Mental Health
at the Johns Hopkins Bloomberg School of
Public Health
A History of the Department
Karen Kruse Thomas, PhD
Historian of the
Johns Hopkins Bloomberg School of Public Health
copyright 2013
Contents
1. Origins of Mental Hygiene at Johns Hopkins......................................................... 1
2. Research on child development and developmental disabilities ......................... 14
3. Mental Hygiene and Behavioral Sciences in the 1960s....................................... 22
4. Treating substance abuse ................................................................................... 27
5. Mental Hygiene in the 1980s and ’90s ................................................................ 35
6. The Department of Mental Health in the 21st Century ......................................... 44
Selected Honors and Awards ................................................................................... 53
Selected Faculty Publications of the Department of Mental Health .......................... 54
Chairs of the Department of Mental Hygiene (1961-2004) and
Department of Mental Health (2004-present)
Paul V. Lemkau, MD, MPH
1941-74
Abraham M. Lilienfeld, MD, MPH
interim 1974-1975
Alan D. Miller, MD, MPH
interim 1955-57
Ernest Gruenberg, MD, DrPH
1975-81
1
2
Wallace Mandell, MD, MPH
interim 1993-97
Sheppard G. Kellam, MD
1982-93
John C. S. Breitner, MD
1997-2001
William W. Eaton, PhD
interim 2001-03; 2003-2013
M. Daniele Fallin, PhD
2013-
3
1. Origins of Mental Hygiene at Johns
Hopkins
In May 1908, the Philadelphia steel
magnate and philanthropist Henry Phipps
visited the Tuberculosis Division he had
founded at the Johns Hopkins Hospital.
Phipps asked William Henry Welch, Dean of
the Johns Hopkins School of Medicine, to
suggest another project he could sponsor, and
Welch gave Phipps a copy of A Mind That
Found Itself. The book, authored by recovered
asylum patient Clifford W. Beers, had
generated national attention for the mental
hygiene movement with its descriptions of the
horrors of straightjackets, padded cells, and
brutal attendants. One month later, the Johns
Hopkins Hospital publicly announced Phipps’
$1.5 million endowment to establish the Henry
Phipps Psychiatric Clinic. To develop a
Department of Psychiatry at Johns Hopkins,
Welch invited Adolf Meyer, a Swiss
pathologist and psychiatrist at Cornell who
emphasized the inseparability of mental and
physical problems and founded the field of
psychobiology. In April 1913, the Henry
Phipps Psychiatric Clinic officially opened.
Since then, the Department has occupied a
distinguished place in the history of psychiatry,
with a continuous tradition of excellence in
patient care, teaching, and research. 1
A few years after the Phipps Clinic
opened, Welch relinquished the deanship of
medicine to become the founding dean of the
Johns Hopkins School of Hygiene and Public
Health. In 1916, the Rockefeller Foundation
awarded the initial grant to establish the first
independent degree-granting graduate school
of public health in the world. Its very name,
with hygiene before public health, reflected the
primacy of Welch’s emphasis on scientific
research on the German institute of hygiene
model. Welch remained a major proponent of
the mental hygiene movement and in 1923
was elected president of the National
Committee for Mental Hygiene, which Beers
had founded in 1909. Welch wanted to include
a department of mental hygiene in the School,
but this goal was shelved until after Welch’s
4
death, perhaps because mental hygiene did
not fit easily within the School’s framework of
laboratory-based science dedicated to fighting
infectious disease.
The Great Depression and World War II
transformed public health practice, medical
science, and American politics. Public health
instruction
had
previously
emphasized
bacteriological and environmental methods of
fighting infectious disease. Public health
administration was a required course, but
students devoted little time to it until after the
war, when it began to displace the basic
sciences as the main focus of public health
courses
alongside
biostatistics
and
epidemiology. Title VI of the 1935 Social
Security Act provided the first federal aid to
train state and local health department
personnel. The legislation required states to
establish minimum criteria for staff whose
salaries were paid with federal funds, with a
recommended one year of coursework in an
approved school of public health. After 1935,
funding from the Social Security Act, the U.S.
Public Health Service (PHS), and the
Rockefeller Foundation promoted two major
trends: an emphasis on the MPH as the
primary public health degree and the
development of specialized training programs
in growth areas such as mental hygiene,
venereal disease control, and maternal and
child health. As federal and state health
programs stimulated health departments to
provide a widening array of personal health
services, the binary classifications of
prevention/cure and social/individual began to
blur. 2
The Eastern Health District was a onesquare-mile model research and training area
established in 1932 with a Rockefeller grant
and administered jointly by the School of
Hygiene and Public Health and the Baltimore
3
City Health Department. The Eastern Health
District (EHD) was unique for its academic
affiliation as a population laboratory and
clinical site for public health students that
would parallel the Johns Hopkins Hospital’s
role in medical education. The EHD hosted
clinics for mental hygiene that involved
medical school faculty and provided clinical
training to both Hygiene students and Johns
Hopkins Hospital residents and graduate
4
nurses. Since community studies of disease
were only as meaningful as the underlying
knowledge about the base population,
Hygiene faculty and students painstakingly
collected and analyzed demographic data on
EHD residents’ age, sex, race, occupation,
economic status, and family size. This
baseline data was checked against patient
records from local hospitals, physicians, and
EHD clinics to analyze the distribution and
spread of mental illness, as well as infectious
5
and chronic diseases. During the 1940s, the
School’s dean, Lowell J. Reed, emphasized
that the District was “becoming increasingly
valuable in the teaching and research program
of the School.” School of Hygiene alumni
carried the Eastern Health District model
across the United States and to countries
around the world. Wallace Mandell, for
example, developed a state mental health plan
for Texas that modeled its community mental
health districts on those in Baltimore. He
placed child guidance clinics across the state
so that parents were no more than a one-hour
drive away. Reed urged the Rockefeller
Foundation to extend its support for additional
teaching personnel in mental hygiene and
other disciplines for as long as possible, noting
that “the moment the war is over, it is obvious
that there will be a great rush to graduate
6
training in the field of public health.”
The 1940s transformed both mental health
and public health in the United States.
Seclusion and physical restraint had been
routinely used methods to control the behavior
of institutionalized mental patients, even those
who showed little sign of violent tendencies.
The straightjacket and the solitary confinement
cell became the iconic symbols of mental
7
institutions in the popular imagination. The
deinstitutionalization of mental patients from
state hospitals began immediately after World
War II and accelerated after passage of the
federal construction grant program for
community mental health centers in 1963. As
mental health historian Gerald Grob notes,
deinstitutionalization was not a coherent
policy, but “the result of a series of incremental
8
and unrelated developments.”
The 1940s saw the first major discoveries
regarding the etiology and effective drug
therapies for various somatic conditions that
were
traditionally
classified
as
psychopathology. Once hospitalization was no
longer the sole treatment option, a growing list
of heretofore psychiatric diseases were
usurped by other medical specialties. By the
mid-1950s, pediatricians and neurologists had
assumed
responsibility
for
epileptics.
Neurosyphilitic paresis, a leading cause of
admissions to state mental hospitals prior to
1945, yielded to the introduction of penicillin
therapy for syphilis. Antibiotics and improved
prevention measures for many infectious
diseases had virtually eliminated delirium,
once a severe psychiatric management
problem in young pneumonia and typhoid
patients.
Antipsychotics
such
as
chlorpromazine significantly reduced the threat
of violence that had been a basic justification
for
commitment,
thereby
dramatically
accelerating the migration of psychiatric
diseases and adult patients out of state mental
hospitals. An increasing proportion of
psychiatric practice was devoted to the
management and treatment of mentally and
physically disabled children. 9
In tandem with these developments, the
School’s primary sponsor, the Rockefeller
Foundation, placed new emphasis on clinical
knowledge as essential to research and
training in public health as well as medicine,
which informed its support for establishing a
new mental hygiene MPH program at Johns
10
Hopkins.
State and federal categorical
programs also underwrote the establishment
or expansion of a wave of specialized MPH
tracks at Johns Hopkins and relieved the
Division of Mental Hygiene from dependence
11
on short-term Rockefeller grants.
Most
importantly, the postwar expansion of the
National Institutes of Health fueled the growth
of Psychiatry, Mental Hygiene and the other
clinical divisions of the Schools of Medicine
12
and Hygiene.
5
The armed forces were eager to employ
MPH graduates trained in mental hygiene to
screen recruits and treat mentally ill
13
servicemen and veterans. In 1941, School of
Hygiene officials met with the PHS Mental
Hygiene Division, the Mental Hygiene Society,
and the Maryland Commission of Mental
Health to outline a new eighteen-month
graduate program in community mental health
designed to prepare psychiatrists and other
specialists to administer public mental health
14
programs.
As head of the Mental Hygiene program at
Johns Hopkins from 1939 until 1978, Paul V.
Lemkau set the international standard for the
study of mental disorders in large populations
and in community settings and taught the
15
fundamentals of mental health research. His
wide-ranging research interests spanned
community
mental
health,
psychiatric
epidemiology, preventive psychiatry, planning
for mental health services, the prevention and
early diagnosis of psychiatric problems in
children and aging adults, and international
comparisons of psychiatric diagnosis and
16
treatment.
Lemkau held a joint appointment in the
Department of Psychiatry, where he had been
a resident for five years under Adolf Meyer.
But from the beginning Lemkau channeled the
mental hygiene program toward community
epidemiology and spent little time at the
medical school. He and other mental hygiene
leaders, such as fellow Meyer resident
Alexander Leighton, were consciously trying to
transcend the limits of mental hospitals and to
identify and treat early mental illness through
programs in schools and colleges, child
guidance clinics, and other outpatient settings.
Whereas students in the syphilis control MPH
program divided their time between lab work,
the Johns Hopkins Hospital syphilis clinic, and
the Eastern Health District, mental hygiene
students worked exclusively in the EHD,
reflecting the philosophy that mental illness
was preventable and caused as much by
Adolf Meyer (center), chair of Psychiatry in the Johns Hopkins School of Medicine and director of
the Henry Phipps Psychiatric Clinic, pictured in 1935 with his residents. Paul V. Lemkau is on the
front row, second from left; Alexander Leighton is on the second row, far right.
6
social maladjustment and environmental
17
factors as by somatic disorders.
The
mental
hygiene
program
demonstrated that the PHS and School of
Hygiene, despite their close relationship, did
not always share the same priorities. When
the PHS asked the School to waive the
required MPH bacteriology course to enable
officers to concentrate on mental hygiene
courses, the School of Hygiene Advisory
1
Board refused, since the course had already
“been stripped of a great deal of
bacteriological technic which it contained in
previous years,” and the mental hygiene
students would still need to understand “the
principles of bacteriological and virus disease
as they relate to epidemiology and to public
health in general.” The board felt that a bare
minimum of half the academic year should be
devoted to common requirements “if the
general public health course is to serve its
purpose of developing general public health
concepts in people with as varied interests as
medical health officers, psychiatrists, sanitary
18
engineers, public health nurses, etc., . . . .”
Although the Advisory Board prevailed for the
time being, the addition of more specialized
tracks brought increasing pressure to reduce
the time allotted to common public health
19
courses in the intensive MPH schedule.
Paul Lemkau was a prolific teacher who
prepared the behavioral component for the
new Biology of Disease course that replaced
microbiology as the MPH science requirement
in 1955. Lemkau declared in his division’s
annual
report
that
"Active
teaching
participation in Pathobiology I signaled
behavior study as a recognized basic science
in the School." Lemkau taught labs based on
social class distribution and differences in
availability of treatment for schizophrenia, as
well as on the effect of sensory stress on
performance on a psychological test. Marcia
Cooper taught a lab demonstrating the use of
1
The Advisory Board was composed of all the
full professors in the School of Hygiene and
served as its governing body.
children's drawings as an index of normal and
20
deviant development.
In tandem with the medical school’s
forensic pathology course for public health
students (which offered experience in the
laboratory of the Chief Medical Examiner of
Maryland), Lemkau also taught and conducted
research on forensic psychiatry. The
Department hosted a guest lecture by
Manfred Guttmacher, the psychiatrist who
testified at the trial of Jack Ruby (notorious for
shooting John F. Kennedy’s assassin Lee
Harvey Oswald before rolling news cameras).
Lemkau advised the state Department of
Public Welfare on psychiatric care for juvenile
delinquents and worked closely with the
Baltimore Police Department and the
Baltimore Council of Social Agencies on a
study of the police’s role in the hospitalization
of the mentally ill. To emphasize the
importance of onsite medical care for
psychiatric emergencies as an important
aspect of local psychiatry services, he
conducted a demonstration project on
emergency home care in Baltimore, where
more
than
a
third
of
psychiatric
hospitalizations involved the police and
incarceration, although violence was only
rarely a factor. Lemkau showed that
emergency home psychiatric care could help
reduce police involvement in hospitalization
and allow for voluntary hospitalization in a
larger proportion of cases. 21
The careers
of
Lemkau’s
students during
the
1950s
illustrate
the
broad influence
of the Hopkins
master
and
doctor of public
health programs
in mental hygiene. The first DrPH graduate in
mental hygiene was Alberta Szalita-Pemow,
a physician and neurologist from Warsaw,
Poland, who received a scholarship to
Hopkins from the National Council of Jewish
Women for outstanding women who would
7
return to Europe to rebuild war-torn Jewish
communities. She had practiced in Russia and
Poland before the war and in France during
and after the war. While she was at a medical
conference in Russia, Szalita-Pemow’s
husband and children were killed in the
22
Holocaust. The year before her graduation
from the School of Hygiene and Public Health
in 1950, Szalita-Pemow had joined the staff of
the Chestnut Lodge in Maryland, where she
met another Jewish refugee psychoanalyst,
Frieda Fromm-Reichmann. Chestnut Lodge
was a family-owned asylum on country estate
near Rockville, Maryland, and it became,
along with the Phipps Clinic at Hopkins and
Sheppard-Pratt Hospital north of Baltimore, a
nationally known pioneer in advancing mental
health care. Szalita-Pemow was electrified by
the “extraordinary atmosphere that pervaded
Chestnut Lodge,” a place she described as
“bursting with the ideas and struggles of a
group of sharp-minded, brilliant people totally
devoted to the challenging and difficult task of
the treatment of schizophrenia.”
With Fromm-Reichmann and three other
Chestnut Lodge colleagues, she organized a
clinical research group with a grant from the
Social Research Fund that produced some of
the first studies of the use of psychoanalysis in
treating
schizophrenia,
including
the
therapeutic use of intuition. The resulting
article that Szalita-Pemow published in 1955
in the Journal of the American Psychoanalytic
Association became a widely cited milestone
in the field, selected in 2000 as one of the 20
most influential papers by the International
Society for Psychological Treatments for
Schizophrenia and other Psychoses. SzalitaPemow helped to establish psychoanalytic
institutes in Norway and in Israel at Tel Aviv
University, and later in her career she was a
training and supervising analyst at Columbia
University and the William A. White Institute in
New York. 23
Graduates of the Hopkins Mental Hygiene
program would shape the creation of the
National Institute of Mental Health and direct
the agency from 1949 to 1970. Robert H.
Felix (MPH 1942), a member of the first
8
Robert H. Felix, first director of the National
Institute of Mental Health from 1949 to 1964
mental hygiene class, recalled taking a
biostatistics course from the eminent dean of
the School of Hygiene, Lowell J. Reed. “Oh,
God, how he would lay into us about the lousy
statistics in medicine and he would use mental
health as the most horrible example. He would
take a journal article and give you the data
and conclusions, and then he would go back
and tear it to shreds. Then the guys [in class]
would kid me, and I decided God, if I ever had
the chance, one thing I would do was develop
the finest mental health statistics department
in the world.”
After Felix was appointed director of NIMH
in 1949, he quickly hired Reed's star student,
Morton Kramer, as head of the Biometrics
Branch. A few years later, Felix made a
presentation before the Milbank Foundation on
progress in mental health statistics, with slides
provided by Kramer. Before the lights went up,
he told the audience, “I swore by everything
that I held holy that I was going to develop
statistics so good that I will make Lowell Reed
stand at Washington's Monument at the
corner of Charles and Monument Street and
eat them for breakfast without any coffee to
wash it down. The lights came up and there
sat Lowell Reed, who was a Milbank trustee.
He had a grin on his face and he said, you
have paid me the highest compliment a
24
student can pay a teacher, and I'll eat them!”
Lemkau and Felix together helped
develop the National Mental Health Act of
1946, which channeled federal resources into
psychiatric research and training programs
and created the National Institute of Mental
Health in 1948. Felix first conceived the idea
for NIMH as a student at Hopkins, when he
was working on an epidemiology assignment
on polio in New Zealand, and realized that
schizophrenia clustered geographically the
same way as polio. He believed that a national
campaign to address mental illness could be
modeled on the polio campaign then being
mounted by President Franklin D. Roosevelt
and the National Foundation for Infantile
Paralysis, with the same elements of research,
training, and community services. After Felix
was appointed head of the new PHS Division
of Mental Hygiene, Surgeon General Thomas
Parran called him in and asked how he would
structure a national mental health program.
The next morning, he presented to Parran the
outline for what he originally called a National
Neuropsychiatric Institute. 25 As the first
director of NIMH from 1949 to 1964, Felix was
a prime architect of national programs that
revolutionized mental health research, training
and treatment of the mentally ill. He served as
president of the American Psychiatric
Association in 1960-61 and left NIMH to
become dean of medicine at St. Louis
26
University.
Together with the postwar expansion of
the
Veterans
Administration
residency
program, NIMH training grants provided more
generous stipends for psychiatry residencies
in order to increase the number of physicians
entering the specialty, particularly community
mental health. The NIMH was unique among
NIH institutes because it integrated research
with a social mission of training and clinical
services. Felix and Lemkau's influence
ensured that NIMH went beyond basic and
clinical biomedical research to include and
support behavioral and social science
research--fields in which the Department
Mental Hygiene at Johns Hopkins would
27
excel.
Felix was the first of many early leaders at
NIMH to be trained in the Hopkins Mental
Hygiene MPH program; likewise, many Mental
Hygiene faculty have had NIMH backgrounds.
Morton Kramer, faculty member from 1976 to
1984, headed the NIMH Biometrics Branch
from 1949 to 1976, which compiled, analyzed,
and evaluated national statistics on the
incidence and prevalence of mental illness,
consulted with outside agencies, and
conducted a census of patients in mental
institutions.
Future
department
chair
Sheppard G. Kellam was at the NIMH Clinical
Neuropharmacology Research Center during
the early 1960s, where he directed research
on the quantification of social interaction in a
psychiatric ward and also developed a Social
Interaction Matrix to study the effects of major
28
tranquilizers in the ward.
Another future
department chair, William W. Eaton, was
assistant chief of the agency's Center for
Epidemiologic Studies from 1978 to 1983.
Bob Felix sent his lieutenants to Hopkins
for advanced training in public mental health,
including Robert T. Hewitt (MPH 1948), head
of the NIMH Hospital Services Branch, Dale
Cameron (MPH 1951), assistant director of
NIMH, Alan D. Miller (MPH 1951), head of the
NIMH Mental Health Study Center, and
Stanley F. Yolles (MPH 1957), who
succeeded Felix as NIMH director. Felix told
Miller that he “must go to Hopkins, because of
Paul Lemkau.” Miller had attended a seminar
with Dr. Lemkau, and “was bowled over; I
29
needed no persuasion.”
Yolles joined the staff of the NIMH Mental
Health Study Center in 1956, where he
worked with Miller and Mabel L. Ross. Miller
told Yolles that the Center’s research had to
benefit the community, and that the same “first
do no harm” principle that applied in medicine
was just as true of the residents of Prince
George's County, Maryland. Miller, Ross, and
Yolles applied sophisticated epidemiological
reasoning that would become a hallmark at
9
NIMH. Yolles recalled, “In looking for
community indicators of mental health or
mental illness, we noted that there was a very
high correlation between juvenile delinquency
as an index of dysfunction in the community,
and a high rate of reading disabilities. We
looked at the epidemiology of reading
disabilities as an indicator of other pathology
in the same sense that one in a laboratory
looks for E. coli as an indicator of
contamination by typhoid or other pathogenic
organisms.”
To gain the cooperation of the community
and the school district, “we couldn't be too
nosy and too proud. So we gave the school
system carte blanche consultation with their
counseling personnel and attendance people,
we would hold case conferences in the
schools with the guidance person, and we had
seminars for them at the Mental Health Study
Center.” Yolles attributed the Center's
successful research and its elevated status in
the community directly to the staff’s MPH
training (he and Miller at Hopkins, Ross at
Harvard). Yolles also used his public health
knowledge to build bridges with health officials
charged with administering NIMH-funded
programs. One evening over dinner with the
health officer of Oklahoma City, where he was
speaking on NIMH’s Community Advisory
Board Clinics, Yolles was asked if he liked his
hotel accommodations. He surprised his host
by replying, “I find the hotel very nice, except
you have a very severe problem with back
siphonage of water from the bathtub.” 30
Yolles served as the second NIMH
director from 1964 to 1970. Although he
earned a master’s in parasitology from the
Harvard School of Public Health and fought
insect-borne diseases in the Caribbean during
the war, Yolles concluded that he “could no
longer be satisfied with a one-to-one
relationship with a microscope,'' and decided
to pursue psychiatry. Like Felix and many
other Mental Hygiene alumni, Yolles worked
with drug addicts at the Public Health Service
Hospital in Lexington, Kentucky, where he
abolished the use of bars and handcuffs to
restrain patients. The experience galvanized
10
his commitment to finding more humane and
effective methods for preventing and treating
drug abuse.
As NIMH director in the turbulent 1960s,
Yolles denounced what he saw as "stupid,
punitive laws" that criminalized drug use. He
testified before Congress that strict penalties
failed as a deterrent, since addiction was a
medical and social problem. Yolles made
headlines by calling for abolishing mandatory
sentences and giving judges greater discretion
to deal with drug users, especially first-time
offenders. Regarding marijuana possession,
he said, “I know of no clearer instance in
which the punishment for an infraction of the
law is more harmful than the crime.” This view
would later be famously advocated by
President Jimmy Carter early in his term, until
Peter Bourne, special assistant for health
issues, forced Carter to backtrack after a
scandal erupted over Bourne’s own use of
illegal drugs and connections with the National
Organization for the Reform of Marijuana
Laws.
Although Yolles persuaded the Justice
Department to reduce federal penalties for
marijuana, he also angered the Nixon
administration, which worsened conflicts over
the budget and direction of NIMH. When the
administration announced that Yolles had
been dismissed, he penned a resignation
letter the same day in which he accused Nixon
of “abandonment of the mentally ill.” In 1971,
Yolles became the founding chair of the
department of psychiatry at the State
University of New York School of Medicine at
Stony Brook until he retired in 1981. He also
directed the Long Island Research Institute
from 1974 to 1981. 31
In addition to their efforts to guide federal
mental health reform, Division of Mental
Hygiene faculty and alumni helped the state
and local governments of Maryland and New
York to establish and expand community
mental health services. From 1949 to 1953,
the School allowed Paul Lemkau to remain on
the faculty while serving as head of the
Maryland Division of Mental Hygiene, where
he expanded on the existing system of state
mental hospitals to develop a modern program
of community mental health services. Lemkau
also worked as a consultant to the New York
State Mental Health Commission under
Ernest M. Gruenberg, executive director from
1949 to 1954. Gruenberg favored the English
model of basing community health services in
a psychiatric hospital, but Lemkau preferred
the public health department, as was the
policy in the Netherlands. Gruenberg, a
professor of psychiatry at Columbia, also
directed the psychiatric and epidemiology
research unit of the New York State
Department of Mental Hygiene. Together, they
worked to enact the 1954 New York State
Community Mental Health Act and other laws
to develop the state's mental health programs
and establish community facilities. In 1975,
Gruenberg succeeded Lemkau as chair of
32
Mental Hygiene at Hopkins.
Under Mayor Robert F. Wagner and
Health Commissioner Leona Baumgartner,
New York City took the lead in establishing a
Community Mental Health Board under the
new law. From 1955 to 1957, Lemkau took a
leave of absence to serve as New York City’s
director of Mental Health Services during the
33
initial implementation phase. He asked Bob
Felix to send Alan Miller to Hopkins to serve
as interim chair. Several of Lemkau's students
followed him to New York and stayed. Rema
Lapouse (MPH 1950) headed the Mental
Disease Unit in the Division of Epidemiology at
the New York City Public Health Research
Institute. She became one of the foremost
epidemiologists of pediatric mental disorders,
as well as co-founder of the APHA Mental
Health Section. Marvin Earl Perkins (MPH
1956) was the first Commissioner of Mental
Health Services for New York City as well as
34
the District of Columbia.
The community mental health programs in
New York and Maryland as well as at the
NIMH Mental Health Study Center were all
models for federal legislation to establish and
support community mental health centers as
an alternative to state mental hospitals. The
influence of Hopkins-trained NIMH staff,
including Bob Felix, Stan Yolles, and Alan
Miller, was essential for crafting a national
program that addressed the major mental
health needs of states and communities on a
population basis and ensured access for all
citizens. The passage of the 1963 Mental
Retardation Facilities and Community Mental
Health Centers Construction Act marked a
new era of increased federal support for
mental health services, and NIMH assumed
responsibility for monitoring the community
mental health centers program nationwide.
In 1964, Miller left NIMH to become New
York State Commissioner of Mental Hygiene.
Under his leadership in the first decade after
the program's inception, New York built 26
mental health centers at a total cost of $99
million, with 15 percent of the total from
federal funds. Testifying before Congress in
1973, Miller described the impact of the Act on
his state’s mental health program:
A well functioning community health
service can make a significant impact
on admission rates and more
importantly resident patient rates in
state hospitals. Since the care of the
long term state hospitalized patient
represents a tremendous expenditure
of public money, continuation and
expansion of the mental health center
program is fiscally sound. The saving in
human distress and the elimination of
the personally damaging effects of long
term
hospitalization
in
remote
impersonal institutions are, of course,
too well known to require further
description.
Yet in the context of Nixon-era retrenchment
of federal programs, Miller also remarked on
the irony that “on the one hand the
Department of Health, Education, and
Welfare,
through
the
Developmental
Disabilities Services Act, is making specific
grants to states to help plan for
deinstitutionalization of the mentally retarded
but on the other is threatening to extinguish
the Community Mental Health Center
program, which has the potential to be a great
force for deinstitutionalization of the mentally
ill.” 35
11
In the two decades from the creation of
the Division of Mental Hygiene in 1942 to the
passage of the Community Mental Health
Centers legislation, Hopkins mental health
faculty and alumni were national leaders in
creating and developing health policy that
firmly established mental health as both a
central concern of public health practice and a
legitimate focus of research within NIH. By
uniting scientific medicine with psychiatric
epidemiology that was deeply rooted in
community needs and realities, the Division
helped gain wider acceptance for Lemkau’s
contested idea that mental health belonged in
public health.
1
Janet
Farrar
Worthington,
“When
Psychiatry Was Very Young,” Hopkins
Medicine (Winter 2008). For an in-depth
treatment of Adolf Meyer and the Phipps
Clinic, see Susan D. Lamb, Pathologist of the
Mind: Adolf Meyer, Psychobiology and the
Phipps Psychiatric Clinic at the Johns Hopkins
Hospital, 1908-1917 (2010 dissertation in
History
of
Medicine,
Johns
Hopkins
University).
2
William Shonick, Government and Health
Services:
Government's
Role
in
the
Development of U.S. Health Services 19301980 (Oxford University Press, 1995), 93;
Elizabeth Fee, Disease and Discovery: The
History of the Johns Hopkins School of
Hygiene and Public Health 1916-1939 (Johns
Hopkins University Press, 1987), 180-81, 220.
3
George Rosen, A History of Public
Health, 446-52; Paul Starr, The Social
Transformation of American Medicine (Basic
Books, 1982), 194-96.
4
Fee, Disease and Discovery, 179, 184214; "Report on the Eastern Health District to
the IHD,” 1941, 1942, 1943, JHSPH Dean’s
Office Correspondence Series 3a, box
502037, “Rockefeller Foundation” folder, Alan
Mason Chesney Medical Archives of the
Johns Hopkins Medical Institutions (AMC).
5
"Eastern and Western Health Districts
Enlarge," Baltimore Health News 15.10 (Oct.
1938), 76-77; Fee, Disease and Discovery,
179, 184-214; "Report on the Eastern Health
District to the IHD,” 1941, 1942, 1943; Thomas
Turner, Heritage of Excellence, 367.
12
6
“Report on the Mental Hygiene Study to
the IHD 1941,” “Rockefeller Foundation”
folder; Allen Freeman, “Annual Report of the
Department of Public Health Administration
1942-43,”
JHSPH
Dean’s
Office
Correspondence Series 3a, box 502031,
“Department Reports to the Dean 1942-1943”
folder, AMC; Nov. 1, 1943 EHD Committee
minutes, Huntington Williams papers, box
505733, "Eastern Health District Committee
Meetings 1933-1955" folder, AMC; Reed to
Ferrell June 30, 1943, “Rockefeller Foundation
Sept 1941-Mar 1942” folder; Wallace Mandell
interview Aug. 29, 2012.
7
Gerald Grob, “Deinstitutionalization: The
Illusion of Policy,” Journal of Policy History 9.1
(1997), 49-52; Shonick, Government and
Health Services, 188-89; Ernest M. Gruenberg
and J. Archer, “Abandonment of Responsibility
for the Seriously Mentally Ill,” Milbank
Memorial Fund Quarterly/Health and Society
57.4 (Fall 1979), 485-506.
8
Grob, “Deinstitutionalization,” 48.
9
Grob, “Deinstitutionalization,” 48-51;
Paul V. Lemkau, “Prevention in Psychiatry,”
AJPH 55 (Apr. 1965), 554-60.
10
C.-E. A. Winslow, "American Public
Health Association, Report of Accreditation
Visit, Committee on Professional Education,
The Johns Hopkins School of Hygiene and
Public Health," Nov. 21-23, 1949, Thomas B.
Turner papers, box 50564, "Development
Comm." folder, AMC.
11
Shonick, Government and Health
Services, 95; Starr, Social Transformation of
American Medicine, 343-46; Fee and
Rosenkrantz, “Professional Education for
Public Health in the United States,” 236-37;
Parran, “Surmounting Obstacles to Health
Progress,” 168-72.
12
Turner, Heritage of Excellence, 397.
13
Brandt, No Magic Bullet, tk; Starr, Social
Transformation of American Medicine, 344-45.
14
SHPH Advisory Board Minutes, vol. 4,
May 27, 1941 p. 46, AMC.
15
"Dr. Paul V. Lemkau, pioneer in mental
hygiene, dies at 82," Baltimore Sun Apr. 30,
1992.
16
Paul Lemkau bio file, AMC; SHPH
Advisory Board Minutes, vol. 4, May 27, 1941
p. 46; Leo Kanner to Lowell Reed May 22,
1941, JHSPH Dean’s Office Correspondence
Series 3a, box 502034, "Kahn-Kar May 1941-
Jun 1944" folder; Fee, Disease and Discovery,
198; Reed to Roy C. Heflebower June 24,
1941, JHSPH Dean’s Office Correspondence
Series 3a, box 502034, "Lee-Lem Jun 1941Mar 1944" folder.
17
Paul V. Lemkau bio file, AMC; Hans
Pols, “Divergences in Psychiatry During the
Depression: Somatic Psychiatry, Community
Mental Hygiene, and Social Reconstruction,”
Journal of the History of the Behavioral
Sciences 37 (Fall 2001), 369–388.
18
Lowell J. Reed to Victor Vogel June 5,
1941 and Vogel to Reed June 6, 1941, JHSPH
Dean’s Office Correspondence Series 3a, box
502041, "U.S. Public Health Service Feb
1940-June 1941" folder.
19
1944-45 SHPH Catalog, 21-24.
20
Paul Lemkau, Division of Mental
Hygiene 1957-58 Annual Report, “President’s
Report” folder.
21
1961-62 SHPH Catalog, 66; Paul V.
Lemkau to John T. Cowles Apr. 9, 1963 and
Mental Hygiene annual reports for 1957-58
and 1963-64, box 504582, "Mental Hygiene"
folder.
22
"Humanitarian Service to Displaced
Persons," San Antonio Express July 11, 1948.
23
Gail A. Hornstein, To Redeem One
Person Is to Redeem the World: A Life of
Frieda Fromm-Reichmann (Simon and
Schuster,
2002),
181,
307-09;
ISPS
Newsletter 4.1 (Sept. 2000), 14; Alberta B.
Szalita-Pemow, “The “intuitive process” and its
relation to work with schizophrenics,” Journal
of American Psychoanalytic Association 3.1
(1955).
24
Robert H. Felix NIMH oral history
interview, May 27, 1975, pp. 29-30.
25
Felix interview, 32-40; Ingrid G.
Farreras, Caroline Hannaway, and Victoria A.
Harden, eds., Mind, Brain, Body, and
Behavior: Foundations of Neuroscience and
Behavioral Research at the National Institutes
of Health (IOS Press, 2004), 9-10.
26
Robert H. Felix obituary, New York
Times Apr. 3, 1990.
27
Farreras, Hannaway, and Harden, Mind,
Brain, Body, and Behavior, 10.
28
Joel Elkes, "Psychopharmacology:
Finding One's Way," in Farreras, Hannaway,
and Harden, Mind, Brain, Body, and Behavior,
201-20; Shepherd G. Kellam, “A Method for
Assessing Social Contacts: Its Application
During a Rehabilitation Program on a
Psychiatric Ward,” Journal of Nervous and
Mental Diseases 132 (1961): 277-88.
29
Alan D. Miller email to Bill Eaton, June
12, 2013.
30
Stanley F. Yolles NIMH interview April
21, 1975, 11-14.
31
Stanley F. Yolles obituary, New York
Times Jan. 21, 2001.
32
Ernest M. Gruenberg bio file, AMC.
33
Paul V. Lemkau, Mental Health
Resources in New York City (New York City
Community Mental Health Board, 1957); Grob,
“Deinstitutionalization," 48-73.
34
JHSPH Dean’s Office Correspondence
Series 3a, box 504577, "NYC Community
Mental Health Board" folder; “Administrative
MD: Marvin Earl Perkins,” New York Times
Nov 1, 1961.
35
Alan D. Miller, testimony on renewal of
the Community Mental Health Centers Act
before the House Committee on Interstate and
Foreign Commerce Subcommittee on Public
Health and Environment, May 9, 1973, p. 120.
13
2. Research on child development and
developmental disabilities
The School of Hygiene’s prewar research
on the social epidemiology of the family had
focused on the physical and mental health of
mothers and children. This research
blossomed after Ernest L. Stebbins arrived in
1947 as director of the School and chair of the
Department of Public Health Administration,
1
which housed the Division of Mental Hygiene.
In 1949, Charles-Edward A. Winslow of Yale
named “the challenge of mental and emotional
disease [as] probably the greatest single
objective of the public health program of the
2
future.” In his review of Lemkau’s seminal
textbook, Mental Hygiene and Public Health,
Winslow
wrote,
"To
control
these
environmental factors [that influence mental
health] is a legitimate and ultimately
inescapable task of public health.” Personality
development during childhood was fraught
with mental health risks, and helping parents
to modify and manage them successfully was
“sure to be recognized ultimately as even
more important (even if also more difficult)
than the measures now taken for the
prevention and early treatment of infectious
and nutritional diseases." Winslow also
recognized mental hygiene as a critical factor
in the success of every health department
clinic, the core work of every good public
health nurse, the effectiveness of all health
education, and the sound administration and
public relations of a health department. He
noted, “Such new procedures as childbirth
without anesthesia, and rooming-in for infants
are primarily mental hygiene technics.” 3
In 1950, Ruth Freeman joined the
Department of Public Health Administration
faculty to head the new Division of Public
Health Nursing, and Freeman and Lemkau
began seeking NIMH funds for projects on
4
psychiatric education and nursing education.
The Division of Mental Hygiene began to
enroll more nurses, many of whom had
worked in the Eastern Health District and
contributed to the School’s studies of maternal
5
and child health and mental hygiene. To raise
14
awareness of the role of public health nurses
in promoting the mental as well as physical
health of their clients, Lemkau served as
psychiatric advisor for Broken Appointment
(1955), a documentary film that explored the
emotional aspects of public health nursing.
During this period, the majority of public health
administration courses dealt with clinical
medical care programs in nursing, maternal
and child health, mental hygiene, and venereal
6
disease.
Such programs reflected an
increasing “emphasis on health problems that
require individualized rather than mass
treatment [and] necessitated the use of a
multi-disciplinary
professional
group
in
planning and effectuation of health programs,”
7
according to Freeman.
Freeman
collaborated
with
Marcia
Cooper in the Division of Mental Hygiene,
who also promoted interdisciplinary research
and training. Cooper directed the Eastern
Health District’s Mothers Advisory Service,
which brought psychiatrists, public health
nurses, and medical social workers together to
offer practical childrearing advice and support
for mothers. Child guidance clinics utilizing
interdisciplinary teams had their roots in the
diagnostic outpatient clinics established for
mentally disturbed juveniles at the turn of the
twentieth century in cities such as Boston,
Chicago, and Philadelphia. By 1930 there
were over 200 child guidance clinics
registered with the National Committee for
8
Mental Hygiene.
The Mothers Advisory Service received
referrals from local physicians and all the
childcare agencies in Baltimore City as well as
many across the state. By the 1950s, the
Mothers Advisory Service was one of the few
remaining threads of the School’s relationship
with the EHD, and Cooper moved into
assisting clinics and social agencies in
evaluating children with special needs in
placement for foster care and adoption.
Cooper’s multi-disciplinary team from the
Division of Mental Hygiene, Baltimore City
Schools, the School Health Division of the City
Health Department, and the Johns Hopkins
Hospital departments of Child Psychiatry,
Marcia Cooper observes children playing at
the Mothers Advisory Service, circa 1959.
Photo courtesy of the Alan Mason Chesney
Medical Archives of the Johns Hopkins
Medical Institutions.
Neurology, and Otology also helped
coordinate the medical and educational needs
of children with brain injury or communication
handicaps,
including
screenings
for
9
participation in experimental classes.
Ruth Freeman and Marcia Cooper
challenged gender and disciplinary barriers in
the physician-centric culture of Hopkins to
fulfill the 1939 Parran-Farrand Report’s charge
to provide unified training to all types of public
health workers. With the growth of programs
like the Mothers Advisory Service, maternal
and child health services became the largest
clinical component of most public health
departments. Though still grounded in
pediatrics and obstetrics, maternal and child
health had broadened to include psychiatry
and other clinical specialties involved in the
care
of
physically
handicapped
and
developmentally disabled children. Public
health nurses remained central to the field, but
social workers played an increasingly critical
10
role.
In 1959, the American Psychopathological
Association convened its 49th annual meeting
to discuss the comparative epidemiology of
mental disorders, a field that had emerged as
a major strength at the Johns Hopkins School
of Hygiene and Public Health. The School’s
representatives at this historic meeting
included Benjamin Pasamanick, Abraham
M. Lilienfeld, and Paul Lemkau. Also present
were future Hopkins Mental Hygiene faculty
members Morton Kramer and Ernest
Gruenberg (see picture on next page).
The School’s research on the links among
pregnancy,
premature
birth,
and
developmental disabilities built upon the
statistical and methodological foundation of
the earlier Family Studies and obeyed
biostatistician Margaret Merrell’s dictum that
“public health problems that are related to
families as such demand classification and
analysis on a family unit basis.” 11 Taken
together, the studies conducted during the
1950s and ’60s by psychiatrists Lemkau and
Pasamanick in the Division of Mental Hygiene,
epidemiologist Abe Lilienfeld, pediatricians
Paul A. Harper and Hilda Knobloch in the
Division of Maternal and Child Health, and
biostatistician Rowland V. Rider must be
considered among the School’s most farreaching contributions to public health
research. The pregnancy, prematurity, and
development
studies
shared
three
characteristics.
They
used
innovative
methodology that helped to establish the
etiology and incidence of several poorly
understood congenital conditions. Carefully
planned, large-scale case-control studies
highlighted race and socioeconomic status as
critical factors in both initial damage to the
fetus or infant and in the child’s subsequent
development. Finally, in both their publications
and advisory roles to health officials and
policymakers, School of Hygiene faculty
emphasized the broad preventive applications
of their research for policy and practice.
15
Many congenital neurological conditions,
such as cerebral palsy and epilepsy, were
thought to be hereditary. Scientific racism
remained influential, and many medical
researchers attributed the higher reported
rates of mental retardation and behavioral
disorders among black children to biological
racial inferiority. However, little was known
about the distribution of birth defects in the
population or their long-term effects on
12
development. Benjamin Pasamanick and his
wife Hilda Knobloch investigated these issues
by examining infants and young children, with
special attention to the role of the family’s race
and socioeconomic status. In his early
research on black infants in Harlem and New
Haven,
Connecticut,
Pasamanick
had
disputed theories of racial inferiority and
concluded that lower birth weights and poorer
nutrition explained higher rates of mental
13
retardation among black children. Without
exception, the archival photographs that depict
16
the School of Hygiene’s activities in the
Mother’s Advisory Service and the maternal
and child health clinics of the Eastern Health
District show white students and faculty
observing or caring for African American
women and children who resided in the
predominantly
black
neighborhood
14
surrounding the medical campus.
Race affected the collection and
interpretation of data, sometimes in surprising
ways. Lilienfeld and Pasamanick had
expected the rates of prematurity and neonatal
abnormalities to be higher among cases than
controls, but this was only true for white
infants, while rates for black infants were
nearly as high among controls as cases. The
lower overall percentage of hospitalized births
among black women had resulted in a
selectively higher proportion of abnormal
pregnancies and deliveries among those for
15
whom hospital records were available.
School segregation actually facilitated the
selection of controls in the retrospective study
of maternal and fetal precursors of behavior
problems in children who had been referred to
the Baltimore City Public Schools Division of
Special Services. Each child with behavior
problems was matched with “another child of
the same sex in the same class [who had not
been referred, which] resulted in automatic
matching by race, economic status, and age
16
due to segregation and school districting.”
The disadvantages of racial discrimination
and dire poverty faced by most inner-city East
Baltimore residents were borne out in the
School
of
Hygiene’s
research,
with
consequential implications for public health
policy and practice. By correlating data from
birth certificates, hospital records, and census
tracts, Pasamanick, Knobloch, and Lilienfeld
found that the rate of maternal complications
among 700 infants born in Baltimore hospitals
was 5 percent among whites in the highest
economic quintile, 15 percent among whites in
the lowest economic quintile, and 51 percent
among nonwhites. Black rates of premature
birth were also “strikingly greater than those in
the lowest socioeconomic white groups,”
which led the authors to hypothesize that
“Negro socioeconomic status is lower than
that in even the lowest white groups” and
therefore
“prematurity
rates
increase
exponentially
below
certain
economic
thresholds.” 17 Of over 42,000 live births to
mothers in Baltimore hospitals, 11 percent of
black infants were premature, compared to
only 7 percent of white infants. Of those born
to mothers over age 30, 22 percent of blacks
18
and 9 percent of whites were premature.
At the conclusion of their 1956 article on
precursors of neuropsychiatric disorder,
Lilienfeld,
Pasamanick,
and
Rogers
emphasized that their findings “above all
indicate areas where preventive measures
may serve to decrease the enormous weight
of individual and social loss and suffering.”
During the 1950s, state and local health
departments began to more fully incorporate
the care of mentally and physically
handicapped children into maternal and child
health programs. About 30 percent of children
served by crippled children’s agencies had
congenital malformations, the largest single
19
diagnostic category. Lemkau and Harper,
with Hopkins pediatrician Robert Cooke,
played major roles in the establishment and
expansion of programs that significantly
increased the scope and reach of services for
mentally and physically handicapped children.
But divisions among the three chairs reflected
disciplinary and political splits over which
medical specialties and federal agencies
should have primary responsibility for such
services. Psychiatrists on state boards of
mental health had traditionally overseen
institutions for mentally retarded children, but
the psychoanalysts who came to dominate the
profession believed such children were
incapable of benefiting from psychotherapy.
As historian of mental retardation Edward
Shorter has noted, “The analysts had
breathtakingly erroneous notions of the
causes of [mental retardation], believing it to
be the result of faulty parent-child dynamics, of
‘refrigerator mothers’ and the like.” During an
era when few doctors chose to specialize in
mental retardation, considered a hopeless and
incurable condition that inevitably led to
institutionalization, Cooke and Lemkau both
dedicated themselves to bettering the quality
of care and public programs then available for
developmentally disabled children, while
Harper helped to ensure that pediatricians
were trained to recognize early signs of
developmental problems in infants and young
children. 20
Pediatricians believed that their specialty
should take the lead in caring for mentally
handicapped children, but it was the
outspoken Cooke rather than the softspoken
Harper who clashed with psychiatrists on this
issue. In Cooke’s own department, Leo
Kanner, the psychiatrist who had established
the first child psychiatry service in a pediatric
hospital, upheld psychiatry’s role in evaluating
and treating children with delayed mental and
emotional development. Harper and Lemkau
had been active in reform efforts in the
Maryland Department of Health and Mental
Hygiene and Lemkau had also chaired one of
17
the earliest National Institute of Mental Health
reviews of program development in mental
retardation. While Lemkau was critical of the
psychoanalysts’ abandonment of the field, he
wanted progressive mental hygienists to
oversee care for mentally disabled children
within state health departments. During the
1960s, Lemkau led the Department of Mental
Hygiene at Hopkins to develop an active
research and training program in the
epidemiology of mental retardation, and in
1965 the Department began a contract with
the City of Baltimore “to provide qualified and
adequate psychiatric services for the conduct
of the City Health Department's full-time
mental hygiene clinic for children in the
21
Eastern Health District.”
Lemkau and Harper opposed Cooke on
the issue of creating an NIH institute for
studying children's diseases. Harper and
Representative John Fogarty were among
those who wanted children's health research
to remain based in the Children's Bureau, but
Cooke felt that the Bureau's personnel had
'neither the interest nor the capacities to
develop intensive research programs of a
basic nature in the biological or behavioral
aspects of human development.'” Lemkau,
with close ties to NIMH, shared that Institute’s
desire to retain its oversight of research on
mental retardation. When Cooke, with the
support of the rest of President Kennedy’s
task force on health, proposed to establish a
new child health institute within NIH, they ran
afoul of director James Shannon. Shannon
had been loyal to the categorical disease
model of the agency’s early years and resisted
the creation of age-based institutes, and
Department of Health, Education and Welfare
(HEW) secretary Abraham Ribicoff was also
uninterested in a child health institute. With
persistent lobbying, Cooke and the Kennedys
won over Fogarty and his influential colleague
Senator Lister Hill, and the National Institute of
Child Health and Human Development
(NICHD) was established and funded in
1963. 22
Although Pasamanick and Knobloch left
Hopkins in 1955, the longitudinal data from
18
their studies of Baltimore children enabled
them to create a developmental screening
inventory
for
infants
based
on
a
comprehensive clinical evaluation method that
had been tested to measure its predictive
value and capacity to distinguish intellectual
from motor disability. Such improved
screening methods were essential for
accomplishing the goals of the Great Society
child health legislation that aimed to provide
comprehensive prevention and treatment
23
services to millions of low-income children.
The Baltimore data were also the basis for one
of the first studies of factors in childhood
reading disorders, co-authored by Pasamanick
24
and his doctoral student Ali A. Kawi.
Pasamanick drew upon the Baltimore
studies of mental disease among children and
adults to refute racial bias in epidemiological
studies of mental illness and disability. He
argued that the vast racial disparities reported
in rates of mental illness, whether
physiological or neurotic in origin, were
“largely artifacts consequent to unreliability of
diagnosis which in turn may follow upon class
and caste factors in both examiners and the
examined.” Pasamanick and his co-authors
adjusted for the distribution of prematurity,
race, sex, and socioeconomic status in the
Baltimore population and found a rate of
mental retardation in 15 per thousand infants,
with 13 white and 21 black infants per
thousand affected. In a 1964 article in the
Journal of the National Medical Association,
Pasamanick emphasized that this difference
was not due to innate biological factors, but
rather resulted from much higher black rates
of prematurity and maternal complications that
were rooted in poverty and lack of access to
medical care. 25
The School of Hygiene’s studies of the
complex relationship between complications of
pregnancy,
premature
birth,
abnormal
neonatal conditions, and developmental
disabilities were part of the foundational
developmental research that was instrumental
in convincing Congress to amend the Social
Security Act in 1963 and 1965. These
maternal and child health amendments
authorized federal grants to enable states to
provide comprehensive maternity care to highrisk mothers; to develop high quality,
comprehensive health services for preschool
and school age children; and to broaden
maternal and child health programs to serve
26
children with handicapping conditions. The
provisions of SS Title V lay the groundwork for
a national maternal and child health services
network. These programs were characterized
by a strong federal role in funding and setting
priorities, state administration and provision of
mandatory matching funds, statewide health
planning to meet federal guidelines, and local
delivery of services.
The expansion of the scope and budgets
for federal maternal and child health programs
during the 1960s had three major effects: it
was a major step in the evolution of SS Title V
into a national health system for low-income
mothers and children; it transformed public
health practice by significantly expanding
maternal and child health services at the state
Lemkau noted in one annual report that he
had “carried one person connected with the
School in rather intensive therapy throughout
the year."
and local levels; and it benefited schools of
public health by providing additional support
for research and training in mental health and
maternal and child health, with a heightened
emphasis on public health nursing. 27 These
federal programs would provide fundamental
support for the new departments of Mental
Hygiene and Maternal and Child Health that
grew out of the School of Hygiene’s extensive
research in these areas during the 1950s.
The Division of Mental Hygiene’s research
on the behavioral aspects of infant and child
development provided tools for shaping public
health policy, but also profoundly influenced
the direction of teaching in the School's
master's and doctoral programs. Students and
faculty in Mental Hygiene and Maternal and
Child Hygiene collaborated closely with the
departments of Epidemiology and Biostatistics
to compare normal versus abnormal mental
and physical development in children from
birth onward, with a focus on the origins and
management of congenital and developmental
28
disabilities. Lemkau was a major figure in
psychiatry and public health nationally and
internationally, yet he was also a devoted
teacher and mentor who still made time to
listen to students who sought advice on their
29
own or their children’s problems.
He had long wanted to establish a
laboratory component for mental hygiene
courses that would illustrate course concepts
and engage students in practical application.
Beginning in 1957, the Mental Hygiene course
on psychodynamics and personality formation
included a weekly laboratory session that
required students to choose a topic, formulate
a specific research question, observe and
record data, and report their conclusions in a
final presentation to the class. Students could
study the behavior of children in one of a
variety of settings: in premature nurseries and
preschool classrooms (to compare personality
differences and reactions to sleeping and
waking), in pediatric clinic waiting rooms (to
compare
socioeconomic
differences
in
disciplinary methods), in a supermarket while
shopping with their mothers, or in Boy and Girl
Scout troop meetings (to compare age- and
19
sex-related differences among peers and
between children and adults).
Mental Hygiene students also observed
teenagers at high school dances and in
Baltimore Traffic Court and interviewed child
welfare agency workers to learn the reasons
for moving foster children from one home to
another. Topics that dealt with sexual behavior
or attitudes gave students the opportunity to
test “the extent of tolerance for studies in more
or less sensitive areas." Although several
Baltimore City Public Schools personnel had
initially consented to a proposed study on the
problem of dysmenorrhea among high school
girls in school health programs, the study was
denied final approval at the top administrative
level. School district officials did approve a
similar project on the management of out-ofwedlock pregnancy in a school system, which
uncovered “a previously unrecognized lack of
communication between school and health
authorities that frequently resulted in the
young pregnant girls, a high-risk group,
receiving inadequate prenatal care.” 30
Lemkau’s first-generation research and
teaching on the “continuum of casualty”
applied a life course framework to
understanding the impact of physiological,
social, and environmental factors on children’s
development, behavior, and life chances. This
rich vein of inquiry would blossom further in
the 1980s under Sheppard Kellam’s
chairmanship with the establishment of the
Prevention Research Center and an intensive
long-term intervention in collaboration with the
Baltimore City Public Schools.
1
Lowell Reed, “Annual Report of the
Department of Biostatistics 1942-43,” JHSPH
Dean’s Office Correspondence Series 3a, box
502031, “Department Reports to the Dean
1942-1943” folder, AMC; Fee, Disease and
Discovery, 192-204, 225.
2
C.-E. A. Winslow, "Lemuel Shattuck--Still
a Prophet," AJPH 39 (Feb. 1949), 156-62,
quote p. 160.
3
Paul V. Lemkau, Mental Hygiene in
Public Health (McGraw-Hill, 1949); C.-E. A.
Winslow, "Mental Hygiene in Public Health by
20
Paul V. Lemkau" (review), AJPH 39 (Dec.
1949), 1586-87.
4
Paul Lemkau to Ernest Stebbins Apr. 1,
1950, JHSPH records, Series 3b: O.D.
Financial, box 506104, “1949-50” binder.
5
"Report on the Eastern Health District to
the IHD 1943.”
6
1946-47 SHPH Catalog, 36; 1947-48
SHPH Catalog, 44; 1948-49 SHPH Catalog,
44; 1951-52 SHPH Catalog, 57-63; 1952-53
SHPH Catalog, 59-61.
7
Ruth B. Freeman to Ernest L. Stebbins
Apr. 22, 1952, Turner papers, box 505461,
"Development Committee" folder.
8
Fee, Disease and Discovery, 201-04,
218; George Rosen, “Public Health and
Mental Health: Converging Trends and
Emerging Issues,” in Mental Health Teaching
in Schools of Public Health (Association of
Schools of Public Health, 1961), 22.
9
“1956-57 Report of the SHPH Director,”
JHU Circular 76 (Nov. 1957), 143.
10
William M. Schmidt and Isabelle
Valadian, "A Maternal and Child Health
Bookshelf," AJPH 54 (Apr. 1964), 551-62;
Helen M. Wallace, Health Services for
Mothers and Children (Saunders, 1962);
Harold C. Stuart and Dane G. Prugh, eds.,
The Healthy Child: His Physical, Psychological
and Social Development (Harvard University
Press, 1960).
11
Merrell, "The Family as a Unit in Public
Health Research," 9.
12
Martha Rogers, Abraham M. Lilienfeld,
and Benjamin Pasamanick, Prenatal and
Paranatal Factors in the Development of
Childhood
Behavior
(Acta
Psychiactric
Neurology Supplement No. 102, 1955), 12-18.
13
Benjamin Pasamanick bio file, AMC;
Benjamin Pasamanick, “A comparative study
of the behavioral development of Negro
infants,” Journal of Genetic Psychology 69
(1946), 3-44.
14
Alan Mason Chesney Archives photo
collection.
15
Lilienfeld, Pasamanick, and Rogers,
“Relationship between pregnancy experience
and
the
development
of
certain
neuropsychiatric disorders in childhood,” 638.
16
Lilienfeld, Pasamanick, and Rogers,
“Relationship between pregnancy experience
and
the
development
of
certain
neuropsychiatric disorders in childhood,” 640.
17
Benjamin Pasamanick, Hilda Knobloch,
and Abraham M. Lilienfeld, “Socioeconomic
status
and
some
precursors
of
neuropsychiatric disorder,” American Journal
of Orthopsychiatry 26 (1956), 594-601.
18
Rowland V. Rider, Matthew Tayback,
and Hilda Knobloch, “Associations Between
Premature Birth and Socioeconomic Status,”
AJPH 45.8 (Aug. 1955), 1022–28.
19
Joseph Wortis, “Mental Retardation as a
Public Health Problem,” AJPH 45.5 (May
1955), 632-36; 1966 HEW Annual Report, 50.
20
Shorter, The Kennedy Family, 7-9.
21
Park, The Harriet Lane Home, 270-71;
"Planning in Mental Retardation,” AJPH 47.11
(Nov. 1957), 1482; Paul V. Lemkau, memo on
suggestions for collaboration between the
School of Hygiene and Kennedy Habilitation
Center
for
Physically
and
Mentally
Handicapped Children Jan. 10, 1967, JHSPH
Dean’s Office Correspondence Series 3a, box
504582, "Mental Hygiene" folder; Robert E.
Farber to Ernest L. Stebbins Jan. 22, 1965,
JHSPH Dean’s Office Correspondence Series
3a, box 506162, “Eastern Health District 196365” folder.
22
Shorter, The Kennedy Family, 80-82;
Park, The Harriet Lane Home, 311-12; Robert
E. Cooke to Wilbur J. Cohen, assistant
secretary of HEW, Mar. 30 and July 10, 1961,
Robert E. Cooke papers, box 14JF, "NICHD:
Comprehensive, General (through December
31, 1961)" folder, AMC; “Chronology of
Events,” The NIH Almanac.
23
Hilda Knobloch, Benjamin Pasamanick,
and Earl S. Sherard Jr., “A Developmental
Screening Inventory for Infants,” Pediatrics
38.6 (1966), viii-1.
24
Ali A. Kawi and Benjamin Pasamanick,
“Prenatal and Paranatal Factors in the
Development
of
Childhood
Reading
Disorders,” Monographs of the Society for
Research in Child Development, serial 73, vol.
24, no. 4, (1959).
25
Benjamin
Pasamanick,
“Myths
Regarding Prevalence of Mental Disease in
the American Negro: A Century of Misuse of
Mental Hospital Data and Some New
Findings,” Journal of the National Medical
Association 56.1 (Jan. 1964), 6-17.
26
Park, The Harriet Lane Home, 271, 300;
Kennedy, "Many Hidden Springs,” 18-19.
27
Shonick, Government and Health
Services, 92.
28
1961-62 SHPH Catalog, 45.
29
"Dr. Paul V. Lemkau, pioneer in mental
hygiene, dies at 82," Baltimore Sun Apr. 30,
1992; Lemkau bio file; 1957-58 Division of
Mental Hygiene Annual Report, JHSPH
Dean’s Office Correspondence Series 3a, box
505348, “President’s Report 1958” folder.
30
Paul V. Lemkau, Marcia M. Cooper, and
Guido M. Crocetti, "A laboratory method for
teaching mental hygiene," AJPH 57.12 (Dec.
1967), 2158-62.
21
3. Mental Hygiene and Behavioral
Sciences in the 1960s
In 1955, Herman Hilleboe, Health
Commissioner of New York State, designated
mental disorders as the single greatest cause
1
of disability and illness in America. In the
School of Hygiene, Abe Lilienfeld and Paul
Lemkau both recognized mental illness as
among the most common chronic diseases,
which they believed could best be controlled
with
a
synergistic
combination
of
epidemiological and social science methods.
Lemkau co-authored a Commission on
2
Chronic Illness prevalence study of “obvious
mental illness” in a representative population
sample of 12,000 in Baltimore, and found that
“after conservative estimation approximately
10 per cent of a noninstitutional urban
population are at one moment in time mentally
ill.” The School of Hygiene’s 1960 planning
document likewise judged “the most pressing
single problem in public health” to be mental
illness, but narrowly defined it in psychiatric
terms: “improved techniques for early
diagnosis of mental disturbance, for isolating
physiological and biochemical determinants of
such behavior, for crystallizing preventive
measures for such diseases both on an
individual and community basis and for
developing administrative practices designed
to reduce the present massive drain of such
behavioral difficulties upon society." More than
half of U.S. hospital beds were occupied by
mental patients, and the report called for
"prompt epidemiological exploration coupled
with multidisciplined laboratory research on
biochemical,
pharmacological
and
physiological fronts, all directed toward solving
the problem of mental health." In the view of
the Department of Psychiatry and the
medically-oriented faculty in the School of
Hygiene, “the problem of mental health” was
one of correcting abnormal behavior in
individuals. 3
The 1960s was a watershed decade that
elevated the status of social and behavioral
sciences in academics generally and in public
health particularly. From the federal to the
22
local level, public health agencies accorded
increased funding and attention to preventing
and treating mental illness, and also initiated
new programs that decriminalized substance
abuse and treated it as a form of mental
illness. In schools of public health, the
evolution of social epidemiology methods to
address
problems
such
as
sexually
transmitted disease and narcotics addiction
had important broader implications for risk
factor
epidemiology
and
behavioral
interventions to improve health. Behavioral
sciences evolved to become a methodological
tool
that,
alongside
biostatistics
and
epidemiology, could be used to study any
public health problem.
The Division of Mental Hygiene had
played increasingly significant roles in the
School’s teaching and research programs, but
it did not become a full department until 1962.
By the mid-1950s, most schools of public
health had reduced their emphasis on
traditional laboratory sciences such as
bacteriology in favor of applied fields including
behavioral sciences, sociology, and public
health
administration.
Johns
Hopkins,
however, clung to its traditional strength in labbased
research
and
postponed
the
development of any new social or behavioral
science courses. Ruth Freeman, head of the
public health nursing division of the
Department of Public Health Administration,
was a member of the American Public Health
Association task force that recommended
expanding the public health curriculum to
increase content from social and behavioral
sciences, administration, economics, and
communications. Freeman urged Dean Ernest
Stebbins to apply these recommendations at
the School of Hygiene, exclaiming that she
wanted Johns Hopkins to be “ahead of the
parade instead of behind it!” 4
Freeman identified psychiatric public
health nursing as an important growth area
and recommended enrolling more nurses and
adding a nurse to the Division of Mental
Hygiene faculty. Freeman and Lemkau
recruited Betty Cuthbert, coordinator of
behavioral sciences at the Johns Hopkins
Hospital School of Nursing. Cuthbert was in
the 1959 MPH class with Wallace Mandell
and Abraham Schneidmuhl, who were the
only three MPH students that year with mental
health experience. Cuthbert joined the Mental
Hygiene faculty and led efforts to coordinate
training in psychiatric and public health
nursing among the Johns Hopkins Hospital,
School of Medicine, and School of Hygiene.
Yet as the School of Hygiene shifted more
heavily toward research during the 1960s,
faculty who were not primarily researchoriented lost influence, including Freeman and
Cuthbert. Nurses were also at a disadvantage
because available grants in their field stressed
training, not research, and the Department of
Mental Hygiene slowly lost its early focus on
5
psychiatric nursing.
At the medical school, the Department of
Psychiatry embraced the social and behavioral
sciences. The Introductory Psychiatry Year II
clinical course was renamed Social Sciences
and Medical Psychology in 1959 and changed
again to The Sciences of Behavior in 1961.
The course introduced "the fundamental
concepts and methods of psychology and
sociology and their interrelationships with
anatomy, biochemistry and physiology as they
pertain to psychiatry and to medicine
generally” as well as “the implications of all of
these basic sciences for human personality
and behavior." After the Department of
Psychiatry was renamed Psychiatry and
Behavioral Sciences in 1966, the course
surveyed "the behavioral sciences by
examining normal and pathological personality
functioning reflected in data and concepts
derived
from
clinical,
empirical
and
experimental studies in the fields of human
development, learning, communication, and
neurology." 6
Similar changes were afoot in the School
of Hygiene, which proposed to establish a new
Department of Behavioral Sciences in 1960.
Significantly, however, the School’s longrange plan did not mention the existing
Division of Mental Hygiene, which had never
been oriented toward clinical or basic science
research. Lemkau held a joint appointment in
the medical school but had little interest in
collaborating with somatic psychiatrists. His
catalog statement for Mental Hygiene omitted
the biological causes and drug treatments for
mental disorders; instead, these conditions
were “closely related to cultural, sociologic,
and family environment . . . as well as to the
impact of experiences at different periods of
development of the central nervous system
7
and personality.”
Lemkau and his close ally Paul Harper,
head of the Division of Maternal and Child
Health, had lobbied Stebbins for years to grant
their divisions departmental status. As dean,
Stebbins guided the School through a period
of financial hardship which ended in 1958
when Congress passed the Hill-Rhodes Act
providing direct grants to schools of public
health. With the School on more stable
financial footing, four new departments were
established in 1962: Mental Hygiene, Maternal
and Child Health, Chronic Diseases, and
Radiological Sciences. They were joined in
1967 by a new Department of Behavioral
Sciences, which emphasized a sociological
approach to understanding population health.
Throughout the 1960s, the School of
Hygiene
welcomed
more
sociologists,
psychologists, economists, and demographers
who contributed to public health research on
family planning, community mental health
programs, social and cultural factors in the
etiology of chronic diseases and aging,
comparative
animal
behavior,
and
international health manpower planning. By
1963, ten courses in six departments featured
social and behavioral science content,
including the economic and political aspects of
financing and organizing health services. The
most fundamental such course, Behavioral
Science Perspectives in Public Health,
introduced
methods
in
anthropology,
sociology, and psychology as applied to
“socially-induced pathology in the individual.”
As a wave of concern over the deteriorating
morals of America’s youth washed over the
media and popular culture, School of Hygiene
students discussed case studies on the
problems of "mental deficiency, neglect,
23
delinquency, illegitimacy, abortion, and birth
8
control.”
In 1968, the School of Hygiene opened its
new $4.5 million eight-story Behavioral
Sciences Wing, which enabled the School to
double its enrollment. In 1969, the School’s
ten-year planning document proposed to add
100 faculty positions by 1978-79, with 22 in
Behavioral Sciences, the largest increase of
any department. This wild-eyed optimism for
the future of Behavioral Sciences flowed from
the charisma and vision of founding chair Sol
Levine, a then-steady torrent of federal grant
money, and the expectation that the
department would lead the way in promoting
interdepartmental research and turning out
9
large numbers of doctoral students.
The 1960s social science zeitgeist
increased federal funding for doctoral and
postdoctoral mental health training. Lemkau
and his successor as chair, Ernest Gruenberg,
both emphasized the fundamentally social
nature of mental health and illness. Lemkau
declared in 1961, “the facts [from community
mental health surveys] speak loudly of the
association between social welfare and
psychiatry, between social welfare planning
and psychiatric planning. From a therapeutic
viewpoint, no modern psychiatrist imagines
that psychiatric illness is cured by absolutely
individual treatment. . . . ‘A sound mind in a
sound body’ is no longer an adequate aim.
Social psychiatry is more than a fad, and the
aim must now be ‘a sound mind in a sound
body, a sound family and a sound community’
if it is adequately to express present health
notions.” 10 Lemkau, Gruenberg, and other
advocates of social psychiatry and preventive
mental health influenced the National Institute
of Mental Health to offer specialty training
fellowships in fields such as cultural
anthropology,
sociology,
and
social
psychology, which were considered basic
11
sciences for mental health and psychiatry.
The Department also expanded its
activities and collaborations with laboratory
scientists. When David E. Davis left the
Department of Pathobiology in 1960, Mental
Hygiene inherited his Division of Vertebrate
24
Ecology and renamed it the Laboratory of
Comparative Behavior. Mental Hygiene
maintained ties to the Pathobiology studies of
population ecology, and the laboratory trained
students to observe and analyze the social
behavior of animals in the field in order to
understand how different species maintained
their survival through mechanisms such as
mating and aggression, and how these
behaviors were governed by hormones,
heredity,
learned
experience,
and
12
environment. The program in comparative
behavior also included Stephen A. Weinstein
in Environmental Medicine. Weinstein held a
joint appointment in Psychiatry and Behavioral
Sciences in the School of Medicine, where he
directed the Laboratory of Behavioral
Physiology.
He
started
the
journal
Communications in Behavioral Physiology and
13
Pharmacology in 1966. In the Department of
Biochemistry, Bacon F. Chow’s research
team studied the effects of low protein diets in
pregnant rats on the physical and behavioral
development of offspring. The researchers
also tested methods of reversing these
adverse effects following birth, and found that
feeding the offspring crude pituitary extract
could prevent both physical and behavioral
14
abnormalities from developing.
With this promising foundation, Mental
Hygiene began offering a PhD in comparative
animal behavior in 1965, directed by Edwin
Gould, whose research on bats and shrews
involved
observation
of
mother-infant
interactions (otegeny) and communication
during echolocation. Gould also studied
homing behavior in turtles by fitting them with
tiny radio sets to track them as they crawled
down the halls of the School of Hygiene.
During the 1970s, Gould’s research received
$50,000 annually from the National Science
Foundation and the National Institute for Child
15
Health and Human Development.
Another researcher who used animal
models to study infant development and
behavior was Wallace Mandell, who observed
the effects of maternal alcohol use on rats and
their young. With their similar research
interests, Mandell and Gould taught a course
on comparative mammalian behavior and
infant development. By the early 1970s,
researchers from several countries had
identified maternal alcoholism as a factor in
birth defects and premature birth, and had
also observed withdrawal symptoms in infants
born to alcoholic mothers. But studies of
human alcoholic mothers were complicated by
additional variables such as race and
socioeconomic status, as well as levels of
nutrition, prenatal care, stress, and anxiety,
which made it difficult for researchers “to
divide the factors and isolate the problems
caused by the ethanol component, particularly
in prospective studies.” Mandell concluded,
“Since the proper control over genetic,
environmental and nutritional variables is
difficult in a population of alcoholic patients,
investigations using animal models are
desirable." In his NIAAA grant project, Mandell
used rats to study the effects of gestational
ethanol use on prenatal development and the
offspring’s
subsequent
behaviors.
Experimental and control groups of mothers
were
compared
for
performance
on
development and behavioral tests, and their
offspring were equipped to self-administer
ethanol intragastrically to test their sensitivity
to alcohol. To isolate the effects of ethanol
from those of nutritional stress, Mandell
replaced the calories from ethanol intake with
an equivalent amount of carbohydrate, and
also fed the control and experimental animals
in pairs.
As the largest sponsor of research in the
School of Hygiene and Public Health from
1960 to 1980, the NIH profoundly influenced
the size, structure, and agendas of the
School’s departments. Prior to 1970, Mental
Hygiene had received NIMH training grants
but little for research; after 1970, NIH funding
guided the outcome of administrative
realignments within the School, and ensured
that Mental Hygiene remained an independent
department. 16
1
Herman E. Hilleboe, "Public Health in a
Changing World," AJPH 45, (Dec. 1955),
1517-1524.
2
The Commission on Chronic Illness was
established in 1947 by the American Hospital
Association, American Medical Association,
American Public Health Association, and
American Public Welfare Association. AJPH
37.10 (Oct. 1947), 1256; AJPH 39.8 (Aug.
1949), 1079.
3
Benjamin Pasamanick, Dean W.
Roberts, Paul V. Lemkau, and Dean E.
Krueger, “A Survey of Mental Disease in an
Urban Population. I. Prevalence by Age, Sex,
and Severity of Impairment,” AJPH 47 (Aug.
1957), 923-29; "A Long Range Plan for the
Development of the School of Hygiene and
Public Health" Feb. 13, 1960, JHSPH Dean’s
Office Correspondence Series 3a, box
R111F2, pp. 9-10.
4
Ernest L. Stebbins to Thomas Turner
Dec. 7, 1956, Comments from Staff Members
binder, and Ruth B. Freeman to Thomas
Turner Jan. 25, 1957, Subcommittee to
Review the Curriculum binder, Committee to
Review the Educational Objectives of the
School of Hygiene and Public Health.
5
1961-62 SHPH Catalog, 62, 75, 87;
1964-65 SHPH Catalog, 45; Mandell interview.
6
1964-65 SOM Catalog, 113; 1966-67
SOM Catalog, 117.
7
1961-62 SHPH Catalog, 45.
8
Proposal for a Program in Sociology and
Public Health, 3-5; 1959-60 SHPH Catalog,
43; 1960-61 SHPH catalog, 45; 1962-63
SHPH Catalog, 55-57; 1963-64 SHPH catalog,
35, 55; 1964-65 SHPH Catalog, 56.
9
"A Ten-Year Plan for the School of
Hygiene and Public Health," preliminary draft
Feb. 1969,
JHSPH Dean’s Office
Correspondence Series 3a, box R111F2;
Press release Dec. 15, 1964, Records of the
Office of the JHU President, series 6, box 13,
"Hygiene-General (1964)" folder.
10
Paul V. Lemkau, “Community Planning
for Mental Health,” Public Health Reports 76.6
(June 1961), 489-98, quote p. 489; Ernest
Gruenberg,
“Socially
Shared
Psychopathology,” ch. 7 in A. Leighton, J. A.
Clausen, and R. N. Wilson, eds., Explorations
in Social Psychiatry (Basic Books, Inc., 1957).
25
11
Paul V. Lemkau, “On the Limits of
Mental Health,” AJPH 59.2 (Feb. 1969), 20607.
12
1961-62 SHPH Catalog, 52; Paul V.
Lemkau, Report of the Department of Mental
Health 1963-64, "Mental Hygiene" folder.
13
Stephen A. Weinstein to Milton S.
Eisenhower July 25, 1966, Records of the
Office of the JHU President, series 6, box 13,
"Hygiene-General (1966)" folder.
14
1973-74 Report of the Dean of the
School of Hygiene and Public Health, 6.
15
3a: D.O. Correspondence, box R111F4,
"Sch of Hyg Committee on PhD programs"
folder; "Dept. H33 Mental Hygiene Current
Grants and Contracts" Dec. 9, 1974 and David
E. Price, memo to Steven Muller, Russel H.
Morgan, Robert M. Heyssel, Richard S. Ross,
and Harry Woolf Apr. 7, 1975, 3a D.O.
Correspondence, box R111F6, "Sch of Hyg
Search Committee for Chairman, Department
of Mental Hygiene" folder.
16
Mandell bio file; Wallace Mandell to
John C. Hume Oct. 3, 1975, 3a D.O.
Correspondence, box R111F6, "Mental
Hygiene" folder.
26
4. Treating substance abuse
NIH grants substantially expanded clinical
and basic science activities throughout the
School of Hygiene, even in departments not
traditionally
oriented
toward
laboratory
investigation such as Mental Hygiene. The
Department was an early pace-setter in
alcohol and drug abuse epidemiology, and its
faculty served as key consultants to develop
the substance abuse research programs of
NIMH and two new NIH institutes: the National
Institute on Alcoholism and Alcohol Abuse
(NIAAA) and the National Institute on Drug
Abuse (NIDA). During the 1970s, federal
grants for substance abuse prevention and
treatment were the primary source of growth
for the Department.
After the introduction of powerful new
psychoactive drugs such as thorazine,
psychiatry was decoupled from many forms of
organic disease, and substance abuse
emerged as an important new area of clinical
and basic science research. Abraham M.
Schneidmuhl, director of the mental health
clinic in the Eastern Health District, had
worked with Marcia Cooper’s Mothers
Advisory Service and found that many of the
children’s problems were connected to their
parents’ alcoholism. In 1960, Schneidmuhl
founded an alcoholism clinic with support from
the city and state health departments. A
psychologist and medical social worker
provided weekly group counseling for alcoholic
tuberculosis patients. The clinic was
advertised on local jazz and R&B radio
stations, and it quickly attracted patients of
both sexes and all age, racial, and social
groups. 1
Schneidmuhl worked with his MPH
classmate Wallace Mandell to establish the
EHD alcoholism clinic on a firm footing. They
saw a major need for programs to train
qualified staff to administer drug and alcohol
treatment programs, and Mandell helped
formalize a curriculum for a six-month
alcoholism counselors training program, which
grew rapidly. After Mandell left Baltimore to
work “within a public health conceptual
framework as to how to bring mental health to
Texas,” he continued to consult with
Schneidmuhl and further expanded the
program by obtaining a training grant from the
National Institute of Mental Health. But when
Mandell approached the Johns Hopkins
Hospital about hosting the training program,
hospital officials replied that “we train
2
doctors.”
Schneidmuhl and Mandell’s work on
alcoholism was part of the medicalization of
“social diseases” such as alcoholism and
syphilis that were transformed from objects of
moral condemnation to targets of public health
concern. After Prohibition ended in 1933,
levels of social drinking increased along with
what
psychiatrists,
sociologists,
social
workers, and other experts labeled “excessive,
pathological drinking.” Replacing the former
cultural authority of the temperance movement
was a group of academic researchers and
public health educators who framed habitual
heavy drinking as a new disease, alcoholism,
that
struck
victims
with
susceptible
physiological and psychological traits, whom
they labeled alcoholics. During the 1940s, the
founding of the Yale Center for Studies on
Alcoholism, directed by biostatistician and
physiologist E. M. Jellinek, and the National
Committee for Education on Alcoholism,
headed by publicist Marty Mann, signaled an
era of increased public awareness of and
funding for alcoholism as a problem that could
be solved by scientific research and
therapeutic intervention. 3
The alcoholic beverage and tobacco
industries embraced this paradigm, which
isolated alcoholism and respiratory problems
as individual aberrations from the otherwise
benign, even beneficial, rituals of social
drinking
and
smoking
depicted
in
advertisements and enjoyed by millions of
Americans. In 1954, the tobacco industry
created the Council on Tobacco Research. In
1969, the United States Brewers Association
enlisted Thomas B. Turner, the former chair
of Microbiology in the School of Hygiene and
dean of the School of Medicine from 1957 to
1968, to establish the Medical Advisory Group
27
(forerunner of the Alcoholic Beverage Medical
Research Foundation). The MAG advised the
association’s
members
and
conducted
research on the positive and negative health
effects of alcohol consumption. Key to both
industries’ support for research on alcohol and
tobacco use was their contention that their
products were not in themselves addictive,
and most consumers could use them
responsibly without harming their health.
Accordingly, the Carling Brewing Company,
which produced 800,000 barrels of beer
annually, hosted Schneidmuhl’s weekly
alcoholism treatment seminar in May and June
4
1964.
After the Department of Mental Hygiene
recruited Mandell in 1968, he formalized the
alcoholism counselors training program in
1971 as an MPH track. A few years later, with
a training grant from the National Institute on
Alcoholism and Alcohol Abuse, the program
prepared epidemiologists and administrators
for substance abuse treatment programs—the
first of its kind in the country. By the 1980s,
many directors of state programs were
Hopkins graduates. Yet the NIH began to
28
tighten requirements for training grants and
applicants had to prove that their program was
filling a shortage in a high priority professional
field. The counselor training program was
ultimately a casualty of the debate over
whether the state directors should have an
MPH and background in public health
administration. As state public health agencies
became more politicized and turnover
increased, the demand for administrators with
public health training waned. As Mandell
admitted, “We lost that battle.” 5
Lemkau had tapped Mandell to lead new
research initiatives that focused on preventing
and treating drug and alcohol abuse and drew
from a wellspring of federal mental health
grant programs. Mandell, a clinical and social
psychologist, had been on the front lines of
New York City’s heroin epidemic while working
with disadvantaged urban youth at the Staten
Island Mental Health Society’s Wakoff
Research Center. As a member of New York
Governor Nelson Rockefeller’s commission on
drug abuse, he had assisted in establishing
therapeutic communities to fill the gap in the
mental health system, which excluded drug
6
addicts and alcoholics from treatment.
Unlike alcohol or tobacco, narcotics were
illegal and popular culture invariably
demonized drug users. When the Public
Health Service Narcotic Hospital at Lexington,
Kentucky, opened in 1935, Surgeon General
Hugh Cumming had called narcotics addiction
an endemic but treatable disease whose
victims could be rehabilitated and returned to
society.
The
majority
of
work
in
psychopharmacology had been done at the
hospital’s Addiction Research Center, led by
Abraham Wikler, who published The Relation
of Psychiatry to Pharmacology in 1957. Yet
until the late 1960s, psychiatry was dominated
by psychodynamics and most psychiatrists
considered addiction research a backwater.
Public opinion and federal funding coalesced
around finding a solution to America’s drug
problem, portrayed in a series of often
sensationalistic exposés of the heroin
epidemic that struck inner cities and returning
Vietnam veterans. 7
Mandell was among a new breed of
policy-oriented mental health researchers who
fixed their sights on drug abuse and brought a
previously obscure field to the forefront of
psychiatry. Others included Danny Freedman,
chair of psychiatry at University of Chicago
and the world expert on LSD and
hallucinogens, and Jerome H. Jaffe, a leading
advocate
of
methadone
maintenance
treatment for heroin addiction who became the
first drug czar in 1971 under President Richard
M. Nixon. As Jaffe recalled, “We probably
broke all the rules for psychiatry as we had
been taught it—that you maintain your
distance,
you
don't
form
personal
relationships.
The
passivity
of
[psycho]analysis was not appropriate in the
8
arena in which I found myself.” Jaffe served
as director of the NIDA Addiction Research
Center in Baltimore from 1984 to 1989 and as
director of the SAMSA Office of Evaluation,
Scientific Analysis and Synthesis from 1990 to
1997. He is currently a clinical professor in the
Department of Psychiatry at the University of
Maryland School of Medicine with an adjunct
appointment in the Department of Mental
9
Health at the Bloomberg School.
In the 1970s, federal mental health policy
was redirected toward alcohol and drug abuse
treatment services and program evaluation.
NIMH was reorganized in 1973 as a unit of the
new Alcohol, Drug Abuse and Mental Health
Administration
(ADAMHA),
which
also
included NIAAA and NIDA. These entities
provided strong financial support for research
on substance abuse and also lay the
foundation for the major expansion of the
10
treatment system. As Mandell recalled, when
Nixon charged him and Richard A. Lindblad,
associate director of NIDA, with creating a
network of drug addiction treatment services,
there was no precedent, so they based their
proposals for drug abuse clinics on the
alcoholism model. By 1973, the treatment
programs had been up and running for several
years and Nixon selected Mandell to evaluate
the NIMH grant program in drug abuse
research. On September 11, 1973, the
president announced to a White House
conference on the heroin problem that “we
have turned the corner on drug addiction in
11
the United States.”
Yet Mandell could not
find strong evidence that NIMH grantsupported programs were achieving better
results than those without federal support.
Nixon was furious and sent Mandell packing
back to Baltimore. When he told John C.
Hume, dean of the School of Hygiene, Hume
said philosophically, “Presidents come and go
but the university remains.” Still shaken from
his encounter with Nixon, Mandell was so
relieved to hear Hume’s encouraging
12
response that "I could have kissed him.”
Alcoholism
proved
somewhat
less
politically hazardous than drug abuse. To
house a residential alcoholism treatment
facility, Mandell and Schneidmuhl converted
Baltimore’s Old Bohemian brewery, where
workers had previously lived onsite. Instead of
simply releasing patients with no follow-up, as
existing hospital programs did, the residential
program used the period immediately after
detoxification to educate recovering alcoholics
and connect them with outpatient resources.
This evolved to become the Johns Hopkins
Hospital comprehensive alcoholism treatment
program, which Mandell launched with a grant
13
from NIAAA.
In 1972, Mandell also established the JHU
occupational alcoholism treatment program,
which offered outpatient counseling and
medical services as well as in-patient
detoxification to 130,000 employees of twelve
Baltimore companies. The program received
funding from the U.S. Department of Labor to
prevent job loss among problem drinkers as
well as to counter the negative effects of
workplace alcoholism on productivity, and it
became a model for other employee treatment
programs. But when Department of Labor
policy precluded Mandell from maintaining
control of the data generated by the program,
Dean Hume made him return the $300,000
grant. Perhaps Mandell’s most far-reaching
research on the epidemiology of substance
abuse was a NIAAA study begun in 1979 of
relationships among alcohol control policies,
characteristics of counties, and sex- and race29
specific liver cirrhosis mortality in over 3,000
14
U.S. counties and 100 cities.
When Paul Lemkau announced his
retirement as chair of Mental Hygiene in 1974,
Dean Hume appointed a search committee to
find a new chair. Abe Lilienfeld, a key
collaborator in the Department's early studies
of prematurity and developmental disabilities,
had just retired as chair of Epidemiology and
now served as interim chair of Mental
Hygiene. The search committee surveyed the
current state of the fields of mental health and
psychiatry, which were “in confusion and
disarray” because “the amateur counsellors
[sic] and encounter groups are taking over.”
According to the committee, half of all medical
school psychiatry departments were led by
acting chairmen. Moreover, only four schools
of public health housed departments of mental
hygiene or the equivalent (and all but the
department at Johns Hopkins would fold by
the decade’s end). The committee concluded,
“the need for new initiatives in the field of
Mental Health is apparent.” 15
Initially, dean emeritus Ernest Stebbins
called to offer the chairmanship to Alan Miller,
who was preparing to retire as New York State
Mental Health Commissioner. Miller declined
in favor of becoming dean of students at
Albany Medical College, where he led in
establishing a community mental health
center. Miller suggested his longtime New
York colleague Ernest M. Gruenberg, who
had headed the state's Mental Health
30
Research Center and was now chair of
psychiatry at Columbia University. After 52
meetings, the search committee offered
Gruenberg the chairmanship in May 1975. In
addition to his considerable administrative
experience in mental health agencies,
Gruenberg had published extensively on
mental
health
epidemiology and
the
distribution of mental disorders in populations,
specializing in evaluating the effectiveness of
integrated services to treat schizophrenia. 16
The search committee had also faced
fiscal and administrative pressures from within
the University for some form of merger
involving
Mental
Hygiene,
Behavioral
Sciences, and Psychiatry, but all three
remained independent departments. Although
Mental Hygiene remained a relatively small
department,
Gruenberg
and
Mandell’s
success in attracting federal grants from a
range of agencies enabled research activities
and fellowship support to grow. In 1970-71,
the Department of Behavioral Sciences had
been significantly larger than the Department
of Mental Hygiene as measured by budget,
faculty, and student enrollment, and both
departments received roughly three-quarters
of their funding from federal grants. But by the
end of the decade, federal grants enabled
Mental Hygiene’s budget to more than triple,
while Behavioral Sciences’ budget shrank and
became dependent on general funds for
nearly two-thirds of its support. 17
Mental Hygiene External Funding in 1974
Investigator
Gould
Lemkau
Lemkau
Lemkau
Lemkau
Mandell
Research topic
Maternal-infant behavior and
echolocation
EHD child mental hygiene clinics
Drug abuse demonstration project
Mental health in public health
Training grant
Substance abuse training and research
Total:
Annual amount
Funding agency
$50,000 NSF and NICHD
$70,000
$80,000
$100,000
$55,000
$750,000
City of Baltimore
NIDA
NIMH
NIMH
Dept. of Labor/
NIAAA
$1.15 million
Source: "Dept. H33 Mental Hygiene Current Grants and Contracts" Dec. 9, 1974, "Sch of Hyg
Search Committee for Chairman, Department of Mental Hygiene" folder; 1973-74 JHU Supporting
Schedules to the Financial Statements, 75.
Behavioral Sciences and Mental Hygiene Departmental Funding, 1970-71 and 1979-80
Year
1970-71
1979-80
Department
Behavioral Sciences
Mental Hygiene
Behavioral Sciences
Mental Hygiene
Total Budget
$353,000
$237,000
$281,000
$962,000
General Funds
$29,000
$50,000
$181,000
$307,000
Government
$271,000
$188,000
$88,550
$620,000
Source: 1970-71 JHU Treasurer’s Report, 54-55; 1979-80 JHU Long Form Financial Report, 116.
31
David Celentano
In the 1980s, the social science methods
originally used to address “social diseases”
such as syphilis and substance abuse were
marshaled against the AIDS epidemic. The
career of one of Mandell’s students illustrates
how social and behavioral science methods
profoundly influenced the development of risk
factor epidemiology. In the early 1970s, David
Celentano had taken a year off after earning a
bachelor’s degree at Hopkins to work in the
University
of
Maryland’s
methadone
maintenance program “in the deepest, most
horrible part of Baltimore, really getting to see
what human suffering and misery were all
about. And when it came time to consider
going to medical school, I thought, ‘I’m never
going to save them one at a time.’” Celentano
instead enrolled in Mandell’s eleven-month
alcoholism
counseling
program,
which
included rotations at different inpatient and
outpatient treatment centers in Baltimore.
Celentano was in one of the earliest cohorts,
“a very close-knit group” of about a dozen
mostly male students, including three or four
recovering alcoholics. The students discussed
their field experiences and learned new
methods for program evaluation. At the time,
substance abuse treatment programs were
rarely expected to show proof of their
effectiveness. Even the Baltimore City Health
Department program was small and had no
coordinated data. 18
Celentano enrolled as a doctoral student
in Behavioral Sciences on an NIAAA
fellowship. His dissertation with Mandell and
32
epidemiologist George Comstock addressed
the epidemiology of alcoholism at a
community level in Hagerstown, Maryland.
Celentano learned to compare different ways
of estimating the prevalence and risk factors
for alcoholism. His doctoral training combined
“the strengths of epidemiological methods and
the theoretical rigor of the social sciences,”
which developed Celentano’s “entire approach
to looking at risk factors and [their]
immutability for different kinds of health
19
conditions.”
Celentano joined the Behavioral Sciences
faculty in 1978. In the 1980s, Celentano and
Mandell applied their expertise in substance
abuse prevention and treatment to addressing
the AIDS epidemic, and they advised B. Frank
Polk, who headed the School’s infectious
disease epidemiology division, on the School’s
early grants to explore the connections
between HIV infection and injection drug
20
use. Celentano was a co-investigator for the
ALIVE (AIDS linked to the intravenous
experience) observational cohort study of HIV
infection among 3,000 intravenous drug users
in Baltimore since 1987. Using baseline data
from the ALIVE study, Celentano’s group
demonstrated that users who bought drugs or
syringes at shooting galleries (clandestine
locations to buy and use drugs, usually in
abandoned housing) were at much higher risk
of acquiring HIV from using dirty needles. This
insight led to further research on who used the
shooting galleries and why, which addressed
the upstream factors rather than just the route
of the infection.
With ALIVE principal investigator David
Vlahov, Celentano deployed data from the
ALIVE study to overcome the resistance of the
Baltimore City Council and the Maryland State
Legislature, resulting in the establishment of
the largest needle-sharing program in the
country. Needle-sharing programs have
become a prime example of how public health
interventions must address social and
behavioral factors in order to be effective. 21
The AIDS epidemic bolstered the legitimacy of
social and behavioral science methodologies
and promoted their widespread adoption as
indispensable tools for public health research
and practice. In 2009, Celentano became the
first non-MD in the School’s history to chair the
Department of Epidemiology, so that three of
the School’s ten departments were headed by
social or behavioral scientists.
During the 1980s, faculty from Mental
Hygiene and the Johns Hopkins Health
Services Research and Development Center
conducted
foundational
research
on
substance abuse epidemiology in the U.S.,
particularly the quality and availability of
substance abuse treatment services and their
impact on health care organization and
financing. Controlling the risks and minimizing
the damage associated with drug and alcohol
use remains an epic task for U.S. and
international policymakers. Today, about onethird of the Department’s faculty focus on the
epidemiology and prevention of substance
abuse, the most prevalent behavioral disorder.
The Department's research has shown
that school-based interventions among early
elementary-age children are highly effective at
preventing or reducing the use of alcohol,
tobacco, and drugs later in life. Mental Health
faculty have also developed successful family
and community-based interventions to prevent
the onset of drug use among at-risk teens and
to rehabilitate those already using alcohol and
other drugs. Using the innovative methods
they developed and tested, Mental Health
faculty are employing new technologies for
understanding individual and ecological
sources of craving for addictive drugs. Their
findings will be used to craft evidence-based
programs to prevent relapse that can improve
the health and well-being of whole
communities. One promising new approach for
developing effective prevention methods is to
analyze neighborhoods’ influence on use of
alcohol and illegal drugs. 22
1
W. Sinclair Harper, Monthly ReportEastern Health District, Oct. 1960, Mar. 14,
1961, Jan. 9, 1963, Feb. 5, 1963, Oct. 4,
1963, Nov. 1963, Dec. 9, 1963, Feb. 6, 1964,
May 25, 1964, JHSPH Dean’s Office
Correspondence Series 3a, box 506162,
"Eastern Health District 1963-1965" folder;
Paul V. Lemkau, Report of the Department of
Mental Health 1963-64, "Mental Hygiene"
folder; DeWitt Bliss, "Abraham Schneidmuhl,
psychiatrist who trained alcoholism
counselors," Baltimore Sun July 20, 1994;
Tonya Taliaferro and Rosa Pryor-Trust,
African-American Entertainment in Baltimore
(Arcadia Publishing, 2003), 91-95.
2
Bliss, "Abraham Schneidmuhl”; Mandell
interview.
3
Lori Rotskoff, Love On the Rocks: Men,
Women and Alcohol in Post-World War II
America (University of North Carolina Press,
2002), 64-67.
4
Monthly Report-Eastern Health District,
June 30, 1964; “Artist's rendering of new
Carling Brewery to be built in Baltimore,”
Cleveland State University Libraries Cleveland
Memory Project website, accessed Sept. 28,
2011 at www.clevelandmemory.org; Brandt,
Cigarette Century, 332-38.
5
Mandell interview.
6
Philip D. Bonnet, "Mental Hygiene
Search Committee," Nov. 6, 1974, "Sch of Hyg
Search Committee for Chairman, Department
of Mental Hygiene" folder; Wallace Mandell bio
file, AMC; Wallace Mandell, Sheldon
Blackman,
and
Clyde
E.
Sullivan,
Disadvantaged Youth Approaching the World
of Work: A Study of Neighborhood Youth
Corps Enrollees in New York City (Wakoff
Research Center, Staten Island Mental Health
Society, 1969); Bliss, "Abraham Schneidmuhl”;
Mandell interview.
7
Caroline Jean Acker, “The Early Years of
the PHS Narcotic Hospital at Lexington,
Kentucky,” Public Health Reports 112
(May/June 1997), 245-47; Abraham Wikler,
The Relation of Psychiatry to Pharmacology
(Williams and Wilkins, 1957); Eric C.
Schneider, Smack: Heroin and the American
City (University of Pennsylvania Press, 2008).
8
“Conversation with Jerome H. Jaffe,”
Addiction 94.1 (1999), 13-30, quote p. 20.
9
Jerome H. Jaffe CV, JHSPH Faculty
Database.
10
NIH
Almanac,
http://www.nih.gov/about/almanac/historical/ch
ronology_of_events.htm, accessed Sept. 30,
2011; Mandell interview.
33
11
James Q. Wilson, “The Return of
Heroin,” Commentary Apr. 1975.
12
Mandell interview.
13
Mandell bio file; Mandell interview.
14
Ibid.
15
"Report of Mental Hygiene Search
Committee to Department Chairmen (Advisory
Board)" Jan. 7, 1974, and Russell H. Morgan
to David E. Price Apr. 17, 1975, JHSPH
Dean’s Office Correspondence Series 3a, box
R111F6, "Sch of Hyg Search Committee for
Chairman, Department of Mental Hygiene"
folder; 1974-75 University of North Carolina
School of Public Health Catalog, 86.
16
JHSPH Dean’s Office Correspondence
Series 3a, box R111F6, "Sch of Hyg Search
Committee for Chairman, Department of
Mental Hygiene" folder; Miller to Eaton June
12, 2013; Ernest M. Gruenberg CV.
17
1970-71 JHU Treasurer’s Report, 54-55;
1979-80 JHU Long Form Financial Report,
116.
18
David Celentano interview August 9,
2011.
19
Ibid.
20
Mandell interview.
21
Celentano interview; “Seminal HIVInjection Drug User Study Marks 20th
Anniversary,” Nov. 20, 2007, Johns Hopkins
School of Public Health News Center,
http://www.jhsph.edu/publichealthnews/articles
/2007/kirk_ALIVE_anniversary.html, accessed
online Oct. 15, 2011; D. D. Celentano, D.
Vlahov, S. Cohn, J. C. Anthony, L. Solomon
and K. E. Nelson, “Risk factors for shooting
gallery use and cessation among intravenous
drug users, AJPH 81.10 (Oct. 1991), 1291-95.
22
S. G. Kellam and J. C. Anthony
(1998),"Targeting early antecedents to prevent
tobacco
smoking:
Findings
from
an
epidemiologically based randomized field
trial," American Journal of Public Health
88(10), 1490-1495; N. Ialongo, L. Werthamer,
S. G. Kellam, C. H. Brown, S. Wang, and Y. &
Lin (1999), "Proximal impact of two first grade
preventive interventions on the early risk
behaviors for later substance abuse,
depression and antisocial behavior," American
Journal of Community Psychology 27, 599641.
34
5. Mental Hygiene in the 1980s and ’90s
In 1988, Paul Lemkau wrote in the
American Journal of Public Health, “Mental
diseases in all their protean forms again
appear to have outwitted the enthusiasts for
1
an easy-to-understand panacea.” Lemkau
spoke with over half a century of experience
as the foremost advocate of a coordinated
approach to preventing and treating mental
illness that addressed the full spectrum of
patient needs in both hospital and community
outpatient settings. At the turn of the twentieth
century, proponents of the centralization of
long-term psychiatric care in state hospitals
had argued that “although less expensive,
[local care] was substandard and also fostered
chronicity and dependency. Conversely, care
and treatment in hospitals, though more costly
initially, would in the long run be cheaper
because it would enhance the odds of
recovery for some and provide more humane
care for others.” Ironically, the same
arguments were refashioned in the postwar
decades to justify the opposite policy of
decentralization of care and devolution of
authority to local communities, with cost
2
savings as a driving force in policy change.
Often lost in condemnations of the abuses
and failings of state mental institutions was the
fact that they provided more long-lasting and
comprehensive social welfare benefits,
including food, housing, and medical care,
than would otherwise have been available to
most indigent patients, particularly those with
severe mental (and often physical) disabilities.
During the mid-twentieth century, in-patient
psychiatric care in state hospitals was the
largest item in many state budgets and usually
well above total public health expenditures.
For example, Alan D. Miller, who left NIMH to
serve as New York State Commissioner for
Mental Hygiene from 1966 to 1974, oversaw
the state's largest agency and among the
largest health agencies in the nation, with a
budget of over $400 million to care for more
than 111,000 patients in 19 state hospitals and
10 state schools for developmentally disabled
children. 3 As late as 1980, the $6.5 billion
spent by states on mental institutions equaled
the amount for public health services and
represented one-sixth of total state social
welfare
spending.
In
the
wake
of
deinstitutionalization, the noted neurologist
and psychiatrist Oliver Sacks saw a steady
stream of discharged patients who returned for
readmission based on their experiences that
“Bronx State [Hospital] is no picnic, but it is
infinitely better than starving, freezing on the
4
streets, or being knifed on the Bowery.” By
the 1980s, the mental health reform pendulum
had swung back as some critics condemned
community-based care for discharged mental
hospital patients as "in many ways a more
demoralizing, dehumanizing, and dangerous
5
situation" than mental hospital care had been.
While the debate raged on between
proponents of community-based versus
hospital-based mental health care, the
Department of Mental Hygiene at Hopkins
launched two major studies that would define
its mission for the next three decades: the
Epidemiologic Catchment Area Study, begun
in 1979, and a classroom-based intervention
35
initiated with the Baltimore City Public Schools
in 1983 to identify aggressive and disruptive
behavior in early elementary school students
and prevent subsequent negative outcomes
such as poor school performance, substance
abuse, and suicide. These studies established
the department's twin research emphases on
epidemiology
and
prevention,
both
emphasizing a life course epidemiologic
approach to inform population-based studies.
Shortly after Jimmy Carter took office in
1977, he established the President’s
Commission on Mental Health, chaired by
First Lady Rosalyn Carter. The Commission
issued a report calling for expanding research
to accurately determine the prevalence and
6
incidence of mental disorders. NIMH created
the Epidemiologic Catchment Area Program
(ECA) to measure the prevalence of mental
illness in the general population in sites
around the U.S. The agency recruited William
W. Eaton from his position at McGill to
coordinate the ECA program.
At Hopkins in 1979, Gruenberg teamed
with Morton Kramer in Mental Hygiene, Paul
McHugh, chair of the Department of
Psychiatry, and Sam Shapiro, director of the
Johns Hopkins Health Services Research and
Development Center, to apply for a grant to
establish Baltimore as one of five ECA
research sites. Kramer led the competition,
since he had been the first Chief of Biometrics
at NIMH and had founded its Office of
Program Planning and Evaluation in the
1960s, which evolved to become the Division
of Biometry and Epidemiology (including the
Center for Epidemiologic Studies). Kramer, a
1939 Sc.D. graduate of the School of Hygiene
and Public Health, was the first biostatistician
to focus exclusively on mental illness. His
major achievements include creating a model
reporting system
for mental hospital
admissions, discharges, and patients in
residence, and also establishing psychiatric
case registers at various U.S. locations. These
reporting systems and registries became
indispensable in efforts to chronicle and
understand de-institutionalization of patients
with chronic mental illnesses during a new era
of psychopharmacology. Kramer was so
effective at ensuring that epidemiological
methods and research received a high priority
Morton Kramer
Sam Shapiro, Don Steinwachs, and Ann
Skinner (not pictured) from the Health
Services Research and Development Center
collaborated closely with Mental Hygiene
faculty and colleagues at the University of
Maryland on research on individuals with
severe mental illness.
36
in NIMH grant programs that in 1968, Science
magazine reported that he had “contributed
more sense and less nonsense to [NIMH]
policy developments and public statements
than any other member of its staff.'' He served
on the Johns Hopkins Mental Hygiene faculty
7
from 1976 to 1984.
The survey employed lay interviewers who
underwent an intense two-week training
program to administer the complex survey
instrument. In order to determine incidence, or
the rate at which new cases form, as well as
the overall prevalence of mental illness, the
study required sites to conduct an initial
survey and a follow-up survey one year later.
The newly revised DSM-III Diagnostic and
Statistical Manual of Mental Disorders
introduced explicit diagnostic criteria and
classifications of mental illness. The ECA
survey operationalized these classifications
and generated psychiatric diagnoses by
incorporating the clinical diagnosis criteria for
the most prevalent conditions, including
depression, schizophrenia, panic disorder,
obsessive-compulsive
disorder,
and
substance abuse and dependence. Once the
survey identified individuals with a definite or
probable psychiatric disorder, follow-up
questions asked about utilization of mental
health services, including what types of
obstacles may have interfered with seeking
treatment. The ECA studies revealed that
about one-third of Americans would suffer
from at least one type of mental illness during
their lifetimes, and that mental disorders went
untreated in many cases. 8
The ECA Program was the first U01
cooperative grant program in the PHS, which
allowed federal agency staff to negotiate the
terms of a grant and influence its
development.
ECA’s
three
principal
collaborators at NIMH were Ben Locke,
Darrel Regier (who became director of the
American Psychiatric Institute for Research
and Education), and Bill Eaton, Assistant Chief
of the Center for Epidemiologic Studies. Eaton
noted that “the degree of psychological
introspection in the culture had changed a lot
by 1980. You could come and ask people,
basically, have they ever heard voices and
they won’t be completely offended or turn you
9
out the door.”
Carolyn L. Gorman, who began working
as an interviewer for the ECA study in 1979,
loved going door-to-door in East Baltimore.
Few residents refused to participate, despite
the personal nature and length of the survey,
which took about one-and-a-half hours to
complete. Gorman recalled that the questions
on mental illness were less likely to offend
respondents than those on drug use. By sizing
up a house based on the paint job and the
presence or absence or toys and flowers,
Gorman could usually predict whether the
inhabitant would participate. She had a
collection of Polish dolls, and would take a doll
with her on interviews. When one of the many
Polish women in the neighborhood saw her
doll, they would always agree to take the
survey. At the Survey Research Associates
rd
office on 23 Street, Gorman trained most of
the 30 interviewers who conducted the ECA
10
survey.
James C. Anthony, an epidemiologist in
Mental Hygiene who played a key role in the
ALIVE study, contributed to the Baltimore ECA
study’s sophisticated design, and Marshal
Folstein advocated incorporating the MiniMental Status Exam into the survey to identify
cognitive impairment and dementia. Shapiro
designed the questions on mental health
services utilization, which were required for all
five ECA sites. Gruenberg and McHugh, both
psychiatrists, were very skeptical of using a
survey interview to diagnose mental illness.
The Baltimore grant proposal included a
clinical reappraisal component that requested
all the respondents deemed positive for a
mental disorder and a sample of the
remainder to complete a structured interview
with a psychiatrist, who was blinded to the
results. The reappraisal checked the accuracy
of the survey questionnaire by comparing the
results with the clinician’s diagnosis. A total of
810 Baltimore respondents underwent the
appraisal, which represented a major effort
that confirmed the study’s scientific validity. 11
37
At NIMH, Bill Eaton helped to guide the
Baltimore study’s design and argued to
include its clinical reappraisal component at all
the ECA study sites. After winning an
ADAMHA Administrator’s Award for his
implementation of the ECA Program, Eaton
joined the Department of Mental Hygiene
faculty in 1983. The Baltimore study was
unique among the ECA sites for conducting
additional follow-up surveys beyond the oneyear mark. After the first two surveys in 1981
and 1982, the Baltimore study re-interviewed
the participants in 1993 (led by Eaton as
principal investigator, Anthony as co-principal
investigator, and Joseph Gallo as project
director) and again in 2004. One of the
somewhat surprising findings was the degree
to which major depressive disorder was
predictive of the new occurrence of important
physical conditions such as type 2 diabetes,
heart attack, stroke, and breast cancer. The
Department of Mental Health is currently
analyzing the data from four of the five ECA
sites and correlating it with the National Death
Index to determine the influence of
psychopathology on mortality. The outcome
will constitute the largest population-based
study of mental disorders and mortality ever
conducted, with more than 300,000 personyears of observation. 12
As New York City’s commissioner of
mental health in the mid-1950s, Lemkau had
worked very hard to get the school system to
establish the equivalent of a child guidance
clinic in the schools, which achieved modest
success. Lemkau believed that public schools
were the critical place for prevention and had
wanted to initiate collaboration with the
Baltimore City school system. Yet the
Department made little progress toward this
goal until 1982, when Sheppard G. Kellam
was appointed chair. Kellam, a public health
psychiatrist, has played a major role in
establishing concepts and methods for
prevention science and expanding knowledge
about early risk factors and their malleability.
As a faculty member in the Department of
Psychiatry at the University of Chicago,
Kellam met the famous community organizer
38
Saul Alinsky, who was assisting the residents
of the surrounding inner-city Woodlawn
neighborhood in their efforts to confront the
city government and the University of Chicago.
At the community board’s urging, Kellam
helped to develop programs to enable
psychiatric hospitals to provide continuity of
care with an emphasis on prevention. Kellam
observed, “in working through how to relate to
the community of Woodlawn, we learned a
great deal about public health, building
institutional community bases so that the
people that you were working with and
working under could have a say, a powerful
say, like kicking us out or not. In other words,
we’d have oversight by the community.” 13
In response to the concerns of Woodlawn
community leaders about the life course
trajectories of children on Chicago’s South
Side, Kellam in 1966 initiated a populationbased universal intervention study among all
first grade boys and girls (1,242). The study
followed their progress into adolescence,
young adulthood, and midlife, and analyzed
the reasons why some children matured into
healthy, productive adults and others
encountered serious mental, physical, and
social problems. The study attempted to
answer the critical question raised by the
controversial 1965 Moynihan Report, which
suggested that social pathology resulted from
living in communities that lacked strong social
norms, resources, and opportunities. In
contrast, Kellam and his colleagues at the
University of Chicago theorized that social
pathology was embedded at an early age and
was largely independent of factors such as
crime and unemployment, and thus could be
more effectively prevented in individuals. They
coined the term developmental epidemiology
to describe mapping the variation in
developmental paths leading to health or
disorders in defined populations. This
approach applied the public health/Meyerian
concept of the life course to mental health
epidemiology. As individuals moved through
various stages of life with corresponding social
fields (their family of origin, the classroom,
peer group, family of procreation, and
workplace), they had to accomplish a series of
social task demands. Failure in the early
stages would interfere with this progression
and predict failure in the later stages.
Like Lemkau before him, Kellam critiqued
mental health in the 1960s as “bereft of a
developmental approach.” His team worked
closely with Woodlawn community leaders to
develop and implement a developmental
epidemiological prevention research strategy
that precisely aimed interventions at early risk
factors. The Woodlawn Study was among the
first community studies to identify risk factors
for negative health and behavioral outcomes
in an urban minority population. For over four
decades, Woodlawn’s findings on the etiology
of problem behaviors have guided the
development of many preventive interventions.
In 1983, just after arriving at Johns
Hopkins, Kellam collaborated with Eaton, Jim
Anthony, and biostatistician Hendricks Brown
to submit an NIMH grant to launch a
preventive intervention to identify early
antecedents of long-term problem outcomes,
modeled on the Woodlawn Study. In close
partnership with the Baltimore City Public
Schools, Kellam’s team at the Hopkins
Prevention Research Center (PRC) began
with a cohort of 2,311 first-graders in 1985 and
1986, chosen from the same three census
areas in East Baltimore as the ECA. Kellam
continued to use Alinsky’s community
organizing principles, and worked extensively
with parents to build a base of support for the
intervention, which resulted in levels of
participation at 90 percent or higher. When the
Johns Hopkins IRB interacted with the
Baltimore City School Board, the IRB
members were used to focusing on the impact
of research on individuals, not communities.
The School Board members clashed with the
IRB to some extent because Kellam had been
so successful in ensuring that they maintained
ownership of the study. The IRB wanted to
require the study to obtain permission from
each student’s family, and didn’t recognize
“that somebody else in the community, namely
the School board, already had permission and
oversight and ownership and wasn’t about to
allow anybody to use the data no matter what
they wanted to do with it without the School
board overseeing it.”
The Prevention Research Center was one
of the first four such centers funded by NIMH
after Congress mandated that the agency
expand its efforts in prevention. After support
from NIMH faded, NIDA became the main
source of funding for research that examined
the behavioral antecedents of violence, risky
sex, substance abuse, and incarceration.
NICHD also provided support for the child
behavior and development aspects. The
center would ultimately track three cohorts of
children
in
large-scale
epidemiological
randomized field trials to test universal
preventive interventions in first- and secondgrade classrooms. The targeted outcomes
included drug and alcohol abuse and
dependence disorders, daily regular tobacco
use,
antisocial
personality
disorder,
delinquency, and incarceration. The study also
examined patterns in students’ use of schoolbased services as well as the centrally
important outcome of school failure. All of
these problem outcomes shared the early risk
factor of aggressive, disruptive classroom
behavior as early as first and second grades.
The study’s primary intervention was the
“Good Behavior Game,” a classroom behavior
management method for socializing children to
their role of student while offering teachers a
method for managing classroom behavior in a
way that does not compete for instructional
time. By young adulthood, Kellam’s team
observed
significant
and
meaningful
reductions for all of the problem outcomes
targeted
by
the
intervention.
Using
randomized designs crafted with community
and school support, the team examined not
only main effects but the variation in impact on
developmental
paths
and
outcomes.
Recognizing the vital need to bridge the
traditional gap between public education and
public health prevention research, Kellam
moved to the American Institutes for Research
(AIR), a non-profit research group known for
its focus on school and education research. At
AIR, he developed a new Center for
39
Integrating
Education
and
Prevention
Research in Schools, which provided a home
for the third of the three generations of
Baltimore prevention research. After a decade
at AIR, Kellam returned to the Department of
14
Mental Hygiene as Professor Emeritus.
From 1995 to 2002, the Prevention
Research Center was directed by Philip J.
Leaf. Leaf was trained as a sociologist and
came to Hopkins from the Yale Department of
Epidemiology and Public Health, where he
had directed the Center for Health Policy and
Research and previously the Center for Mental
Health Services Research at the Yale
Psychiatric Institute. Yale had been a site in
the Epidemiologic Catchment Area Study, and
Leaf knew Shep Kellam and Ernie Gruenberg.
Leaf and Eaton had both been students of
David Mechanic in the PhD program at the
University of Wisconsin-Madison, Leaf's
research had focused on prevalence rates of
mental illness in institutional settings such as
jails and nursing homes. Frustrated with the
lack of continuity after grant-funded academic
research studies ended, often with negative
effects on community trust in universities, Leaf
was motivated to find new ways for
universities to launch "something that was
40
useful and even if it didn't stay exactly the
same, continued to provide benefits to the
clients of the programs."
In 1991, Leaf interviewed for a faculty
position at Hopkins in Mental Hygiene, but
before he accepted the position, he arranged
meetings with key community leaders in
Baltimore such as City Councilman (and later
State Senator) Nathaniel J. McFadden and
community activist Lucille Gorham. He
discussed his plans to expand communitybased mental health services for children,
especially those who were victims or
witnesses of violence, and asked them
whether they wanted him to come down to
work with them. They agreed, based in part on
the strength of existing relationships among
the East Baltimore community, the Baltimore
City schools and health department, and the
Department of Mental Hygiene.
Leaf arrived just as the cocaine epidemic
was cresting, and heroin remained a serious
problem in Baltimore's poorest inner city
neighborhoods. By 1995, Baltimore City had
lost 25 percent of its 1950 population and the
homicide rate had peaked at 45 per 100,000
population. Within one of the nation's most
violent cities, East Baltimore had even higher
rates of shootings. Fewer than ten schools in
the entire city had at least 40 percent of
students performing at grade level on
standardized tests, and some schools posted
only one or two children who scored at grade
level. Although most children were covered by
the public health insurance plan, which the
School of Hygiene had helped to develop, few
schools had even part-time mental health
clinicians or counselors. Most importantly, few
East Baltimore clinicians knew how to provide
mental health services for children, and no
existing organizations were dedicated to that
purpose or even showed interest in reaching
children or adolescents. Although Baltimore
had changed dramatically since the 1960s
when Paul Lemkau first initiated mental health
programs in Baltimore City schools and
conducted research on police involvement in
psychiatric hospitalizations, Leaf would carry
on
Lemkau's
deep
commitment
to
strengthening community mental health
services.
Beginning in 1992, Leaf led a successful
federal grant in collaboration with the Johns
Hopkins Department of Psychiatry, Maryland
Department of Health and Mental Hygiene,
Baltimore City Health Department, and
Baltimore City Public Schools to expand
community-based mental health services for
children in East Baltimore. The $15 million
grant funded full-time mental health clinicians
in the 18 East Baltimore schools, trained and
hired community mental health workers, and
created the East Baltimore Mental Health
Partnership, which Leaf directed until 2000.
For twenty years, the Partnership and the
Johns Hopkins Community Mental Health
Center expanded and strengthened the
infrastructure of community mental health
services for East Baltimore youth, eventually
reaching more than 120 schools. In 2012,
however, the Johns Hopkins Department of
Psychiatry decided to end its contract to
provide services in local schools, which are
still provided by the University of Maryland,
Catholic Charities, and local providers.
Leaf recalled that in the first 18 months
that the Partnership was operating, three of
the children it served were shot. Many more
witnessed violence in their homes and
neighborhoods, and were often related to the
victims. "The police were enormously
frustrated, because they would come on the
scenes, see not just a traumatized individual
but a traumatized family member, and then
wonder what happened to those families."
After the Baltimore Police responded to a
hostage-taking incident in a housing project in
East Baltimore that was directly across the
street from an elementary school, Leaf
orchestrated the response and conducted
classroom discussions with the students about
what they had seen. Not only were victims of
violence at higher risk for developing
psychiatric disorders, they were also more
likely to become perpetrators themselves.
Acting on the realization that "getting
shot and getting killed in Baltimore is a public
health issue," Leaf has directed since 1996
the Child Development Community Policing
Program, which trains teams of police officers,
mental health clinicians, and community
volunteers to help families and communities to
recover from traumatic incidents of violence,
and to prevent the cycle of violence and
retribution from continuing. The keystone of
the program is relationships with community
leaders, who broker acceptance and trust of
the team members from Johns Hopkins and
the police department. The program responds
to specific crises, but also conducts outreach
in the schools, in homes, even in emergency
rooms where victims of violence were "talking
about who shot them and what somebody
should go do to the people that shot them."
Through counseling and conflict mediation,
Leaf and his team members have chipped
away at what had once been a solid wall of
violence and its sequelae. They have
generated new resources and strategies to
respond to a wide variety of needs expressed
by families and the community. Leaf was also
involved in helping Baltimore City Public
Schools secure major federal funding for its
Safe Streets, Safe Schools, Safe Students
program. Leaf elevated the mission of
prevention in 2000 by establishing the Johns
Hopkins Center for the Prevention of Youth
Violence, one of the first such centers funded
by the Centers for Disease Control and
Prevention.
Leaf emphasized that Baltimore is "one of
the few cities where we have a major
university, a large city, all the city and state
agencies, and the NIH" all within convenient
driving distance of each other. Leaf's group
has been meeting with the Maryland State
Department of Education every Tuesday since
1993, which he called "an enormous
opportunity for Johns Hopkins. We have the
State Department of Health, the State
Department of Juvenile Services, the State
Health Commission, within three or four miles
of Johns Hopkins, and now within three or four
subway stops." Leaf is but one of many Mental
Health faculty who work to facilitate
collaborations between the city and the state,
and among a wide variety of health, education,
41
social welfare, and community service
agencies from the private and public sectors.
Of course, such rich, diverse longstanding
partnerships also greatly facilitate research.
As Leaf observed,"there's also self-interest in
this. So I and my colleagues have been able
to get research grants to do randomized trials
across multiple school systems, because we
have these collaborations not just with
Maryland State Department of Education, or
not just with Baltimore City, but with lots of
school systems." By conducting carefully
designed evaluations and documenting the
effectiveness of community mental health
interventions, the Department of Mental Health
has been able to provide crucial evidence to
convince policymakers to expand successful
programs to reach more people. The
Department has also built a strong doctoral
training program focusing on the delivery,
organization and financing of mental health
services for children. Doctoral students are
able to draw from the research databases of
the Center on Organization and Financing of
Care for the Severely Mentally Ill and also to
collaborate with the Economics of Mental
Health program in the Department of Health
Policy and Management. 15
The Prevention Research Center was
renamed the Center for Prevention and Early
Intervention in 2004, when Nicholas Ialongo
was named director and Leaf stayed on as codirector. The Good Behavior Game remains
the cornerstone of the Center’s work to bridge
the traditional gap in prevention research
between public education and public health,
and Ialongo has broadened and deepened the
intervention’s scope to more fully explore the
extent to which aggressive and disruptive
behavior in early elementary-school children is
predictive of a wide range of problems later in
adolescence and adulthood, as well as
whether these problems can be prevented by
early intervention. Ialongo’s work has
examined the trajectory of not only aggressive
behavior but also other behavioral issues,
such as using first graders' self-reports of
anxious symptoms to predict their adaptive
functioning and anxious symptoms in fifth
42
grade. Over the next decade, the Department
plans to disseminate the Good Behavior
Game and other scientifically proven
classroom-based interventions to schools
around the country.
A new generation
of Mental Health
faculty is applying
the
prevention
research and classroom intervention
model
to
new
contexts such as
preventing bullying
in schools and
conducting mindfulness training to
help
adolescents
cultivate the ability to regulate emotions
effectively and enhance capacities for calm,
sustained attention. Catherine Bradshaw,
who is deputy director of the Center for the
Prevention of Youth Violence and co-directs
the Center for Prevention and Early
Intervention, studies the effects of school
climate on bullying; the development of
aggressive and problem behaviors; and the
effects of exposure to violence, peer
victimization, and environmental stress on
children. She is a nationally recognized expert
on cyber-bullying, and her research has
shown that in middle school, 25 percent of
girls and 11 percent of boys have been cyberbullied via cell phones or computers at least
once.
Based on a promising pilot study, Tamar
Mendelson is systematically evaluating
mindfulness training and yoga programs in
urban school contexts and measuring their
effectiveness in improving students' overall
behavior and ability to concentrate. The
intervention is designed to prevent mental and
behavioral disorders in adolescents, especially
those at high risk for school failure. 16
1
Paul V. Lemkau, "Mental Disorder and
Social Policy," AJPH 78.1 (Jan. 1988), 93.
2
Grob, “Deinstitutionalization,” 49.
3
“Rockefeller Names New Mental Aide,”
New York Times Jan. 30, 1966.
4
Shonick, Government and Health
Services, 187-90; Oliver Sacks, “Asylum,”
foreword to Christopher Payne, Asylum: Inside
the Closed World of State Mental Hospitals
(MIT Press, 2009), 5.
5
J. Westermeyer, “Public health and
chronic mental illness,” AJPH 77 (1987), 66768.
6
Gerald N. Grob, “Public Policy and
Mental Illnesses: Jimmy Carter's Presidential
Commission on Mental Health,” The Milbank
Quarterly Vol. 83, No. 3 (2005), 425-56.
7
William W. Eaton interview, Mar. 22,
2012; James C. Anthony and William W.
Eaton, “In Appreciation: Morton Kramer,
Sc.D.,” Social Psychiatry and Psychiatric
Epidemiology 34 (1999), 1-3.
8
Ann Skinner interview Mar. 14, 2012.
9
Eaton interview Mar. 22, 2012.
10
Carolyn L. Gorman interview Aug. 21,
2012.
11
Eaton interview Mar. 22, 2012.
12
Eaton interview Mar. 22, 2012; A.L.
Gross, J.J. Gallo, and W.W. Eaton,
"Depression and cancer risk: 24 years of
follow-up of the Baltimore Epidemiologic
Catchment Area sample," Cancer Causes &
Control 21.2 (2010), 191-99.
13
Sheppard G. Kellam interview Aug. 22,
2012.
14
Ibid.
15
Philip Leaf interview Mar. 8, 2013.
16
C.P. Bradshaw, E. Pas, J. Bloom, S.
Barrett, P. Hershfeldt, A. Alexander, M.
McKenna, A.E. Chafin, and P. Leaf, "A statewide collaboration to promote safe and
supportive schools: The PBIS Maryland
Initiative," Administration and Policy in Mental
Health and Mental Health Services Research
(2013); L. Feagans Gould, J.K. Dariotis, T.
Mendelson, and M.T. Greenberg, "A schoolbased mindfulness intervention for urban
youth: Exploring moderators of intervention
effects," Journal of Community Psychology
(2013).
43
6. The Department of Mental Health in the
st
21 Century
After Wallace Mandell had served as interim
chair from 1993 to 1997, John C. S. Breitner
was appointed the Department’s fourth chair.
Breitner’s research dealt with aging, dementia,
and cognitive decline, particularly epigenetic
conditions such as Alzheimer's disease in which
environmental
factors
influenced
genetic
expression. Breitner was well acquainted with
mental health at Hopkins and in East Baltimore,
since he had completed a two-year postdoctoral
fellowship in the Department of Mental Hygiene
in 1979 and had been on the Psychiatry faculty
at Johns Hopkins from 1977 to 1984. In a variety
of roles, Breitner led in providing mental health
services to East Baltimore residents, serving as
psychiatrist-in-chief and director of the Mental
Health Service of the East Baltimore Medical
Plan, medical director of the Baltimore City
Hospitals Community Psychiatry Program,
director of the East Baltimore Psychogeriatric
Needs
Assessment
Project,
and
staff
psychiatrist at the Johns Hopkins Hospital
Dementia Research Clinic. Breitner left in 1984
to hold positions at the Mount Sinai School of
Medicine and the Duke University Medical
Center before returning to Baltimore in 1997.
As P.I. for a National Institute on Aging grant
from 1994 to 2001, Breitner conducted a
prospective study of incipient dementia among
1,357 men and 1,889 women in Cache County,
Utah. The researchers investigated multiple
aspects of the epidemiology of dementia,
including the prevalence of neuropsychiatric
symptoms and the preventive effectiveness of
therapy with anti-inflammatory drugs, statins,
anti-oxidants, and vitamin E. The study
determined that vascular factors predict the rate
of progression in Alzheimer disease. Another
major finding was that hormone replacement
therapy reduced or eliminated the sex-specific
risk of developing Alzheimer disease, and that
the risk disappeared entirely with more than ten
years of treatment. Breitner was assisted on the
study by Peter P. Zandi and Michelle C.
Carlson, Mental Health faculty who specialize in
the mental health aspects of aging.
44
Along
with
Breitner, psychiatrist
George Rebok led in
developing research
and training programs
on the mental health
aspects of aging.
Rebok had begun his
graduate research on
aging in 1973, the
year
before
the
National Institute on
Aging (NIA) was established. He applied a
lifespan approach to developmental psychiatry,
and during his postdoctoral fellowship in
Psychiatry at Hopkins he began to emphasize
prevention while studying the effects of
dementia on older drivers. In 1989, Rebok joined
the Mental Hygiene faculty in the Center for
Prevention Research, and recalled that during
his job talk, “I kind of proudly announced that I
had like 120 people in my dissertation,” which
elicited giggles from an audience used to
dealing with thousands of people in populationbased studies. As the subjects of the
Epidemiologic Catchment Area and other large
longitudinal studies grew older, public health
researchers grew more interested in aging
issues. Rebok’s arrival at Hopkins also
coincided with increased public attention to the
social and economic implications of an aging
society,
championed
in
Congress
by
Representative Claude D. Pepper. An indicator
of the tremendous growth of the field of aging
within mental health research is the expansion
of the Cognitive Aging Conference, which began
with about 50 attendees in 1987 and reached
800 in 2012. 1
When Rebok joined the Department in 1989,
there were no community-based interventions
being conducted with adults. Since 1996, Rebok
has been the PI at Johns Hopkins, one of six
sites in the Advanced Cognitive Training for
Independent and Vital Elderly (ACTIVE) study,
the largest cognitive intervention among the
elderly in the United States. The intervention,
funded by NIA, focuses on improving cognitive
ability and preventing cognitive decline among a
cohort of about 3,000 subjects originally, with
approximately 40 percent still being followed. By
slowing or halting the loss of daily functioning,
the goal of the intervention is to “keep people
independent, and keep them out of nursing
homes. If we can improve things like people’s
memory ability, or their reasoning ability, or how
quickly they process information, then you could
improve their daily lives in areas such as
managing their medication, or managing their
finances, or being able to use transportation
better, or to prepare meals. All of the activities
that keep us functioning independently in
society.” Even after the active part of the
intervention to improve memory concluded,
follow-up studies have shown that the positive
effects persist for years afterward.
The ACTIVE study helped the Department
to think more broadly about Kellam’s concept of
developmental epidemiology, which addresses
risk and protective factors and how they vary in
defined populations over time. Rebok thinks
about risk factors dynamically, how they change
over the lifespan. “What’s a risk factor at one
period of life can become a protective factor at
another period of life, and vice versa. I’m really
trying to live up to the label of being a lifespan
researcher, and think in terms of the long reach
of childhood events into middle and later life,
and the importance of really starting
interventions early. And at the same time
realizing that it’s never too late to start
interventions, either.” This has been the basis
for Rebok’s lifecourse intervention, Experience
Corps, which trains older volunteers over 60
years old to volunteer in K-3 classrooms. Linda
Fried, director of the Johns Hopkins Center on
Aging and Health, developed the idea with Mark
Friedman to address the problems of patients
who presented in clinic reporting that they felt
listless, useless, and depressed.
The Experience Corps emphasizes the
value of older adults as a resource, and with NIA
funding since 2006, the Baltimore City Public
Schools have placed over 700 volunteers in over
20 schools. The volunteers become more
physically and socially active through their
interactions with children, teachers, and other
volunteers. This stimulation is also beneficial for
their cognitive ability, and Michelle Carlson has
demonstrated increased brain activity by
comparing volunteers’ MRIs at the beginning
versus the end of the school year. The presence
of Experience Corps volunteers in classrooms
has, in turn, proved highly beneficial for
students, with improved learning and behavior
outcomes as measured by test scores,
vocabulary, and decreased disciplinary referrals.
Teachers and principals agree that Experience
Corps volunteers have had a positive impact on
their schools’ atmosphere and culture. Although
Baltimore was one of the earliest Experience
Corps sites with the most clinical research
conducted to date, the Experience Corps model
has been successfully generalized in 20 cities
nationwide. Together, the ACTIVE Study and
Experience Corps have established the
Department’s extensive evidence base for
cognitive health interventions, and Rebok is
currently extending his research to conduct a
dementia prevention study among displaced
populations in Australia. He co-teaches a course
on Mental Health in Later Life with Joseph Gallo,
who worked with Rebok on the ACTIVE study.
Since 2007, Rebok has also been co-P.I. on an
NIA training grant with Marilyn Albert in
Neurology for the postdoctoral training program
in aging and dementia. 2
After Breitner left Hopkins in 2001, Bill Eaton
served as interim chair until 2004, when he was
appointed chair. The Department had always
been small with a half dozen or so faculty, and a
departmental self-study in 2003 recommended
that Mental Hygiene should double the number
of faculty and expand in the areas of mental
health services research and cognitive health
and aging. Under Eaton’s chairmanship from
2004 to 2013, the Department rebuilt its
master’s program to an enrollment of 15 to 20
students, and expanded the faculty to 19 full3
time positions. Currently, the Department hosts
over 80 students and fellows in degree
programs for the M.H.S., PhD, DrPH, and
postdoctoral training. Specialized training
programs include Psychiatric Epidemiology,
Children's Mental Health Services, Drug
Dependence, and Aging and Dementia.
In 2004, the Department embraced its new
identity by changing its name from Mental
45
Hygiene to Mental Health. The
School had dropped “hygiene”
from its historic name to become
the Bloomberg School of Public
Health in 2001, and Mental
Hygiene was the last vestige of
the old nomenclature. As Kellam
remembered, “there was a
general atmosphere in public
health that [hygiene] was sissy
stuff. I used to joke about it;
we’d have the orientation, you
know, for the new students—the
chairs would go up and we’d
make jokes about mental floss.
That’s what mental hygiene was,
4
you know.”
As
a
mental
health
epidemiologist, Eaton’s work
has focused on explaining the
risk factors, natural history, and
consequences of major mental
disorders, particularly schizophrenia. To study
schizophrenia and more common mental
disorders like depression and anxiety, he has
used data from from the Baltimore cohort from
the ECA study and psychiatric case registers in
several locations around the world. Like David
Celentano in the Department of Epidemiology,
Eaton is the first chair of Mental Health to hold a
PhD rather than an MD, and his training in
sociology frames his approach to understanding
the occurrence of what he terms “the subset of
bizarre behaviors that generally are labeled as
psychiatric disorders.” In the early 1990s, Eaton
began analyzing data on schizophrenia from the
system of registers in Denmark, whose rich data
sets made it the “best place to study
schizophrenia, from an epidemiologic point of
view.” By the 2000s, Eaton’s research had
evolved to point to the relationship of
autoimmune diseases to risk for schizophrenia.
Autism and schizophrenia have traditionally
been considered separate disorders, but new
research is pointing to common factors,
including increased risk among patients with
autoimmune diseases, especially celiac disease
and sensitivity to wheat. Eaton has extensively
explored these and other important risk factors
46
Shep Kellam with postdoctoral fellows
for schizophrenia and other psychoses. But
Eaton recognizes that “these theories are big,
black boxes. They don’t really know what’s
going on because the immune system is so
complicated. The most complicated organ on the
planet is the human brain. The next, most
complicated: human immune system. So you put
the two of them together, you’re out in infinity.” 5
One of Eaton’s school-wide contributions
has been the two-quarter series in measurement
that he created with biostatistician Karen
Bandeen-Roche in 1992. The joint course
teaches assessment techniques for human
subjects research, drawn from diverse fields
including
psychometrics,
sociology,
and
epidemiology.
Few
other
courses
on
measurement, so crucial to public health
research, draw from such a broad range of
disciplines. Students learn how to establish
different thresholds along a continuum that
defines a disease, such as hypertension, a
blood titer, an impairment, a disability, or a
cluster
of
symptoms.
Mental
health
professionals confront the issue of how to
quantify and categorize disease much more than
general epidemiologists and physicians do, but
the principles are the same for any type of
disorder or condition. Eaton notes that
“rheumatoid arthritis looks just like a psychiatric
disorder." In rheumatoid arthritis, "you have to
have a certain number of swollen joints. They
have to be symmetric,” and psychiatric diagnosis
likewise classifies disease based on how many
symptoms in a cluster are present. "The
advantage of public health is that we can
actually statistically evaluate the qualities of the
diagnosis in various, different ways. You need
epidemiology to do that because you need a
6
population-based sample to do it.”
Eaton and Anthony’s course in psychiatric
epidemiology helps students understand comorbidity, expressed as multiple variables.
Since psychiatric illnesses frequently occur
together, mental health epidemiologists are
ahead of the curve in understanding and treating
co-morbidity. As Eaton observes, mental
illnesses present the opportunity for primary
prevention of secondary disorders, for example
when depression is linked with anxiety, or vice
versa, treating the depression also prevents the
secondary disorder. “Now we think if you treat
depressive disorder, you’ll prevent strokes, and
heart attacks, and diabetes. The epidemiologic
evidence is very suggestive, but people haven’t
proven it yet.” Indeed, the Department’s current
research focuses on how patients actually use
medications with the goal of promoting
7
adherence to prescription guidelines.
In 1991, when Eaton served on the Institute
of Medicine Committee on Prevention of Mental
Disorders, the committee’s review of prevention
efforts to date identified only approximately a
dozen proven methods of preventing mental
8
illness. In the past two decades, there has been
such progress on prevention research that
approximately sixty mental disorders are now
regarded as preventable by intervention. Many
disorders, such as those caused by nutritional
deficiencies, infections, or head trauma, are
generally disappearing in the Western
industrialized countries, but are still common in
the developing world. Mandell noted, “once we
figured out how to prevent the disorder, it no
longer is considered a mental illness or in the
purview of psychiatry. Psychiatry is not involved
with prevention.” Unlike when Mandell began his
career in the 1950s, today, “mental health is
accepted as part of public health—both the
service delivery part and the prevention part.
And particularly, as the mental or psychiatric
institutions have disappeared from the
landscape, it becomes even more important that
there be a public health service system to help
mentally ill drug abusers and alcoholic
individuals in the community. And that’s the
current challenge that we are facing.” 9
Today, the Department continues to build on
its historic strengths in three areas: 1)
population-based approaches to preventing and
treating substance abuse disorders; 2)
psychiatric
epidemiology
and
statistical
methods, with applications for evaluating and
strengthening mental health systems, and 3) the
causes and prevention of developmental and
behavioral disorders from infancy through
adolescence. Since 2000, new research and
teaching programs have developed in the areas
of cognitive health and aging; youth violence;
socioeconomic
stratification
and
mental
disorders; psychiatric and behavioral genetics;
and global mental health. The Department hosts
four centers:
Founded
1983
Name
Center for Prevention
and Early Intervention
Director
Nicholas
Ialongo
2000
Center for Prevention
of Youth Violence
Phil Leaf
2006
Center for Mental
Health Initiatives
William
Eaton
2012
Moore Center for the
Prevention of Child
Sexual Abuse
Elizabeth
Letourneau
2013
Wendy Klag Center for
Autism and
Developmental
Disabilities
Daniele
Fallin
Mental Health faculty are also actively
involved in three university-wide centers based
in the Bloomberg School including the Center on
Aging and Health and the Urban Health Institute.
47
Purpose
Funding
Title
Year
Professorships and
Faculty
Recruitment
$3.62M
Sylvia and Harold Halpert Professorship
2005
Child Sexual Abuse Recruitment
2010
Dr. Ali and Rose Kawi Professorship
2011
Paul V. Lemkau Scholarship Fund
2002
Lucy Shum Memorial Scholarship
2010
Dr. Ali and Rose Kawi Scholarship Fund
2011
Center for Mental Health Initiatives
2006
Moore Family Center for Prevention of Child Sexual Abuse
2012
Morton Kramer Fund
2002
Annual Giving Fund
2002
Scholarships
Establish Centers
General Use
$204K
$7.5M
$30K
In just over a decade, the Department of
Mental Health has successfully increased
private support for its key programs. More than
50 donors (including private foundations) have
generously given over $11 million to establish
and advance critical research and training in
public mental health.
Mental Health faculty continue to make
major contributions to analyzing population-level
changes in mental health. The Department’s
well-established body of research on the use of
psychoactive medications, treatment-seeking for
psychiatric disorders (including the effects of
social stigma), and comorbidity of mental and
physical disorders will serve as the basis for
evaluating the 2010 Affordable Care Act’s
effectiveness in improving overall health and
mental health care for individuals with mental
and behavioral disorders. Faculty will use
simulation and forecasting techniques to predict
the long-term population-level impact of policies
on access to care, service utilization and
treatment outcomes. To provide a stronger,
permanent base for these activities, the
Department hopes to establish a Center for
Psychiatric Epidemiology, which will distill new
insights from existing national datasets that
currently sit underutilized. In collaboration with
the School’s other departments, Mental Health
students and faculty at the center will design
48
studies and answer important questions
regarding the future development of mental
health care in the U.S.
Going forward,
the Department will
apply
its
rich,
unique expertise to
bring public health
knowledge
and
methods to bear
on
the
most
complex
mental
health
issues
facing
societies
throughout
the
world, such as child sexual abuse and autism. In
2012, Mental Health established the Moore
Center for the Prevention of Child Sexual
Abuse, the first academic research center of its
kind. The Moore Center will promote a public
health approach to preventing child sexual
abuse through research, policy analysis and
education. “Our overarching goal,” founding
director Elizabeth Letourneau stated, “is to
move our nation’s response to child sexual
abuse from a criminal justice orientation,
focused on after-the-fact responses, to a more
comprehensive
approach
that
focuses
significant resources on the prevention of child
sexual abuse.”
Autism is another important emerging public
health problem that will demand increasing
mental health expertise reinforced by the unique
perspective of public health. By developing
sensitive screening instruments for detecting
developmental and intellectual disabilities and
by conducting research to guide and support
caregivers of autistic individuals, the Department
of Mental Health can make major contributions
toward solving the puzzle of autism and related
conditions.
M. Daniele Fallin, who succeeded Bill
Eaton as chair on July 15, 2013, is a genetic
epidemiologist who focuses on neuropsychiatric
disorders including autism, Alzheimer's disease,
schizophrenia, and bipolar disorder. She also
studies the genetic predisposition to features
affecting aging populations such as muscle
strength and frailty. Fallin comes to Mental
Health from the Department of Epidemiology,
where she directed the Center for Autism and
Developmental
Disabilities
Epidemiology
(renamed and expanded in 2013 as the Wendy
Klag Center for Autism and Developmental
Disabilities).
In January 2013, Fallin and co-investigator
David Valle, who directs the McKusick-Nathans
Institute of Genetic Medicine in the School of
Medicine, received a $2.5 million grant from the
Burroughs Wellcome Fund to support the
Maryland Genetics, Epidemiology and Medicine
program (MdGEM). The program, jointly
administered by the Bloomberg School and the
School of Medicine, will allow researchers to
cross-train genetic epidemiologists and human
geneticists
simultaneously,
increasing
collaboration and furthering the missions of both
fields.
Fallin finds a natural home in the
Department of Mental Health, whose faculty
have facilitated major advances in the complex
and rapidly developing scientific arena of
statistical methods in psychiatric and behavioral
genetics. Innovative new studies propose to
expand the understanding of the genetic basis of
dementia, bipolar disorder, substance use
disorders, and other mental and behavioral
disorders. Brion Maher is applying statistical
genetics to study genetic and environmental
contributions to both psychiatric and substance
use disorders. Maher is associated with the
Obsessive-Compulsive Disorder Family Study in
the Johns Hopkins Department of Psychiatry,
and
with
the
Molecular
Genetics
of
Schizophrenia
Collaboration,
a
multi-site
international group funded by the NIMH
Schizophrenia Genetics Initiative. He has used
techniques such as genome-wide association
scans to locate the specific chromosome regions
associated with heightened risk for mental
disorders. Peter P. Zandi, who directs the
Psychiatric Epidemiology training program, is
leading the Department's foray into the new field
of
pharmacogenetics,
which
facilitates
individualized
prescription
and
treatment
(“personalized medicine” or “in-health”). 10
Global Mental Health
The Johns Hopkins School of Public Health
has been committed to promoting public mental
health internationally ever since William Henry
Welch helped Clifford Beers to organize the
International Committee for Mental Hygiene in
1919. The ICMH was reorganized in 1930 at the
International Congress of Mental Hygiene,
where Welch served as vice president. At the
Third International Congress of Mental Hygiene
in London in 1948, the ICMH was transformed
into the World Federation for Mental Health.
Psychiatrists conceived the WFMH both as an
advocacy agency for world peace and a bridging
organization between the United Nations and
the
world's
voluntary
mental
health
11
associations.
At the First World Health Assembly in 1948,
Morton Kramer was the only mental health
specialist among the U.S. Delegation. The first
director-general of WHO was the Canadian
psychiatrist G. Brock Chisholm, with whom
Kramer helped to found the WHO Expert
Committee on Mental Health. The committee's
first report declared that "the most important
single long-term principle for the future work of
WHO in the fostering of mental health” was to
ensure that international public health programs
upheld “the responsibility for promoting the
mental as well as the physical health of the
community.” In 1950, mental health was among
49
six major global initiatives launched by WHO,
and mental health garnered just under $1
million—almost one-fifth of the organization’s
12
total budget.
Kramer conducted foundational studies on
international variation in mental hospitals' first
admission rates. He played leading roles in the
U.S.-U.K. cross-national studies on psychiatric
diagnosis, the International Pilot Study of
Schizophrenia, and the still-evolving refinements
in psychiatric diagnostic methods and the
international
classifications
of
diseases.
Kramer's disciplined approach to psychiatric
problems is apparent in the international
discussions of psychiatric epidemiologists over a
half century, published in the Milbank Memorial
Fund collections and the proceedings of the
World Psychiatric Association's Section on
Epidemiology and Social Psychiatry. Kramer’s
colleagues Jim Anthony and Bill Eaton credit
him for his “vision that psychiatric diagnosis
might be made sufficiently reliable and valid to
warrant biostatistical scrutiny and to yield an
epidemiology of specific psychiatric disorders.” 13
Alongside Kramer, Paul Lemkau and Robert
Felix served on the WHO Expert Committee on
Mental Health shortly after its creation until the
late 1970s. As a WHO consultant, Lemkau
conducted surveys of mental health in Japan,
Yugoslavia, and Italy, as well as Venezuela,
Mexico, and other Latin American countries.
Lemkau’s studies of psychiatric epidemiology in
Yugoslavia remain classics in the field, and in
1969, he chaired the World Mental Health
14
Assembly in Washington, DC.
Today,
Johns
Hopkins remains the
only school of public
health in the world with
a department of mental
health, which hosts one
of the largest groups of
students and faculty
devoted
to
global
mental health. The
Judith K. Bass
global mental health
unit is headed by
Judith K Bass (PhD 2004), with collaborators
Wietse Tol, Laura Murray, and International
50
Health faculty member Paul Bolton. Bass, an
advisee of Bill Eaton, works to design and
evaluate methods for assessing mental health
and mental illness in non-Western cultures, and
uses them to investigate the effectiveness of
innovative
prevention
and
intervention
strategies. Her past experience in addressing
the mental health needs of disaster victims and
refugees has taken her from the North Carolina
coast to the villages of Northern Uganda. Her
current projects include evaluating mental health
interventions for populations affected by torture
and trauma; and assessing perinatal depression
among HIV-infected women in Brazil. 15
th
In 2012, the Department celebrated its 50
anniversary and published the reference and
text, Public Mental Health (Oxford University
Press). Public mental health is enjoying a
groundswell, such as the 2007 Lancet article
series that asserted there is “No Health without
Mental Health” and the World Health
Organization’s release in 2009 of its mental
health Global Action Plan (mhGAP) to recognize
the global burden of mental disorders and the
need for a comprehensive, coordinated
response from the world’s governments.
Mental Health faculty have demonstrated
national and international leadership in
designing and implementing cost-effective
mental health interventions for low-resource
settings,
especially
among
vulnerable
populations recently subjected to war, genocide
or natural disaster. In the developing world, an
estimated 35 percent of women have been
raped, and depression is rampant. Equipping
public and mental health professionals in these
countries with the tools to more efficiently deliver
mental health interventions would have an
enormous effect size, since proven methods of
prevention and treatment already exist for the
most common mental health conditions, and
these methods are even more effective in lowresource settings. 16
With a new chair, a vibrant research
agenda, and three highly regarded NIH-funded
training programs (with one in global mental
health under review), the Department is ready to
enter its second half-century of leadership in
public mental health.
1
George Rebok interview Mar. 13, 2013.
Ibid.
3
Eaton interview Aug. 27, 2012.
4
Kellam interview.
5
William W. Eaton JHSPH website faculty
profile; William W. Eaton interview Aug. 27,
2012.
6
Eaton interview Aug. 27, 2012.
7
Ibid.
8
Eaton interview Mar. 22, 2012.
9
Mandell interview.
10
P.P. Zandi PP and J.T. Judy, "The promise
and reality of pharmacogenetics in psychiatry,"
Psychiatric Clinics of North America 33.1 (2010),
181-224.
11
Eugene B. Brody, “The World Federation
for Mental Health: its origins and contemporary
relevance to WHO and WPA policies,” World
Psychiatry 3 (2004), 54–55.
12
James A. Doull and Morton Kramer, “The
First World Health Assembly,” Public Health
Reports 63.43 (Oct. 28, 1949), 1379-1403;
“Mental Health on a Global Scale.” AJPH 39.5
(May 1949), 662-663.
13
Anthony and Eaton, “In Appreciation:
Morton Kramer, Sc.D.”
14
Lemkau bio file.
15
Judith K. Bass JHSPH website faculty
profile.
16
Martin Prince et al, “No Health without
Mental Health,” The Lancet 370.9590 (2007),
859-77.
2
51
Oral History Interviews
Conducted by Karen Kruse Thomas:
William W. Eaton, March 22, 2012; Aug. 27, 2012
David Celentano, August 9, 2011
Carolyn L. Gorman, August 21, 2012
Sheppard G. Kellam, August 22, 2012
Philip J. Leaf, March 8, 2013
Wallace Mandell, August 29, 2012
George W. Rebok, March 13, 2013
Elizabeth Ann Skinner, March 14, 2012
Conducted by Eli A. Rubenstein for the National Institute of Mental Health Oral History Project,
National Library of Medicine:
Robert H. Felix, May 27, 1975
Alan D. Miller, June 21, 1976; Nov. 5, 1977
Stanley F. Yolles, April 21, 1975; May 1, 1975; Aug. 23, 1975; April 21, 1975; May 1, 1975;
Aug. 23, 1975
52
Selected Honors and Awards
Alcohol, Drug Abuse and Mental Health Administration
1980 William W. Eaton, Administrator’s Award for Meritorious Performance
American Psychiatric Association
1969 Paul V. Lemkau, vice-president
American Psychopathological Association
1968 Benjamin Pasamanick, president
2004 William W. Eaton, president
American Public Health Association Mental Health, Epidemiology, and Statistics Sections, Rema
Lapouse Award for lifetime contributions to public health and prevention science
1973
1974
1976
1988
1996
2000
Morton Kramer
Paul V. Lemkau
Ernest M. Gruenberg
Alan D. Miller
Sheppard G. Kellam
William W. Eaton
National Institute on Drug Abuse
2008 Sheppard G. Kellam, Director's Special Award
Presidential Early Career Award for Scientists and Engineers
2005 C. Debra M. Furr-Holden (NIAAA)
2010 Catherine P. Bradshaw (U.S. Department of Education)
Society for Prevention Research
1998-2001 Sheppard G. Kellam, president
2008 Sheppard G. Kellam, Presidential Award
2010 Catherine P. Bradshaw, Early Career Award
Strömgren Foundation
2005 William W. Eaton, Erik Strömgren Medal
World Federation for Mental Health
1999 Sheppard G. Kellam, Distinguished Public Mental Health Award
53
Selected Faculty Publications of the Department of Mental Health
1940s
P. Lemkau, C. Tietze, and M. Cooper (1941). Report of Progress in Developing a Mental Hygiene
Component of a City Health District. American Journal of Psychiatry 97, 805.
C. Tietze, P. Lemkau, and M. Cooper. (1941). Schizophrenia, Manic-Depressive Psychosis, and
Socio-Economic Status. American Journal of Sociology 47, 167-175.
C. Tietze, P. Lemkau, and M. Cooper (1942). Personality Disorder and Spatial Mobility. American
Journal of Sociology 45, 29-39.
Paul V. Lemkau (1949). Mental Hygiene in Public Health. McGraw-Hill.
1950s
P. Lemkau, C. Tietze, and M. Cooper (1951). A survey of statistical studies on the prevalence and
incidence of mental disorder in sample population. Public Health Reports 58, 1909-1927. 55(4),
1382-1387.
M. Cooper, P. V. Lemkau, and B. Pasamanick (1953). The Implications of the Psychogenetic
Hypothesis for Mental Hygiene. American Journal of Psychiatry 110, 436-42.
A. M. Lilienfeld and B. Pasamanick (1954). The Association of Maternal and Fetal Factors with the
Development of Epilepsy. JAMA 155, 719-724.
Abraham M. Lilienfeld, Benjamin Pasamanick, and Martha Rogers (1955). Relationship between
pregnancy experience and the development of certain neuropsychiatric disorders in childhood.
American Journal of Public Health 45, 637-43.
Martha Rogers, Abraham M. Lilienfeld, and Benjamin Pasamanick (1955). Prenatal and Paranatal
Factors in the Development of Childhood Behavior. Acta Psychiactric Neurology Supplement No.
102, 12-18.
Benjamin Pasamanick, Hilda Knobloch, and Abraham M. Lilienfeld (1956). Socioeconomic status and
some precursors of neuropsychiatric disorder. American Journal of Orthopsychiatry 26, 594601.Paul V. Lemkau (1956). Prevention of Psychiatric Illness. JAMA 162(9).
Paul V. Lemkau (1956). I. Factors in the Evaluation of Mental Retardation: Epidemiological Aspects,
in The Evaluation and Treatment of the Mentally Retarded Child in Clinics (New York Medical
College and the National Association for Retarded Children, Inc.).
Morton Kramer (1957). A Discussion of the Concepts of Incidence and Prevalence as Related to
Epidemiologic Studies of Mental Disorders. American Journal of Public Health 47(7), 826-40.
Paul V. Lemkau, Sylvan S. Furman, Ruth Farbman, Madeliene Lay, and Margaret Bailey (1957). The
Operations of the New York State Community Mental Health Services Act in New York City.
American Journal of Psychiatry 113, 686-690.
Benjamin Pasamanick, Dean W. Roberts, Paul V. Lemkau, and Dean E. Krueger (1957). A Survey of
Mental Disease in an Urban Population. I. Prevalence by Age, Sex, and Severity of Impairment.
American Journal of Public Health 47, 923-29.
54
Paul V. Lemkau (1958). Basic Issues in Psychiatry (McGraw-Hill).
Paul V. Lemkau and Guido M. Crocetti (1958). Vital statistics of schizophrenia. In Leopold Bellak, ed.,
Schizophrenia: A Review of the Syndrome (Logos), 64-81.
Benjamin Pasamanick and Peter H. Knapp, eds. (1958). Social Aspects of Psychiatry Psychiatric
Research Reports 10 (American Psychiatric Association).
Ali A. Kawi and Benjamin Pasamanick (1959). Prenatal and Paranatal Factors in the Development of
Childhood Reading Disorders. Monographs of the Society for Research in Child Development,
serial 73, 24(4).
1960s
Paul V. Lemkau (1961). Community Planning for Mental Health. Public Health Reports 76(6), 489-98.
Paul V. Lemkau and Guido M. Crocetti (1962). An Urban Population's Opinion and Knowledge About
Mental Illness. American Journal of Psychiatry 118, 692-700.
Paul V. Lemkau and Guido M. Crocetti (1963). Public opinion of psychiatric home care in an urban
area. American Journal of Public Health, 53, 409-414.
Paul V. Lemkau (1965). Prevention in Psychiatry. American Journal of Public Health 55(4), 554-560.
Morton Kramer (1969). Applications of mental health statistics: uses in mental health programmes of
statistics derived from psychiatric services and selected vital and morbidity records (World Health
Organization).
Paul V. Lemkau (1969). On the Limits of Mental Health. American Journal of Public Health 59.2, 20607.
1970s
P.V. Lemkau, Z. Kulcar, G.M. Crocetti, B. Kesic (1971). Selected aspects of the epidemiology of
psychoses in Croatia, Yugoslavia. I. Background and use of psychiatric hospital statistics.
American Journal of Epidemiology 94(2), 112-7.
Z. Kulcar, G. M. Crocetti, P. V. Lemkau, and B. Kesic (1971). Selected aspects of the epidemiology of
psychoses in Croatia, Yugoslavia. II. Pilot studies of communities. American Journal of
Epidemiology 94, 118-125.
G. M. Crocetti, P. V. Lemkau, Z. Kulcar, and B. Kesic (1971). Selected aspects of the epidemiology of
psychoses in Croatia, Yugoslavia. 3. The cluster sample and the results of the pilot survey.
American Journal of Epidemiology 94, 126-134.
E.M. Gruenberg, D.M. Turns, S.P. Segal, and M. Solomon (1972) Social breakdown syndrome:
environmental and host factors associated with chronicity. American Journal of Public Health
62(1), 91-94.
Ernest M. Gruenberg (1973). Progress in psychiatric epidemiology. Psychiatric Quarterly 47(1), 1-11.
S.G. Kellam, J.D. Branch, K.C. Agrawal, and M.E. Ensminger (1975). Mental health and going to
school: The Woodlawn program of assessment, early intervention, and evaluation. University of
Chicago.
55
E.M. Gruenberg (1976). Limitation of the mental health data base. Medical Care 14(5 Suppl), 71-77.
Ernest M. Gruenberg (1977). The failures of success. The Milbank Memorial Fund Quarterly 55, 3-24.
1980s
W.W. Eaton, D.A. Regier, B.Z. Locke, and C.A. Taube (1981). The Epidemiologic Catchment Area
Program of the NIMH. Public Health Reports 96, 319-325.
Darrel A. Regier, Jerome K. Myers, Morton Kramer, Lee N. Robins, Dan G. Blazer, Richard L. Hough,
William W. Eaton, and Ben Z. Locke (1984). The NIMH Epidemiologic Catchment Area Program:
Historical Context, Major Objectives, and Study Population Characteristics. Archives of General
Psychiatry 41(10), 934-941.
James C. Anthony, Marshal Folstein, Alan J. Romanoski, Michael R. Von Korff, Gerald R. Nestadt,
Raman Chahal, Altaf Merchant, C. Hendricks Brown, Sam Shapiro, Morton Kramer, and Ernest
M. Gruenberg (1985). Comparison of the lay Diagnostic Interview Schedule and a standardized
psychiatric diagnosis: Experience in Eastern Baltimore. Archives of General Psychiatry 42, 667675.
P.J. Leaf, M.L. Bruce, G.L. Tischler, M.M. Weissman, and J.K. Myers (1988). Factors affecting the
utilization of specialty and general medical mental health services. Medical Care 26, 9-26.
W. W. Eaton, M. Kramer, J. C Anthony, A. Dryman, S. Shapiro, and B.Z. Locke (1989). The incidence
of specific DIS/DSM-III Mental Disorders: data from the NIMH Epidemiologic Catchment Area
Program. Acta Psychiatrica Scandinavica 79, 163-178.
1990s
J.C.S. Breitner, E.A. Murphy, and M.A. Woodbury (1991). Case-control studies of environmental
influences in diseases with genetic determinants, with an application to Alzheimer's disease.
American Journal of Epidemiology 33, 246-256.
S.G. Kellam, L. Werthamer-Larsson, L.J. Dolan, C.H. Brown, L.S. Mayer, G.W. Rebok, J.C. Anthony,
J. Laudolff, G. Edelsohn, and L. Wheeler (1991). Developmental epidemiologically-based
preventive trials: Baseline modeling of early target behaviors and depressive symptoms.
American Journal of Community Psychology 19, 563-584.
W. Mandell, W.W. Eaton, and J.C. Anthony (1992). Alcoholism and Occupations. A review and
analysis of 104 occupations. Journal of Clinical and Experimental Research Alcoholism, 734-746.
D.M. Steinwachs, J.D. Kasper, and E.A. Skinner (1992). Family Perspectives on Meeting the Needs
for Care of Severely Mentally Ill Relatives: A National Survey. Final Report to the National
Alliance for the Mentally Ill by Johns Hopkins University and the University of Maryland, Center on
Organization and Financing of Care for the Severely Mentally Ill.
N. Ialongo, G. Edelsohn, L. Werthamer-Larsson, L. Crockett, and S. Kellam (1993). Are self-reported
depressive symptoms in first-grade children developmentally transient phenomena? A further
look. Development and Psychopathology 5, 431-455.
J.J. Gallo, J.C. Anthony, and B.O. Muthén (1994). Age differences in the symptoms of depression: A
latent trait analysis. Journal of Gerontology: Psychological Sciences 49, 251-264.
W. Mandell, D. Vlahov, C.A. Latkin, D. Carran, M. Oziemkowska, and L. Reedt (1994). Changes in
HIV risk behaviors among counseled injecting drug users. Journal of Drug Issues, 555-567.
56
J.C.S. Breitner, K.A. Welsh, B.A. Gau, W.M. McDonald, D.C. Steffens, A.M. Saunders, et al (1995).
Alzheimer's disease in the National Academy of Sciences-National Research Council Registry of
aging twin veterans. III. Detection of cases, longitudinal results, and observations on twin
concordance. Archives of Neurology 52, 763-771.
P.J. Leaf, M. Alegria, P. Cohen, S.H. Goodman, S. Horwitz, C.W. Hoven, W.E. Narrow, M. VandenKiernan, and D.A. Regier (1996). Mental Health Services Use in the Community and Schools:
Results from the Four Community MECA Study. Journal of the American Academy of Child and
Adolescent Psychiatry 35(7), 889-97.
J.J. Gallo, P.V. Rabins, C.G. Lyketsos, A.Y. Tien, and J.C. Anthony (1997). Depression without
sadness: Functional outcomes of nondysphoric depression in later life. Journal of the American
Geriatrics Society 45, 570-578.
S. G. Kellam and J. C. Anthony (1998). Targeting early antecedents to prevent tobacco smoking:
Findings from an epidemiologically based randomized field trial. American Journal of Public
Health 88(10), 1490-1495.
N. Ialongo, L. Werthamer, S. G. Kellam, C. H. Brown, S. Wang, and Y. & Lin (1999). Proximal impact
of two first grade preventive interventions on the early risk behaviors for later substance abuse,
depression and antisocial behavior. American Journal of Community Psychology 27, 599-641.
2000s
W. W. Eaton (2001). The Sociology of Mental Disorders. Third Edition. Greenwood Press.
B.S. Maher, M.L. Marazita, R.E. Ferrell, and M.M. Vanyukov (2002). Dopamine system genes and
attention deficit hyperactivity disorder: A meta-analysis. Psychiatric Genetics 12(4), 207-15.
R. Mojtabai, M. Olfson, and D. Mechanic (2002). Mental disorders, perceived need and help seeking
in the community. Archives of General Psychiatry 59, 77-84.
P.P. Zandi, M.C. Carlson, B.L. Plassman, K.A. Welsh-Bohmer, L.S. Mayer, and D.C. Steffens (2002).
Hormone replacement therapy and incidence of Alzheimer disease in older women: The Cache
County Study. JAMA 288(17), 2123-9.
J.C.S. Breitner and P.P. Zandi (2003). Effects of estrogen plus progestin on risk of dementia. JAMA
290(13), 1706-1707.
C.M. Schaeffer, H. Petras, N. Ialongo, J. Poduska, and S. Kellam (2003). Modeling growth in boys’
aggressive behavior across elementary school: Links to later criminal involvement, conduct
disorder, and antisocial personality disorder. Developmental Psychology 39, 1020-1035.
William Eaton, Preben Bo Mortensen, Esben Agerbo, Majella Byrne, Ole Mors, Henrik Ewald (2004).
Coeliac disease and schizophrenia: population based case control study with linkage of Danish
national registers. British Medical Journal 328, 438-439.
N. Ialongo, A. Koenig-McNaught, B. Wagner, J. Pearson, B. McCreary, J. Poduska, and S. Kellam
(2004). African American children's reports of depressed mood, hopelessness, and suicidal
ideation and later suicide attempts. Suicide and Life-Threatening Behavior 34(4), 395-407.
N. Ialongo, B. McCreary, J.L. Pearson, A.L. Koenig, N.B. Schmidt, J. Poduska, and S.G. Kellam
(2004). Major depressive disorder in a population of urban African-American young adults:
prevalence, correlates, comorbidity and unmet mental health service need. Journal of Affective
Disorders 79, 127-136.
57
P.J. Leaf and S.G. Keys (2005). Collaborating for Violence Prevention: Training Health Professionals
to Work with Schools. American Journal of Preventive Medicine 29 (5S2), 279-287.
E.J. Letourneau and M.H. Miner (2005). Juvenile sex offenders: A case against the legal and clinical
status quo. Sexual Abuse: A Journal of Research and Treatment 17, 313-331.
P.K. Alexandre, M.T. French, C. Weisner, et al (2006). The Effects of Treatment History and Cost on
Long-Term Outcomes for Problem Drinkers. Journal of Addictive Diseases 25(1), 105–117.
J. Bass, R. Neugebauer, K.F. Clougherty, H. Verdeli, P. Wickramaratne, L. Ndogoni, L. Speelman, M.
Weissman, and P. Bolton (2006). Group interpersonal psychotherapy for depression in rural
Uganda: 6-month follow-up of a randomized controlled trial. British Journal of Psychiatry 288,
567-573.
William W. Eaton, editor (2006). Medical and Psychiatric Comorbidity Over the Course of Life.
American PsychoPathological Association.
D. Ompad, S. Strathdee, D. Celentano, C. Latkin, J. Poduska, S. Kellam, and N. Ialongo (2006).
Predictors of early initiation of vaginal and oral sex among urban young adults in Baltimore,
Maryland. Archives of Sexual Behavior 35, 53–65.
S.L. Willis, S.L. Tennstedt, M. Marsiske, K. Ball, J. Elias, K.M. Koepke, J.N. Morris, G.W. Rebok, F.W.
Unverzagt, A.M. Stoddard, and E. Wright (2006). Long-term Effects of Cognitive Training on
Everyday Functional Outcomes in Older Adults. JAMA 296(23), 2805-2814.
J.J. Gallo, H.R. Bogner, K.H. Morales, E.P. Post, J.Y. Lin, and M.L. Bruce (2007). The effect on
mortality of a practice-based depression intervention program for older adults in primary care: A
cluster randomized trial. Annals of Internal Medicine 146(10), 689-698.
R. Mojtabai (2007). Americans’ attitudes towards mental health treatment seeking: 1990-2003.
Psychiatric Services 58, 642-651.
C.D.M. Furr-Holden, M.J. Smart, J.P. Pokorni, N.S. Ialongo, P.J. Leaf, H. Holder, and J.C. Anthony
(2008). The NIfETy method for environmental assessment of neighborhood-level indicators of
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