o d 1933-37, a n d w o u l d h a v e r e a c h e d t h e i r a v e r a g e l e n g t h o f s t a y a n d ( e ) a d e c l i n e i n s y p h i l i t i c b r a i n s y n -d r o m e a s a r e s u l t o f p u b l i c • h e a l t h m e a s u r e s . I n d i s c u s s i n g t h o s e f a c t o r s d e p e n d a n t o n h o s p i t a l p r a c t i c e , t h e y p o i n t o u t t h a t a s h o r t e r m e a n d u r a t i o n o f s t a y w o u l d c a u s e a d e c l i n e i n p r e v a l e n c e , i f a d m i s -s i o n s r e m a i n e d f a i r l y c o n s t a n t . . I t i s d i f f i c u l t t o a p p l y t h e s e e x p l a n a t i o n s t o t h e C a n a d i a n e x p e r i e n c e . D a t a f r o m t h e p r e s e n t s t u d y d o n o t s u p p o r t t h e i r h y p o t h e s i s t h a t t h e l o w " b i r t h r a t e i n t h e * 3 0 ' s w a s r e s p o n s i b l e f o r a d e c l i n e i n t h e p r e v a l e n c e ' o f ' s c h i z o p h r e n i a . T h e r e w a s a d e c l i n e i n t h e h o s p i t a l i z e d p r e v a l e n c e r a t e p e r 1 , 0 0 0 i n t h i s a g e g r o u p , w h i c h i n d i c a t e s t h a t t h e r e d u c t i o n w a s n o t e n t i r e l y d u e t o c h a n g e s i n d e m o g r a p h i c c h a r a c t e r i s t i c s o f t h e p o p u l a t i o n . T h i s i n c r e a s e i n p a t i e n t s o n b o o k s f o r l e s s t h a n o n e y e a r a n d d e c r e a s e s f o r l o n g e r s t a y p a t i e n t s , i n d i c a t e s t h a t a s h o r t e r d u r a t i o n o f s t a y , r a t h e r t h a n f e w e r p e o p l e i n t h i s a g e g r o u p , w a s r e -s p o n s i b l e f o r t h e d e c l i n e i n t h e h o s p i t a l i z e d p r e v a -l e n c e o f s c h i z o p h r e n i a . A g a i n , C a n a d i a n d a t a d o n o t s u p p o r t t h e s u p -p o s i t i o n t h a t s e p a r a t i o n o f p a t i e n t s a d m i t t e d i n t h e y e a r s 1 9 3 3 t o 1 9 3 7 c o n t r i b u t e d t o t h e d e c l i n e . T h e a s s u m p t i o n t h a t l a r g e n u m b e r s o f t h i s c o h o r t a c h i e v e d t h e i r " a v e r a g e " l e n g t h o f s t a y b e t w e e n 1 9 5 5 a n d I960 i s u n j u s t i f i e d . T h e t e r m " a v e r a g e " w a s n o t f u r t h e r d e f i n e d ; i t c a n m e a n t h e m e a n , m e d i a n , o r m o d e . T h e a r i t h m e t i c mean i s n o t a h e l p f u l i n d e x , as i t i s n o t the p o i n t a t w h i c h most p a t i e n t s a r e d i s c h a r g e d . The median l e n g t h o f s t a y f o r C a n a d i a n p a t i e n t s has "been e s t i m a t e d a t 84 months f o r p a t i e n t s under c a r e , o r under s i x and-a h a l f months f o r d i s c h a r g e s (Canada, DBS, I 9 6 0 ) ; even g r a n t i n g a wide v a r i a t i o n between the two p o p u l a t i o n s , t h e median p o i n t s would have been r e a c h e d l o n g ..before 1955. The mode, o r p o i n t a t w h i c h most p a t i e n t s were d i s c h a r g e d , would have been r e a c h e d d u r i n g t h e f i r s t two y e a r s o f h o s p i t a l i z a t i o n . E s t i -mates o f r e t e n t i o n made i n t h e p r e s e n t s t u d y (see T a b l e 29) i n d i c a t e t h a t o n l y 6% o f a d m i s s i o n s a r e s t i l l u n der i n s t i t u t i o n a l c a r e t e n y e a r s l a t e r . T h i s number would be s t i l l f u r t h e r d e p l e t e d by 1955. ( I t i s e s t i m a t e d t h a t a p p r o x i m a t e l y 3 , 0 0 0 p a t i e n t s on books i n C a n a d i a n i n s t i t u t i o n s i n 1955 were a d m i t t e d p r i o r t o 1940. T h i s number c o n s t i t u t e s o n l y 4.4$ o f a l l p a t i e n t s under c a r e i n 1955; and of c o u r s e n o t a l l o f t h e s e were 1933-to-1937 a d m i s s i o n s . ) D e p a r t u r e o f members o f the 1933 t o 1937 c o h o r t , t h e r e f o r e , v/ould be a m i n o r f a c t o r i n changes i n p r e v a l e n c e d u r i n g 1955 t o 1958. P a t i e n t s . w i t h s y p h i l i t i c b r a i n syndrome c o n s t i -t u t e a v e r y s m a l l p o r t i o n o f p a t i e n t s i n m e n t a l h o s -p i t a l s ( a p p r o x i m a t e l y 1.8$ i n C a n a d i a n i n s t i t u t i o n s ) , and a d e c l i n e i n t h i s g r o u p would have o n l y a s l i g h t 88. a f f e c t on h o s p i t a l p r e v a l e n c e r a t e s . N e i t h e r would a s h o r t e r mean d u r a t i o n of s t a y n e c e s s a r i l y cause .a d e c l i n e i n p r e v a l e n c e . D i f f e r e n t p a t t e r n s of d i s c h a r g e and m o r t a l i t y a f f e c t mean dura-t i o n . Por example, T a b l e 32 shows t h a t d i f f e r e n t r e l e a s e p a t t e r n s a f f e c t mean d u r a t i o n of s t a y . T a b l e 32 Median and mean d u r a t i o n of s t a y i n H y p o t h e t i c a l  I n s t i t u t i o n s w i t h d i f f e r e n t r e l e a s e p a t t e r n s I n s t . A I n s t . B Number admitted 1,000 1,000 D i s c h a r g e d under l.mo. 5 0 0 800 D i s c h a r g e d 1-12 months 200 D i s c h a r g e d 1 - 5 y e a r s 200 D i s c h a r g e d 5-10 y e a r s 100 200 Median d u r a t i o n of s t a y 5-g- mo. 1 mo. Mean dura,tion of s t a y 9 . 5 mo. 2.2 mo. Data c o n c e r n i n g r e c e n t changes i n the number, c h a r a c t e r i s t i c s and r e t e n t i o n of p a t i e n t s i n mental i n s t i t u t i o n s p r o v i d e some i n s i g h t i n t o the phenomenon of the s e l e c t i o n of p a t i e n t s f o r h o s p i t a l i z a t i o n . I n the f i r s t p l a c e , due to the acute bed shortage, the number of admissions i s r e s t r i c t e d t o the number of d i s c h a r g e s and deaths. C h a r a c t e r i s t i c s of the p a t i e n t s i n i n s t i t u t i o n s are a l s o a f a c t o r i n d i r e c t l y i n f l u e n c -i n g the type of p a t i e n t s admitted, because of p u b l i c 8 9 . a t t i t u d e s t oward t h e i n s t i t u t i o n s engendered hy r e l e a s e and t r e a t m e n t p o l i c i e s . Thus t h e r e l a t i o n s h i p between t h e c h a r a c t e r i s t i c s of a d m i s s i o n s and r e s i d e n t p a t i e n t s i s a r e c i p r o c a l one, s i n c e t h e t y p e of p a t i e n t s a d m i t -t e d o b v i o u s l y a f f e c t s t h e r e s i d e n t p o p u l a t i o n as w e l l . S i n c e p r e v a l e n c e i s a f u n c t i o n o f i n c i d e n c e and d u r a t i o n , o r P =f (I X D) , a change i n any p a r t of t h i s e q u a t i o n a f f e c t s b o t h t h e . o t h e r s . . The e v i d e n c e drawn f r o m t h i s s t u d y shows, t h a t a change i n D ( l e n g t h of. s t a y ) was l a r g e l y - r e s p o n s i b l e f o r - t h e changes i n p r e v a l e n c e . 90. USES AND LIMITATIONS OP DATA  Source data The data r e l a t i n g to mental i n s t i t u t i o n s made av a i l a b l e i n annual p u b l i c a t i o n s of the DBS i s d e t a i l e d and extensive. Comprehensive reports of patient movement by age, sex, diagnosis, m a r i t a l status, type of i n s t i t u t i o n , method of committment, residence, immigration, and occu-pation, as w e l l as reports on accommodation, u t i l i z a t i o n , f a c i l i t i e s , personnel, and finances, f o r Canada and f o r the separate provinces, are included i n Mental Health  S t a t i s t i c s . The Supplement: Patients i n I n s t i t u t i o n s includes age, sex, diagnostic, and length of stay char-a c t e r i s t i c s of patients under i n s t i t u t i o n a l care. Such d e t a i l e d and comprehensive coverage i s unique i n s t a t i s t i c a l r eporting of mental i l l n e s s . By contrast, the National I n s t i t u t e of Mental Health i n the United States receives schedules from public mental h o s p i t a l s only. Submissions are voluntary, and d e f i n i t i o n s and tabulations are not standardized, although, i n 1951, a Model Reporting Areas was set up, with aims which included c l a r i f y i n g d e f i n i t i o n s , stand-a r d i z i n g t ables, and improving standards of s t a t i s t i c a l r e p o r t i n g . Currently, (1961) 21 states are members of the Model Reporting Area. Submissions to the NIMH eover 91. (a) patient movement by sex, (b) f i r s t admissions by age, sex, and diagnosis, (o) resident patients by age, sex, and diagnosis, and (d) personnel and finances. I t i s not possib l e to tabulate t h i s data on a n a t i o n a l scale, as the reports are of aggregate numbers, not i n d i v i d u a l patients (Kramer, Pollack, and Redick, 1961). In the United Kingdom, data concerning a l l admissions and discharges are c o l l e c t e d and transfered to cards by a l l designated mental h o s p i t a l s i n England and Wales. These cards are sent to the General Register's o f f i c e , where they are c o l l a t e d and paired with f i r s t admission cards already i n the index. In t h i s way, i t i s possible to keep a continuous record of the i n d i v i d u a l periods of h o s p i t a l i z a t i o n . (Brooke, 1959). Shortcomings of the United States health s t a t i s t i c s l i m i t the scope of epidemiological surveys, and have been decried by most i n v e s t i g a t o r s i n t h i s f i e l d . Pugh and McMahon (1962) point out that none of t h e i r sources consider diagnosis simultaneously with age and sex, and that t h e i r data f o r f i r s t admissions do not give information concerning age, sex, and m a r i t a l status. This information i s provided by DBS f o r Canadian pat i e n t s . Kramer et a l (1961), discussing changes i n hos-p i t a l i z e d prevalence, state that "the absence of r e l a t i v e patient movement data s p e c i f i c f o r age, sex, diagnosis, and length of stay make i t p a r t i c u l a r l y d i f f i c u l t to de-9 2 . termine i n which segments of the h o s p i t a l i z e d pat i ent popula t ion the changes are occurr ing" (p. 7 6 ) . As has been noted, t h i s in format ion a l so i s a v a i l a b l e i n Canada. Some a d d i t i o n s could be made to the r e p o r t s of the DBS to f u r t h e r increase t h e i r usefulness . A tab le showing pa t i en t s on books by age group, d iagnos t i c group, and length of stay i s one. A l s o , a tab le showing exac t ly how many mental i n s t i t u t i o n s of var ious types (a) ex i s t i n Canada, (b) repor t on summary schedules , and (c) send i n morbid i ty cards f o r the var ious years would help to c l a r i f y some of the year to year changes i n the pat i ent popu la t ion . A great deal of p o t e n t i a l l y u s e f u l m a t e r i a l i s a v a i l a b l e but has not been publ i shed by DBS. Tabulat ions on such v a r i a b l e s as m a r i t a l s ta tus , type of i n s t i t u t i o n , re s idence , immigrat ion, and occu-pat ion of p a t i e n t s under care of mental i n s t i t u t i o n s , would provide u s e f u l in format ion as a bas i s f o r more d e t a i l e d study of the c h a r a c t e r i s t i c s of p a t i e n t s i n p s y c h i a t r i c i n s t i t u t i o n s . .Findings The present study does not attempt to g ive s p e c i f i c reasons f o r the recent reduc t ion i n dura t ion of s tay among sect ions of pa t i en t s under care , but 93. shows that t h i s i s an important area f o r f u r t h e r study. I t a l so i n d i c a t e s that r e s u l t s obtained from such s tudies must be considered i n the l i g h t of the e f f ec t of the change i n durat ion upon h o s p i t a l i z e d prevalence and on the admission of new cases. I t i s apparent tha t , although r e t e n t i o n ra tes have become somewhat lower, approximately 4 ,000 pa t i en t s are s t i l l being added y e a r l y to that group who w i l l r e -q u i r e eontinuous h o s p i t a l care f o r many years , many u n t i l death. ' T h i s impl i e s that care and treatment of long-term pat i en t s are problems of prime importance, and w i l l remain so f o r many years to come. In s tudies i n which the research sample i s drawn from the h o s p i t a l popu la t ion , the present paper d e l i n -eates some of the requirements i n terms of age, sex, d iagnos i s , l eng th of h o s p i t a l i z a t i o n , and type of i n s t i t u t i o n , i f r e s u l t s are to be genera l i zed to the mental h o s p i t a l populat ion as a whole. They a l so show to what extent i n v e s t i g a t i o n us ing more l i m i t e d samples can be g e n e r a l i z e d . F igures presented i n t h i s study can be used as a measure against which to assess fu ture changes i n the popula t ion under the care of mental i n s t i t u t i o n s . They can a l so he used to c a l c u l a t e p r o b a b i l i t i e s of discharge f o r i n s t i t u t i o n a l i z e d pat i ent s as a whole, or f o r pa t i en t s wi th s p e c i f i c age, sex, and d iagnos t i c c h a r a c t e r i s t i c s . Suggestions have been made regarding DBS t a b u l a -t i o n s requ ired f o r moie s p e c i f i c s tud ie s . v 95. SUMMARY Data on pat i en t s i n Canadian mental i n s t i t u t i o n s were analysed to determine (a) the number and composi-t i o n of pa t i en t s under eare i n I960, and (b) what changes have occurred i n t h i s populat ion between 1955 and I960. S i g n i f i c a n t changes i n age, sex, d i a g n o s t i c , and l ength of stay c h a r a c t e r i s t i c s were found to have taken p l a c e . Retent ion rates had decreased, but were s t i l l h i g h . Data on prevalence was compared with f i n d i n g s of other ep idemio log ica l s t u d i e s . Reasons suggested i n the l i t e r a t u r e f o r the recent trends i n h o s p i t a l i z a t i o n f o r p s y c h i a t r i c i l l n e s s were discussed and compared with f a c t o r s suggested by data from the present study. Advantages and l i m i t a t i o n s of DBS data were d i scussed , and suggestions f o r f u r t h e r study put forward. 96 REFERENCES American P u b l i c Hea l th Assn . Inc . Mental D i s o r d e r s . A  Guide to C o n t r o l Methods. HY, APHA, 1962. ~ , Ash, P . The r e l i a b i l i t y of p s y c h i a t r i c diagnoses . J . Abn. s o c . P s y c h o l . . 1949, 44, 272-276. Blum, R . H . Case I d e n t i f i c a t i o n i n P s y c h i a t r i c Epidemiology; Methods and Problems. The Milbank Memorial Fund q u a r t . , J u l y 1962, 40 ,3 , 253-287: • . •-• - ... . • ' Bremer, J . A s o c i a l p s y c h i a t r i c i n v e s t i g a t i o n of a smal l community i n Northern Norway. Acta p s y c h i a t r i c a et  n e u r o l . Soand. , S u p p l . 62, 1951. B r i l l , H . , and Pat ton , R . E . Ana lys i s of popula t ion r e d u c t i o n i n New York State mental h o s p i t a l s f o r the f i r s t f o u r years of l a r g e - s c a l e therapy wi th psychotropic drugs . Amer. J . P s y c h i a t . , 1959, 11.6, 495-510. Brooke, E i l e e n M. P r o c . Royal Soc. M e d . , 1959, 52, 280-283. Cameron, N . The f u n c t i o n a l psychoses. In J . McV. Hunt (ed.) P e r s o n a l i t y and the behaviour d i s o r d e r s . N .Y . . , Ronald Pres s , 1944, 861-921. • .-. - .... ' Canada, Dominion Bureau of S t a t i s t i c s , C l a s s i f i c a t i o n of Mental D i s o r d e r s . No. 9005-520 (undated) - . _. Popula t ion estimates (age and sex) . S u p p l . to "ref. paper No. 40. Ottawa, Queen's P r i n t e r , 1957. Supplement; Pa t i en t s i n I n s t i t u t i o n s 1955-1957. Ottawa, Queen's P r i n t e r , 1959. _ . Estimated popula t ion by sex and age group f o r  Canada and provinces 1960. Ottawa, Queen's P r i n t e r , 1960. Mental Hea l th S t a t i s t i c s 1960. Ottawa, Queen's P r i n t e r , 1962a. Supplement: P a t i e n t s i n I n s t i t u t i o n s 1960. Ottawa, Queen's P r i n t e r , 1962b. ~ __. 1961 census of Canada. B u l l e t i n 1.2-2. Ottawa, Queen's P r i n e t e r , 1962c. 97. G a r s t a i r s , G . M . and Brown, G.W. A census of p s y c h i a t r i c cases i n two c o n t r a s t i n g communities. J . Ment. S c i . . 1 9 5 8 104, 72-81. " ; Dunham, H.W. Some p e r s i s t e n t problems i n the epidemiology of mental d i s o r d e r s . Amer. J . P s y c h i a t . , 1953, 59, 567 , 5 7 5 , Eaton , J . W . and W e i l , R . J . Cul ture and mental d i s o r d e r s . The Free Pres s , Glencoe , 1 9 W . England, The R e g i s t r a r G e n e r a l . S t a t i s t i c a l review of  England and Wales f o r the three years 1954-1956. London, HMSO, 1960. E s q u i r o l , E . Des maladies mentales. Tome I I . P a r i s , B a i l l i e r e , 1838. """" E y s e n c k , H J . C l a s s i f i c a t i o n and the problem of d i a g n o s i s . In Eysenck, H . J . (ed.) Handb. Aon. P s y c h o l . . London, Pitman, 1960. F a r i s , R . E . L . and Dunham, H.W. Mental d i sorders i n urban areas . Chicago, U . of Chicago Pres s , 1 9 3 9 . F i s h e r , J . W . and C l a r k e , E . E . The d e r i v a t i o n of ra tes of  s eparat ion from mental h o s p i t a l s . Report Ser ies No. 1, Mental Hea l th D i v i s i o n , Dept. of Nat iona l Hea l th and Wel fare . Ottawa, DNHW, 1 9 5 5 . F o u l d s , G . A . The r e l i a b i l i t y of the p s y c h i a t r i c , and the v a l i d i t y of the p s y c h o l o g i c a l , d iagnoses . J . Ment*7 S c i . , 1955, 101, 851 - 8 6 2 . Frumkin,R.M.Occupat ion and major mental d i s o r d e r s . In Rose, A . M . (ed.) Mental h e a l t h and mental d i s o r d e r . N . Y . , Norton, 1955^ ~ — " " " " Goldhamer, H . and M a r s h a l l , A.W. Psychosis and C i v i l i z a t i o n . Glencoe , the Free P r e s s , 1949. ' ~~ Gruenberg, E . M . I n t e r r e l a t i o n s betwwen the s o c i a l environmentHand p s y c h i a t r i c d i s o r d e r s . .1., Milbank Memorial Fund, 1 9 5 3 . H o l l i n g s h e a d , A . B . and R e d l i e h , F . C . S o c i a l c l a s s and  mental i l l n e s s . N . Y . , Wiley & Sons, 1958. 98. Hunt, W . A , , Wi t t son , C , A . and Hunt, E . B . A t h e o r e t i c and p r a c t i c a l a n a l y s i s of the d iagnos t i c process . In Hoch, P . H . and Zubin J . ( eds . ) , Current problems i n  p s y c h i a t r i c d i a g n o s i s . N . Y . , Grune & Stratton,1953. Jaco , E . G . The s o c i a l epidemiology of mental d i s o r d e r s . N . Y . , R u s s e l l Sage Foundat ion, i960 . " Jahoda, M. Current concept of mental h e a l t h . Monograph Ser i e s No. 1, J o i n t Commission on mental i l l n e s s and h e a l t h . N . Y . , B a s i c , 1958. Kramer, M , A d i s c u s s i o n of the concept of inc idence and prevalence as r e l a t e d to ep idemio log i ca l s tudies of mental d i seases . Amer. J . Pub. H e a l t h , J u l y 1957, 47,7 , 826-840. ~ _ _ and P o l l a c k , E . S . Problems i n the i n t e r p r e t a t i o n of trends i n the popula t ion movement of the p u b l i c mental h o s p i t a l s . Amer. J . Pub. H e a l t h . Aug. 1958, 48,8, 1003-1019. — . and Redick , P . E . Studies of the Incidence and prevalence of h o s p i t a l i z e d mental d i s o r d e r s i n the U . S . : Current s tatus and fu ture g o a l s . In Hoch, P . H . and Zubin , J . (eds.) Comparative epidemiology of the mental d i s o r d e r s . N . Y . , Grune & S t r a t t o n , 1961. ~ L a n d i s , G . and Page, J . B . Modern soc i e ty and mental  d i s o r d e r s . N . Y . , P a r r a r & R i n e h a r t , 1938. L e i g h t o n , B . D i s t r i b u t i o n of p s y c h i t r i c symptoms i n a smal l town. Am.er . J . P s y c h i a t . , 1956, 112, 716-726. Lemkau,P, T i e t z e , C . and Cooper, M. Mental hygiene problems i n an urban d i s t r i c t . Ment. Hygiene 1942, 26, 110-119. Lewis , A . Current f i e l d s tudies i n mental d i s o r d e r s i n b r i t a i n . Iff Hoch, P . H . and Zubin , J . (eds) , Comparative epidemiology of the mental d i s o r d e r s . N . Y . , Grune & S t r a t t o n , 1961. Llewel lyn-Thomas, E . The prevalence of p s y c h i a t r i c symptoms w i t h i n an i s l a n d f i s h i n g v i l l a r * Canad.  Med. A s s . J . , 1960, 83, 5. 9 9 . Meehl , P . E . Some ruminations on the v a l i d a t i o n of c l i n i c a l procedures . Canad. J . P s y c h o l . , 1959, 13 ( 2 ) , 102-128. M o r r i s , J . N . Uses of epidemiology. Edinburgh, E . & S. L i v i n g s t one, 1957. N o r r i s , V e r a . Mental. I l l n e s s i n London. London, Chapman and H a l l , 1959. O n t a r i o , Dept . of H e a l t h . 30th Annaal Report , 1960. Pasamanick, B . , Roberts , D . W . , Lemkau, P . , and Krueger , D . E . A survey of mental disease i n an urban p o p u l a t i o n . Amer. J . Pub. H e a l t h , 1947, 4 7 , 923. » _ _ _ » * and . A survey of mental disease i n an urban popu la t ion ; prevalence by race and income. In Pasamanick, B. (ed.) Epidemiology of mental d i s o r d e r . Washington, D . C . , Amer. A s s . f o r the Advancement of S c i . , 1959, Pub. No. 60, 183-202. P l u n k e t t , R . J . and Gordon, J . E . Epidemiology of mental  d i s o r d e r s . N . Y . , Bas i c Books, 1960. Pugh, T . F . and MacMahon, B . E p i d e m i o l o g i c a l f i n d i n g s i n  U . S . mental h o s p i t a l d a t a . Boston, L i t t l e & Brown, 1962. '. McMahon, B . , Pugh, T . P . , and Ipsen, J . E p i d e m i o l o g i c a l  methods. Toronto , L i t t l e , B r o w n , 1 9 ° 0 . Roe, A . I n t e g r a t i o n of p e r s o n a l i t y theory and c l i n i c a l p r a c t i c e . J . Abn. soc . p s y c h o l . , 1949. 4 4 , 36-41. Rose, A . M . and Stub, H . R . Summary of s tudies on the inc idence of mental d i s o r d e r s . In Rose, A . M . (ed.) Mental h e a l t h and mental d i s o r d e r , N.Y.- , Morton, 1955. Roth, W.P. and L u t o n , P . H . The mental h e a l t h program i n Tennessee. Amer. J . P s y c h i a t . . 1942/43, 9 9 , 662-6 7 5 . S r o l e , L . , Langner, T . S . , M i c h a e l , S . T . , Opler , M . K . , and Rennie, T . A . C . Mental h e a l t h i n the metropo l i s : the Midtown Manhatten~"study. V . I . N . Y . , McGraw- ' H i l l , 1962. 100. S tenge l , E . C l a s s i f i c a t i o n of mental d i s o r d e r s . B u l l , of the WHO. 1959, 2 1 , 6 0 1 - 6 6 3 . Krei tman, N . The r e l i a b i l i t y of p s y c h i a t r i c d i a g n o s i s . J . Ment. S c i . . 1961 ,107^76-886. U . S . , Dept . of H e a l t h , Educat ion and Wel fare . The model  r e p o r t i n g area f o r mental h o s p i t a l statisTTIc'sT Wash. , DHEW, 1961. ~~~~ • • '•' -. Hea l th educat ion and welfare t rends , 1961 e d i t i o n , , annual s u p p l . to the monthly H e a l t h , Educat ion and Welfare i n d i c a t o r s . Wash., DHEW, 1961. APPENDIX A Canada. Pat i ent s i n i n s t i t u t i o n s , December 31 Year Number Rate per 1 0 0 , 0 0 0 1932 3 3 , 2 9 0 317 1936 3 9 , 8 3 3 364 1937 4 1 , 6 7 7 377 1938 4 2 , 6 8 7 383 1939 ' 4 3 , 2 7 5 384 1940 4 4 , 1 6 3 388 1941 45 , 135 392 1942 4 5 , 9 3 7 394 1943 4 6 , 6 3 1 395 1944 4 7 , 2 7 9 396 1945 4 8 , 0 5 6 398 1946 49 , 1 6 3 400 1947 5 0 , 2 0 3 400 1948 5 1 , 0 5 0 398 1949 5 2 , 6 6 3 392 1950 5 3 , 9 5 7 394 1951 5 5 , 3 9 5 395 1952 57 ,621 399 1953 6 0 , 5 7 4 408 1954 6 2 , 3 2 3 408 1955 6 3 , 6 8 3 406 1956 6 5 , 1 0 7 405 1957 6 5 , 7 6 8 396 1958 6 6 , 2 6 3 389 1959 6 6 , 4 3 3 381 1960 6 6 , 3 3 9 3 7 2 " (Canada, DBS, 196OA) 1 0 2 . Appendix B United States . Resident pat i ent s i n mental h o s p i t a l s .  Number and r a t i o per 100,, 000 Year Number Rat io per 100,000 1903 149,596 242.0 1909 179,600 266.2 1922 267,261 309. f 1933 394,347 383.9 1935 421,102 399.9 1940 483,506 437.8 1941 493,814 448.0 1942 500,383 458.1 1943 500,985 476.9 1944 507,482 490.0 1945 519,681 500.8 1946 528,965 463.8 1947 540,958 463.9 1948 556,387 471.6 1949 566,101 475.0 1950 577,755 479.1 1951 584,427 486.3 1952 596,384 491.0 1953 608,249 494.4 1954 621,642 497.7 1955 632,551 498.7 1956 626,567 487.3 1957 620,544 472.9 1958 620,289 464.I 1959 616,964 453.4 Hea l th Educat ion and Welfare Trends, 1961 E d i t i o n , Annual Supplement to the Monthly H e a l t h , Educat ion , and Welfare I n d i c a t o r s , U . S . Department of H e a l t h , Educa t ion , and Welfare , O f f i c e of the Secretary . Page 27. 103 APPENDIX G England and Wales. Mental H o s p i t a l s . Trends i n estimated ra tes per 100.000 home popu la t ion on December 31. 1951-56 Year Sex Rat io per 100,000 1951 M 289 P 362 : 1952 M 290 P 365 , 1953 M 294 f 368 1954 M 296 P 370 1955 M 292 P 366 1956 M 288 P 361 (England, The R e g i s t r a r G e n e r a l , 1960, p . 1 4 ) . 104. APPENDIX D , D i r e c t o r y of p s y c h i a t r i c f a c i l i t i e s . 1960 P s y c h i a t r i c L o c a t i o n Name t bed capac i ty NEWFOUNDLAND S t . John's H o s p i t a l f o r mental and nervous 8 3 5 diseases P . E . I . -Charbttetown R i v e r s i d e hosp. and H i l l s b o r o u g h 3 7 7 General Hosp. NOVA SCOTIA Bridgetown Annapol is County H o s p . * 60 Cole Harbour H a l i f a x County Hosp. * 500 Dartmouth Nova S c o t i a Hosp. 6 5 0 H a l i f a x Camp H i l l , H o s p 2 2 H a l i f a x Mental Hosp. * 3 3 0 V i c t o r i a General H o s p . * * 2 4 Pugwash Cumberland County Home 2 0 0 S t e l l a r t o n P i c t o u County H o s p . * 1 6 0 Sydney R i v e r Gape Breton Hosp. * 5 0 0 Truro N . S . T r a i n i n g School 1 6 8 W a t e r v i l l e Kings County Hosp * 1 0 5 N . B . Campbellton P r o v i n c i a l Hosp 600 Lancas ter Lancaster Hosp 2 5 P r o v i n c i a l Hosp. 1 ,350 Mono ton Mono ton Hosp. * 11 S t . John S t . John General Hosp. * 2 7 QUE. A u s t i n C e c i l Memorial Home * * 225 B a i e - S t . - P a u l H o p i t a l Ste-Anne 1 , 1 5 0 Beaconsf ie ld A l l a n e r o f t * * 14 Chicout imi H o t e l - D i e u S t . - V a l l i e r 5 0 105. D i s r a e l i Foyer Ste-Luce * * 164 Gamelin H o p i t a l St -Jean-deDieu 5 , 6 9 5 J o l i e t t e H o p i t a l S t -Ghar le s de J o l i e t t e 1 , 3 3 3 Lae Etchemin Sanatorium Begin 2 2 0 L e v i s Ho*e l -Dieu de L e v i s 1 0 Masta i C l i n i q u e Roy-Rousseau 1 6 0 H o p i t a l St -Michel -Archange 5 , 0 0 0 Sanatorium M a s t a i * * 3 3 M o n t - J o l i Sanatorium St-Georges * * 240 Montreal A l l a n Memorial I n s t i t u t e * * 128 C e n t r e d 1 O r i e n t a t i o n * * 21 H o p i t a l de Bordeaux 700 H o p i t a l Maisonneuve 3 9 H o p i t a l Notre-Dame * * 26 H o p i t a l Ste-Jeanne d 'Arc * * 24 H o p i t a l S t e -Jus t ine * * 1 2 H 6 t e l - D i e u de Montreal*-** 4 1 I n s t i t u t A l b e r t Prevost 145 Jewish General Hosp. * * 1 6 Montreal Ch i ldrens Hosp. *.* 14 Montreal General Hosp. * * 3 0 Queen Mary Veterans' H o s p . * * 5 0 H o p i t a l S t -Beno i t 1 4 0 Quebec H o p i t a l de 1 ' E n f a n t Jesus** 2 0 H o p i t a l de St-Sacrement * * 2 0 H 6 p i t a l S t -Foy . * * 2 5 Hotel-Dieu-De-Sacre'-Coeur-de-J^sus 275 R i v i e r e - d e s - P r a i r i e s H o p i t a l Mont-Providence 1 , 1 0 0 Roberval H o p i t a l S t e - E l i z a b e t h 7 5 0 Ste-Anne-de-Bel levue Ste-Anne's H o s p i t a l 4 9 8 St -Ferdinand H o p i t a l S t - J u l i e h 1 , 4 6 3 S t - H i l a i r e Foyer Dieppe * * 1 2 0 Sherbrooke .Hop. General S t - V i n c e n t - d e - P a u l * * 1 0 T r o i s R i v i e r e s H o p i t a l Ste-Marie * * 1 2 Verdun Verdun Protes tant Hosp. 1 , 5 7 4 106. ONT. Aurora The Ont. Hosp. 250 Brant ford Brant ford General Hosp. 24 B r o c k v i l l e The Ont. Hosp 1,544 Cobourg The Ont. Hosp. 320 Guelph Horaewood Sanatarium 225 Hamilton The Ont. Hosp. 1,4,65 Kings ton I n s t , of Psychotherapy 14 Kings ton General Hosp. 40 The Ont. Hosp. 1,445 Sunnyside C h i l d r e n ' s V i l l a g e * * 1 4 London S t . Joseph's Hosp. 30 The Ont. Hosp. \ 1,100 V i c t o r i a Hosp. 52 Westminster Hosp. 873 Newmarket Warrendale School f o r G i r l s * * 1 8 New Toronto The Ont. Hosp. 1 , 1 0 0 North Bay The Ont. Hosp. 764 O r i l l i a The Ont. Hosp. School 2 ,400 Ottawa Ottawa C i v i c Hosp. 40 Ottawa Gen Hosp. 30 Protes tant C h i l d r e n ' s V i l l a g e * * 13 Owen Sound General and Marine Hosp. * * 20 P l a i n f i e l d Ont. Home f o r Menta l ly Retarded 43 Pat i en t s * * Penetanguishene The Ont. Hosp. 600 Por t A r t h u r The Ont. Hosp. 764 S t . C a t h e r i n e ' s S t . Catherines General Hosp. 24 S t . Thomas The Ont. Hosp. 1,822 Smith P a l l s The Ont. Hosp. School 2,038 Sudbury Sudbury General Hosp. 33 This t l e town The Ont. Hosp. 75 Toronto S t . M i c h a e l ' s Hosp. 30 Sunnybrook Hosp. 56 Sunnyside P r i v a t e Hosp. 9 107. Alcoho l i sm and Drug A d d i c t i o n Research 15 Foundation * The Ont. Hosp. 850 Wel les l ey Hosp. 40 Toronto P s y c h i a t r i c Hosp. 64 Toronto Western Hosp. 35 Women's Col lege Hosp. 20 Vine land Bethesda Home 85 Whitby The Ont. Hosp. 1 ,574 Wil lowdale Willowdale P r i v a t e Hosp. 9 Windsor M e t r o p o l i t a n General Hosp. 30 Woodstock The Ont. Hosp. 1 ,518 MAN. Brandon Hosp. f o r Mental Diseases 1 ,350 Portage l a P r a i r i e Man. School f o r Menta l ly 1,014 Defec t ive Persons. S t . Boniface S t . Boniface Hosp. 24 S t . V i t a l S t . Boniface Sasatorium * * 58 S e l k i r k Hosp. f o r Mental Diseases 1,005 Winnipeg C h i l d r e n ' s Home of Winnipeg * * 10 Deer Lodge Hosp. 60 Winnipeg Psychopathic Hosp. 56 M i s e r i c o r d i a Hosp. 17 Winnipeg General Hosp. 86 SASK. Moose Jaw Moose Jaw Union Hosp. 21 Sask. T r a i n i n g School 1 ,109 N . B a t t l e f o r d Sask. Hosp. 1 ,120 Regina Regina Gen. Hosp. Munroe Wing 34 Regina Grey Nuns' Hosp. * * 11 Saskatoon U n i v e r s i t y Hosp. 39 Weyburn Sask. Hosp. 950 ALTA. Calgary Calgary General Hosp. 22 108. Colone l Be lcher Hosp. 15 Camrose Rosehaven Home f o r the Aged * 510 Claresholm P r o v i n c i a l A u x i l i a r y Mental Hosp. 112 Edmonton P r o v i n c i a l Mental I n s t i t u t e 1,600 U n i v e r s i t y of A l b e r t a Hosp. * 68 Ponoka P r o v i n c i a l Mental Hosp. 1,077 Raymond P r o v i n c i a l A u x i l i a r y Mental Hosp. 134 Red Deer Beerhome 1,050 P r o v i n c i a l T r a i n i n g School 792 Linden House 28 B . C . C o l q u i t z P r o v i n c i a l Mental Hosp. 222 Essondale Crease C l i n i c of P s y c h o l o g i c a l 228 Medicine P r o v i n c i a l Mental Hosp. 2,662 Vai leyview Hosp. 780 New Westminster Hollywood Hosp. 73 Woodlands School 1,473 Terrace Skeenaview Hosp. 300 T r a n q u i l l e T r a n q u i l l e School 150 Vancouver Shaughnessy Hosp. 42 Vancouver General Hosp. 40 Vernon B e l l v i e w Hosp. 239 V i c t o r i a Royal J u b i l e e Hosp. 24 * Did not send i n morbid i ty cards f o r 1960. *'* Did not repor t i n any form i n 1960. (Canada, DBS, 1960a) 109 APPENDIX E Diagnos t i c categor ies used i n the present t h e s i s . D e f i n i t i o n s and common a l t e r n a t i v e terms SCHIZOPHRENIA A . Schizophrenic d i s o r d e r s . In t h i s group of psychot ic reac t ions there i s disturbance i n r e a l i t y r e l a t i o n -ships and concept formations wi th dis turbances of a f f e c t , behaviour, and i n t e l l e c t i n v a r y i n g degrees and mixtures . The d i sorders are marked by a s trong tendency to r e t r e a t from r e a l i t y , by emotional disharmony, unpredic table d is turbances i n stream of thought, aggressive behaviour and, i n some, by d e t e r i o r a t i o n . 1 . Simple type . These reac t ions d i s p l a y some de fec t ive i n t e r e s t wi th gradual development of an apathet ic s tate and i n d i f f e r e n c e but without any other s t r i k i n g l y p e c u l a i r behaviour and without express ion of de lus ions of h a l l u c i n a t i o n s . Simple sch izophrenia i s charac ter i zed by i n c r e a s i n g s e v e r i t y of symptoms over a long per iod of time wi th some apparent mental d e t e r i o r a t i o n . A l s o : primary dementia dementia simplex 110. primary sch izophren ia simple sch izophrenia Hebephrenic type . These reac t ions are charac -t e r i z e d hy a shallow a f f e c t and u n p r e d i c t a b l e , s i l l y behaviour which appears i n c o n s i s t e n t wi th the ideas expressed. Neologisms, b i z a r r e i d e a s , and co in ing of words or phrases are common. H a l l u c i n a t i o n s and de lus ions are a l so qu i te common, and r e g r e s s i o n f a i r y r a p i d . A l s o : dementia, paraphrenic hebephrenia paraphrenia Catatonic type . These r e a c t i o n s are u s u a l l y charac ter i zed by conspicuous a l t e r n a t i n g s tates of marked genera l i n h i b i t i o n (s tupor, negat iv i sm, and waxy f l e x i b i l i t y ) and ex-cess ive motor a c t i v i t y and excitement. The l a t t e r shows marked impulsiveness and b e l l i g e r e n c e . In r e t r o s p e c t the sensorium i s u s u a l l y found to have remained c l e a r . Re-g r e s s i o n to a vegetat ive s tate may occur . A l s o : c a t a t o n i a Paranoid type . This group i s charac ter i zed by prominence of d e l u s i o n s , g e n e r a l l y ideas of g r a n d i o s i t y and p e r s e c u t i o n . Consis tent emotional r e a c t i o n of aggresivemess due to 111. delus ions of persecut ion i s very f requent . The p a t i e n t f r e q u e n t l y responds to h a l l u c i n a t i o n s * which occur i n great v a r i e t y . Excess ive r e l i g i o s i t y or vast d e l u s i o n a l systems of omnipotence, gen ius , and s p e c i a l a b i l i t y are a l s o . f o u n d . The systematized paranoid hypo-chondr iaca l s ta tes are inc luded i n t h i s group. 5 . Acute sch izophrenic r e a c t i o n . Acute u n d i f f e r e n t i a t e d eases of schizophrenic r e a c t i o n . The symptoms u s u a l l y d isappear i n a few weeks but tend to r e c u r . I f the c o n d i t i o n progresses , i t u s u a l l y f a l l s i n t o one of the more c l e a r l y def ined types . 6. Latent s c h i z o p h r e n i a . Chronie u n d i f f e r e n t i a t e d cases , u s u a l l y r e f e r r e d to as l a t e n t , i n c i p i e n t , or prepsychot ic s c h i z o p h r e n i a . A l s o : Schizophrenic r e s i d u a l s ta te , (Restzustand) 7 . S o h i z o - a f f e c t i v e psychos i s . Pat i ent s e x h i b i t a mixture of schizophrenic and a f f e c t i v e r e a c t i o n s . Includes a f f e c t i v e reac t ions wi th schizophrenic t h i n k i n g or b i z a r r e behaviour, a l so cases where the pre-psyehot ic p e r s o n a l i t y i s i n c o n s i s t e n t wi th the present ing psychot ic symptoms. A l s o : Schizothymia 112 8 . Other and u n s p e c i f i e d . Cases which cannot be c l a s s i f i e d i n the previous groups . A l s o : Autism Dementia praecox Juven i l e s c h i z . B . Paranoia and paranoid s t a t e s . Pa t i en t s show f i x e d susp ic ions and l o g i c a l l y e laborated ideas of per secu t ion , g e n e r a l l y a r e s u l t of m i s i n t e r p r e t a t i o n of an a c t u a l occurrence . The emotional r e a c t i o n s are u s u a l l y cons i s t ent wi th the i d e a s . H a l l u c i -nat ions are u s u a l l y not present . The pa t i en t s are prone to take a c t i o n against t h e i r suspected persecutors . The abnormal ideas are f requent ly i s o l a t e d from the p a t i e n t ' s normal ideas and may be d i f f i c u l t to e l i c i t . I I . AFFECTIVE PSYCHOSES A . Manic depress ive r e a c t i o n . The pa t i en t s are charac ter i zed by marked changes i n mood and a tendency to remiss ion and recurrence . In a d d i t i o n to the a f f e c t i v e changes, i l l u s i o n s , d e l u s i o n s , and h a l l u c i n a t i o n s by occur . 1 . Manic and c i r c u l a r . Character ized by e l a t i o n or i r r i t a b i l i t y wi th over ta lkat iveness or f l i g h t of ideas and increased motor a c t i v i t y . 113 Occas iona l ly b r i e f periods of depress ion may occur . A l s o : A l t e r n a t i n g i n s a n i t y C i r c u l a r i n s a n i t y Cyclothymia Hypomania . Ag i ta ted m.d. r e a c t i o n . 2. , Depress ive . Pat i ent s wi th marked depress ion of mood and with ,mental and motor r e t a r d a t i o n . A g i t a t i o n , apprehension and anxiety may a l s o be present . Includes perprexed and stuporous r e a c t i o n s . 3. Other. Gases wi th mixtures of 1 and 2 where i t i s d i f f i c u l t to say which phase predominates. I n v o l u t i o n a l me lancho l ia . This group inc ludes psychot ic r e a c t i o n s charac ter i zed by depress ion dur ing the i n v o l u t i o n a l p e r i o d , u s u a l l y o c c u r r i n g i n p a t i e n t s of the compulsive p e r s o n a l i t y type and g e n e r a l l y without previous h i s t o r y of manic-depress ive r e a c t i o n . These r e a c t i o n s tend to have a long course , and may .be manifested by worry, i n t r a c t a b i l i t y , ensomnia, g u i l t , anx ie ty , a g i t a t i o n , d e l u s i o n a l i d e a s , and somatic compla ints . A g i t a t i o n and depress ion are common i n many p a t i e n t s , whi le others present a paranoid i d e a . Somatic p r e -occupation to a d e l u s i o n a l degree i s common. 1 1 4 . A l s o : c l i m a c t e r i c melanchol ia Menopausal melanchol ia I I I SENILE PSYCHOSES A . S e n i l e psychos i s . Includes those who are having a-psychot ic r e a c t i o n and e x h i b i t such symptoms as exaggerat ion of normal s e n i l e mental changes, marked l o s s of memory of recent event, i n a b i l i t y to concentrate , m i s i d e n t i f i c a t i o n , f a b r i c a t i o n and f a u l t y o r i e n t a t i o n . Determinat ion , i r r i t a b i l i t y , confus ion , de lus ions or depress ion or excitement may predominate. D e t e r i o r a t i o n may be minimal or i t may progress to a s tate of vegetat ive ex i s t ence . A l s o : C e r e b r a l atrophy or degeneration w i th psychosis at ages 6 5 or over . Dementia of o ld age. B . P r e s e n i l e psychoses. Those who show severe p r o -gre s s ive b r a i n syndrome at a r e l a t i v e l y e a r l y age. There i s a gradua l l o s s of memory, changes i n p e r c e p t i o n , changes i n personal h a b i t s , and d i s -o r i e n t a t i o n . I n t e l l e c t u a l impairment appears f a i r y e a r l y , whereas l o s s of s leep and d e b i l i t y are of ten l a t e r symptoms. B e t e r i o r a t i o n i s a prominent 115 f e a t u r e . Onset u s u a l l y occurs between 40 and 60, but e a r l i e r cases have been r e p o r t e d . Included are P i c k ' s d i sease , Alzhe imer 's d i sease , and d i f f u s e c o n v o l u t i o n a l atrophy. A l s o : Circumscribed atrophy of b r a i n , P r e s e n i l e s c l e r o s i s . C . Psychosis w i th c e r e b r a l a r t e r i o s c l e r o s i s . Chronic progress ive mental d is turbances occurr ing i n connect ion wi th c e r e b r a l a r t e r i o s c l e r o s i s . The symptoms a r e : d i f f i c u l t y i n sustained c e r e -b r a t i o n , confus ion , l o s s of memory, and genera l impairment of the i n t e l l e c t i n v a r y i n g degrees. P r e s e r v a t i o n of the p e r s o n a l i t y and i n s i g h t i n t o the defects may be present i n e a r l y or mi ld cases , but i n severe c i r c u l a t o r y d is turbance wi th c e r e b r a l d e s t r u c t i o n , mental enfeeblement may be f a r advanced. Also* Organic b r a i n disease wi th psychosis IV. ALCOHOLIC PSYCHOSIS. Gases wi th b r a i n damage ranging from very mi ld to very severe and r e s u l t i n g from the use of a l c o h o l , or where one can reasonably assume that a l c o h o l i s the main e t i o l o g i c a l f a c t o r . This 116. inc ludes p a t h o l o g i c a l i n t o x i c a t i o n . A l s o : Delerium tremens A l c o h o l i c h a l l u c i n o s i s K o r s a k o f f ' s syndrome OTHER PSYCHOSES A . S y p h i l i s of c e n t r a l nervous system wi th psychosis 1. Juven i l e n e u r o s y p h i l i s . Includes dementia p a r a l y t i c a j u v e n a l i s , j u v e n i l e tabes , and j u v e n i l e tabopares i s . 2. Tabes d o r s a l i s wi th psychosis A l s o : Spas t i c a t a x i a Charcot ' s j o i n t d i s . Tabet ic ar thropathy . 3 . General P a r a l y s i s of insane ( s y p h i l i t i c meningo-encepha l i t i s ) . Cases showing r a p i d l y or s lowly progress ive organic i n t e l l e c t u a l and emotional defects with p h y s i c a l s igns and symptoms of parenchymatous s y p h i l i s of the nervous system and completely p o s i t i v e sero logy , i n c l u d i n g the p a r e t i c go ld curve . OTHER PSYCHOSES A . Late e f f e c t s of acute i n f e c t i o u s e n c e p h a l i t i s Includes p o s t e n c e p h a l i t i c Parkinsonian syndrome 1 1 7 . B. Psychosis of other demonstrable e t i o l o g y . These psychoses r e s u l t from r e l a t i v e l y permanent and i r r e v e r s i b l e , d i f f u s e impairment of cerebral t i s s u e f u n c t i o n . They are c l a s s i f i e d according to the cause of impairment of b r a i n f u n c t i o n . There may be varying degrees of progress, but some disturbance of memory, judgement, o r i e n t a t i o n , comprehension, and a f f e c t p e r s i s t permanently. 1. Resulting from b r a i n tumor 2. Resulting from epilepsy and other convulsive  d i s o r d e r s. Cases which show psychosis i n connection with i d i o p a t h i c epilepsy. This includes e p i l e p t i c d e t e r i o r a t i o n , e p i l e p t i c clouded states and e p i l e p t i c confusion. Most show a gradual development of mental dul l n e s s , Slowness of a s s o c i a t i n g and impairment of memory and other i n t e l l e c t u a l functions as w e l l as apathy. 3 . Secondary or due to i n f e c t i v e or p a r a s i t i c  diseases. Only those due to severe general systemic i n f e c t i o n s , e.g., pneumonia or typhoid. 4. Secondary or due to a l l e r g i c , endocrine, metabolic and n u t r i t i o n a l diseases. 5. Secondary or due to diseases of the blood, blood-forming organs and c i r c u l a t o r y system. 118. Chronic organic mental d is turbances o c c u r r i n g i n connect ion wi th c i r c u l a t o r y disturbance other than c e r e b r a l a r t e r i o s c l e r o s i s . 6. Secondary or due to diseases of the nervous  system or sense organs. 7. Secondary or due to drugs and other exogenous  poisons . 8. Secondary or due to a c c i d e n t s , v i o l e n c e , or  othesfr trauma. Cases of acute psychosis that occur immediately a f t e r i n j u r y of the head through e x t e r n a l v io l ence i n c l u d i n g o p e r a t i o n . 9. Secondary or due to other d i seases . G . Other and unspec i f i ed psychoses. Those cases that show abnormal r e a c t i o n s e s s e n t i a l l y of an emotional and v o l i t i o n a l nature apparently on the bas i s of c o n s t i t u t i o n a l d e f e c t , which cannot be c l a s s i f i e d under the above groups . NEUROSES. These d i s o r d e r s u s u a l l y present evidence of p e r i o d i c or continuous maladjustment of v a r y i n g degrees from e a r l y l i f e . There i s usual ly n e i t h e r gross d i s t o r t i o n of r e a l i t y nor a marked d i s o r g a n i -z a t i o n of the p e r s o n a l i t y . The main features are anxie ty and t ens ion , e i t h e r d i r e c t l y f e l t and expressed, or unconsciously and automat ica l ly c o n t r o l l e d by var ious p s y c h o l o g i c a l defence 1 1 9 . mechanisms. S tress may b r i n g about acute symptomatic express ion of such d i s o r d e r s by var ious r e a c t i o n s . 1 . Anxiety r e a c t i o n . Pat i en t s experience more or l e s s continuous d i f f u s e anxiety and apprehension. Acute panic and acute t ens ion are very common, and emotional t ens ion i s h i g h . 2. H y s t e r i c a l r e a c t i o n . Anxiety i s converted i n t o f u n c t i o n a l symptoms and expressed i n organs or par t s of the body, u s u a l l y those that are mainly under vo luntary c o n t r o l . 3. Phobic r e a c t i o n . The anxiety i s attached to some s p e c i f i c f e a r . The pat i ent t r i e s to avoid s p e c i f i c objects or s i t u a t i o n s i n the e f f o r t to overcome h i s a n x i e t y . 4 . Obsessive-compulsive r e a c t i o n . Character ized by obsessive ruminat ion or preoccupat ion wi th c e r t a i n ideas and by r e p e t i t i v e impulses to perform c e r t a i n a c t s . The acts may be recognized by the pa t i en t as unreasonable, but the impulse to perform them cannot be c o n t r o l l e d . 5. Neurot ic -depress ive r e a c t i o n . Pat ients show depress ion i n r e a c t i o n to obvious ex terna l causes. React ion i s of a more marked degree and longer d u r a t i o n than normal . Anxiety i s to some extent replaced by depress ion or s e l f - d e p r e c a t i o n . Pee l ings of g u i l t are common. 120. Psyehoneurosis w i th somatic symptoms (somatizat ion  r eac t ion ) a f f e c t i n g c i r c u l a t o r y system. There i s p e r s i s t e n t attachment to the c a r d i o v a s c u l a r system. Includes f u n c t i o n a l heart d i sease . A l s o : Cardiac as thenia Da Costa ' s syndrome E f f o r t syndrome (psychogenic) Angina Hypertension Migraine Somatizat ion r e a c t i o n a f f e e t i n g d ige s t i ve system Includes psychogenic mucous c o l i t i s , f u n c t i o n a l d i a r r h o e a , s p a s t i c c o l o n , f u n c t i o n a l syspeps ia , and c y c l i c a l vomi t ing , aerop#agy, and g lobus . Somatizat ion r e a c t i o n a f f e c t i n g other systems. Other psychoneurotic d i sorders a . Hypochondriacal r e a c t i o n . Pat i ent s show an e s s e n t i a l l y obsessive preoccupat ion wi th the s tate o£ t h e i r h e a l t h or of var ious organs, and a v a r i e t y of somatic compla ints , which are not r e l i e v e d when absence of p a t h o l o g i c a l disease i s demonstrated, b . D e p e r s o n a l i z a t i o n . There i s a l o s s of a f f e c t i v e response wi th a f e e l i n g that every th ing , i n c l u d i n g the p a t i e n t , i s u n r e a l . Stupor , fugues, and amnesias may occur . 121 . c." Occupational neuroses. Used where the occupat ion i s a causat ive f a c t o r i n the neuros i s . d . Asthenic r e a c t i o n . The pa t i en t complains of motor and mental f a t i g u e , dimished power of concentrat ion and pressure i n the head, s c a l p , neck, or s p i n e . e. Mixed psychoneurotic d i s o r d e r s , f . Other and unspec i f i ed psychoneurotic d i s o r d e r s V I I . ALCOHOLISM. A . Acute . Cases wi th temporary dis turbance caused by excessive use of a l c o h o l . B . Chronic Those cases where there i s repeated and long continued use of a l c o h o l , i . e . , a d d i c t i o n to a l c o h o l without recognizable under ly ing d i s o r d e r . MENTAL DEFICIENCY  I d i o c y . Severe mental subnormal i ty . I m b e c i l i t y . Moderate mental subnormal i ty . Moron. M i l d mental subnormal i ty . B o r d e r l i n e i n t e l l i g e n c e . Backwardness. Mongolism. Character ized by anomalies of the s k u l l , eyes, and tongue. Other and unspec i f i ed types . Includes amaurotic f a m i l y i d i o c y , phenylpyruvic o l i g o p h r e n i a , and Tay-Sachs d i sease . V I I I . A . B . C . D. E . F . 122. 12. OTHER CHARACTER AMD BEHAVIOUR DISORDERS A . P a t h o l o g i c a l p e r s o n a l i t y 1... Sch izo id p e r s o n a l i t y . Pa t i en t s show shyness, s e n s i t i v e n e s s , see lus iveness , and l a c k of s o c i a b i l i t y , of ten associated with e c c e n t r i c i t y . 2. Paranoid p e r s o n a l i t y . Pa t i en t s show suspicous-ness , envy, j ea lousy , and d i f f i c u l t y i n mainta in ing personal r e l a t i o n s h i p s . 3. Cyclothymic p e r s o n a l i t y . The pat i ent s e x h i b i t a l t e r n a t i n g moods of e l a t i o n and sadness. 4. Inadequate p e r s o n a l i t y . Pat i ent s are unable to adapt to s p e c i f i c s i t u a t i o n s , such as marriage , home l i f e , or occupat ion . 5 . A n t i s o c i a l p e r s o n a l i t y . Pa t i en t s show emotional immaturity or c h i l d i s h n e s s wi th marked defects of judgement. There i s no evidence of l e a r n i n g by experience . Impulsive r e a c t i o n , changes i n mood, and r a t i o n a l i z a t i o n are common. 6. A s o c i a l p e r s o n a l i t y . These cases often develop i n an abnormal s o c i a l environment. Other than i n a b i l i t y to apprec iate norms of behaviour the pat i en t s show l i t t l e p e r s o n a l i t y d e v i a t i o n . 7. Sexual d e v i a t i o n . Where not symptomatic of some other p s y c h i a t r i c d i s o r d e r . 123 B . Immature p e r s o n a l i t y . 1 . Emotional i n s t a b i l i t y . These pat i ent s show undue excitement and become i n e f f e c t i v e when faced wi th even minor s t r e s s s i t u a t i o n s . 2 . Passive dependency. The pat i en t s are dependent, he lp lessness and i n d e c i s i o n s being the predominant c h a r a c t e r i s t i c s . 3 . Aggress iveness . Character ized by temper tantrums, i r r i t a b i l i t y , and des t ruc t ive behaviour. 4. E n u r e s i s . Where i t i s the predominant symptom, of the p e r s o n a l i t y d i s o r d e r . C . Brug a d d i c t i o n . Other than a l a h o l i s m . , D . Primary chi ldhood behaviour d i s o r d e r s . C h i l d r e n under 16 w i th p e r s o n a l i t y d i s o r d e r s not elsewhere c l a s s i f i a b l e . E . Other and unspec i f i ed c h a r a c t e r , behaviour and  i n t e l l i g e n c e d i s o r d e r s . Where the s p e c i f i c symptom i s the outstanding f ea ture of the case . 1 . S p e c i f i c l e a r n i n g defects 2 . Stammering and s t u t t e r i n g , non-organic . 3 . Other speech impediments, non-organic . 4. Acute s i t u a t i o n a l maladjustment. Trans ient cond i t ions due to s t r e s s . 1 2 4 . X . OTHER DIAGNOSES A . S y p h i l i s without psychosis B . Not elsewhere c l a s s i f i e d C . Mental ohservat ion without need f o r f u r t h e r medica l care . 1 2 5 . APPENDIX ff Canada, P o p u l a t i o n , i n thousands, by sex and age group. Sex Year Age group 20 2 0 - 5 9 60+ Male 1955 3 , 1 4 7 . 2 3 , 9 3 6 . 8 8 7 4 . 6 1960 3 , 7 5 3 . 3 4 , 3 4 1 . 1 9 3 3 . 0 1961 3 , 8 9 5 . 1 4 , 3 5 7 . 1 9 6 6 . 7 Pemale 1955 3 , 0 3 0 . 0 3 , 8 4 7 . 3 8 6 2 . 1 1960 3 , 5 9 8 . 0 4 , 2 1 6 . 9 9 7 1 . 6 1961 3 , 7 2 9 . 3 4 , 2 8 1 . 9 1 ,008 .1 Both 1955 6 , 1 7 7 . 2 7 , 7 8 4 . 1 1 , 7 3 6 . 7 i 9 6 0 7 , 3 5 1 . 3 8 , 5 5 8 . 0 1 , 9 0 4 . 7 1961 7 , 6 2 4 . 5 8 , 6 3 9 . 0 1 , 9 7 4 . 8 1955 (Canada, DBS, 1957) 1960 (Canada, DBS, 1960c) 1961 (Canada, DBS, 1962) 126 APPENDIX G O n t a r i o . Pat i ent s i n res idence i n h o s p i t a l s and h o s p i t a l  s c h o o l s . 1937-1960. Number and r a t i o per 100.. < Year Menta l ly i l l Menta l ly d e f i c i e n t Number Rat io Number Rat io 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 0,104 0,473 0,474 0,384 0,594 0,688 0,734 0,772 0,830 1.047 1 ,314 1 ,813 1,910 2 , 0 6 3 2,322 2,620 2,942 3,327 3,461 3,600 3,794 3,711 3,733 3,619 278 285 282 277 279 275 274 272 271 270 271 276 272 270 268 264 262 261 255 252 245 23,6 232 224 3 , 3 8 3 3 , 5 8 3 3 , 7 7 3 3 , 9 3 0 3 , 8 9 2 4 ,040 4 , 0 9 2 4 , 1 5 0 4 ,243 4 ,424 4 ,606 4 , 6 4 6 4 , 8 4 4 5,177 5 , 5 3 0 5 ,773 6 ,015 6 ,254 6r626 7 , 0 0 3 7 ,226 7 , 4 1 9 7 , 7 4 7 8 ,131 93 98 102 105 103 104 105 105 106 108 110 109 111 116 120 120 122 122 126 129 129 128 130 133 (Ontario Dept . of H e a l t h , i 9 6 0 , p.78) 127. APPENDIX H Canada. Pa t i en t s on books by age, sex, and d iagnos t i c  group. Age- and s e x - s p e c i f i c frequencies Sex Diagnos t i c group Age group Year < 2 0 2 0 - 5 9 60+ Male A l l 1955 268 1 7 , 6 3 8 8 , 3 6 7 Psychoses i 9 6 0 374 16 ,170 8 ,540 Neuroses 1955 17 449 126 1960 17 514 192 Mental 1955 4 , 9 0 3 5,46.1 . 629 D e f i c i e n c y 1960 5,1-94 6 ,006 711 Other 1955 279 1 ,554 302 Diagnoses I960 569 2 , 0 2 3 , 581 Pemale A l l 1955 242 14 ,865 8 , 9 4 4 Psychoses 1960 290 13,1.71 8,921 Neuroses 1955 32 779 218 1960 48 1 , 0 3 9 315 Mental 1955 3 , 4 4 6 4 , 7 9 3 662 Def i c i ency 1960 •3,644 5 , 1 7 8 668 Other 1955 332 1,126 191 Diagnoses 1960 525 1,262 413 128. APPENDIX I Panada. Pat i en t s on books, by age, sex and l ength of  s t a y . Age- and s e x - s p e c i f i o f r e q u e n c i e s . Sex Age Year Length of s tay ( i n years) <1 1 -2 ' 2-5 \ ; 5+ Male <• 20 1955 1 ,219 892 1,784 1 ,531 1960 1,359 954 1,543 2 , 3 2 9 20-59 1955 4,020 1,771 3,623 1 6 , 1 8 3 1960 5,515 .1,44:1 2,724: 1 5 , 1 9 7 60+ 1955 1,304 661 1,278 6,270 1960 1,822 716 1,144 6,440 Pemale <20 1955 876 668 1,208 1 ,227 i960 1,055 619 ' 854" 1,589 20-59 1955 4,226 1 ,492 3,164 13 ,245 1960 5,588 1,462 2,184 11,651 60+ 1955 1,526 721 1,444 6,435 196O 2,031 818 1,358 6,287 129. APPENDIX J Canada. Pa t i en t s on books, by sex, d iagnos t i c group,  and l ength of s tay . S e x - s p e c i f i c frequenc ies Sex Diagnos t i c Group Year Length of stay ( i n years) : 1 . 1-2 2-5 Hale A l l 1955 4,468 2,069 4,067 17,037 Psychoses 1960 5,389 1,717 3,027 15,129 Neuroses 1955 347 50 66 160 i960 450 62 66 157 Mental 1955 1,053 932 2,142 6,450 D e f i c i e n c y 1960 1,357 863 1,571 7,406 Other 1955 860 339 543 1,115 Diagnoses 1960 1,455 471 667 1,391 Pemale A l l 1955 4,888 1,853 3,763 14,312 Psychoses 1960 5,936 1,891 2,771 12,090 Neuroses 1955 596 84 136 262 1960 916 125 120 247 Mental 1955 765 684 1,556 5,593 D e f i c i e n c y 1960 950 539 1,346 6,014 Other 1955 511 289 428 1,008 Diagnoses 196O 897 340 530 1,224 

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
http://iiif.library.ubc.ca/presentation/dsp.831.1-0105740/manifest

Comment

Related Items