Madness has accompanied man for millennia, most likely reaching back to the caves of prehistory. Mental illness was known to the ancient Indians who wrote about it in the ayurvedic text, Charaka Samhita. Whilst the ancient Greeks and Romans regarded mental disorders, psychosis in particular, as supernatural phenomena, Hippocrates wondered they might have a physiological basis. Not long afterwards, the Church stepped in with its own take on madness and turned to exorcism to rid the insane of evil humours, a period coinciding with the Dark Ages.
The baton of progress in mental illness passed to the Arabs in the Golden Age of Islam (8th to 13th centuries). The mentally ill of the era were to treated with respect, clothed and cared for. In his well received Canon of Medicine, Persian physician Abu-Ali al-Husayn ibn Abdalah ibn-Sina (mercifully shortened to Avicenna, 980-1030) provided descriptions and treatments for an array of neuropsychiatric conditions, including insomnia, mania, vertigo, paralysis, stroke, epilepsy, depression, and male sexual dysfunction and recognized psychosomatic disease, in which the mental state could trigger changes elsewhere in the body. Treatment for psychiatric patients of the day included baths, music and occupational therapy.
Meanwhile, in England…
In 1247, the Bishop-elect of Bethlehem, Goffredo de Prefetti, was tasked with converting property donated by a Londoner, Simon FitzMary to a centre for collecting alms that would support the war efforts in the Holy Land, house the poor* and provide a place for his ecclesiastical confreres to hang out between exocisms and stints at the Inquisition. Formally known at first as the Priory of the New Order of our Lady of Bethlehem, it was popularly known as Bedlam Hospital. The exact year in which Bethlem Hospital began to specialize in the care and control of the insane is unknown, but has been pegged at 1377, making it world’s oldest hospital for the insane in continuous operation.
*We often forget that hospital was linked in earlier times to hospitality; use of hospital as a place to manage patients reflects a more recent definition of hospital; the reader can satisfy his curiosity with the wikipedia entry on Bethlem hospital.
Hogarth’s final painting (of 8) a Rake’s Progress, ending in Bedlam
In contrast to the respectful deference and humane treatment accorded those with mental illness in the Arab world of the era, management of Bethlem’s diciest (see image, a Rake’s Progress) consisted of chaining them to the walls or floors, whilst those deemed harmless were free to wander the halls. Fast-forward to 1621, Oxford scholar Robert Burton wrote an early work on depression, The Anatomy of Melancholy* and asserted that there was no greater cause of melancholy than idleness, and no better cure than business or, said another way, busy hands are happy hands.
*The long title is The Anatomy of Melancholy, What it is: With all the Kinds, Causes, Symptomes, Prognostickes, and Several Cures of it. In Three Maine Partitions with their several Sections, Members, and Subsections. Philosophically, Medicinally, Historically, Opened and Cut Up
English physician, Wm Battie’s Treatise on Madness (1758) decried Bethlem’s barbaric treatment of the mentally ill, preferring instead, cleanliness, good food, fresh air and interaction with friends and family. By the late 1700s, the inefficacy of restraint as a therapeutic modality was increasingly recognized across Europe and the insane unchained, in France, through the work of Dr Philippe Pinel at the Salpêtriére Asylum for Insane Women in Paris (1795) and in the early 1800s at Bethlem Hospital and elsewhere. The mid- to late 19th and early 20th centuries saw major shifts in legislature in England, France and America, and a wave of construction of institutions for those deemed mentally ill. The nascent field of psychiatry’s scope broadened to include mood disorders and delusions.
Modern pharmacologic management of psychiatric disorders
Emil Kraepelin (1856-1926) German psychiatrist, the founder of modern psychiatry, penned the page-turner Compendium of Psychiatry, which later morphed into a larger, multivolume Textbook of Psychiatry and Neuroscience. His major contributions to the field included classification of mental disorders based on expert analysis of individual cases. He felt that psychiatry was a legitimate branch of medicine and research should be conducted with the same rigor and rules as other branches of medicine and science. Kraepelin ignored the theories of anatomic psychiatry, in particular, phrenology, and rejected Freudians’ focus on innate or early sexuality as a cause of mental illness. In later life, his research interest focused on racial hygiene and eugenics.His death in 1928 spared him from seeing the downside of adopting a national eugenics policy.
Chlorpromazine’s discovery in 1950 ushered in the pharmacologic management of psychiatric disorders*. It was used for schizophrenia, bipolar disorder, ADHD, and presurgical anxiety, and were followed by butyrophenones, lithium and other agents, including second generation neuroleptics and atypical antipsychotics.
*Ending the tragic, but brief period in which lobotomies were used to manage patients with psychotic episodes, leaving them with permanent sequelae, as portrayed by Jack Nicholson in One Flew Over the Cuckoo’s Nest.
Psychiatric disorders in the 21st century are usually managed on an outpatient basis, using one of the nearly 100 agents now on the market. The treating psychiatrist may use the latest DSM* to establish the diagnosis. Exploring the role of genetics in mental disorders is once again becoming fashionable; the tools are more sophisticated than they were in the early 20th century, the agenda isn’t biased and patient protections are in place. Answers to whether mental illness can be linked to defective genes lies over the horizon.
*Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM 5), 2013, American Psychiatric Association, Washington, DC
Psychiatry-Psychology practice, as a general rule, patients with mental health issues that don’t require “big guns” pharmacologic agents can be adequately managed by psychologists, whose forte is counselling and talk therapy, The cynical view of psychological and psychiatric therapy, that one-third get better, one-third stay the same and one-third get worse, articulated in the 20th century appears to hold true in the 21st. Effective permanent treatment of these patients is still beyond the horizon.