Transcript The History of Mental Health Treatment

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
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
Two Extremes
The history of the care and treatment of the
mentally ill represents an endless journey
between two extremes:
1)
2)
Confinement in a mental hospital
Living in the community
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
Earth
Black Bile
Cold
Air
Yellow B.
Dry
Fire
Phlegm
Wet
Water
Blood
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

th
17





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 Python’s Village Idiot
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
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
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
individual’s psychology and thereby change his
behavior
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)
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
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
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)
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

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
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
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
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 MedicoPsychological Association (AMPA) to reflect its desired
focus as a more “medical” specialty and to dissociate itself
from institutions
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

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
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
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 couldn’t or wouldn’t 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
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
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
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 didn’t work
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
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
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
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
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)

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
Post-War Changes in Healthcare

After 1945, the nation’s healthcare system
underwent major changes as a result of:
1)
2)
3)

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
CMHCs

Community Mental Health Centers were
established in every state during the 1950s on the
theories of:
1)
2)
3)

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
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
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)
Optimism Reigns Supreme

During the 1950s, psychiatry was once again
optimistic:
1)
2)
3)

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
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
Medicaid and Medicare

Came on the heals of the Civil Rights Movement



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 didn’t qualify for benefits


The first time that patient rights were really discussed
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
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
The Asylum Era at an End

4 major factors contributed to their closure:
1)
2)
3)
4)
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