The History of Mental Health Treatment

1. 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

2. 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

3. 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

4. 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

6. 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

8. 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 Python’s Village Idiot

9. 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

10. 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

12. 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

14. 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)

15. 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

17. 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

19. 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)

20. 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

21. 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

23. 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

24. 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

25. 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

27. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

40. 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)

42. 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

43. Post-War Changes in Healthcare • After 1945, the nation’s 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

44. 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

45. 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

46. 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)

47. 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

48. 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

49. 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 didn’t 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

50. 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