From Barbaric to Compassionate: The ‘Then and Now’ of Mental Health Treatment
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From Barbaric to Compassionate: The ‘Then and Now’ of Mental Health Treatment

The first centers for housing and caring for people with mental disorders were built in Europe from the 1400s through the 1700s. Before the idea that behavioral problems were part of a disorder of the mind, people with mental disorders were believed to be witches or to be possessed by demons. (Interestingly, we still hear this language used today when people refer to “my demons.”) As a result, they were frequently shunned by society. What’s more, they were often hidden away or abandoned by their families out of shame and fear. Those who were believed to be a threat ended up in prisons, where physical abuse and deplorable conditions were common. With this kind of history, is it any wonder that many people today continue to feel shameful about behavioral health issues? Fortunately, as we will see, times have changed, and such shame is not only unnecessary, it can be dangerous. Today, we have many excellent treatments, and stigma just gets in the way of people getting help that may be life-changing and even life-saving.

Visitors were permitted to see these poor souls, but it was often as a kind of entertainment or ‘freak show.’

Before there were modern psychiatric hospitals, there were places known as “madhouses” or “asylums.” One of the most well-known of these was Bethlem Royal Hospital in London. The history of this facility, better known by the nickname “Bedlam,” epitomizes how people with mental illness were treated at the time. At “Bedlam,” and similar institutions, people were kept in small rooms and chained or tied up if they were thought to be potentially violent. Visitors were permitted to see these poor souls, but it was often as a kind of entertainment or “freak show.” In the worst cases, inmates lived in filth, including their excrement, and rarely had the chance to bathe. Food was limited, as physicians believed that a bland, restricted diet would somehow help them. Hence, patients often went hungry, and many were in a constant state of near-starvation.

1733 Depiction of ‘Bedlam’ by William Hogarth

The Enlightenment Era of the 1800s was the beginning of a turning point towards more humane mental health treatment. During this time, the field of psychiatry began to develop, and notable advances were made in understanding and treating mental disorders. Mental health advocates like William Tuke, Philippe Pinel, and Dorothea Dix helped foster significant changes. These individuals pushed for humane, moral and compassionate care for people with mental disorders. In 1796, William Tuke, a British Quaker and merchant, raised funds to open the York Retreat to care for patients with mental illness. His work influenced the French physician, Philippe Pinel, who advocated for institutions to remove physical restraints and promote more daily social interactions for patients. Pinel was able to implement such strategies at a hospital in Paris called La Salpêtrière. In the United States, Dorothea Dix investigated how patients were treated and lobbied state and federal governments to institute broad-based improvements in mental health care. A real American hero for people with mental disorders, Dix’s advocacy led to the building of 32 state psychiatric hospitals around the country.

In parallel with these reforms, driven by the need to organize data on mental health, a classification system of disorders was developed in the United States in the late 1800s. This sparked further work by a consortium of professional health organizations, including the precursor to the American Psychiatric Association (APA) and a branch of the American Medical Association, to develop a diagnostic framework for people with psychiatric conditions. After many decades of work, this culminated in the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM).

Unfortunately, despite these advancements, in the first half of the 1900s mental health care was marred by some genuinely barbaric treatments, like lobotomies, malaria therapy, and insulin shock therapy.  Frontal lobotomies consisted of a thin, sharp metal rod being forced through the side of the eye or nose and into the frontal lobes of the brain. The rod was scraped side to side to sever connections between the front and the rest of the brain. The procedure’s advocates argued that it subdued patients’ illnesses when, in reality, it left most with severe brain damage and no real improvement at all. Though this method was controversial even in its own time, thousands of people were subjected to the horrific ‘treatment’ in America and Europe between the 1930s and 1950s.

Dorothea Dix

In the early 1900s, malaria therapy involved infecting patients suffering from mental disturbance with malaria, due to the belief that the subsequent high fevers would improve their symptoms. This idea originated from the observation that some patients who exhibited particular symptoms (such as partial paralysis, delusions, and personality changes) got better if they happened to develop an infection and a fever. It was later discovered that those patients had advanced syphilis, which affects the central nervous system and causes psychiatric symptoms. At the time there was no known direct cure for syphilis. Treponema pallidum, the bacteria that cause syphilis, is sensitive to heat and is killed by fever. Doctors knew they had a treatment for malaria (a drug called quinine) so they would infect the patient with malaria, which would cause a fever. Once the fever eliminated syphilis, the malaria was treated with quinine. The problem with this method was that doctors at the time did not understand why it worked, and they applied the treatment to people with mental disorders that had nothing to do with syphilis. Many Schizophrenia patients needlessly suffered from this treatment and got no benefit whatsoever.

 Frontal lobotomies consisted of a thin, sharp metal rod being forced through the side of the eye or nose and into the frontal lobes of the brain. The rod was scraped side to side to sever connections between the front and the rest of the brain.

The idea of inducing seizures as treatment for ‘insanity,’ as it was then called, originated with the ancient theory that someone could not have both seizures and insanity at the same time. Insulin shock therapy was used as a treatment for Schizophrenia and involved giving patients high doses of insulin to induce temporary coma and seizures. They did this on a daily basis for weeks. At the very least, these patients became obese from the high insulin doses, while many others suffered the bodily harm of dangerously low blood pressure and violent, uncontrolled seizures. As with lobotomy, supporters of this method believed, without any real evidence, that it improved the patient’s condition. The only real improvement these procedures provided was sedation; hence it decreased undesirable behaviors. However, this effect came with a high risk of brain damage and permanent disability.

Towards the middle of the 1900s, mainly due to the advent of new, effective medications, but also because of a lack of resources, institutions in Western countries began to close. Treatment moved toward a community-based model. New medications helped alleviate some symptoms, returned patients to higher levels of functioning, and fewer patients required full-time inpatient care. New approaches to psychotherapy emerged as well. Psychologists like Abraham Maslow (best known for Maslow’s Hierarchy of Needs), introduced Humanistic Psychology, emphasizing self-actualization and developing a person’s full potential.  Psychologist Carl Rogers introduced Client-centered therapy which seeks to help a person achieve growth and fulfillment.  These and others demonstrated a dramatic shift in the way we thought about mental health.

Today, modern psychiatric hospitals are primarily used for short-term stabilization of acute illness and emergency situations where someone’s safety is at risk due to their illness. Hospitals are highly regulated, and in order to be accredited by The Joint Commission (a nonprofit organization that provides accreditation to health facilities) are subject to regular inspections to assure safety, efficacy, and quality.  These hospital units generally bridge to community-based outpatient support, such as therapy and intensive day programs that are a step-down from the full-time hospital. These different modalities often work in tandem and provide different levels of care based on the needs of an individual throughout their illness course.  Today we also have a range of different kinds of mental health professionals including psychiatrists, nurse practitioners, psychologists, social workers, and counselors.  Providers are held to established standards of care and are required to maintain ongoing continuing education in order to keep their professional licenses.

The community-based model has become more robust, and new technologies like telepsychiatry have extended the reach of care to patients where and when they need it. People can connect with their providers, support groups or other resources using computers and mobile devices.

Our understanding of brain function has grown by leaps and bounds over the past 20 years with the advent of imaging technologies such as functional magnetic resonance imaging (fMRI) and positron emission tomography (PET). Many safer and more effective medications have been developed to help with a whole spectrum of symptoms including mood symptoms, hallucinations and delusions, anxiety, obsessions and compulsions, and more. Psychotherapies that are evidence-based and demonstrated through research to produce measurable results are now the norm in mental health treatment.  Psychotherapeutic approaches like Cognitive Behavior Therapy, Dialectical Behavior Therapy, Short-term psychodynamic therapy, and others have replaced traditional Psychoanalysis, for example.  Modern treatments generally include medications (when they can be helpful) along with psychotherapy.

Most importantly, we must continue to work vigorously toward the goals of spreading awareness and reliable information, breaking down barriers, and improving access for all.

Looking to the future, technology promises to play a big role in the progress we can make in mental health care.  One of the most significant advancements that psychiatry can make now is to move towards personalized care. Personalized care narrows down diagnoses and treatments based on an individual’s needs and information. It ensures patient engagement in the development, implementation, and evaluation of a treatment plan. New technologies that have grown out of the human genome project now make it possible to determine which medications will be most effective and least likely to cause side effects in a given person based on their genetic makeup. The capability to provide personalized care requires the ability to access, collect, and analyze data including population data, statistics, genetic information, validity of diagnoses, safety and efficacy of various treatments. In this era of big data and analytics, technology provides a means to accomplish this. Of course, we must also be mindful of protecting the privacy of peoples’ health information.

Technology can also address some of the societal barriers facing mental health treatment. Awareness and education can be made available to more people through the internet, and mobile device-based tools. The public, as well as healthcare providers not trained in mental health, can use technology to expand their knowledge about mental health. In turn, better education and awareness help address shortages of mental health care providers, promotes timely and appropriate care, and reduces stigma.

Technology helps to apply the lessons learned over the centuries to make leaps in mental health care and management. As with many health conditions, earlier intervention leads to better outcomes in mental health. New technologies can make this possible through improved availability and use of data, early identification, and engaging people in care sooner.

An essential contribution technology can make to health care is that it enables the more efficient use of limited resources. Personalizing care is ideal, but it will require a different way to allocate resources. Technology can help gather input from people living with mental illnesses to help inform the most needed advancements. Learning from past and current challenges is crucial to building resilient health systems and methods for improvement.

As we acquire more knowledge about neurobiology, neurochemistry, brain function, and genetics, psychiatry’s understanding of the causes of mental disorders, and ways to treat – hopefully even cure – them will continue to improve.

We’ve come quite a long way from the days of demons, chains, and freak shows, and the future looks very bright for continued progress in mental health diagnosis and treatment. Most importantly, we must continue to work vigorously toward the goals of spreading awareness and reliable information, breaking down barriers, and improving access for all.

Resources
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  3. Brought to Life. (2017). Humours. Available at http://www.sciencemuseum.org.uk/broughttolife/techniques/humours. Accessed on 3/2018.
  4. U.S. National Library of Medicine. (2013). Four Humors. Available at https://www.nlm.nih.gov/exhibition/shakespeare/fourhumors.html. Accessed on 3/2018.
  5. Lumen Learning. (2017). Mental Health Treatment: Past and Present. Available at https://courses.lumenlearning.com/wsu-sandbox/chapter/mental-health-treatment-past-and-present/. Accessed on 3/2018.
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  7. Brought to Life. (2017). William Tuke. Available at http://www.sciencemuseum.org.uk/broughttolife/people/williamtuke. Accessed on 3/2018.
  8. BBC. (2014). William Tuke. Available at http://www.bbc.co.uk/history/historic_figures/tuke_william.shtml. Accessed on 3/2018.
  9. Unite for Sight. (2015). A Brief History of Mental Illness and the U.S. Mental Health Care System. Available at http://www.uniteforsight.org/mental-health/module2. Accessed on 3/2018.
  10. APA. (2018). DSM History. Available at https://www.psychiatry.org/psychiatrists/practice/dsm/history-of-the-dsm. Accessed on 3/2018.
  11. Counselling Directory. (2018). The History of Counselling and Psychotherapy. Available at http://www.counselling-directory.org.uk/history.html. Accessed on 3/2018.
  12. Smith, M. (2013). Deinstitutionalization and After. Available at https://www.psychologytoday.com/blog/short-history-mental-health/201305/deinstitutionalization-and-after. Accessed on 3/2018.
  13. Insel, T. (2011). Treatment Development: The Past 50 Years. Available at https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2011/treatment-development-the-past-50-years.shtml. Accessed on 3/2018.
  14. Naslund, J. A., Aschbrenner, K. A., Araya, R., Marsch, L. A., Unützer, J., Patel, V., & Bartels, S. J. (2017). Digital technology for treating and preventing mental disorders in low-income and middle-income countries: a narrative review of the literature. The Lancet Psychiatry, 4(6), 486-500.
  15. Clinical Implementation of Pharmacogenetic Decision Support Tools for Antidepressant Drug Prescribing. Zejer Z, Carpenter LL, Kalin NH, et al.  American Journal of Psychiatry. Published online: April 25, 2018
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