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

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 Alan D. Miller, MD, MPH 1941-74 interim 1955-57

Abraham M. Lilienfeld, MD, MPH Ernest Gruenberg, MD, DrPH interim 1974-1975 1975-81

Wallace Mandell, MD, MPH Sheppard G. Kellam, MD interim 1993-97 1982-93

John C. S. Breitner, MD William W. Eaton, PhD 1997-2001 interim 2001-03; 2003-2013

M. Daniele Fallin, PhD 2013-

1. Origins of Mental Hygiene at Johns death, perhaps because mental hygiene did Hopkins not fit easily within the School’s framework of laboratory-based science dedicated to fighting In May 1908, the Philadelphia steel infectious disease. magnate and philanthropist Henry Phipps The Great Depression and World War II visited the Tuberculosis Division he had transformed public health practice, medical founded at the Johns Hopkins Hospital. science, and American politics. Public health Phipps asked William Henry Welch, Dean of instruction had previously emphasized the Johns Hopkins School of Medicine, to bacteriological and environmental methods of suggest another project he could sponsor, and fighting infectious disease. Public health Welch gave Phipps a copy of A Mind That administration was a required course, but Found Itself. The book, authored by recovered students devoted little time to it until after the asylum patient Clifford W. Beers, had war, when it began to displace the basic generated national attention for the mental sciences as the main focus of public health hygiene movement with its descriptions of the courses alongside biostatistics and horrors of straightjackets, padded cells, and epidemiology. Title VI of the 1935 Social brutal attendants. One month later, the Johns Security Act provided the first federal aid to Hopkins Hospital publicly announced Phipps’ train state and local health department $1.5 million endowment to establish the Henry personnel. The legislation required states to Phipps Psychiatric Clinic. To develop a establish minimum criteria for staff whose Department of Psychiatry at Johns Hopkins, salaries were paid with federal funds, with a Welch invited Adolf Meyer, a Swiss recommended one year of coursework in an pathologist and psychiatrist at Cornell who approved school of public health. After 1935, emphasized the inseparability of mental and funding from the Social Security Act, the U.S. physical problems and founded the field of Public Health Service (PHS), and the psychobiology. In April 1913, the Henry Rockefeller Foundation promoted two major Phipps Psychiatric Clinic officially opened. trends: an emphasis on the MPH as the Since then, the Department has occupied a primary public health degree and the distinguished place in the history of psychiatry, development of specialized training programs with a continuous tradition of excellence in in growth areas such as mental hygiene, patient care, teaching, and research.1 venereal disease control, and maternal and A few years after the Phipps Clinic child health. As federal and state health opened, Welch relinquished the deanship of programs stimulated health departments to medicine to become the founding dean of the provide a widening array of personal health Johns Hopkins School of Hygiene and Public services, the binary classifications of Health. In 1916, the Rockefeller Foundation prevention/cure and social/individual began to 2 awarded the initial grant to establish the first blur. independent degree-granting graduate school The Eastern Health District was a one- of public health in the world. Its very name, square-mile model research and training area with hygiene before public health, reflected the established in 1932 with a Rockefeller grant primacy of Welch’s emphasis on scientific and administered jointly by the School of research on the German institute of hygiene Hygiene and Public Health and the Baltimore 3 model. Welch remained a major proponent of City Health Department. The Eastern Health the mental hygiene movement and in 1923 District (EHD) was unique for its academic was elected president of the National affiliation as a population laboratory and Committee for Mental Hygiene, which Beers clinical site for public health students that had founded in 1909. Welch wanted to include would parallel the Johns Hopkins Hospital’s a department of mental hygiene in the School, role in medical education. The EHD hosted but this goal was shelved until after Welch’s clinics for mental hygiene that involved

medical school faculty and provided clinical deinstitutionalization was not a coherent training to both Hygiene students and Johns policy, but “the result of a series of incremental Hopkins Hospital residents and graduate and unrelated developments.”8 nurses.4 Since community studies of disease The 1940s saw the first major discoveries were only as meaningful as the underlying regarding the etiology and effective drug knowledge about the base population, therapies for various somatic conditions that Hygiene faculty and students painstakingly were traditionally classified as collected and analyzed demographic data on psychopathology. Once hospitalization was no EHD residents’ age, sex, race, occupation, longer the sole treatment option, a growing list economic status, and family size. This of heretofore psychiatric diseases were baseline data was checked against patient usurped by other medical specialties. By the records from local hospitals, physicians, and mid-1950s, pediatricians and neurologists had EHD clinics to analyze the distribution and assumed responsibility for epileptics. spread of mental illness, as well as infectious Neurosyphilitic paresis, a leading cause of and chronic diseases.5 During the 1940s, the admissions to state mental hospitals prior to School’s dean, Lowell J. Reed, emphasized 1945, yielded to the introduction of penicillin that the District was “becoming increasingly therapy for syphilis. Antibiotics and improved valuable in the teaching and research program prevention measures for many infectious of the School.” School of Hygiene alumni diseases had virtually eliminated delirium, carried the Eastern Health District model once a severe psychiatric management across the United States and to countries problem in young pneumonia and typhoid around the world. Wallace Mandell, for patients. Antipsychotics such as example, developed a state mental health plan chlorpromazine significantly reduced the threat for Texas that modeled its community mental of violence that had been a basic justification health districts on those in Baltimore. He for commitment, thereby dramatically placed child guidance clinics across the state accelerating the migration of psychiatric so that parents were no more than a one-hour diseases and adult patients out of state mental drive away. Reed urged the Rockefeller hospitals. An increasing proportion of Foundation to extend its support for additional psychiatric practice was devoted to the teaching personnel in mental hygiene and management and treatment of mentally and other disciplines for as long as possible, noting physically disabled children.9 that “the moment the war is over, it is obvious In tandem with these developments, the that there will be a great rush to graduate School’s primary sponsor, the Rockefeller training in the field of public health.”6 Foundation, placed new emphasis on clinical The 1940s transformed both mental health knowledge as essential to research and and public health in the United States. training in public health as well as medicine, Seclusion and physical restraint had been which informed its support for establishing a routinely used methods to control the behavior new mental hygiene MPH program at Johns of institutionalized mental patients, even those Hopkins.10 State and federal categorical who showed little sign of violent tendencies. programs also underwrote the establishment The straightjacket and the solitary confinement or expansion of a wave of specialized MPH cell became the iconic symbols of mental tracks at Johns Hopkins and relieved the institutions in the popular imagination.7 The Division of Mental Hygiene from dependence deinstitutionalization of mental patients from on short-term Rockefeller grants.11 Most state hospitals began immediately after World importantly, the postwar expansion of the War II and accelerated after passage of the National Institutes of Health fueled the growth federal construction grant program for of Psychiatry, Mental Hygiene and the other community mental health centers in 1963. As clinical divisions of the Schools of Medicine mental health historian Gerald Grob notes, and Hygiene.12

The armed forces were eager to employ children and aging adults, and international MPH graduates trained in mental hygiene to comparisons of psychiatric diagnosis and screen recruits and treat mentally ill treatment.16 servicemen and veterans.13 In 1941, School of Lemkau held a joint appointment in the Hygiene officials met with the PHS Mental Department of Psychiatry, where he had been Hygiene Division, the Mental Hygiene Society, a resident for five years under Adolf Meyer. and the Maryland Commission of Mental But from the beginning Lemkau channeled the Health to outline a new eighteen-month mental hygiene program toward community graduate program in community mental health epidemiology and spent little time at the designed to prepare psychiatrists and other medical school. He and other mental hygiene specialists to administer public mental health leaders, such as fellow Meyer resident programs.14 Alexander Leighton, were consciously trying to As head of the Mental Hygiene program at transcend the limits of mental hospitals and to Johns Hopkins from 1939 until 1978, Paul V. identify and treat early mental illness through Lemkau set the international standard for the programs in schools and colleges, child study of mental disorders in large populations guidance clinics, and other outpatient settings. and in community settings and taught the Whereas students in the syphilis control MPH fundamentals of mental health research.15 His program divided their time between lab work, wide-ranging research interests spanned the Johns Hopkins Hospital syphilis clinic, and community mental health, psychiatric the Eastern Health District, mental hygiene epidemiology, preventive psychiatry, planning students worked exclusively in the EHD, for mental health services, the prevention and reflecting the philosophy that mental illness early diagnosis of psychiatric problems in 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.

social maladjustment and environmental children's drawings as an index of normal and factors as by somatic disorders.17 deviant development.20 The mental hygiene program In tandem with the medical school’s demonstrated that the PHS and School of forensic pathology course for public health Hygiene, despite their close relationship, did students (which offered experience in the not always share the same priorities. When laboratory of the Chief Medical Examiner of the PHS asked the School to waive the Maryland), Lemkau also taught and conducted required MPH bacteriology course to enable research on forensic psychiatry. The officers to concentrate on mental hygiene Department hosted a guest lecture by courses, the School of Hygiene Advisory Manfred Guttmacher, the psychiatrist who Board1 refused, since the course had already testified at the trial of Jack Ruby (notorious for “been stripped of a great deal of shooting John F. Kennedy’s assassin Lee bacteriological technic which it contained in Harvey Oswald before rolling news cameras). previous years,” and the mental hygiene Lemkau advised the state Department of students would still need to understand “the Public Welfare on psychiatric care for juvenile principles of bacteriological and virus disease delinquents and worked closely with the as they relate to epidemiology and to public Baltimore Police Department and the health in general.” The board felt that a bare Baltimore Council of Social Agencies on a minimum of half the academic year should be study of the police’s role in the hospitalization devoted to common requirements “if the of the mentally ill. To emphasize the general public health course is to serve its importance of onsite medical care for purpose of developing general public health psychiatric emergencies as an important concepts in people with as varied interests as aspect of local psychiatry services, he medical health officers, psychiatrists, sanitary conducted a demonstration project on engineers, public health nurses, etc., . . . .”18 emergency home care in Baltimore, where Although the Advisory Board prevailed for the more than a third of psychiatric time being, the addition of more specialized hospitalizations involved the police and tracks brought increasing pressure to reduce incarceration, although violence was only the time allotted to common public health rarely a factor. Lemkau showed that courses in the intensive MPH schedule.19 emergency home psychiatric care could help Paul Lemkau was a prolific teacher who reduce police involvement in hospitalization prepared the behavioral component for the and allow for voluntary hospitalization in a new Biology of Disease course that replaced larger proportion of cases.21 microbiology as the MPH science requirement The careers in 1955. Lemkau declared in his division’s of Lemkau’s annual report that "Active teaching students during participation in Pathobiology I signaled the 1950s behavior study as a recognized basic science illustrate the in the School." Lemkau taught labs based on broad influence social class distribution and differences in of the Hopkins availability of treatment for schizophrenia, as master and well as on the effect of sensory stress on doctor of public performance on a psychological test. Marcia health programs Cooper taught a lab demonstrating the use of in mental hygiene. The first DrPH graduate in mental hygiene was Alberta Szalita-Pemow, a physician and neurologist from Warsaw, 1 Poland, who received a scholarship to The Advisory Board was composed of all the full professors in the School of Hygiene and Hopkins from the National Council of Jewish served as its governing body. Women for outstanding women who would

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 Holocaust.22 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 Robert H. Felix, first director of the National Chestnut Lodge,” a place she described as Institute of Mental Health from 1949 to 1964 “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.” mental hygiene class, recalled taking a With Fromm-Reichmann and three other biostatistics course from the eminent dean of Chestnut Lodge colleagues, she organized a the School of Hygiene, Lowell J. Reed. “Oh, clinical research group with a grant from the God, how he would lay into us about the lousy Social Research Fund that produced some of statistics in medicine and he would use mental the first studies of the use of psychoanalysis in health as the most horrible example. He would treating schizophrenia, including the take a journal article and give you the data therapeutic use of intuition. The resulting and conclusions, and then he would go back article that Szalita-Pemow published in 1955 and tear it to shreds. Then the guys [in class] in the Journal of the American Psychoanalytic would kid me, and I decided God, if I ever had Association became a widely cited milestone the chance, one thing I would do was develop in the field, selected in 2000 as one of the 20 the finest mental health statistics department most influential papers by the International in the world.” Society for Psychological Treatments for After Felix was appointed director of NIMH Schizophrenia and other Psychoses. Szalita- in 1949, he quickly hired Reed's star student, Pemow helped to establish psychoanalytic Morton Kramer, as head of the Biometrics institutes in Norway and in Israel at Tel Aviv Branch. A few years later, Felix made a University, and later in her career she was a presentation before the Milbank Foundation on training and supervising analyst at Columbia progress in mental health statistics, with slides University and the William A. White Institute in provided by Kramer. Before the lights went up, New York.23 he told the audience, “I swore by everything Graduates of the Hopkins Mental Hygiene that I held holy that I was going to develop program would shape the creation of the statistics so good that I will make Lowell Reed National Institute of Mental Health and direct stand at Washington's Monument at the the agency from 1949 to 1970. Robert H. corner of Charles and Monument Street and Felix (MPH 1942), a member of the first eat them for breakfast without any coffee to

wash it down. The lights came up and there support behavioral and social science sat Lowell Reed, who was a Milbank trustee. research--fields in which the Department He had a grin on his face and he said, you Mental Hygiene at Johns Hopkins would have paid me the highest compliment a excel.27 student can pay a teacher, and I'll eat them!”24 Felix was the first of many early leaders at Lemkau and Felix together helped NIMH to be trained in the Hopkins Mental develop the National Mental Health Act of Hygiene MPH program; likewise, many Mental 1946, which channeled federal resources into Hygiene faculty have had NIMH backgrounds. psychiatric research and training programs Morton Kramer, faculty member from 1976 to and created the National Institute of Mental 1984, headed the NIMH Biometrics Branch Health in 1948. Felix first conceived the idea from 1949 to 1976, which compiled, analyzed, for NIMH as a student at Hopkins, when he and evaluated national statistics on the was working on an epidemiology assignment incidence and prevalence of mental illness, on polio in New Zealand, and realized that consulted with outside agencies, and schizophrenia clustered geographically the conducted a census of patients in mental same way as polio. He believed that a national institutions. Future department chair campaign to address mental illness could be Sheppard G. Kellam was at the NIMH Clinical modeled on the polio campaign then being Neuropharmacology Research Center during mounted by President Franklin D. Roosevelt the early 1960s, where he directed research and the National Foundation for Infantile on the quantification of social interaction in a Paralysis, with the same elements of research, psychiatric ward and also developed a Social training, and community services. After Felix Interaction Matrix to study the effects of major was appointed head of the new PHS Division tranquilizers in the ward.28 Another future of Mental Hygiene, Surgeon General Thomas department chair, William W. Eaton, was Parran called him in and asked how he would assistant chief of the agency's Center for structure a national mental health program. Epidemiologic Studies from 1978 to 1983. The next morning, he presented to Parran the Bob Felix sent his lieutenants to Hopkins outline for what he originally called a National for advanced training in public mental health, Neuropsychiatric Institute.25 As the first including Robert T. Hewitt (MPH 1948), head director of NIMH from 1949 to 1964, Felix was of the NIMH Hospital Services Branch, Dale a prime architect of national programs that Cameron (MPH 1951), assistant director of revolutionized mental health research, training NIMH, Alan D. Miller (MPH 1951), head of the and treatment of the mentally ill. He served as NIMH Mental Health Study Center, and president of the American Psychiatric Stanley F. Yolles (MPH 1957), who Association in 1960-61 and left NIMH to succeeded Felix as NIMH director. Felix told become dean of medicine at St. Louis Miller that he “must go to Hopkins, because of University.26 Paul Lemkau.” Miller had attended a seminar Together with the postwar expansion of with Dr. Lemkau, and “was bowled over; I the Veterans Administration residency needed no persuasion.”29 program, NIMH training grants provided more Yolles joined the staff of the NIMH Mental generous stipends for psychiatry residencies Health Study Center in 1956, where he in order to increase the number of physicians worked with Miller and Mabel L. Ross. Miller entering the specialty, particularly community told Yolles that the Center’s research had to mental health. The NIMH was unique among benefit the community, and that the same “first NIH institutes because it integrated research do no harm” principle that applied in medicine with a social mission of training and clinical was just as true of the residents of Prince services. Felix and Lemkau's influence George's County, Maryland. Miller, Ross, and ensured that NIMH went beyond basic and Yolles applied sophisticated epidemiological clinical biomedical research to include and reasoning that would become a hallmark at

NIMH. Yolles recalled, “In looking for his commitment to finding more humane and community indicators of mental health or effective methods for preventing and treating mental illness, we noted that there was a very drug abuse. high correlation between juvenile delinquency As NIMH director in the turbulent 1960s, as an index of dysfunction in the community, Yolles denounced what he saw as "stupid, and a high rate of reading disabilities. We punitive laws" that criminalized drug use. He looked at the epidemiology of reading testified before Congress that strict penalties disabilities as an indicator of other pathology failed as a deterrent, since addiction was a in the same sense that one in a laboratory medical and social problem. Yolles made looks for E. coli as an indicator of headlines by calling for abolishing mandatory contamination by typhoid or other pathogenic sentences and giving judges greater discretion organisms.” to deal with drug users, especially first-time To gain the cooperation of the community offenders. Regarding marijuana possession, and the school district, “we couldn't be too he said, “I know of no clearer instance in nosy and too proud. So we gave the school which the punishment for an infraction of the system carte blanche consultation with their law is more harmful than the crime.” This view counseling personnel and attendance people, would later be famously advocated by we would hold case conferences in the President Jimmy Carter early in his term, until schools with the guidance person, and we had Peter Bourne, special assistant for health seminars for them at the Mental Health Study issues, forced Carter to backtrack after a Center.” Yolles attributed the Center's scandal erupted over Bourne’s own use of successful research and its elevated status in illegal drugs and connections with the National the community directly to the staff’s MPH Organization for the Reform of Marijuana training (he and Miller at Hopkins, Ross at Laws. Harvard). Yolles also used his public health Although Yolles persuaded the Justice knowledge to build bridges with health officials Department to reduce federal penalties for charged with administering NIMH-funded marijuana, he also angered the Nixon programs. One evening over dinner with the administration, which worsened conflicts over health officer of Oklahoma City, where he was the budget and direction of NIMH. When the speaking on NIMH’s Community Advisory administration announced that Yolles had Board Clinics, Yolles was asked if he liked his been dismissed, he penned a resignation hotel accommodations. He surprised his host letter the same day in which he accused Nixon by replying, “I find the hotel very nice, except of “abandonment of the mentally ill.” In 1971, you have a very severe problem with back Yolles became the founding chair of the siphonage of water from the bathtub.”30 department of psychiatry at the State Yolles served as the second NIMH University of New York School of Medicine at director from 1964 to 1970. Although he Stony Brook until he retired in 1981. He also earned a master’s in parasitology from the directed the Long Island Research Institute Harvard School of Public Health and fought from 1974 to 1981.31 insect-borne diseases in the Caribbean during In addition to their efforts to guide federal the war, Yolles concluded that he “could no mental health reform, Division of Mental longer be satisfied with a one-to-one Hygiene faculty and alumni helped the state relationship with a microscope,'' and decided and local governments of Maryland and New to pursue psychiatry. Like Felix and many York to establish and expand community other Mental Hygiene alumni, Yolles worked mental health services. From 1949 to 1953, with drug addicts at the Public Health Service the School allowed Paul Lemkau to remain on Hospital in Lexington, Kentucky, where he the faculty while serving as head of the abolished the use of bars and handcuffs to Maryland Division of Mental Hygiene, where restrain patients. The experience galvanized he expanded on the existing system of state

mental hospitals to develop a modern program Miller, was essential for crafting a national of community mental health services. Lemkau program that addressed the major mental also worked as a consultant to the New York health needs of states and communities on a State Mental Health Commission under population basis and ensured access for all Ernest M. Gruenberg, executive director from citizens. The passage of the 1963 Mental 1949 to 1954. Gruenberg favored the English Retardation Facilities and Community Mental model of basing community health services in Health Centers Construction Act marked a a psychiatric hospital, but Lemkau preferred new era of increased federal support for the public health department, as was the mental health services, and NIMH assumed policy in the Netherlands. Gruenberg, a responsibility for monitoring the community professor of psychiatry at Columbia, also mental health centers program nationwide. directed the psychiatric and epidemiology In 1964, Miller left NIMH to become New research unit of the New York State York State Commissioner of Mental Hygiene. Department of Mental Hygiene. Together, they Under his leadership in the first decade after worked to enact the 1954 New York State the program's inception, New York built 26 Community Mental Health Act and other laws mental health centers at a total cost of $99 to develop the state's mental health programs million, with 15 percent of the total from and establish community facilities. In 1975, federal funds. Testifying before Congress in Gruenberg succeeded Lemkau as chair of 1973, Miller described the impact of the Act on Mental Hygiene at Hopkins.32 his state’s mental health program: Under Mayor Robert F. Wagner and A well functioning community health Health Commissioner Leona Baumgartner, service can make a significant impact New York City took the lead in establishing a on admission rates and more Community Mental Health Board under the importantly resident patient rates in new law. From 1955 to 1957, Lemkau took a state hospitals. Since the care of the leave of absence to serve as New York City’s long term state hospitalized patient director of Mental Health Services during the represents a tremendous expenditure initial implementation phase.33 He asked Bob of public money, continuation and Felix to send Alan Miller to Hopkins to serve expansion of the mental health center as interim chair. Several of Lemkau's students program is fiscally sound. The saving in followed him to New York and stayed. Rema human distress and the elimination of Lapouse (MPH 1950) headed the Mental the personally damaging effects of long Disease Unit in the Division of Epidemiology at term hospitalization in remote the New York City Public Health Research impersonal institutions are, of course, Institute. She became one of the foremost too well known to require further epidemiologists of pediatric mental disorders, description. as well as co-founder of the APHA Mental Yet in the context of Nixon-era retrenchment Health Section. Marvin Earl Perkins (MPH of federal programs, Miller also remarked on 1956) was the first Commissioner of Mental the irony that “on the one hand the Health Services for New York City as well as Department of Health, Education, and the District of Columbia.34 Welfare, through the Developmental The community mental health programs in Disabilities Services Act, is making specific New York and Maryland as well as at the grants to states to help plan for NIMH Mental Health Study Center were all deinstitutionalization of the mentally retarded models for federal legislation to establish and but on the other is threatening to extinguish support community mental health centers as the Community Mental Health Center an alternative to state mental hospitals. The program, which has the potential to be a great influence of Hopkins-trained NIMH staff, force for deinstitutionalization of the mentally including Bob Felix, Stan Yolles, and Alan ill.”35

In the two decades from the creation of the Division of Mental Hygiene in 1942 to the passage of the Community Mental Health 6 “Report on the Mental Hygiene Study to Centers legislation, Hopkins mental health the IHD 1941,” “Rockefeller Foundation” faculty and alumni were national leaders in folder; Allen Freeman, “Annual Report of the creating and developing health policy that Department of Public Health Administration 1942-43,” JHSPH Dean’s Office firmly established mental health as both a Correspondence Series 3a, box 502031, central concern of public health practice and a “Department Reports to the Dean 1942-1943” legitimate focus of research within NIH. By folder, AMC; Nov. 1, 1943 EHD Committee uniting scientific medicine with psychiatric minutes, Huntington Williams papers, box epidemiology that was deeply rooted in 505733, "Eastern Health District Committee community needs and realities, the Division Meetings 1933-1955" folder, AMC; Reed to helped gain wider acceptance for Lemkau’s Ferrell June 30, 1943, “Rockefeller Foundation Sept 1941-Mar 1942” folder; Wallace Mandell contested idea that mental health belonged in interview Aug. 29, 2012. public health. 7 Gerald Grob, “Deinstitutionalization: The Illusion of Policy,” Journal of Policy History 9.1 (1997), 49-52; Shonick, Government and 1Janet Farrar Worthington, “When Health Services, 188-89; Ernest M. Gruenberg Psychiatry Was Very Young,” Hopkins and J. Archer, “Abandonment of Responsibility Medicine (Winter 2008). For an in-depth for the Seriously Mentally Ill,” Milbank treatment of Adolf Meyer and the Phipps Memorial Fund Quarterly/Health and Society Clinic, see Susan D. Lamb, Pathologist of the 57.4 (Fall 1979), 485-506. 8 Grob, “Deinstitutionalization,” 48. Mind: Adolf Meyer, Psychobiology and the 9 Phipps Psychiatric Clinic at the Johns Hopkins Grob, “Deinstitutionalization,” 48-51; Hospital, 1908-1917 (2010 dissertation in Paul V. Lemkau, “Prevention in Psychiatry,” AJPH 55 (Apr. 1965), 554-60. History of Medicine, Johns Hopkins 10 University). C.-E. A. Winslow, "American Public 2 William Shonick, Government and Health Health Association, Report of Accreditation Services: Government's Role in the Visit, Committee on Professional Education, Development of U.S. Health Services 1930- The Johns Hopkins School of Hygiene and 1980 (Oxford University Press, 1995), 93; Public Health," Nov. 21-23, 1949, Thomas B. Elizabeth Fee, Disease and Discovery: The Turner papers, box 50564, "Development Comm." folder, AMC. History of the Johns Hopkins School of 11 Hygiene and Public Health 1916-1939 (Johns Shonick, Government and Health Hopkins University Press, 1987), 180-81, 220. Services, 95; Starr, Social Transformation of 3 George Rosen, A History of Public American Medicine, 343-46; Fee and Health, 446-52; Paul Starr, The Social Rosenkrantz, “Professional Education for Transformation of American Medicine (Basic Public Health in the United States,” 236-37; Books, 1982), 194-96. Parran, “Surmounting Obstacles to Health 4 Fee, Disease and Discovery, 179, 184- Progress,” 168-72. 12 Turner, Heritage of Excellence, 397. 214; "Report on the Eastern Health District to 13 the IHD,” 1941, 1942, 1943, JHSPH Dean’s Brandt, No Magic Bullet, tk; Starr, Social Transformation of American Medicine, 344-45. Office Correspondence Series 3a, box 14 502037, “Rockefeller Foundation” folder, Alan SHPH Advisory Board Minutes, vol. 4, May 27, 1941 p. 46, AMC. Mason Chesney Medical Archives of the 15 Johns Hopkins Medical Institutions (AMC). "Dr. Paul V. Lemkau, pioneer in mental 5 "Eastern and Western Health Districts hygiene, dies at 82," Baltimore Sun Apr. 30, 1992. Enlarge," Baltimore Health News 15.10 (Oct. 16 1938), 76-77; Fee, Disease and Discovery, Paul Lemkau bio file, AMC; SHPH 179, 184-214; "Report on the Eastern Health Advisory Board Minutes, vol. 4, May 27, 1941 District to the IHD,” 1941, 1942, 1943; Thomas p. 46; Leo Kanner to Lowell Reed May 22, Turner, Heritage of Excellence, 367. 1941, JHSPH Dean’s Office Correspondence Series 3a, box 502034, "Kahn-Kar May 1941-

Jun 1944" folder; Fee, Disease and Discovery, During a Rehabilitation Program on a 198; Reed to Roy C. Heflebower June 24, Psychiatric Ward,” Journal of Nervous and 1941, JHSPH Dean’s Office Correspondence Mental Diseases 132 (1961): 277-88. Series 3a, box 502034, "Lee-Lem Jun 1941- 29 Alan D. Miller email to Bill Eaton, June Mar 1944" folder. 12, 2013. 17 Paul V. Lemkau bio file, AMC; Hans 30 Stanley F. Yolles NIMH interview April Pols, “Divergences in Psychiatry During the 21, 1975, 11-14. Depression: Somatic Psychiatry, Community 31 Stanley F. Yolles obituary, New York Mental Hygiene, and Social Reconstruction,” Times Jan. 21, 2001. Journal of the History of the Behavioral 32 Ernest M. Gruenberg bio file, AMC. Sciences 37 (Fall 2001), 369–388. 33 Paul V. Lemkau, Mental Health 18 Lowell J. Reed to Victor Vogel June 5, Resources in New York City (New York City 1941 and Vogel to Reed June 6, 1941, JHSPH Community Mental Health Board, 1957); Grob, Dean’s Office Correspondence Series 3a, box “Deinstitutionalization," 48-73. 502041, "U.S. Public Health Service Feb 34 JHSPH Dean’s Office Correspondence 1940-June 1941" folder. Series 3a, box 504577, "NYC Community 19 1944-45 SHPH Catalog, 21-24. Mental Health Board" folder; “Administrative 20 Paul Lemkau, Division of Mental MD: Marvin Earl Perkins,” New York Times Hygiene 1957-58 Annual Report, “President’s Nov 1, 1961. Report” folder. 35 Alan D. Miller, testimony on renewal of 21 1961-62 SHPH Catalog, 66; Paul V. the Community Mental Health Centers Act Lemkau to John T. Cowles Apr. 9, 1963 and before the House Committee on Interstate and Mental Hygiene annual reports for 1957-58 Foreign Commerce Subcommittee on Public and 1963-64, box 504582, "Mental Hygiene" Health and Environment, May 9, 1973, p. 120. 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

2. Research on child development and awareness of the role of public health nurses developmental disabilities in promoting the mental as well as physical health of their clients, Lemkau served as The School of Hygiene’s prewar research psychiatric advisor for Broken Appointment on the social epidemiology of the family had (1955), a documentary film that explored the focused on the physical and mental health of emotional aspects of public health nursing. mothers and children. This research During this period, the majority of public health blossomed after Ernest L. Stebbins arrived in administration courses dealt with clinical 1947 as director of the School and chair of the medical care programs in nursing, maternal Department of Public Health Administration, and child health, mental hygiene, and venereal 6 which housed the Division of Mental Hygiene.1 disease. Such programs reflected an In 1949, Charles-Edward A. Winslow of Yale increasing “emphasis on health problems that named “the challenge of mental and emotional require individualized rather than mass disease [as] probably the greatest single treatment [and] necessitated the use of a objective of the public health program of the multi-disciplinary professional group in future.”2 In his review of Lemkau’s seminal planning and effectuation of health programs,” 7 textbook, Mental Hygiene and Public Health, according to Freeman. Winslow wrote, "To control these Freeman collaborated with Marcia environmental factors [that influence mental Cooper in the Division of Mental Hygiene, health] is a legitimate and ultimately who also promoted interdisciplinary research inescapable task of public health.” Personality and training. Cooper directed the Eastern development during childhood was fraught Health District’s Mothers Advisory Service, with mental health risks, and helping parents which brought psychiatrists, public health to modify and manage them successfully was nurses, and medical social workers together to “sure to be recognized ultimately as even offer practical childrearing advice and support more important (even if also more difficult) for mothers. Child guidance clinics utilizing than the measures now taken for the interdisciplinary teams had their roots in the prevention and early treatment of infectious diagnostic outpatient clinics established for and nutritional diseases." Winslow also mentally disturbed juveniles at the turn of the recognized mental hygiene as a critical factor twentieth century in cities such as Boston, in the success of every health department Chicago, and Philadelphia. By 1930 there clinic, the core work of every good public were over 200 child guidance clinics health nurse, the effectiveness of all health registered with the National Committee for 8 education, and the sound administration and Mental Hygiene. public relations of a health department. He The Mothers Advisory Service received noted, “Such new procedures as childbirth referrals from local physicians and all the without anesthesia, and rooming-in for infants childcare agencies in Baltimore City as well as are primarily mental hygiene technics.”3 many across the state. By the 1950s, the In 1950, Ruth Freeman joined the Mothers Advisory Service was one of the few Department of Public Health Administration remaining threads of the School’s relationship faculty to head the new Division of Public with the EHD, and Cooper moved into Health Nursing, and Freeman and Lemkau assisting clinics and social agencies in began seeking NIMH funds for projects on evaluating children with special needs in psychiatric education and nursing education.4 placement for foster care and adoption. The Division of Mental Hygiene began to Cooper’s multi-disciplinary team from the enroll more nurses, many of whom had Division of Mental Hygiene, Baltimore City worked in the Eastern Health District and Schools, the School Health Division of the City contributed to the School’s studies of maternal Health Department, and the Johns Hopkins and child health and mental hygiene.5 To raise Hospital departments of Child Psychiatry,

social workers played an increasingly critical role.10 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 Marcia Cooper observes children playing at “public health problems that are related to the Mothers Advisory Service, circa 1959. families as such demand classification and 11 Photo courtesy of the Alan Mason Chesney analysis on a family unit basis.” Taken Medical Archives of the Johns Hopkins together, the studies conducted during the Medical Institutions. 1950s and ’60s by psychiatrists Lemkau and Pasamanick in the Division of Mental Hygiene, epidemiologist Abe Lilienfeld, pediatricians Neurology, and Otology also helped Paul A. Harper and Hilda Knobloch in the coordinate the medical and educational needs Division of Maternal and Child Health, and of children with brain injury or communication biostatistician Rowland V. Rider must be handicaps, including screenings for considered among the School’s most far- participation in experimental classes.9 reaching contributions to public health Ruth Freeman and Marcia Cooper research. The pregnancy, prematurity, and challenged gender and disciplinary barriers in development studies shared three the physician-centric culture of Hopkins to characteristics. They used innovative fulfill the 1939 Parran-Farrand Report’s charge methodology that helped to establish the to provide unified training to all types of public etiology and incidence of several poorly health workers. With the growth of programs understood congenital conditions. Carefully like the Mothers Advisory Service, maternal planned, large-scale case-control studies and child health services became the largest highlighted race and socioeconomic status as clinical component of most public health critical factors in both initial damage to the departments. Though still grounded in fetus or infant and in the child’s subsequent pediatrics and obstetrics, maternal and child development. Finally, in both their publications health had broadened to include psychiatry and advisory roles to health officials and and other clinical specialties involved in the policymakers, School of Hygiene faculty care of physically handicapped and emphasized the broad preventive applications developmentally disabled children. Public of their research for policy and practice. health nurses remained central to the field, but

Many congenital neurological conditions, the School of Hygiene’s activities in the such as cerebral palsy and epilepsy, were Mother’s Advisory Service and the maternal thought to be hereditary. Scientific racism and child health clinics of the Eastern Health remained influential, and many medical District show white students and faculty researchers attributed the higher reported observing or caring for African American rates of mental retardation and behavioral women and children who resided in the disorders among black children to biological predominantly black neighborhood racial inferiority. However, little was known surrounding the medical campus.14 about the distribution of birth defects in the Race affected the collection and population or their long-term effects on interpretation of data, sometimes in surprising development.12 Benjamin Pasamanick and his ways. Lilienfeld and Pasamanick had wife Hilda Knobloch investigated these issues expected the rates of prematurity and neonatal by examining infants and young children, with abnormalities to be higher among cases than special attention to the role of the family’s race controls, but this was only true for white and socioeconomic status. In his early infants, while rates for black infants were research on black infants in Harlem and New nearly as high among controls as cases. The Haven, Connecticut, Pasamanick had lower overall percentage of hospitalized births disputed theories of racial inferiority and among black women had resulted in a concluded that lower birth weights and poorer selectively higher proportion of abnormal nutrition explained higher rates of mental pregnancies and deliveries among those for retardation among black children.13 Without whom hospital records were available.15 exception, the archival photographs that depict School segregation actually facilitated the

selection of controls in the retrospective study served by crippled children’s agencies had of maternal and fetal precursors of behavior congenital malformations, the largest single problems in children who had been referred to diagnostic category.19 Lemkau and Harper, the Baltimore City Public Schools Division of with Hopkins pediatrician Robert Cooke, Special Services. Each child with behavior played major roles in the establishment and problems was matched with “another child of expansion of programs that significantly the same sex in the same class [who had not increased the scope and reach of services for been referred, which] resulted in automatic mentally and physically handicapped children. matching by race, economic status, and age But divisions among the three chairs reflected due to segregation and school districting.”16 disciplinary and political splits over which The disadvantages of racial discrimination medical specialties and federal agencies and dire poverty faced by most inner-city East should have primary responsibility for such Baltimore residents were borne out in the services. Psychiatrists on state boards of School of Hygiene’s research, with mental health had traditionally overseen consequential implications for public health institutions for mentally retarded children, but policy and practice. By correlating data from the psychoanalysts who came to dominate the birth certificates, hospital records, and census profession believed such children were tracts, Pasamanick, Knobloch, and Lilienfeld incapable of benefiting from psychotherapy. found that the rate of maternal complications As historian of mental retardation Edward among 700 infants born in Baltimore hospitals Shorter has noted, “The analysts had was 5 percent among whites in the highest breathtakingly erroneous notions of the economic quintile, 15 percent among whites in causes of [mental retardation], believing it to the lowest economic quintile, and 51 percent be the result of faulty parent-child dynamics, of among nonwhites. Black rates of premature ‘refrigerator mothers’ and the like.” During an birth were also “strikingly greater than those in era when few doctors chose to specialize in the lowest socioeconomic white groups,” mental retardation, considered a hopeless and which led the authors to hypothesize that incurable condition that inevitably led to “Negro socioeconomic status is lower than institutionalization, Cooke and Lemkau both that in even the lowest white groups” and dedicated themselves to bettering the quality therefore “prematurity rates increase of care and public programs then available for exponentially below certain economic developmentally disabled children, while thresholds.”17 Of over 42,000 live births to Harper helped to ensure that pediatricians mothers in Baltimore hospitals, 11 percent of were trained to recognize early signs of black infants were premature, compared to developmental problems in infants and young only 7 percent of white infants. Of those born children.20 to mothers over age 30, 22 percent of blacks Pediatricians believed that their specialty and 9 percent of whites were premature.18 should take the lead in caring for mentally At the conclusion of their 1956 article on handicapped children, but it was the precursors of neuropsychiatric disorder, outspoken Cooke rather than the softspoken Lilienfeld, Pasamanick, and Rogers Harper who clashed with psychiatrists on this emphasized that their findings “above all issue. In Cooke’s own department, Leo indicate areas where preventive measures Kanner, the psychiatrist who had established may serve to decrease the enormous weight the first child psychiatry service in a pediatric of individual and social loss and suffering.” hospital, upheld psychiatry’s role in evaluating During the 1950s, state and local health and treating children with delayed mental and departments began to more fully incorporate emotional development. Harper and Lemkau the care of mentally and physically had been active in reform efforts in the handicapped children into maternal and child Maryland Department of Health and Mental health programs. About 30 percent of children Hygiene and Lemkau had also chaired one of

the earliest National Institute of Mental Health their studies of Baltimore children enabled reviews of program development in mental them to create a developmental screening retardation. While Lemkau was critical of the inventory for infants based on a psychoanalysts’ abandonment of the field, he comprehensive clinical evaluation method that wanted progressive mental hygienists to had been tested to measure its predictive oversee care for mentally disabled children value and capacity to distinguish intellectual within state health departments. During the from motor disability. Such improved 1960s, Lemkau led the Department of Mental screening methods were essential for Hygiene at Hopkins to develop an active accomplishing the goals of the Great Society research and training program in the child health legislation that aimed to provide epidemiology of mental retardation, and in comprehensive prevention and treatment 1965 the Department began a contract with services to millions of low-income children.23 the City of Baltimore “to provide qualified and The Baltimore data were also the basis for one adequate psychiatric services for the conduct of the first studies of factors in childhood of the City Health Department's full-time reading disorders, co-authored by Pasamanick mental hygiene clinic for children in the and his doctoral student Ali A. Kawi.24 Eastern Health District.”21 Pasamanick drew upon the Baltimore Lemkau and Harper opposed Cooke on studies of mental disease among children and the issue of creating an NIH institute for adults to refute racial bias in epidemiological studying children's diseases. Harper and studies of mental illness and disability. He Representative John Fogarty were among argued that the vast racial disparities reported those who wanted children's health research in rates of mental illness, whether to remain based in the Children's Bureau, but physiological or neurotic in origin, were Cooke felt that the Bureau's personnel had “largely artifacts consequent to unreliability of 'neither the interest nor the capacities to diagnosis which in turn may follow upon class develop intensive research programs of a and caste factors in both examiners and the basic nature in the biological or behavioral examined.” Pasamanick and his co-authors aspects of human development.'” Lemkau, adjusted for the distribution of prematurity, with close ties to NIMH, shared that Institute’s race, sex, and socioeconomic status in the desire to retain its oversight of research on Baltimore population and found a rate of mental retardation. When Cooke, with the mental retardation in 15 per thousand infants, support of the rest of President Kennedy’s with 13 white and 21 black infants per task force on health, proposed to establish a thousand affected. In a 1964 article in the new child health institute within NIH, they ran Journal of the National Medical Association, afoul of director James Shannon. Shannon Pasamanick emphasized that this difference had been loyal to the categorical disease was not due to innate biological factors, but model of the agency’s early years and resisted rather resulted from much higher black rates the creation of age-based institutes, and of prematurity and maternal complications that Department of Health, Education and Welfare were rooted in poverty and lack of access to (HEW) secretary Abraham Ribicoff was also medical care.25 uninterested in a child health institute. With The School of Hygiene’s studies of the persistent lobbying, Cooke and the Kennedys complex relationship between complications of won over Fogarty and his influential colleague pregnancy, premature birth, abnormal Senator Lister Hill, and the National Institute of neonatal conditions, and developmental Child Health and Human Development disabilities were part of the foundational (NICHD) was established and funded in developmental research that was instrumental 1963.22 in convincing Congress to amend the Social Although Pasamanick and Knobloch left Security Act in 1963 and 1965. These Hopkins in 1955, the longitudinal data from maternal and child health amendments

authorized federal grants to enable states to and local levels; and it benefited schools of provide comprehensive maternity care to high- public health by providing additional support risk mothers; to develop high quality, for research and training in mental health and comprehensive health services for preschool maternal and child health, with a heightened and school age children; and to broaden emphasis on public health nursing.27 These maternal and child health programs to serve federal programs would provide fundamental children with handicapping conditions.26 The support for the new departments of Mental provisions of SS Title V lay the groundwork for Hygiene and Maternal and Child Health that a national maternal and child health services grew out of the School of Hygiene’s extensive network. These programs were characterized research in these areas during the 1950s. by a strong federal role in funding and setting The Division of Mental Hygiene’s research priorities, state administration and provision of on the behavioral aspects of infant and child mandatory matching funds, statewide health development provided tools for shaping public planning to meet federal guidelines, and local health policy, but also profoundly influenced delivery of services. the direction of teaching in the School's The expansion of the scope and budgets master's and doctoral programs. Students and for federal maternal and child health programs faculty in Mental Hygiene and Maternal and during the 1960s had three major effects: it Child Hygiene collaborated closely with the was a major step in the evolution of SS Title V departments of Epidemiology and Biostatistics into a national health system for low-income to compare normal versus abnormal mental mothers and children; it transformed public and physical development in children from health practice by significantly expanding birth onward, with a focus on the origins and maternal and child health services at the state management of congenital and developmental disabilities.28 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 own or their children’s problems.29 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 Lemkau noted in one annual report that he compare socioeconomic differences in had “carried one person connected with the disciplinary methods), in a supermarket while School in rather intensive therapy throughout shopping with their mothers, or in Boy and Girl the year." Scout troop meetings (to compare age- and

sex-related differences among peers and between children and adults). Mental Hygiene students also observed Paul V. Lemkau" (review), AJPH 39 (Dec. teenagers at high school dances and in 1949), 1586-87. 4 Baltimore Traffic Court and interviewed child Paul Lemkau to Ernest Stebbins Apr. 1, welfare agency workers to learn the reasons 1950, JHSPH records, Series 3b: O.D. Financial, box 506104, “1949-50” binder. for moving foster children from one home to 5 "Report on the Eastern Health District to another. Topics that dealt with sexual behavior the IHD 1943.” or attitudes gave students the opportunity to 6 1946-47 SHPH Catalog, 36; 1947-48 test “the extent of tolerance for studies in more SHPH Catalog, 44; 1948-49 SHPH Catalog, or less sensitive areas." Although several 44; 1951-52 SHPH Catalog, 57-63; 1952-53 SHPH Catalog, 59-61. Baltimore City Public Schools personnel had 7 initially consented to a proposed study on the Ruth B. Freeman to Ernest L. Stebbins Apr. 22, 1952, Turner papers, box 505461, problem of dysmenorrhea among high school "Development Committee" folder. girls in school health programs, the study was 8 Fee, Disease and Discovery, 201-04, denied final approval at the top administrative 218; George Rosen, “Public Health and level. School district officials did approve a Mental Health: Converging Trends and similar project on the management of out-of- Emerging Issues,” in Mental Health Teaching wedlock pregnancy in a school system, which in Schools of Public Health (Association of Schools of Public Health, 1961), 22. uncovered “a previously unrecognized lack of 9 “1956-57 Report of the SHPH Director,” communication between school and health JHU Circular 76 (Nov. 1957), 143. authorities that frequently resulted in the 10 William M. Schmidt and Isabelle young pregnant girls, a high-risk group, Valadian, "A Maternal and Child Health receiving inadequate prenatal care.”30 Bookshelf," AJPH 54 (Apr. 1964), 551-62; Lemkau’s first-generation research and Helen M. Wallace, Health Services for teaching on the “continuum of casualty” Mothers and Children (Saunders, 1962); Harold C. Stuart and Dane G. Prugh, eds., applied a life course framework to The Healthy Child: His Physical, Psychological understanding the impact of physiological, and Social Development (Harvard University social, and environmental factors on children’s Press, 1960). development, behavior, and life chances. This 11 Merrell, "The Family as a Unit in Public rich vein of inquiry would blossom further in Health Research," 9. 12 the 1980s under Sheppard Kellam’s Martha Rogers, Abraham M. Lilienfeld, chairmanship with the establishment of the and Benjamin Pasamanick, Prenatal and Paranatal Factors in the Development of Prevention Research Center and an intensive Childhood Behavior (Acta Psychiactric long-term intervention in collaboration with the Neurology Supplement No. 102, 1955), 12-18. Baltimore City Public Schools. 13 Benjamin Pasamanick bio file, AMC; Benjamin Pasamanick, “A comparative study of the behavioral development of Negro 1 Lowell Reed, “Annual Report of the infants,” Journal of Genetic Psychology 69 (1946), 3-44. Department of Biostatistics 1942-43,” JHSPH 14 Dean’s Office Correspondence Series 3a, box Alan Mason Chesney Archives photo collection. 502031, “Department Reports to the Dean 15 1942-1943” folder, AMC; Fee, Disease and Lilienfeld, Pasamanick, and Rogers, Discovery, 192-204, 225. “Relationship between pregnancy experience 2 C.-E. A. Winslow, "Lemuel Shattuck--Still and the development of certain neuropsychiatric disorders in childhood,” 638. a Prophet," AJPH 39 (Feb. 1949), 156-62, 16 quote p. 160. Lilienfeld, Pasamanick, and Rogers, 3 Paul V. Lemkau, Mental Hygiene in “Relationship between pregnancy experience Public Health (McGraw-Hill, 1949); C.-E. A. and the development of certain Winslow, "Mental Hygiene in Public Health by neuropsychiatric disorders in childhood,” 640.

17 Benjamin Pasamanick, Hilda Knobloch, 27 Shonick, Government and Health and Abraham M. Lilienfeld, “Socioeconomic Services, 92. status and some precursors of 28 1961-62 SHPH Catalog, 45. neuropsychiatric disorder,” American Journal 29 "Dr. Paul V. Lemkau, pioneer in mental of Orthopsychiatry 26 (1956), 594-601. hygiene, dies at 82," Baltimore Sun Apr. 30, 18 Rowland V. Rider, Matthew Tayback, 1992; Lemkau bio file; 1957-58 Division of and Hilda Knobloch, “Associations Between Mental Hygiene Annual Report, JHSPH Premature Birth and Socioeconomic Status,” Dean’s Office Correspondence Series 3a, box AJPH 45.8 (Aug. 1955), 1022–28. 505348, “President’s Report 1958” folder. 19 Joseph Wortis, “Mental Retardation as a 30 Paul V. Lemkau, Marcia M. Cooper, and Public Health Problem,” AJPH 45.5 (May Guido M. Crocetti, "A laboratory method for 1955), 632-36; 1966 HEW Annual Report, 50. teaching mental hygiene," AJPH 57.12 (Dec. 20 Shorter, The Kennedy Family, 7-9. 1967), 2158-62. 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 1963- 65” folder. 22Shorter, 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.

3. Mental Hygiene and Behavioral local level, public health agencies accorded Sciences in the 1960s increased funding and attention to preventing and treating mental illness, and also initiated In 1955, Herman Hilleboe, Health new programs that decriminalized substance Commissioner of New York State, designated abuse and treated it as a form of mental mental disorders as the single greatest cause illness. In schools of public health, the of disability and illness in America.1 In the evolution of social epidemiology methods to School of Hygiene, Abe Lilienfeld and Paul address problems such as sexually Lemkau both recognized mental illness as transmitted disease and narcotics addiction among the most common chronic diseases, had important broader implications for risk which they believed could best be controlled factor epidemiology and behavioral with a synergistic combination of interventions to improve health. Behavioral epidemiological and social science methods. sciences evolved to become a methodological Lemkau co-authored a Commission on tool that, alongside biostatistics and Chronic Illness2 prevalence study of “obvious epidemiology, could be used to study any mental illness” in a representative population public health problem. sample of 12,000 in Baltimore, and found that The Division of Mental Hygiene had “after conservative estimation approximately played increasingly significant roles in the 10 per cent of a noninstitutional urban School’s teaching and research programs, but population are at one moment in time mentally it did not become a full department until 1962. ill.” The School of Hygiene’s 1960 planning By the mid-1950s, most schools of public document likewise judged “the most pressing health had reduced their emphasis on single problem in public health” to be mental traditional laboratory sciences such as illness, but narrowly defined it in psychiatric bacteriology in favor of applied fields including terms: “improved techniques for early behavioral sciences, sociology, and public diagnosis of mental disturbance, for isolating health administration. Johns Hopkins, physiological and biochemical determinants of however, clung to its traditional strength in lab- such behavior, for crystallizing preventive based research and postponed the measures for such diseases both on an development of any new social or behavioral individual and community basis and for science courses. Ruth Freeman, head of the developing administrative practices designed public health nursing division of the to reduce the present massive drain of such Department of Public Health Administration, behavioral difficulties upon society." More than was a member of the American Public Health half of U.S. hospital beds were occupied by Association task force that recommended mental patients, and the report called for expanding the public health curriculum to "prompt epidemiological exploration coupled increase content from social and behavioral with multidisciplined laboratory research on sciences, administration, economics, and biochemical, pharmacological and communications. Freeman urged Dean Ernest physiological fronts, all directed toward solving Stebbins to apply these recommendations at the problem of mental health." In the view of the School of Hygiene, exclaiming that she the Department of Psychiatry and the wanted Johns Hopkins to be “ahead of the 4 medically-oriented faculty in the School of parade instead of behind it!” Hygiene, “the problem of mental health” was Freeman identified psychiatric public one of correcting abnormal behavior in health nursing as an important growth area individuals.3 and recommended enrolling more nurses and The 1960s was a watershed decade that adding a nurse to the Division of Mental elevated the status of social and behavioral Hygiene faculty. Freeman and Lemkau sciences in academics generally and in public recruited Betty Cuthbert, coordinator of health particularly. From the federal to the behavioral sciences at the Johns Hopkins

Hospital School of Nursing. Cuthbert was in the medical school but had little interest in the 1959 MPH class with Wallace Mandell collaborating with somatic psychiatrists. His and Abraham Schneidmuhl, who were the catalog statement for Mental Hygiene omitted only three MPH students that year with mental the biological causes and drug treatments for health experience. Cuthbert joined the Mental mental disorders; instead, these conditions Hygiene faculty and led efforts to coordinate were “closely related to cultural, sociologic, training in psychiatric and public health and family environment . . . as well as to the nursing among the Johns Hopkins Hospital, impact of experiences at different periods of School of Medicine, and School of Hygiene. development of the central nervous system Yet as the School of Hygiene shifted more and personality.”7 heavily toward research during the 1960s, Lemkau and his close ally Paul Harper, faculty who were not primarily research- head of the Division of Maternal and Child oriented lost influence, including Freeman and Health, had lobbied Stebbins for years to grant Cuthbert. Nurses were also at a disadvantage their divisions departmental status. As dean, because available grants in their field stressed Stebbins guided the School through a period training, not research, and the Department of of financial hardship which ended in 1958 Mental Hygiene slowly lost its early focus on when Congress passed the Hill-Rhodes Act psychiatric nursing.5 providing direct grants to schools of public At the medical school, the Department of health. With the School on more stable Psychiatry embraced the social and behavioral financial footing, four new departments were sciences. The Introductory Psychiatry Year II established in 1962: Mental Hygiene, Maternal clinical course was renamed Social Sciences and Child Health, Chronic Diseases, and and Medical Psychology in 1959 and changed Radiological Sciences. They were joined in again to The Sciences of Behavior in 1961. 1967 by a new Department of Behavioral The course introduced "the fundamental Sciences, which emphasized a sociological concepts and methods of psychology and approach to understanding population health. sociology and their interrelationships with Throughout the 1960s, the School of anatomy, biochemistry and physiology as they Hygiene welcomed more sociologists, pertain to psychiatry and to medicine psychologists, economists, and demographers generally” as well as “the implications of all of who contributed to public health research on these basic sciences for human personality family planning, community mental health and behavior." After the Department of programs, social and cultural factors in the Psychiatry was renamed Psychiatry and etiology of chronic diseases and aging, Behavioral Sciences in 1966, the course comparative animal behavior, and surveyed "the behavioral sciences by international health manpower planning. By examining normal and pathological personality 1963, ten courses in six departments featured functioning reflected in data and concepts social and behavioral science content, derived from clinical, empirical and including the economic and political aspects of experimental studies in the fields of human financing and organizing health services. The development, learning, communication, and most fundamental such course, Behavioral neurology."6 Science Perspectives in Public Health, Similar changes were afoot in the School introduced methods in anthropology, of Hygiene, which proposed to establish a new sociology, and psychology as applied to Department of Behavioral Sciences in 1960. “socially-induced pathology in the individual.” Significantly, however, the School’s long- As a wave of concern over the deteriorating range plan did not mention the existing morals of America’s youth washed over the Division of Mental Hygiene, which had never media and popular culture, School of Hygiene been oriented toward clinical or basic science students discussed case studies on the research. Lemkau held a joint appointment in problems of "mental deficiency, neglect,

delinquency, illegitimacy, abortion, and birth Ecology and renamed it the Laboratory of control.”8 Comparative Behavior. Mental Hygiene In 1968, the School of Hygiene opened its maintained ties to the Pathobiology studies of new $4.5 million eight-story Behavioral population ecology, and the laboratory trained Sciences Wing, which enabled the School to students to observe and analyze the social double its enrollment. In 1969, the School’s behavior of animals in the field in order to ten-year planning document proposed to add understand how different species maintained 100 faculty positions by 1978-79, with 22 in their survival through mechanisms such as Behavioral Sciences, the largest increase of mating and aggression, and how these any department. This wild-eyed optimism for behaviors were governed by hormones, the future of Behavioral Sciences flowed from heredity, learned experience, and the charisma and vision of founding chair Sol environment.12 The program in comparative Levine, a then-steady torrent of federal grant behavior also included Stephen A. Weinstein money, and the expectation that the in Environmental Medicine. Weinstein held a department would lead the way in promoting joint appointment in Psychiatry and Behavioral interdepartmental research and turning out Sciences in the School of Medicine, where he large numbers of doctoral students.9 directed the Laboratory of Behavioral The 1960s social science zeitgeist Physiology. He started the journal increased federal funding for doctoral and Communications in Behavioral Physiology and postdoctoral mental health training. Lemkau Pharmacology in 1966.13 In the Department of and his successor as chair, Ernest Gruenberg, Biochemistry, Bacon F. Chow’s research both emphasized the fundamentally social team studied the effects of low protein diets in nature of mental health and illness. Lemkau pregnant rats on the physical and behavioral declared in 1961, “the facts [from community development of offspring. The researchers mental health surveys] speak loudly of the also tested methods of reversing these association between social welfare and adverse effects following birth, and found that psychiatry, between social welfare planning feeding the offspring crude pituitary extract and psychiatric planning. From a therapeutic could prevent both physical and behavioral viewpoint, no modern psychiatrist imagines abnormalities from developing.14 that psychiatric illness is cured by absolutely With this promising foundation, Mental individual treatment. . . . ‘A sound mind in a Hygiene began offering a PhD in comparative sound body’ is no longer an adequate aim. animal behavior in 1965, directed by Edwin Social psychiatry is more than a fad, and the Gould, whose research on bats and shrews aim must now be ‘a sound mind in a sound involved observation of mother-infant body, a sound family and a sound community’ interactions (otegeny) and communication if it is adequately to express present health during echolocation. Gould also studied notions.”10 Lemkau, Gruenberg, and other homing behavior in turtles by fitting them with advocates of social psychiatry and preventive tiny radio sets to track them as they crawled mental health influenced the National Institute down the halls of the School of Hygiene. of Mental Health to offer specialty training During the 1970s, Gould’s research received fellowships in fields such as cultural $50,000 annually from the National Science anthropology, sociology, and social Foundation and the National Institute for Child psychology, which were considered basic Health and Human Development.15 sciences for mental health and psychiatry.11 Another researcher who used animal The Department also expanded its models to study infant development and activities and collaborations with laboratory behavior was Wallace Mandell, who observed scientists. When David E. Davis left the the effects of maternal alcohol use on rats and Department of Pathobiology in 1960, Mental their young. With their similar research Hygiene inherited his Division of Vertebrate interests, Mandell and Gould taught a course

on comparative mammalian behavior and infant development. By the early 1970s, 1 researchers from several countries had Herman E. Hilleboe, "Public Health in a identified maternal alcoholism as a factor in Changing World," AJPH 45, (Dec. 1955), birth defects and premature birth, and had 1517-1524. 2 also observed withdrawal symptoms in infants The Commission on Chronic Illness was born to alcoholic mothers. But studies of established in 1947 by the American Hospital Association, American Medical Association, human alcoholic mothers were complicated by American Public Health Association, and additional variables such as race and American Public Welfare Association. AJPH socioeconomic status, as well as levels of 37.10 (Oct. 1947), 1256; AJPH 39.8 (Aug. nutrition, prenatal care, stress, and anxiety, 1949), 1079. 3 which made it difficult for researchers “to Benjamin Pasamanick, Dean W. divide the factors and isolate the problems Roberts, Paul V. Lemkau, and Dean E. caused by the ethanol component, particularly Krueger, “A Survey of Mental Disease in an Urban Population. I. Prevalence by Age, Sex, in prospective studies.” Mandell concluded, and Severity of Impairment,” AJPH 47 (Aug. “Since the proper control over genetic, 1957), 923-29; "A Long Range Plan for the environmental and nutritional variables is Development of the School of Hygiene and difficult in a population of alcoholic patients, Public Health" Feb. 13, 1960, JHSPH Dean’s investigations using animal models are Office Correspondence Series 3a, box R111F2, pp. 9-10. desirable." In his NIAAA grant project, Mandell 4 used rats to study the effects of gestational Ernest L. Stebbins to Thomas Turner Dec. 7, 1956, Comments from Staff Members ethanol use on prenatal development and the binder, and Ruth B. Freeman to Thomas offspring’s subsequent behaviors. Turner Jan. 25, 1957, Subcommittee to Experimental and control groups of mothers Review the Curriculum binder, Committee to were compared for performance on Review the Educational Objectives of the development and behavioral tests, and their School of Hygiene and Public Health. 5 offspring were equipped to self-administer 1961-62 SHPH Catalog, 62, 75, 87; 1964-65 SHPH Catalog, 45; Mandell interview. ethanol intragastrically to test their sensitivity 6 1964-65 SOM Catalog, 113; 1966-67 to alcohol. To isolate the effects of ethanol SOM Catalog, 117. from those of nutritional stress, Mandell 7 1961-62 SHPH Catalog, 45. replaced the calories from ethanol intake with 8 Proposal for a Program in Sociology and an equivalent amount of carbohydrate, and Public Health, 3-5; 1959-60 SHPH Catalog, also fed the control and experimental animals 43; 1960-61 SHPH catalog, 45; 1962-63 in pairs. SHPH Catalog, 55-57; 1963-64 SHPH catalog, 35, 55; 1964-65 SHPH Catalog, 56. As the largest sponsor of research in the 9 "A Ten-Year Plan for the School of School of Hygiene and Public Health from Hygiene and Public Health," preliminary draft 1960 to 1980, the NIH profoundly influenced Feb. 1969, JHSPH Dean’s Office the size, structure, and agendas of the Correspondence Series 3a, box R111F2; School’s departments. Prior to 1970, Mental Press release Dec. 15, 1964, Records of the Hygiene had received NIMH training grants Office of the JHU President, series 6, box 13, but little for research; after 1970, NIH funding "Hygiene-General (1964)" folder. 10 Paul V. Lemkau, “Community Planning guided the outcome of administrative for Mental Health,” Public Health Reports 76.6 realignments within the School, and ensured (June 1961), 489-98, quote p. 489; Ernest that Mental Hygiene remained an independent Gruenberg, “Socially Shared department.16 Psychopathology,” ch. 7 in A. Leighton, J. A. Clausen, and R. N. Wilson, eds., Explorations in Social Psychiatry (Basic Books, Inc., 1957).

11 Paul V. Lemkau, “On the Limits of Mental Health,” AJPH 59.2 (Feb. 1969), 206- 07. 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.

4. Treating substance abuse framework as to how to bring mental health to Texas,” he continued to consult with NIH grants substantially expanded clinical Schneidmuhl and further expanded the and basic science activities throughout the program by obtaining a training grant from the School of Hygiene, even in departments not National Institute of Mental Health. But when traditionally oriented toward laboratory Mandell approached the Johns Hopkins investigation such as Mental Hygiene. The Hospital about hosting the training program, Department was an early pace-setter in hospital officials replied that “we train alcohol and drug abuse epidemiology, and its doctors.”2 faculty served as key consultants to develop Schneidmuhl and Mandell’s work on the substance abuse research programs of alcoholism was part of the medicalization of NIMH and two new NIH institutes: the National “social diseases” such as alcoholism and Institute on Alcoholism and Alcohol Abuse syphilis that were transformed from objects of (NIAAA) and the National Institute on Drug moral condemnation to targets of public health Abuse (NIDA). During the 1970s, federal concern. After Prohibition ended in 1933, grants for substance abuse prevention and levels of social drinking increased along with treatment were the primary source of growth what psychiatrists, sociologists, social for the Department. workers, and other experts labeled “excessive, After the introduction of powerful new pathological drinking.” Replacing the former psychoactive drugs such as thorazine, cultural authority of the temperance movement psychiatry was decoupled from many forms of was a group of academic researchers and organic disease, and substance abuse public health educators who framed habitual emerged as an important new area of clinical heavy drinking as a new disease, alcoholism, and basic science research. Abraham M. that struck victims with susceptible Schneidmuhl, director of the mental health physiological and psychological traits, whom clinic in the Eastern Health District, had they labeled alcoholics. During the 1940s, the worked with Marcia Cooper’s Mothers founding of the Yale Center for Studies on Advisory Service and found that many of the Alcoholism, directed by biostatistician and children’s problems were connected to their physiologist E. M. Jellinek, and the National parents’ alcoholism. In 1960, Schneidmuhl Committee for Education on Alcoholism, founded an alcoholism clinic with support from headed by publicist Marty Mann, signaled an the city and state health departments. A era of increased public awareness of and psychologist and medical social worker funding for alcoholism as a problem that could provided weekly group counseling for alcoholic be solved by scientific research and tuberculosis patients. The clinic was therapeutic intervention.3 advertised on local jazz and R&B radio The alcoholic beverage and tobacco stations, and it quickly attracted patients of industries embraced this paradigm, which both sexes and all age, racial, and social isolated alcoholism and respiratory problems 1 groups. as individual aberrations from the otherwise Schneidmuhl worked with his MPH benign, even beneficial, rituals of social classmate Wallace Mandell to establish the drinking and smoking depicted in EHD alcoholism clinic on a firm footing. They advertisements and enjoyed by millions of saw a major need for programs to train Americans. In 1954, the tobacco industry qualified staff to administer drug and alcohol created the Council on Tobacco Research. In treatment programs, and Mandell helped 1969, the United States Brewers Association formalize a curriculum for a six-month enlisted Thomas B. Turner, the former chair alcoholism counselors training program, which of Microbiology in the School of Hygiene and grew rapidly. After Mandell left Baltimore to dean of the School of Medicine from 1957 to work “within a public health conceptual 1968, to establish the Medical Advisory Group

(forerunner of the Alcoholic Beverage Medical tighten requirements for training grants and Research Foundation). The MAG advised the applicants had to prove that their program was association’s members and conducted filling a shortage in a high priority professional research on the positive and negative health field. The counselor training program was effects of alcohol consumption. Key to both ultimately a casualty of the debate over industries’ support for research on alcohol and whether the state directors should have an tobacco use was their contention that their MPH and background in public health products were not in themselves addictive, administration. As state public health agencies and most consumers could use them became more politicized and turnover responsibly without harming their health. increased, the demand for administrators with Accordingly, the Carling Brewing Company, public health training waned. As Mandell which produced 800,000 barrels of beer admitted, “We lost that battle.”5 annually, hosted Schneidmuhl’s weekly Lemkau had tapped Mandell to lead new alcoholism treatment seminar in May and June research initiatives that focused on preventing 1964.4 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 addicts and alcoholics from treatment.6 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 After the Department of Mental Hygiene Abraham Wikler, who published The Relation recruited Mandell in 1968, he formalized the of Psychiatry to Pharmacology in 1957. Yet alcoholism counselors training program in until the late 1960s, psychiatry was dominated 1971 as an MPH track. A few years later, with by psychodynamics and most psychiatrists a training grant from the National Institute on considered addiction research a backwater. Alcoholism and Alcohol Abuse, the program Public opinion and federal funding coalesced prepared epidemiologists and administrators around finding a solution to America’s drug for substance abuse treatment programs—the problem, portrayed in a series of often first of its kind in the country. By the 1980s, sensationalistic exposés of the heroin many directors of state programs were epidemic that struck inner cities and returning 7 Hopkins graduates. Yet the NIH began to Vietnam veterans.

Mandell was among a new breed of conference on the heroin problem that “we policy-oriented mental health researchers who have turned the corner on drug addiction in fixed their sights on drug abuse and brought a the United States.”11 Yet Mandell could not previously obscure field to the forefront of find strong evidence that NIMH grant- psychiatry. Others included Danny Freedman, supported programs were achieving better chair of psychiatry at University of Chicago results than those without federal support. and the world expert on LSD and Nixon was furious and sent Mandell packing hallucinogens, and Jerome H. Jaffe, a leading back to Baltimore. When he told John C. advocate of methadone maintenance Hume, dean of the School of Hygiene, Hume treatment for heroin addiction who became the said philosophically, “Presidents come and go first drug czar in 1971 under President Richard but the university remains.” Still shaken from M. Nixon. As Jaffe recalled, “We probably his encounter with Nixon, Mandell was so broke all the rules for psychiatry as we had relieved to hear Hume’s encouraging been taught it—that you maintain your response that "I could have kissed him.”12 distance, you don't form personal Alcoholism proved somewhat less relationships. The passivity of politically hazardous than drug abuse. To [psycho]analysis was not appropriate in the house a residential alcoholism treatment arena in which I found myself.”8 Jaffe served facility, Mandell and Schneidmuhl converted as director of the NIDA Addiction Research Baltimore’s Old Bohemian brewery, where Center in Baltimore from 1984 to 1989 and as workers had previously lived onsite. Instead of director of the SAMSA Office of Evaluation, simply releasing patients with no follow-up, as Scientific Analysis and Synthesis from 1990 to existing hospital programs did, the residential 1997. He is currently a clinical professor in the program used the period immediately after Department of Psychiatry at the University of detoxification to educate recovering alcoholics Maryland School of Medicine with an adjunct and connect them with outpatient resources. appointment in the Department of Mental This evolved to become the Johns Hopkins Health at the Bloomberg School.9 Hospital comprehensive alcoholism treatment In the 1970s, federal mental health policy program, which Mandell launched with a grant was redirected toward alcohol and drug abuse from NIAAA.13 treatment services and program evaluation. In 1972, Mandell also established the JHU NIMH was reorganized in 1973 as a unit of the occupational alcoholism treatment program, new Alcohol, Drug Abuse and Mental Health which offered outpatient counseling and Administration (ADAMHA), which also medical services as well as in-patient included NIAAA and NIDA. These entities detoxification to 130,000 employees of twelve provided strong financial support for research Baltimore companies. The program received on substance abuse and also lay the funding from the U.S. Department of Labor to foundation for the major expansion of the prevent job loss among problem drinkers as treatment system.10 As Mandell recalled, when well as to counter the negative effects of Nixon charged him and Richard A. Lindblad, workplace alcoholism on productivity, and it associate director of NIDA, with creating a became a model for other employee treatment network of drug addiction treatment services, programs. But when Department of Labor there was no precedent, so they based their policy precluded Mandell from maintaining proposals for drug abuse clinics on the control of the data generated by the program, alcoholism model. By 1973, the treatment Dean Hume made him return the $300,000 programs had been up and running for several grant. Perhaps Mandell’s most far-reaching years and Nixon selected Mandell to evaluate research on the epidemiology of substance the NIMH grant program in drug abuse abuse was a NIAAA study begun in 1979 of research. On September 11, 1973, the relationships among alcohol control policies, president announced to a White House characteristics of counties, and sex- and race-

specific liver cirrhosis mortality in over 3,000 Research Center and was now chair of U.S. counties and 100 cities.14 psychiatry at Columbia University. After 52 When Paul Lemkau announced his meetings, the search committee offered retirement as chair of Mental Hygiene in 1974, Gruenberg the chairmanship in May 1975. In Dean Hume appointed a search committee to addition to his considerable administrative find a new chair. Abe Lilienfeld, a key experience in mental health agencies, collaborator in the Department's early studies Gruenberg had published extensively on of prematurity and developmental disabilities, mental health epidemiology and the had just retired as chair of Epidemiology and distribution of mental disorders in populations, now served as interim chair of Mental specializing in evaluating the effectiveness of Hygiene. The search committee surveyed the integrated services to treat schizophrenia.16 current state of the fields of mental health and The search committee had also faced psychiatry, which were “in confusion and fiscal and administrative pressures from within disarray” because “the amateur counsellors the University for some form of merger [sic] and encounter groups are taking over.” involving Mental Hygiene, Behavioral According to the committee, half of all medical Sciences, and Psychiatry, but all three school psychiatry departments were led by remained independent departments. Although acting chairmen. Moreover, only four schools Mental Hygiene remained a relatively small of public health housed departments of mental department, Gruenberg and Mandell’s hygiene or the equivalent (and all but the success in attracting federal grants from a department at Johns Hopkins would fold by range of agencies enabled research activities the decade’s end). The committee concluded, and fellowship support to grow. In 1970-71, “the need for new initiatives in the field of the Department of Behavioral Sciences had Mental Health is apparent.”15 been significantly larger than the Department Initially, dean emeritus Ernest Stebbins of Mental Hygiene as measured by budget, called to offer the chairmanship to Alan Miller, faculty, and student enrollment, and both who was preparing to retire as New York State departments received roughly three-quarters Mental Health Commissioner. Miller declined of their funding from federal grants. But by the in favor of becoming dean of students at end of the decade, federal grants enabled Albany Medical College, where he led in Mental Hygiene’s budget to more than triple, establishing a community mental health while Behavioral Sciences’ budget shrank and center. Miller suggested his longtime New became dependent on general funds for York colleague Ernest M. Gruenberg, who nearly two-thirds of its support.17 had headed the state's Mental Health

Mental Hygiene External Funding in 1974

Investigator Research topic Annual amount Funding agency Gould Maternal - infant behavior and $50,000 NSF and NICHD echolocation Lemkau EHD child mental hygiene clinics $70,000 City of Baltimore Lemkau Drug abuse demonstration project $80,000 NIDA Lemkau Mental health in public health $100,000 NIMH Lemkau T raining grant $55,000 NIMH Mandell Substance abuse training and research $750,000 Dept. of Labor/ NIAAA Total: $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 Department Total Budget General Funds Government 1970-71 Behavioral Sciences $353,000 $29,000 $271,000 Mental Hygiene $237,000 $50,000 $188,000 1979-80 Behavioral Sciences $281,000 $181,000 $88,550 Mental Hygiene $962,000 $307,000 $620,000

Source: 1970-71 JHU Treasurer’s Report, 54-55; 1979-80 JHU Long Form Financial Report, 116.

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.” David Celentano Celentano joined the Behavioral Sciences faculty in 1978. In the 1980s, Celentano and In the 1980s, the social science methods Mandell applied their expertise in substance originally used to address “social diseases” abuse prevention and treatment to addressing such as syphilis and substance abuse were the AIDS epidemic, and they advised B. Frank marshaled against the AIDS epidemic. The Polk, who headed the School’s infectious career of one of Mandell’s students illustrates disease epidemiology division, on the School’s how social and behavioral science methods early grants to explore the connections profoundly influenced the development of risk between HIV infection and injection drug 20 factor epidemiology. In the early 1970s, David use. Celentano was a co-investigator for the Celentano had taken a year off after earning a ALIVE (AIDS linked to the intravenous bachelor’s degree at Hopkins to work in the experience) observational cohort study of HIV University of Maryland’s methadone infection among 3,000 intravenous drug users maintenance program “in the deepest, most in Baltimore since 1987. Using baseline data horrible part of Baltimore, really getting to see from the ALIVE study, Celentano’s group what human suffering and misery were all demonstrated that users who bought drugs or about. And when it came time to consider syringes at shooting galleries (clandestine going to medical school, I thought, ‘I’m never locations to buy and use drugs, usually in going to save them one at a time.’” Celentano abandoned housing) were at much higher risk instead enrolled in Mandell’s eleven-month of acquiring HIV from using dirty needles. This alcoholism counseling program, which insight led to further research on who used the included rotations at different inpatient and shooting galleries and why, which addressed outpatient treatment centers in Baltimore. the upstream factors rather than just the route Celentano was in one of the earliest cohorts, of the infection. “a very close-knit group” of about a dozen With ALIVE principal investigator David mostly male students, including three or four Vlahov, Celentano deployed data from the recovering alcoholics. The students discussed ALIVE study to overcome the resistance of the their field experiences and learned new Baltimore City Council and the Maryland State methods for program evaluation. At the time, Legislature, resulting in the establishment of substance abuse treatment programs were the largest needle-sharing program in the rarely expected to show proof of their country. Needle-sharing programs have effectiveness. Even the Baltimore City Health become a prime example of how public health Department program was small and had no interventions must address social and 21 coordinated data.18 behavioral factors in order to be effective. Celentano enrolled as a doctoral student The AIDS epidemic bolstered the legitimacy of in Behavioral Sciences on an NIAAA social and behavioral science methodologies fellowship. His dissertation with Mandell and 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 Correspondence Series 3a, box 506162, Department of Epidemiology, so that three of "Eastern Health District 1963-1965" folder; the School’s ten departments were headed by Paul V. Lemkau, Report of the Department of social or behavioral scientists. Mental Health 1963-64, "Mental Hygiene" folder; DeWitt Bliss, "Abraham Schneidmuhl, During the 1980s, faculty from Mental psychiatrist who trained alcoholism Hygiene and the Johns Hopkins Health counselors," Baltimore Sun July 20, 1994; Services Research and Development Center Tonya Taliaferro and Rosa Pryor-Trust, conducted foundational research on African-American Entertainment in Baltimore substance abuse epidemiology in the U.S., (Arcadia Publishing, 2003), 91-95. 2 particularly the quality and availability of Bliss, "Abraham Schneidmuhl”; Mandell substance abuse treatment services and their interview. 3 Lori Rotskoff, Love On the Rocks: Men, impact on health care organization and Women and Alcohol in Post-World War II financing. Controlling the risks and minimizing America (University of North Carolina Press, the damage associated with drug and alcohol 2002), 64-67. use remains an epic task for U.S. and 4 Monthly Report-Eastern Health District, international policymakers. Today, about one- June 30, 1964; “Artist's rendering of new third of the Department’s faculty focus on the Carling Brewery to be built in Baltimore,” Cleveland State University Libraries Cleveland epidemiology and prevention of substance Memory Project website, accessed Sept. 28, abuse, the most prevalent behavioral disorder. 2011 at www.clevelandmemory.org; Brandt, The Department's research has shown Cigarette Century, 332-38. that school-based interventions among early 5 Mandell interview. 6 elementary-age children are highly effective at Philip D. Bonnet, "Mental Hygiene preventing or reducing the use of alcohol, Search Committee," Nov. 6, 1974, "Sch of Hyg tobacco, and drugs later in life. Mental Health Search Committee for Chairman, Department of Mental Hygiene" folder; Wallace Mandell bio faculty have also developed successful family file, AMC; Wallace Mandell, Sheldon and community-based interventions to prevent Blackman, and Clyde E. Sullivan, the onset of drug use among at-risk teens and Disadvantaged Youth Approaching the World to rehabilitate those already using alcohol and of Work: A Study of Neighborhood Youth other drugs. Using the innovative methods Corps Enrollees in New York City (Wakoff they developed and tested, Mental Health Research Center, Staten Island Mental Health faculty are employing new technologies for Society, 1969); Bliss, "Abraham Schneidmuhl”; Mandell interview. understanding individual and ecological 7 Caroline Jean Acker, “The Early Years of sources of craving for addictive drugs. Their the PHS Narcotic Hospital at Lexington, findings will be used to craft evidence-based Kentucky,” Public Health Reports 112 programs to prevent relapse that can improve (May/June 1997), 245-47; Abraham Wikler, the health and well-being of whole The Relation of Psychiatry to Pharmacology communities. One promising new approach for (Williams and Wilkins, 1957); Eric C. Schneider, Smack: Heroin and the American developing effective prevention methods is to City (University of Pennsylvania Press, 2008). analyze neighborhoods’ influence on use of 8 22 “Conversation with Jerome H. Jaffe,” alcohol and illegal drugs. Addiction 94.1 (1999), 13-30, quote p. 20. 9 Jerome H. Jaffe CV, JHSPH Faculty Database. 10 1 W. Sinclair Harper, Monthly Report- NIH Almanac, Eastern Health District, Oct. 1960, Mar. 14, http://www.nih.gov/about/almanac/historical/ch 1961, Jan. 9, 1963, Feb. 5, 1963, Oct. 4, ronology_of_events.htm, accessed Sept. 30, 1963, Nov. 1963, Dec. 9, 1963, Feb. 6, 1964, 2011; Mandell interview. May 25, 1964, JHSPH Dean’s Office

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 HIV- Injection 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, 599- 641.

5. Mental Hygiene in the 1980s and ’90s decentralization of care and devolution of authority to local communities, with cost savings as a driving force in policy change.2 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 In 1988, Paul Lemkau wrote in the represented one-sixth of total state social American Journal of Public Health, “Mental welfare spending. In the wake of diseases in all their protean forms again deinstitutionalization, the noted neurologist appear to have outwitted the enthusiasts for and psychiatrist Oliver Sacks saw a steady an easy-to-understand panacea.”1 Lemkau stream of discharged patients who returned for spoke with over half a century of experience readmission based on their experiences that as the foremost advocate of a coordinated “Bronx State [Hospital] is no picnic, but it is approach to preventing and treating mental infinitely better than starving, freezing on the illness that addressed the full spectrum of 4 streets, or being knifed on the Bowery.” By patient needs in both hospital and community the 1980s, the mental health reform pendulum outpatient settings. At the turn of the twentieth had swung back as some critics condemned century, proponents of the centralization of community-based care for discharged mental long-term psychiatric care in state hospitals hospital patients as "in many ways a more had argued that “although less expensive, demoralizing, dehumanizing, and dangerous [local care] was substandard and also fostered 5 situation" than mental hospital care had been. chronicity and dependency. Conversely, care While the debate raged on between and treatment in hospitals, though more costly proponents of community-based versus initially, would in the long run be cheaper hospital-based mental health care, the because it would enhance the odds of Department of Mental Hygiene at Hopkins recovery for some and provide more humane launched two major studies that would define care for others.” Ironically, the same its mission for the next three decades: the arguments were refashioned in the postwar Epidemiologic Catchment Area Study, begun decades to justify the opposite policy of in 1979, and a classroom-based intervention

initiated with the Baltimore City Public Schools Psychiatry, and Sam Shapiro, director of the in 1983 to identify aggressive and disruptive Johns Hopkins Health Services Research and behavior in early elementary school students Development Center, to apply for a grant to and prevent subsequent negative outcomes establish Baltimore as one of five ECA such as poor school performance, substance research sites. Kramer led the competition, abuse, and suicide. These studies established since he had been the first Chief of Biometrics the department's twin research emphases on at NIMH and had founded its Office of epidemiology and prevention, both Program Planning and Evaluation in the emphasizing a life course epidemiologic 1960s, which evolved to become the Division approach to inform population-based studies. of Biometry and Epidemiology (including the Shortly after Jimmy Carter took office in Center for Epidemiologic Studies). Kramer, a 1977, he established the President’s 1939 Sc.D. graduate of the School of Hygiene Commission on Mental Health, chaired by and Public Health, was the first biostatistician First Lady Rosalyn Carter. The Commission to focus exclusively on mental illness. His issued a report calling for expanding research major achievements include creating a model to accurately determine the prevalence and reporting system for mental hospital incidence of mental disorders.6 NIMH created admissions, discharges, and patients in the Epidemiologic Catchment Area Program residence, and also establishing psychiatric (ECA) to measure the prevalence of mental case registers at various U.S. locations. These illness in the general population in sites reporting systems and registries became around the U.S. The agency recruited William indispensable in efforts to chronicle and W. Eaton from his position at McGill to understand de-institutionalization of patients coordinate the ECA program. with chronic mental illnesses during a new era At Hopkins in 1979, Gruenberg teamed of psychopharmacology. Kramer was so with Morton Kramer in Mental Hygiene, Paul effective at ensuring that epidemiological McHugh, chair of the Department of methods and research received a high priority

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 Morton Kramer severe mental illness.

in NIMH grant programs that in 1968, Science basically, have they ever heard voices and magazine reported that he had “contributed they won’t be completely offended or turn you more sense and less nonsense to [NIMH] out the door.” 9 policy developments and public statements Carolyn L. Gorman, who began working than any other member of its staff.'' He served as an interviewer for the ECA study in 1979, on the Johns Hopkins Mental Hygiene faculty loved going door-to-door in East Baltimore. from 1976 to 1984.7 Few residents refused to participate, despite The survey employed lay interviewers who the personal nature and length of the survey, underwent an intense two-week training which took about one-and-a-half hours to program to administer the complex survey complete. Gorman recalled that the questions instrument. In order to determine incidence, or on mental illness were less likely to offend the rate at which new cases form, as well as respondents than those on drug use. By sizing the overall prevalence of mental illness, the up a house based on the paint job and the study required sites to conduct an initial presence or absence or toys and flowers, survey and a follow-up survey one year later. Gorman could usually predict whether the The newly revised DSM-III Diagnostic and inhabitant would participate. She had a Statistical Manual of Mental Disorders collection of Polish dolls, and would take a doll introduced explicit diagnostic criteria and with her on interviews. When one of the many classifications of mental illness. The ECA Polish women in the neighborhood saw her survey operationalized these classifications doll, they would always agree to take the and generated psychiatric diagnoses by survey. At the Survey Research Associates incorporating the clinical diagnosis criteria for office on 23rd Street, Gorman trained most of the most prevalent conditions, including the 30 interviewers who conducted the ECA depression, schizophrenia, panic disorder, survey. 10 obsessive-compulsive disorder, and James C. Anthony, an epidemiologist in substance abuse and dependence. Once the Mental Hygiene who played a key role in the survey identified individuals with a definite or ALIVE study, contributed to the Baltimore ECA probable psychiatric disorder, follow-up study’s sophisticated design, and Marshal questions asked about utilization of mental Folstein advocated incorporating the Mini- health services, including what types of Mental Status Exam into the survey to identify obstacles may have interfered with seeking cognitive impairment and dementia. Shapiro treatment. The ECA studies revealed that designed the questions on mental health about one-third of Americans would suffer services utilization, which were required for all from at least one type of mental illness during five ECA sites. Gruenberg and McHugh, both their lifetimes, and that mental disorders went psychiatrists, were very skeptical of using a untreated in many cases.8 survey interview to diagnose mental illness. The ECA Program was the first U01 The Baltimore grant proposal included a cooperative grant program in the PHS, which clinical reappraisal component that requested allowed federal agency staff to negotiate the all the respondents deemed positive for a terms of a grant and influence its mental disorder and a sample of the development. ECA’s three principal remainder to complete a structured interview collaborators at NIMH were Ben Locke, with a psychiatrist, who was blinded to the Darrel Regier (who became director of the results. The reappraisal checked the accuracy American Psychiatric Institute for Research of the survey questionnaire by comparing the and Education), and Bill Eaton, Assistant Chief results with the clinician’s diagnosis. A total of of the Center for Epidemiologic Studies. Eaton 810 Baltimore respondents underwent the noted that “the degree of psychological appraisal, which represented a major effort introspection in the culture had changed a lot that confirmed the study’s scientific validity.11 by 1980. You could come and ask people,

At NIMH, Bill Eaton helped to guide the Saul Alinsky, who was assisting the residents Baltimore study’s design and argued to of the surrounding inner-city Woodlawn include its clinical reappraisal component at all neighborhood in their efforts to confront the the ECA study sites. After winning an city government and the University of Chicago. ADAMHA Administrator’s Award for his At the community board’s urging, Kellam implementation of the ECA Program, Eaton helped to develop programs to enable joined the Department of Mental Hygiene psychiatric hospitals to provide continuity of faculty in 1983. The Baltimore study was care with an emphasis on prevention. Kellam unique among the ECA sites for conducting observed, “in working through how to relate to additional follow-up surveys beyond the one- the community of Woodlawn, we learned a year mark. After the first two surveys in 1981 great deal about public health, building and 1982, the Baltimore study re-interviewed institutional community bases so that the the participants in 1993 (led by Eaton as people that you were working with and principal investigator, Anthony as co-principal working under could have a say, a powerful investigator, and Joseph Gallo as project say, like kicking us out or not. In other words, director) and again in 2004. One of the we’d have oversight by the community.”13 somewhat surprising findings was the degree In response to the concerns of Woodlawn to which major depressive disorder was community leaders about the life course predictive of the new occurrence of important trajectories of children on Chicago’s South physical conditions such as type 2 diabetes, Side, Kellam in 1966 initiated a population- heart attack, stroke, and breast cancer. The based universal intervention study among all Department of Mental Health is currently first grade boys and girls (1,242). The study analyzing the data from four of the five ECA followed their progress into adolescence, sites and correlating it with the National Death young adulthood, and midlife, and analyzed Index to determine the influence of the reasons why some children matured into psychopathology on mortality. The outcome healthy, productive adults and others will constitute the largest population-based encountered serious mental, physical, and study of mental disorders and mortality ever social problems. The study attempted to conducted, with more than 300,000 person- answer the critical question raised by the years of observation.12 controversial 1965 Moynihan Report, which As New York City’s commissioner of suggested that social pathology resulted from mental health in the mid-1950s, Lemkau had living in communities that lacked strong social worked very hard to get the school system to norms, resources, and opportunities. In establish the equivalent of a child guidance contrast, Kellam and his colleagues at the clinic in the schools, which achieved modest University of Chicago theorized that social success. Lemkau believed that public schools pathology was embedded at an early age and were the critical place for prevention and had was largely independent of factors such as wanted to initiate collaboration with the crime and unemployment, and thus could be Baltimore City school system. Yet the more effectively prevented in individuals. They Department made little progress toward this coined the term developmental epidemiology goal until 1982, when Sheppard G. Kellam to describe mapping the variation in was appointed chair. Kellam, a public health developmental paths leading to health or psychiatrist, has played a major role in disorders in defined populations. This establishing concepts and methods for approach applied the public health/Meyerian prevention science and expanding knowledge concept of the life course to mental health about early risk factors and their malleability. epidemiology. As individuals moved through As a faculty member in the Department of various stages of life with corresponding social Psychiatry at the University of Chicago, fields (their family of origin, the classroom, Kellam met the famous community organizer peer group, family of procreation, and

workplace), they had to accomplish a series of allow anybody to use the data no matter what social task demands. Failure in the early they wanted to do with it without the School stages would interfere with this progression board overseeing it.” and predict failure in the later stages. The Prevention Research Center was one Like Lemkau before him, Kellam critiqued of the first four such centers funded by NIMH mental health in the 1960s as “bereft of a after Congress mandated that the agency developmental approach.” His team worked expand its efforts in prevention. After support closely with Woodlawn community leaders to from NIMH faded, NIDA became the main develop and implement a developmental source of funding for research that examined epidemiological prevention research strategy the behavioral antecedents of violence, risky that precisely aimed interventions at early risk sex, substance abuse, and incarceration. factors. The Woodlawn Study was among the NICHD also provided support for the child first community studies to identify risk factors behavior and development aspects. The for negative health and behavioral outcomes center would ultimately track three cohorts of in an urban minority population. For over four children in large-scale epidemiological decades, Woodlawn’s findings on the etiology randomized field trials to test universal of problem behaviors have guided the preventive interventions in first- and second- development of many preventive interventions. grade classrooms. The targeted outcomes In 1983, just after arriving at Johns included drug and alcohol abuse and Hopkins, Kellam collaborated with Eaton, Jim dependence disorders, daily regular tobacco Anthony, and biostatistician Hendricks Brown use, antisocial personality disorder, to submit an NIMH grant to launch a delinquency, and incarceration. The study also preventive intervention to identify early examined patterns in students’ use of school- antecedents of long-term problem outcomes, based services as well as the centrally modeled on the Woodlawn Study. In close important outcome of school failure. All of partnership with the Baltimore City Public these problem outcomes shared the early risk Schools, Kellam’s team at the Hopkins factor of aggressive, disruptive classroom Prevention Research Center (PRC) began behavior as early as first and second grades. with a cohort of 2,311 first-graders in 1985 and The study’s primary intervention was the 1986, chosen from the same three census “Good Behavior Game,” a classroom behavior areas in East Baltimore as the ECA. Kellam management method for socializing children to continued to use Alinsky’s community their role of student while offering teachers a organizing principles, and worked extensively method for managing classroom behavior in a with parents to build a base of support for the way that does not compete for instructional intervention, which resulted in levels of time. By young adulthood, Kellam’s team participation at 90 percent or higher. When the observed significant and meaningful Johns Hopkins IRB interacted with the reductions for all of the problem outcomes Baltimore City School Board, the IRB targeted by the intervention. Using members were used to focusing on the impact randomized designs crafted with community of research on individuals, not communities. and school support, the team examined not The School Board members clashed with the only main effects but the variation in impact on IRB to some extent because Kellam had been developmental paths and outcomes. so successful in ensuring that they maintained Recognizing the vital need to bridge the ownership of the study. The IRB wanted to traditional gap between public education and require the study to obtain permission from public health prevention research, Kellam each student’s family, and didn’t recognize moved to the American Institutes for Research “that somebody else in the community, namely (AIR), a non-profit research group known for the School board, already had permission and its focus on school and education research. At oversight and ownership and wasn’t about to AIR, he developed a new Center for

Integrating Education and Prevention useful and even if it didn't stay exactly the Research in Schools, which provided a home same, continued to provide benefits to the for the third of the three generations of clients of the programs." Baltimore prevention research. After a decade In 1991, Leaf interviewed for a faculty at AIR, Kellam returned to the Department of position at Hopkins in Mental Hygiene, but Mental Hygiene as Professor Emeritus.14 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 community- based 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 From 1995 to 2002, the Prevention violent cities, East Baltimore had even higher Research Center was directed by Philip J. rates of shootings. Fewer than ten schools in Leaf. Leaf was trained as a sociologist and the entire city had at least 40 percent of came to Hopkins from the Yale Department of students performing at grade level on Epidemiology and Public Health, where he standardized tests, and some schools posted had directed the Center for Health Policy and only one or two children who scored at grade Research and previously the Center for Mental level. Although most children were covered by Health Services Research at the Yale the public health insurance plan, which the Psychiatric Institute. Yale had been a site in School of Hygiene had helped to develop, few the Epidemiologic Catchment Area Study, and schools had even part-time mental health Leaf knew Shep Kellam and Ernie Gruenberg. clinicians or counselors. Most importantly, few Leaf and Eaton had both been students of East Baltimore clinicians knew how to provide David Mechanic in the PhD program at the mental health services for children, and no University of Wisconsin-Madison, Leaf's existing organizations were dedicated to that research had focused on prevalence rates of purpose or even showed interest in reaching mental illness in institutional settings such as children or adolescents. Although Baltimore jails and nursing homes. Frustrated with the had changed dramatically since the 1960s lack of continuity after grant-funded academic when Paul Lemkau first initiated mental health research studies ended, often with negative programs in Baltimore City schools and effects on community trust in universities, Leaf conducted research on police involvement in was motivated to find new ways for psychiatric hospitalizations, Leaf would carry universities to launch "something that was on Lemkau's deep commitment to

strengthening community mental health the Child Development Community Policing services. Program, which trains teams of police officers, Beginning in 1992, Leaf led a successful mental health clinicians, and community federal grant in collaboration with the Johns volunteers to help families and communities to Hopkins Department of Psychiatry, Maryland recover from traumatic incidents of violence, Department of Health and Mental Hygiene, and to prevent the cycle of violence and Baltimore City Health Department, and retribution from continuing. The keystone of Baltimore City Public Schools to expand the program is relationships with community community-based mental health services for leaders, who broker acceptance and trust of children in East Baltimore. The $15 million the team members from Johns Hopkins and grant funded full-time mental health clinicians the police department. The program responds in the 18 East Baltimore schools, trained and to specific crises, but also conducts outreach hired community mental health workers, and in the schools, in homes, even in emergency created the East Baltimore Mental Health rooms where victims of violence were "talking Partnership, which Leaf directed until 2000. about who shot them and what somebody For twenty years, the Partnership and the should go do to the people that shot them." Johns Hopkins Community Mental Health Through counseling and conflict mediation, Center expanded and strengthened the Leaf and his team members have chipped infrastructure of community mental health away at what had once been a solid wall of services for East Baltimore youth, eventually violence and its sequelae. They have reaching more than 120 schools. In 2012, generated new resources and strategies to however, the Johns Hopkins Department of respond to a wide variety of needs expressed Psychiatry decided to end its contract to by families and the community. Leaf was also provide services in local schools, which are involved in helping Baltimore City Public still provided by the University of Maryland, Schools secure major federal funding for its Catholic Charities, and local providers. Safe Streets, Safe Schools, Safe Students Leaf recalled that in the first 18 months program. Leaf elevated the mission of that the Partnership was operating, three of prevention in 2000 by establishing the Johns the children it served were shot. Many more Hopkins Center for the Prevention of Youth witnessed violence in their homes and Violence, one of the first such centers funded neighborhoods, and were often related to the by the Centers for Disease Control and victims. "The police were enormously Prevention. frustrated, because they would come on the Leaf emphasized that Baltimore is "one of scenes, see not just a traumatized individual the few cities where we have a major but a traumatized family member, and then university, a large city, all the city and state wonder what happened to those families." agencies, and the NIH" all within convenient After the Baltimore Police responded to a driving distance of each other. Leaf's group hostage-taking incident in a housing project in has been meeting with the Maryland State East Baltimore that was directly across the Department of Education every Tuesday since street from an elementary school, Leaf 1993, which he called "an enormous orchestrated the response and conducted opportunity for Johns Hopkins. We have the classroom discussions with the students about State Department of Health, the State what they had seen. Not only were victims of Department of Juvenile Services, the State violence at higher risk for developing Health Commission, within three or four miles psychiatric disorders, they were also more of Johns Hopkins, and now within three or four likely to become perpetrators themselves. subway stops." Leaf is but one of many Mental Acting on the realization that "getting Health faculty who work to facilitate shot and getting killed in Baltimore is a public collaborations between the city and the state, health issue," Leaf has directed since 1996 and among a wide variety of health, education,

social welfare, and community service grade. Over the next decade, the Department agencies from the private and public sectors. plans to disseminate the Good Behavior Of course, such rich, diverse longstanding Game and other scientifically proven partnerships also greatly facilitate research. classroom-based interventions to schools As Leaf observed,"there's also self-interest in around the country. this. So I and my colleagues have been able A new generation to get research grants to do randomized trials of Mental Health across multiple school systems, because we faculty is applying have these collaborations not just with the prevention Maryland State Department of Education, or research and class- not just with Baltimore City, but with lots of room intervention school systems." By conducting carefully model to new designed evaluations and documenting the contexts such as effectiveness of community mental health preventing bullying interventions, the Department of Mental Health in schools and has been able to provide crucial evidence to conducting mind- convince policymakers to expand successful fulness training to programs to reach more people. The help adolescents Department has also built a strong doctoral cultivate the ability to regulate emotions training program focusing on the delivery, effectively and enhance capacities for calm, organization and financing of mental health sustained attention. Catherine Bradshaw, services for children. Doctoral students are who is deputy director of the Center for the able to draw from the research databases of Prevention of Youth Violence and co-directs the Center on Organization and Financing of the Center for Prevention and Early Care for the Severely Mentally Ill and also to Intervention, studies the effects of school collaborate with the Economics of Mental climate on bullying; the development of Health program in the Department of Health aggressive and problem behaviors; and the Policy and Management.15 effects of exposure to violence, peer The Prevention Research Center was victimization, and environmental stress on renamed the Center for Prevention and Early children. She is a nationally recognized expert Intervention in 2004, when Nicholas Ialongo on cyber-bullying, and her research has was named director and Leaf stayed on as co- shown that in middle school, 25 percent of director. The Good Behavior Game remains girls and 11 percent of boys have been cyber- the cornerstone of the Center’s work to bridge bullied via cell phones or computers at least the traditional gap in prevention research once. between public education and public health, Based on a promising pilot study, Tamar and Ialongo has broadened and deepened the Mendelson is systematically evaluating intervention’s scope to more fully explore the mindfulness training and yoga programs in extent to which aggressive and disruptive urban school contexts and measuring their behavior in early elementary-school children is effectiveness in improving students' overall predictive of a wide range of problems later in behavior and ability to concentrate. The adolescence and adulthood, as well as intervention is designed to prevent mental and whether these problems can be prevented by behavioral disorders in adolescents, especially early intervention. Ialongo’s work has those at high risk for school failure.16 examined the trajectory of not only aggressive behavior but also other behavioral issues, such as using first graders' self-reports of 1 Paul V. Lemkau, "Mental Disorder and anxious symptoms to predict their adaptive Social Policy," AJPH 78.1 (Jan. 1988), 93. 2 functioning and anxious symptoms in fifth 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), 667- 68. 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 school- based mindfulness intervention for urban youth: Exploring moderators of intervention effects," Journal of Community Psychology (2013).

6. The Department of Mental Health in the Along with 21st Century Breitner, psychiatrist George Rebok led in After Wallace Mandell had served as interim developing research chair from 1993 to 1997, John C. S. Breitner and training programs was appointed the Department’s fourth chair. on the mental health Breitner’s research dealt with aging, dementia, aspects of aging. and cognitive decline, particularly epigenetic Rebok had begun his conditions such as Alzheimer's disease in which graduate research on environmental factors influenced genetic aging in 1973, the expression. Breitner was well acquainted with year before the mental health at Hopkins and in East Baltimore, National Institute on since he had completed a two-year postdoctoral Aging (NIA) was established. He applied a fellowship in the Department of Mental Hygiene lifespan approach to developmental psychiatry, in 1979 and had been on the Psychiatry faculty and during his postdoctoral fellowship in at Johns Hopkins from 1977 to 1984. In a variety Psychiatry at Hopkins he began to emphasize of roles, Breitner led in providing mental health prevention while studying the effects of services to East Baltimore residents, serving as dementia on older drivers. In 1989, Rebok joined psychiatrist-in-chief and director of the Mental the Mental Hygiene faculty in the Center for Health Service of the East Baltimore Medical Prevention Research, and recalled that during Plan, medical director of the Baltimore City his job talk, “I kind of proudly announced that I Hospitals Community Psychiatry Program, had like 120 people in my dissertation,” which director of the East Baltimore Psychogeriatric elicited giggles from an audience used to Needs Assessment Project, and staff dealing with thousands of people in population- psychiatrist at the Johns Hopkins Hospital based studies. As the subjects of the Dementia Research Clinic. Breitner left in 1984 Epidemiologic Catchment Area and other large to hold positions at the Mount Sinai School of longitudinal studies grew older, public health Medicine and the Duke University Medical researchers grew more interested in aging Center before returning to Baltimore in 1997. issues. Rebok’s arrival at Hopkins also As P.I. for a National Institute on Aging grant coincided with increased public attention to the from 1994 to 2001, Breitner conducted a social and economic implications of an aging prospective study of incipient dementia among society, championed in Congress by 1,357 men and 1,889 women in Cache County, Representative Claude D. Pepper. An indicator Utah. The researchers investigated multiple of the tremendous growth of the field of aging aspects of the epidemiology of dementia, within mental health research is the expansion including the prevalence of neuropsychiatric of the Cognitive Aging Conference, which began symptoms and the preventive effectiveness of with about 50 attendees in 1987 and reached therapy with anti-inflammatory drugs, statins, 800 in 2012.1 anti-oxidants, and vitamin E. The study When Rebok joined the Department in 1989, determined that vascular factors predict the rate there were no community-based interventions of progression in Alzheimer disease. Another being conducted with adults. Since 1996, Rebok major finding was that hormone replacement has been the PI at Johns Hopkins, one of six therapy reduced or eliminated the sex-specific sites in the Advanced Cognitive Training for risk of developing Alzheimer disease, and that Independent and Vital Elderly (ACTIVE) study, the risk disappeared entirely with more than ten the largest cognitive intervention among the years of treatment. Breitner was assisted on the elderly in the United States. The intervention, study by Peter P. Zandi and Michelle C. funded by NIA, focuses on improving cognitive Carlson, Mental Health faculty who specialize in ability and preventing cognitive decline among a the mental health aspects of aging. cohort of about 3,000 subjects originally, with

approximately 40 percent still being followed. By demonstrated increased brain activity by slowing or halting the loss of daily functioning, comparing volunteers’ MRIs at the beginning the goal of the intervention is to “keep people versus the end of the school year. The presence independent, and keep them out of nursing of Experience Corps volunteers in classrooms homes. If we can improve things like people’s has, in turn, proved highly beneficial for memory ability, or their reasoning ability, or how students, with improved learning and behavior quickly they process information, then you could outcomes as measured by test scores, improve their daily lives in areas such as vocabulary, and decreased disciplinary referrals. managing their medication, or managing their Teachers and principals agree that Experience finances, or being able to use transportation Corps volunteers have had a positive impact on better, or to prepare meals. All of the activities their schools’ atmosphere and culture. Although that keep us functioning independently in Baltimore was one of the earliest Experience society.” Even after the active part of the Corps sites with the most clinical research intervention to improve memory concluded, conducted to date, the Experience Corps model follow-up studies have shown that the positive has been successfully generalized in 20 cities effects persist for years afterward. nationwide. Together, the ACTIVE Study and The ACTIVE study helped the Department Experience Corps have established the to think more broadly about Kellam’s concept of Department’s extensive evidence base for developmental epidemiology, which addresses cognitive health interventions, and Rebok is risk and protective factors and how they vary in currently extending his research to conduct a defined populations over time. Rebok thinks dementia prevention study among displaced about risk factors dynamically, how they change populations in Australia. He co-teaches a course over the lifespan. “What’s a risk factor at one on Mental Health in Later Life with Joseph Gallo, period of life can become a protective factor at who worked with Rebok on the ACTIVE study. another period of life, and vice versa. I’m really Since 2007, Rebok has also been co-P.I. on an trying to live up to the label of being a lifespan NIA training grant with Marilyn Albert in researcher, and think in terms of the long reach Neurology for the postdoctoral training program of childhood events into middle and later life, in aging and dementia.2 and the importance of really starting After Breitner left Hopkins in 2001, Bill Eaton interventions early. And at the same time served as interim chair until 2004, when he was realizing that it’s never too late to start appointed chair. The Department had always interventions, either.” This has been the basis been small with a half dozen or so faculty, and a for Rebok’s lifecourse intervention, Experience departmental self-study in 2003 recommended Corps, which trains older volunteers over 60 that Mental Hygiene should double the number years old to volunteer in K-3 classrooms. Linda of faculty and expand in the areas of mental Fried, director of the Johns Hopkins Center on health services research and cognitive health Aging and Health, developed the idea with Mark and aging. Under Eaton’s chairmanship from Friedman to address the problems of patients 2004 to 2013, the Department rebuilt its who presented in clinic reporting that they felt master’s program to an enrollment of 15 to 20 listless, useless, and depressed. students, and expanded the faculty to 19 full- The Experience Corps emphasizes the time positions.3 Currently, the Department hosts value of older adults as a resource, and with NIA over 80 students and fellows in degree funding since 2006, the Baltimore City Public programs for the M.H.S., PhD, DrPH, and Schools have placed over 700 volunteers in over postdoctoral training. Specialized training 20 schools. The volunteers become more programs include Psychiatric Epidemiology, physically and socially active through their Children's Mental Health Services, Drug interactions with children, teachers, and other Dependence, and Aging and Dementia. volunteers. This stimulation is also beneficial for In 2004, the Department embraced its new their cognitive ability, and Michelle Carlson has identity by changing its name from Mental

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, you know.”4 As a mental health epidemiologist, Eaton’s work has focused on explaining the Shep Kellam with postdoctoral fellows risk factors, natural history, and

consequences of major mental disorders, particularly schizophrenia. To study for schizophrenia and other psychoses. But schizophrenia and more common mental Eaton recognizes that “these theories are big, disorders like depression and anxiety, he has black boxes. They don’t really know what’s used data from from the Baltimore cohort from going on because the immune system is so the ECA study and psychiatric case registers in complicated. The most complicated organ on the several locations around the world. Like David planet is the human brain. The next, most Celentano in the Department of Epidemiology, complicated: human immune system. So you put Eaton is the first chair of Mental Health to hold a the two of them together, you’re out in infinity.”5 PhD rather than an MD, and his training in One of Eaton’s school-wide contributions sociology frames his approach to understanding has been the two-quarter series in measurement the occurrence of what he terms “the subset of that he created with biostatistician Karen bizarre behaviors that generally are labeled as Bandeen-Roche in 1992. The joint course psychiatric disorders.” In the early 1990s, Eaton teaches assessment techniques for human began analyzing data on schizophrenia from the subjects research, drawn from diverse fields system of registers in Denmark, whose rich data including psychometrics, sociology, and sets made it the “best place to study epidemiology. Few other courses on schizophrenia, from an epidemiologic point of measurement, so crucial to public health view.” By the 2000s, Eaton’s research had research, draw from such a broad range of evolved to point to the relationship of disciplines. Students learn how to establish autoimmune diseases to risk for schizophrenia. different thresholds along a continuum that Autism and schizophrenia have traditionally defines a disease, such as hypertension, a been considered separate disorders, but new blood titer, an impairment, a disability, or a research is pointing to common factors, cluster of symptoms. Mental health including increased risk among patients with professionals confront the issue of how to autoimmune diseases, especially celiac disease quantify and categorize disease much more than and sensitivity to wheat. Eaton has extensively general epidemiologists and physicians do, but explored these and other important risk factors the principles are the same for any type of

disorder or condition. Eaton notes that career in the 1950s, today, “mental health is “rheumatoid arthritis looks just like a psychiatric accepted as part of public health—both the disorder." In rheumatoid arthritis, "you have to service delivery part and the prevention part. have a certain number of swollen joints. They And particularly, as the mental or psychiatric have to be symmetric,” and psychiatric diagnosis institutions have disappeared from the likewise classifies disease based on how many landscape, it becomes even more important that symptoms in a cluster are present. "The there be a public health service system to help advantage of public health is that we can mentally ill drug abusers and alcoholic actually statistically evaluate the qualities of the individuals in the community. And that’s the diagnosis in various, different ways. You need current challenge that we are facing.”9 epidemiology to do that because you need a Today, the Department continues to build on population-based sample to do it.”6 its historic strengths in three areas: 1) Eaton and Anthony’s course in psychiatric population-based approaches to preventing and epidemiology helps students understand co- treating substance abuse disorders; 2) morbidity, expressed as multiple variables. psychiatric epidemiology and statistical Since psychiatric illnesses frequently occur methods, with applications for evaluating and together, mental health epidemiologists are strengthening mental health systems, and 3) the ahead of the curve in understanding and treating causes and prevention of developmental and co-morbidity. As Eaton observes, mental behavioral disorders from infancy through illnesses present the opportunity for primary adolescence. Since 2000, new research and prevention of secondary disorders, for example teaching programs have developed in the areas when depression is linked with anxiety, or vice of cognitive health and aging; youth violence; versa, treating the depression also prevents the socioeconomic stratification and mental secondary disorder. “Now we think if you treat disorders; psychiatric and behavioral genetics; depressive disorder, you’ll prevent strokes, and and global mental health. The Department hosts heart attacks, and diabetes. The epidemiologic four centers: evidence is very suggestive, but people haven’t proven it yet.” Indeed, the Department’s current Founded Name Director 1983 Center for Prevention Nicholas research focuses on how patients actually use and Early Intervention Ialongo medications with the goal of promoting adherence to prescription guidelines.7 2000 Center for Prevention Phil Leaf of Youth Violence In 1991, when Eaton served on the Institute of Medicine Committee on Prevention of Mental 2006 Center for Mental William Disorders, the committee’s review of prevention Health Initiatives Eaton efforts to date identified only approximately a 2012 Moore Center for the Elizabeth dozen proven methods of preventing mental Prevention of Child Letourneau illness.8 In the past two decades, there has been Sexual Abuse such progress on prevention research that 2013 Wendy Klag Center for Daniele approximately sixty mental disorders are now Autism and Fallin regarded as preventable by intervention. Many Developmental disorders, such as those caused by nutritional Disabilities deficiencies, infections, or head trauma, are generally disappearing in the Western Mental Health faculty are also actively industrialized countries, but are still common in involved in three university-wide centers based the developing world. Mandell noted, “once we in the Bloomberg School including the Center on figured out how to prevent the disorder, it no Aging and Health and the Urban Health Institute. longer is considered a mental illness or in the purview of psychiatry. Psychiatry is not involved with prevention.” Unlike when Mandell began his

Purpose Funding Title Year

Professorships and $3.62M Sylvia and Harold Halpert Professorship 2005 Faculty Child Sexual Abuse Recruitment 2010 Recruitment Dr. Ali and Rose Kawi Professorship 2011 Scholarships $204K Paul V. Lemkau Scholarship Fund 2002 Lucy Shum Memorial Scholarship 2010 Dr. Ali and Rose Kawi Scholarship Fund 2011 Establish Centers $7.5M Center for Mental Health Initiatives 2006 Moore Family Center for Prevention of Child Sexual Abuse 2012 General Use $30K Morton Kramer Fund 2002 Annual Giving Fund 2002

In just over a decade, the Department of studies and answer important questions Mental Health has successfully increased regarding the future development of mental private support for its key programs. More than health care in the U.S. 50 donors (including private foundations) have Going forward, generously given over $11 million to establish the Department will and advance critical research and training in apply its rich, public mental health. unique expertise to Mental Health faculty continue to make bring public health major contributions to analyzing population-level knowledge and changes in mental health. The Department’s methods to bear well-established body of research on the use of on the most psychoactive medications, treatment-seeking for complex mental psychiatric disorders (including the effects of health issues social stigma), and comorbidity of mental and facing societies physical disorders will serve as the basis for throughout the evaluating the 2010 Affordable Care Act’s world, such as child sexual abuse and autism. In effectiveness in improving overall health and 2012, Mental Health established the Moore mental health care for individuals with mental Center for the Prevention of Child Sexual and behavioral disorders. Faculty will use Abuse, the first academic research center of its simulation and forecasting techniques to predict kind. The Moore Center will promote a public the long-term population-level impact of policies health approach to preventing child sexual on access to care, service utilization and abuse through research, policy analysis and treatment outcomes. To provide a stronger, education. “Our overarching goal,” founding permanent base for these activities, the director Elizabeth Letourneau stated, “is to Department hopes to establish a Center for move our nation’s response to child sexual Psychiatric Epidemiology, which will distill new abuse from a criminal justice orientation, insights from existing national datasets that focused on after-the-fact responses, to a more currently sit underutilized. In collaboration with comprehensive approach that focuses the School’s other departments, Mental Health significant resources on the prevention of child students and faculty at the center will design sexual abuse.”

Autism is another important emerging public contributions to both psychiatric and substance health problem that will demand increasing use disorders. Maher is associated with the mental health expertise reinforced by the unique Obsessive-Compulsive Disorder Family Study in perspective of public health. By developing the Johns Hopkins Department of Psychiatry, sensitive screening instruments for detecting and with the Molecular Genetics of developmental and intellectual disabilities and Schizophrenia Collaboration, a multi-site by conducting research to guide and support international group funded by the NIMH caregivers of autistic individuals, the Department Schizophrenia Genetics Initiative. He has used of Mental Health can make major contributions techniques such as genome-wide association toward solving the puzzle of autism and related scans to locate the specific chromosome regions conditions. associated with heightened risk for mental M. Daniele Fallin, who succeeded Bill disorders. Peter P. Zandi, who directs the Eaton as chair on July 15, 2013, is a genetic Psychiatric Epidemiology training program, is epidemiologist who focuses on neuropsychiatric leading the Department's foray into the new field disorders including autism, Alzheimer's disease, of pharmacogenetics, which facilitates schizophrenia, and bipolar disorder. She also individualized prescription and treatment studies the genetic predisposition to features (“personalized medicine” or “in-health”).10 affecting aging populations such as muscle strength and frailty. Fallin comes to Mental Global Mental Health Health from the Department of Epidemiology, The Johns Hopkins School of Public Health where she directed the Center for Autism and has been committed to promoting public mental Developmental Disabilities Epidemiology health internationally ever since William Henry (renamed and expanded in 2013 as the Wendy Welch helped Clifford Beers to organize the Klag Center for Autism and Developmental International Committee for Mental Hygiene in Disabilities). 1919. The ICMH was reorganized in 1930 at the In January 2013, Fallin and co-investigator International Congress of Mental Hygiene, David Valle, who directs the McKusick-Nathans where Welch served as vice president. At the Institute of Genetic Medicine in the School of Third International Congress of Mental Hygiene Medicine, received a $2.5 million grant from the in London in 1948, the ICMH was transformed Burroughs Wellcome Fund to support the into the World Federation for Mental Health. Maryland Genetics, Epidemiology and Medicine Psychiatrists conceived the WFMH both as an program (MdGEM). The program, jointly advocacy agency for world peace and a bridging administered by the Bloomberg School and the organization between the United Nations and School of Medicine, will allow researchers to the world's voluntary mental health 11 cross-train genetic epidemiologists and human associations. geneticists simultaneously, increasing At the First World Health Assembly in 1948, collaboration and furthering the missions of both Morton Kramer was the only mental health fields. specialist among the U.S. Delegation. The first Fallin finds a natural home in the director-general of WHO was the Canadian Department of Mental Health, whose faculty psychiatrist G. Brock Chisholm, with whom have facilitated major advances in the complex Kramer helped to found the WHO Expert and rapidly developing scientific arena of Committee on Mental Health. The committee's statistical methods in psychiatric and behavioral first report declared that "the most important genetics. Innovative new studies propose to single long-term principle for the future work of expand the understanding of the genetic basis of WHO in the fostering of mental health” was to dementia, bipolar disorder, substance use ensure that international public health programs disorders, and other mental and behavioral upheld “the responsibility for promoting the disorders. Brion Maher is applying statistical mental as well as the physical health of the genetics to study genetic and environmental community.” In 1950, mental health was among

six major global initiatives launched by WHO, Health faculty member Paul Bolton. Bass, an and mental health garnered just under $1 advisee of Bill Eaton, works to design and million—almost one-fifth of the organization’s evaluate methods for assessing mental health total budget.12 and mental illness in non-Western cultures, and Kramer conducted foundational studies on uses them to investigate the effectiveness of international variation in mental hospitals' first innovative prevention and intervention admission rates. He played leading roles in the strategies. Her past experience in addressing U.S.-U.K. cross-national studies on psychiatric the mental health needs of disaster victims and diagnosis, the International Pilot Study of refugees has taken her from the North Carolina Schizophrenia, and the still-evolving refinements coast to the villages of Northern Uganda. Her in psychiatric diagnostic methods and the current projects include evaluating mental health international classifications of diseases. interventions for populations affected by torture Kramer's disciplined approach to psychiatric and trauma; and assessing perinatal depression problems is apparent in the international among HIV-infected women in Brazil.15 discussions of psychiatric epidemiologists over a In 2012, the Department celebrated its 50th half century, published in the Milbank Memorial anniversary and published the reference and Fund collections and the proceedings of the text, Public Mental Health (Oxford University World Psychiatric Association's Section on Press). Public mental health is enjoying a Epidemiology and Social Psychiatry. Kramer’s groundswell, such as the 2007 Lancet article colleagues Jim Anthony and Bill Eaton credit series that asserted there is “No Health without him for his “vision that psychiatric diagnosis Mental Health” and the World Health might be made sufficiently reliable and valid to Organization’s release in 2009 of its mental warrant biostatistical scrutiny and to yield an health Global Action Plan (mhGAP) to recognize epidemiology of specific psychiatric disorders.”13 the global burden of mental disorders and the Alongside Kramer, Paul Lemkau and Robert need for a comprehensive, coordinated Felix served on the WHO Expert Committee on response from the world’s governments. Mental Health shortly after its creation until the Mental Health faculty have demonstrated late 1970s. As a WHO consultant, Lemkau national and international leadership in conducted surveys of mental health in Japan, designing and implementing cost-effective Yugoslavia, and Italy, as well as Venezuela, mental health interventions for low-resource Mexico, and other Latin American countries. settings, especially among vulnerable Lemkau’s studies of psychiatric epidemiology in populations recently subjected to war, genocide Yugoslavia remain classics in the field, and in or natural disaster. In the developing world, an 1969, he chaired the World Mental Health estimated 35 percent of women have been Assembly in Washington, DC.14 raped, and depression is rampant. Equipping Today, Johns public and mental health professionals in these Hopkins remains the countries with the tools to more efficiently deliver only school of public mental health interventions would have an health in the world with enormous effect size, since proven methods of a department of mental prevention and treatment already exist for the health, which hosts one most common mental health conditions, and of the largest groups of these methods are even more effective in low- students and faculty resource settings.16 devoted to global With a new chair, a vibrant research mental health. The agenda, and three highly regarded NIH-funded Judith K. Bass global mental health training programs (with one in global mental unit is headed by health under review), the Department is ready to Judith K Bass (PhD 2004), with collaborators enter its second half-century of leadership in Wietse Tol, Laura Murray, and International public mental health.

1 George Rebok interview Mar. 13, 2013. 2 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. 9Mandell 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.

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

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 Morton Kramer 1974 Paul V. Lemkau 1976 Ernest M. Gruenberg 1988 Alan D. Miller 1996 Sheppard G. Kellam 2000 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

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, 594- 601.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.

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, 206- 07.

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.

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, 667- 675.

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.

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. Vanden- Kiernan, 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.

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 violence, alcohol and other drug exposure. Prevention Science 9(4), 245-255.

Special issue of Drug and Alcohol Dependence 95 (Suppl. 1, 2008).

Kellam, S.G., Reid, J., Balster, R.L. Effects of a universal classroom behavior program in first and second grades on young adult problem outcomes. 1-4.

Kellam, S.G., Brown, C.H., Poduska, J.M., Ialongo, N.S., Wang, W., P. Toyinbo, Petras, H., Ford, C., Windham, A., Wilcox, H.C. Effects of a universal classroom behavior management program in first and second grades on young adult behavioral, psychiatric, and social outcomes. 5-28.

Poduska, J.M., Kellam, S.G., Wang, W., Brown, C.H., Ialongo, N.S., Toyinbo, P. Impact of the Good Behavior Game, a universal classroom-based behavior intervention, on young adult service use for problems with emotions, behavior, or drugs or alcohol. 29-44.

Petras, H., Kellam, S.G., Brown, C.H., Muthen, B.O., Ialongo, N.S., Poduska, J.M. Developmental epidemiological courses leading to antisocial personality disorder and violent and criminal behavior: Effects by young adulthood of a universal preventive intervention in first- and second-grade classrooms. 45-59.

Wilcox, H.C., Kellam, S.G., Brown, C.H., Poduska, J.M., Ialongo, N.S., Wang, W., Anthony, J.C. The impact of two universal randomized first- and second-grade classroom interventions on young adult suicide ideation and attempts. 60-73.

C.H. Brown, W. Wang, S.G. Kellam, B.O. Muthen, H. Petras, P. Toyinbo, J. Poduska, N. Ialongo, P.A. Wyman, P. Chamberlain, Z. Sloboda, D.P. MacKinnon, A. Windham, The Prevention Science and Methodology Group. Methods for testing theory and evaluating impact in randomized field trials: Intent-to-treat analyses for integrating the perspectives of person, place, and time. 74-104.

B.S. Maher, B.P. Riley, and K.S. Kendler (2008). Psychiatric genetics gets a boost. Nature Genetics 40(9), 1042-44.

W. Mandell, M.O. Edelen, S.L. Wenzel, J. Dahl, and P. Ebener (2008). Do dimensions of therapeutic community treatment predict retention and outcomes? Journal of Substance Abuse Treatment 35, 223-231.

T. Mendelson, R.C. Thurston, and L.D. Kubzansky (2008). Affective and cardiovascular effects of experimentally-induced social status. Health Psychology 27, 482-489.

T. Mendelson, D. Rehkopf, and L.D. Kubzansky (2008). Depression among Latinos in the United States: A meta-analytic review. Journal of Consulting and Clinical Psychology, 76, 355-366.

G.W. Rebok (2008). Cognitive Training: Influence on Neuropsychological and Brain Function in Later Life. State of Science Review, Government Office for Science, Mental Capital and Wellbeing: Making the most of ourselves in the 21st century.

A.P. Spira, T. Blackwell, K.L. Stone, S. Redline, J.A. Cauley, S. Ancoli-Israel, and K. Yaffe (2008). Sleep-disordered breathing and cognition in community-dwelling older women. Journal of the American Geriatrics Society 56, 45-50.

P.P. Zandi, P.L. Belmonte, V.L. Willour, F.S. Goes, J.A. Badner, S.G. Simpson, E.S. Gershon, F.J. McMahon, J.R. DePaulo Jr., J.B. Potash, Bipolar Disorder Phenome Group, and National Institute of Mental Health Genetics Initiative Bipolar Disorder Consortium (2008). Association study of Wnt signaling pathway genes in bipolar disorder. Archives of General Psychiatry 65(7), 785-93.

P.K. Alexandre, S. Martins, P. Richard (2009). Disparities in Adequate Mental Health Care for Past- Year Major Depressive Episodes among Caucasian and non-Hispanic Youth. Psychiatric Services 60 (Oct), 1365-1371.

P.K. Alexandre, P. Richard, A. Beauliere, S. Martins (2009). Racial Disparities in Employment Effects of Psychological Distress: A Comparative Study of African- Americans and non-Hispanic Whites. Social Science Journal 46, 201-210.

C.P. Bradshaw, J.H. Zmuda, S.G. Kellam, and N.S. Ialongo (2009). Longitudinal impact of two universal preventive interventions in first grade on educational outcomes in high school. Journal of Educational Psychology 101(4), 926-937.

C.D.M. Furr-Holden, R.B. Voas, J. Lacey, T. Kelley-Baker, E. Romano, and M. Smart (2009). Toward national estimates of alcohol use disorders among drivers: results from the National Roadside Survey Pilot Program. Traffic Injury Prevention 10(5), 403-409.

E.J. Letourneau, S.W. Henggeler, C.M. Borduin, P.A. Schewe, M.R. McCart, J.E. Chapman, and L. Saldana (2009). Multisystemic therapy for juvenile sexual offenders: 1-year results from a randomized effectiveness trial. Journal of Family Psychology 23, 89-102.

E.A. Stuart, M. Azur, C.E. Frangakis, and P. Leaf (2009). Multiple imputation with large datasets: A case study of the Children’s Mental Health Initiative. American Journal of Epidemiology 169(9), 1133-1139.

2010s

T. Mendelson, M.T. Greenberg, J.K. Dariotis, L.F. Gould, B.L. Rhoades, and P.J. Leaf (2010). Feasibility and preliminary outcomes of a school-based mindfulness intervention for urban youth. Journal of Abnormal Child Psychology 38, 985-994.

R. Mojtabai and M. Olfson (2010). National trends in psychotropic medication polypharmacy in office- based psychiatry. Archives of General Psychiatry 67, 26-36.

E.A. Stuart (2010). Matching Methods for Causal Inference: A review and a look forward. Statistical Science 25(1), 1-21.

P.P. Zandi and J.T. Judy (2010). The promise and reality of pharmacogenetics in psychiatry. Psychiatric Clinics of North America 33(1), 181-224.

J. Bass, B. Poudyal, W. Tol, L. Murray, M. Nadison, and P. Bolton (2011). A controlled trial of problem-solving counseling for war-affected adults in Aceh, Indonesia. Social Psychiatry and Psychiatric Epidemiology.

C.D.M. Furr-Holden, M.H. Lee, A.J. Milam, K.S. Lee, R. Johnson, and N.S. Ialongo (2011). The Growth of Neighborhood Disorder and Marijuana Use among Urban Adolescents: Making a Case for Policy. Journal of Studies of Alcohol and Drugs 72(3), 371-9.

S.G. Kellam, A.C.L. Mackenzie, C.H. Brown, J.M. Poduska, W. Wang, H. Petras, H.C. Wilcox (2011). The Good Behavior Game and the Future of Prevention and Treatment. Addiction Science and Clinical Practice 6, 73-84.

B.S. Maher, V.I. Vladimirov, S.J. Latendresse, D.L. Thiselton, R. McNamee, M. Kang, T.B. Bigdeli, X. Chen, B.P. Riley, J.M. Hettema, H. Chilcoat, C. Heidbreder, P. Muglia, E.L. Murrelle, D.M. Dick, F. Aliev, A. Agrawal, H. Edenberg, J. Kramer, J. Nurnberger, J. Tischfield, B. Devlin, R.E. Ferrell, G.P. Kirillova, R.E. Tarter, K.S. Kendler, and M.M. Vanyukov (2011). The AVPR1A gene and Substance Use Disorders: Association, Replication and Functional Evidence. Biological Psychiatry 70(6), 519-27.

G.W. Rebok, et al. Experience Corps: A Civic Engagement-Based Public Health Intervention in the Public Schools (2011). In Paula E. Hartman-Stein and Asenath LaRue, Enhancing Cognitive Fitness in Adults: A Guide to the Use and Development of Community-Based Programs. Chapter 27, 469-487.

E.A. Stuart, S.R. Cole, C.P. Bradshaw, and P.J. Leaf (2011). The use of propensity scores to assess the generalizability of results from randomized trials. The Journal of the Royal Statistical Society, Series A 174(2), 369-386.

W.A. Tol, C. Barbui, A. Galappatti, D. Silove, T.S. Betancourt, R. Souza, A. Golaz, and M. van Ommeren (2011). Mental health and psychosocial support in humanitarian settings: linking practice and research. The Lancet 378, 1581-91.

W.A. Tol, Patel, V., Tomlinson, M., Baingana, F., Galappatti, A., Panter-Brick, C., Silove, D., Sondorp, E., Wessells, M. , and van Ommeren, M. (2011). Research priorities for mental health and psychosocial support in humanitarian settings. PLoS Medicine 8(9), e1001096.

C.P. Bradshaw, T.E. Waasdorp, and P.J. Leaf (2012). Effects of school-wide positive behavioral interventions and supports on child behavior problems. Pediatrics 130(5), e1136-e1145.

W.W. Eaton and the Faculty, Students, and Fellows of the Department of Mental Health, Bloomberg School of Public Health (2012). Public Mental Health. Oxford University Press.

A.P. Spira, K. Covinsky, G.W. Rebok, N. Punjabi, K. Stone, T. Hillier, K. Ensrud, and K. Yaffe (2012). Poor sleep quality and functional decline in older women. Journal of the American Geriatrics Society 60(6), 1092-1098.

A.P. Spira, K. Covinsky, G.W. Rebok, K. Stone, S. Redline, and K. Yaffe (2012). Objectively measured sleep quality and nursing home placement in older women. Journal of the American Geriatrics Society 60, 1237-1243.

W.A. Tol, I.H. Komproe, M.J.D. Jordans, A. Vallipuram, H. Sipsma, S. Sivayokan, R.D. Macy, and J.T.V.M. de Jong (2012). School-based mental health intervention for children affected by war in Sri Lanka: a cluster randomized trial. World Psychiatry 11, 114-22.

T.E. Waasdorp, C.P. Bradshaw, and P.J. Leaf (2012). The impact of School-wide Positive Behavioral Interventions and Supports (SWPBIS) on bullying and peer rejection: A randomized controlled effectiveness trial. Archives of Pediatrics and Adolescent Medicine 116(2), 149-156.

J.K. Bass, J.R.M. Copeland, W.W. Eaton, R.S. Hock, F. Or, P.T. Lee, H. Minas, G.J. Raviola, B. Saraceno, V. Ganju, E. Hayward, T.H. Bornemann, M. Burkey, L. Chen, R. Kidwai, K. Kolappa, N.E. Wallace, and V. Patel (2013). A United Nations General Assembly Special Session for Mental, Neurological and Substance Use Disorders: The Time Has Come. PLoS Medicine.

E.J. Letourneau, D.A. Ellis, S. Naar-King, J.E. Chapman, P.B. Cunningham, and S. Fowler (2013). Multisystemic therapy for poorly adherent youth with HIV: Results from a pilot randomized controlled trial. AIDS Care.