The History of Mental Health Treatment

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The History of Mental Health Treatment

• Jess P. Shatkin, MD, MPH
• Vice Chair for Education
• NYU Child Study Center
• New York University School of Medicine

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Learning Objectives

• Residents will be able to
• 1) Identify the key historical events which led
  to the growth of asylums
• 2) Describe how the fields of psychiatry and
  clinical psychology grew and changed over the
  past 300 years
• 3) Select four factors which led to the eventual
  closure of asylums and the present day focus on
  community care

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Two Extremes

• The history of the care and treatment of the
  mentally ill represents an endless journey
  between two extremes
• Confinement in a mental hospital
• Living in the community

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Humoral Theory

• Following upon humoral theories of illness (both
  mental and physical), disease was caused by an
  imbalance of the humors
• The role of the physician was to assist in
  restoring equilibrium
• Hot Cold Dry Wet
• Earth Air Fire Water
• Black Bile Yellow B. Phlegm Blood

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Three Primary Procedures

• Bleeding (cut)
• Vomiting (emetic)
• Purging (laxative)
• These treatments were nonspecific and applied to
  all that ails you
• They long outlived the theories that justified
  them (even into the 19th century)
• Even once realized to be invalid scientifically,
  doctors would sometimes use an eclectic approach

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17th Century

• Society is rural and agricultural
• Communities are small and scattered
• Mental illness is an individual not societal
  problem to be handled by the family and not the
  State
• Concepts of insanity are fluid and not medical,
  arising more from cultural, popular, and
  intellectual theories
• Monty Pythons Village Idiot

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18th Century American Colonialism

• Institutionalization first appears by the early
  1700s
• Based upon the English principle that society had
  a corporate responsibility to the poor and
  dependent
• Largely precipitated by demographic shifts and
  industrialization leading to population increases
  in cities and a relative increase in the
  proportion of sick and dependent persons
• Geographic mobility leads to less neighborhood
  cohesion
• Medical considerations were minimal the real
  issues were economic and public safety
• Undifferentiated welfare institutions and
  almshouses treated the aged, infirm, very young,
  and mentally ill

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Hospitals

• A recent invention created by affluent trustees
  for the less fortunate, not for themselves
• As late as 1873 there were only 178 hospitals in
  the US (1/3 of which were for the mentally ill)
  with a total of fewer than 50,000 beds
• Currently on the order of 15K hospitals in the
  U.S. and approximately 1.8 million beds

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Moral Treatment

• Preindustrial people tended to accept their fate
  (omnipotent God)
• The 18th Century Enlightenment stressed
  innovation and problem-solving by conscious and
  purposeful human intervention
• Pinel created moral treatment which suggested
  that environmental changes could affect an
  individuals psychology and thereby change his
  behavior

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The Birth of the Asylum

• Pinel rejected the prevailing belief that madness
  was incurable, and he suggested that confinement
  in a well ordered asylum was indispensable
• Benjamin Rush
• William Tuke (created the York Retreat, 1792)

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Asylums (late 1700s early 1800s)

• Bedlam (Bethlehem Hospital) was established in
  the 13th Century but was a storage facility
• Well established American asylums included McLean
  (Boston), Bloomingdale (NYC), Butler
  (Providence), Pennsylvania Hospital
  (Philadelphia), and the Hartford Retreat
  (Connecticut)
• These were set up for wealthy families who would
  not mix with racial and ethnic minorities, for
  whom almshouses remained the only place

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AMSAII

• In 1844 the Association of Medical
  Superintendents of American Institutions for the
  Insane (AMSAII) was founded
• Coincident with the emergence of Psychiatry, the
  2nd subspecialty after surgery
• Later to become the American Psychiatric
  Association
• The first medical specialty organization in the
  nation
• Founded the American Journal of Insanity

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Public Asylums

• By the 1820s it became clear that the wealthy
  asylums could not care for the poor who were
  overwhelming the almshouses and urban streets
• During the second half of the 19th Century, the
  responsibility for the insane slowly fell under
  the jurisdiction of state asylums
• This movement went on for about 100 years, when
  asylum populations hit their peak in 1955
  (roughly 600K patients at that time)
• The massive growth of asylums was more of an
  accident than a proper plan (custodial)

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Psychiatry and Asylums

• Asylums predated psychiatry, not vice versa
• A symbiotic relationship between asylums and
  psychiatrists developed, each conferring
  legitimacy upon the other
• Psychiatry worked hard to establish itself as the
  proper leader of asylums
• Medicine was an unstable career
• There were lots of non-allopathic healers who
  challenged the primacy of MDs

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Moral Treatment in Asylums

• Insanity was due to two causes (1) Lesions in
  the brain and (2) moral causes
• Moral insanity was due to willful violation of
  natural laws that governed human behavior (such
  that immorality, improper living conditions, and
  stresses could precipitate illness)
• Because physical causes could not be addressed,
  treatment focused on the moral causes
  (masturbation, alcohol abuse, excessive ambition,
  jealousy, pride, etc.)
• Treatment was a synthesis of medicines, religion
  and morality (OT, religious exercises,
  recreation, etc)
• Heroic treatments were still used but unjustified

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Psychiatric Job Security (1830-1900)

• Asylum physicians had a good gig going
• They were influential, enjoyed a well paid job,
  and had high status in medicine
• Little interest in joining the AMA upon its
  founding in 1847

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The Reality of Asylum Life (late 1800s)

• But asylum life was rapidly becoming a real mess,
  by the close of the century asylum legitimacy
  was being questioned
• Moral treatment demanded small settings, but
  patient numbers kept increasing
• Psychiatry became largely managerial and
  administrative
• Decreases in infant mortality meant more
  dependent elderly, only some of whom were senile
• Mental hospitals became surrogate old age homes
• Repositories for those with tertiary syphilis
• Mortality rates in asylums were 5x the general
  population due to over-crowding

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Germ Theory

• General medicine now becomes legitimate and
  powerful
• Psychiatrists scrambled to identify new careers
  outside of institutions, articulating novel
  treatments and theories
• A preventative role is seen and following upon
  Freudian theory neurosis and stress become
  legitimate illnesses worth treating
• Neurology tries to discredit psychiatry
• AMSAII changes its name to the American
  Medico-Psychological Association (AMPA) to
  reflect its desired focus as a more medical
  specialty and to dissociate itself from
  institutions

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Dynamic Psychiatry

• Viewed psychic distress along a continuum from
  normal to abnormal
• Treatment focus shifted away from asylums and
  toward psychiatric institutes and hospitals
• Pathological (Psychiatric) Institute established
  in NYC in 1895
• The appearance of the psychiatric hospital
  (mission evaluation, treatment, and referral)
• Bellevue Adult Psych Unit 1879
• Child Unit 1924
• Adolescent Unit 1927

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Psychopathy

• Psychiatry stretched beyond psychopathology to
  include conduct and other behavioral disorders
  within its domain (sexual behavior, criminality,
  etc.)
• This occurs partially because of genuine concern
  and interest and partly because of the desire to
  move somewhat away from the chronic and
  persistently mentally ill who are housed in
  asylums

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Striving for Legitimacy

• The AMPA becomes the APA in 1921
• The Journal of Insanity becomes the American
  Journal of Psychiatry
• Psychiatry is unable to gain a foothold in
  universities before WWII
• The first professional board, the American Board
  of Psychiatry and Neurology, is founded in 1934
  and provides for board certification

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Home Care

• In an effort to decrease costs to the states,
  home care becomes an option in the 1920s and 30s
  (Depression era)
• Families either couldnt or wouldnt manage their
  sick relatives at home
• Meanwhile, overcrowding continues at asylums, and
  there is less and less money available to take
  care of the infrastructure

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New Somatic Treatments

• All from Europe in the 1920s 30s
• Quickly adopted in the US because of the great
  desire to treat the ill
• Received with great optimism
• The states were spending lots of money on
  custodial care
• Psychiatry was anxious to legitimize itself as a
  true medical specialty
• Regardless of their true utility, these somatic
  therapies breathed great hope into American
  psychiatry on the eve of WWII

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Fever Therapy

• Jules Wagner-Jauregg (University of Vienna)
• Based upon the observation that mental symptoms
  occasionally disappeared in mental patients ill
  with typhoid fever
• He injected malarial blood into mentally ill
  patients (aka malarial therapy)
• Received the Nobel Prize in 1927
• Used commonly with syphilitics in the US
• No evidence of its utility

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Diabetic Coma

• Manfred Sakel, Viennese physician
• Based upon his observation that diabetic drug
  addicts treated with insulin in 1928 had a
  decrease in psychotic symptoms
• By the mid-1930s he was routinely using this
  treatment in psychotic illnesss
• The hypoglycemic state resulted in a coma
  relieved by administration of sugar
• Lacked a rationale theory and didnt work

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Metrazol Treatment

• Ladislas von Meduna, Hungarian physician
• Based upon the observation that epileptics are
  rarely schizophrenic, he employed metrazol to
  induce convulsions
• He postulated a biological antagonism between
  the two illnesses
• Little data was collected

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The Problems with Shock

• Many potential side effects to insulin and
  metrazol
• Insulin comas were sometimes fatal and could
  induce seizures, pulmonary edema, and respiratory
  distress (mortality rate of 1 5)
• Metrazol was safer but could lead to fractures
  and respiratory distress
• Still, these treatments became quickly in vogue
  and were to be found in every asylum and
  psychiatric hospital by 1940

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Introducing Electroshock

• A safer alternative to metrazol
• Developed by Ugo Cerletti (Italian physician who
  believed in shock treatment but found insulin and
  metrozol too dangerous)
• Was shown to work effectively, particularly with
  affective disorders and psychotic mood states
• The problem was that psychiatric nosology was so
  shotty as were diagnoses themselves that it was
  hard to apply this treatment to the right
  patient

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Lobotomy

• Egas Moniz, Portugal
• Developed by Moniz in 1935, it was a runaway hit
  with US physicians
• This treatment had a firmer theoretical
  justification than the shock therapies
• A simple surgical procedure that involved
  severing the nerve fibers of the frontal lobe
• Between 1936 and 1951, at least 19,000 lobotomies
  were performed in the US

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World War II

• After 1945 there became a great emphasis upon
  shifting care away from hospitals and into the
  community
• The war had influenced psychiatrists
• They saw the impact of environmental stress
• They saw that non-institutional treatment could
  be beneficial
• They saw how pervasive these illnesses were that
  is, the breadth of psychiatric illness became
  more evident (not just the severe and persistent
  illnesses)

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Psychoanalytic Theory

• By the end of WWII, the APA became more
  psychodynamic and analytical
• These same leaders took control of university
  departments of psychiatry
• There became a contrast between psychiatrists
  focused on institutional patients (with severe
  illness of presumed biological etiology) and
  those focused on psychodynamic and community
  focused treatment

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Post-War Changes in Healthcare

• After 1945, the nations healthcare system
  underwent major changes as a result of
• Federal initiatives
• The development of 3rd party insurance
• A commitment to medical technology and
  specialization
• The NIMH was established and so ended a long
  period of federal passivity in mental health
  policy

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CMHCs

• Community Mental Health Centers were established
  in every state during the 1950s on the theories
  of
• Prevention
• Early identification and treatment (following a
  psychodynamic model)
• Follow-up care for institutionalized and
  hospitalized patients
• State contributions outpaced federal allocations
  because of their optimism and potential financial
  savings

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Psychology

• An historically philosophical field that became
  experimental in the late 1800s in Germany
• Following upon the work of Watson and Skinner,
  claimed to have amassed much data by the 1940s,
  having derived explanatory theories relevant to
  normal and abnormal behavior
• Psychiatrists had little evidence to support
  their treatments and were generally not well
  trained in research methods
• All parties concluded research must be
  multidisciplinary, and the NIMH began to support
  both fields in research and clinical training

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Milieu Therapy (1950s)

• Aka therapeutic community
• Proposed that the environment of an asylum or
  hospital could assist in the treatment of the
  mentally ill by organizing a community or social
  organization which itself would be healing and
  toward which everyone is expected to make a
  contribution
• This contrasted with authoritarian mental
  hospitals in the same way that US democracy
  contrasted with Soviet dictatorship (Cold War)

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Optimism Reigns Supreme

• During the 1950s, psychiatry was once again
  optimistic
• At least one somatic treatment worked really well
  (e.g., ECT)
• A well thought out theoretical psychodynamic
  foundation had been effectively established
• Milieu Therapy had emerged
• However, it was realized that psychotherapeutic
  treatment varied greatly by practitioner and was
  not standardized

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Psychotropic Medications

• Chlorpromazine (Thorazine) was synthesized in the
  late 1950s and was the first psychoactive drug
• Initially developed as an antihistamine
• It helped to bring together biological and
  psychodynamic psychiatrists (who also found this
  and other medications useful)
• Many effective drugs followed and helped move
  patients into the community
• Necessitated all sorts of new practitioners
  (psych nurses, social workers, clinical
  psychologists)
• Of these only psychologists threatened the
  supremacy of psychiatry psychologists desire
  to do psychotherapy led to a big fight

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Medicaid and Medicare

• Came on the heals of the Civil Rights Movement
• The first time that patient rights were really
  discussed
• Medicaid (1965) provided a better reimbursement
  for nursing home care than for mental hospitals
• In 1972 Social Security Disability Insurance
  (SSDI) was expanded to include the mentally
  disabled the Social Security Act was amended to
  provide coverage for people who didnt qualify
  for benefits
• Supplemental Security Income (SSI) was set up to
  provide income for those whose disabilities made
  them incapable of holding a job (e.g., elderly,
  mentally or physically disabled, blind, etc.)
• SSDI and SSI made it still easier for the
  mentally ill to leave hospitals since federal
  payments would allow them to live in the community

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The Reagan Era

• Reagan reversed 3 decades of federal involvement
  in the care of the mentally ill in 1981 with the
  Omnibus Budget Reconciliation Act
• Funding was shifted away from the federal
  government and to states and communities
• Billions of dollars were eventually cut

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The Asylum Era at an End

• 4 major factors contributed to their closure
• The Civil Rights Movement
• The development of pharmacological interventions
• Legislation demanding patients be treated in the
  least restrictive setting (re community)
• Reagan era decreases in funding
• - Psychosis or major mental illness becomes no
  longer a reason to hospitalize someone