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The History of Mental Health Treatment


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Title: 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
  • 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 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
  • Concepts of insanity are fluid and not medical,
    arising more from cultural, popular, and
    intellectual theories
  • Monty Pythons Village Idiot

18th Century American Colonialism
  • Institutionalization first appears by the early
  • Based upon the English principle that society had
    a corporate responsibility to the poor and
  • 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
  • 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

  • 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

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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)

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
  • 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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  • 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
  • The first medical specialty organization in the
  • 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)

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

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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

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
  • 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
  • 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

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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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  • Psychiatry stretched beyond psychopathology to
    include conduct and other behavioral disorders
    within its domain (sexual behavior, criminality,
  • 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

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 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

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 didnt 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
  • 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

  • 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
  • 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

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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

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
  • The NIMH was established and so ended a long
    period of federal passivity in mental health

  • Community Mental Health Centers were established
    in every state during the 1950s on the theories
  • 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

  • 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
  • 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
  • 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
  • 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
  • The first time that patient rights were really
  • 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

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
  • 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