PSYCHIATRY AND HISTORY
Fall 2021 Issue |
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History of Psychiatry: Evolution or Revolution?
By Avneet Madan, MD
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| Dr. Madan |
Psychiatry is considered a relatively young and evolving medical specialty, however concepts of mental illness are ancient. Several recurring themes occur in history; is this a pattern seen in Psychiatry as well?
Psychiatric illness can be traced back to antiquity. Skulls have been found dating back to 6500 BC with signs of trephination, alluding to a belief of supernatural cause of abnormal behavior in humans. Trephination was the “cure” for releasing “spirits” and the leftover skull artifacts were draped around the necks of the afflicted to ward away “evil spirits”.
Texts dating back to 1550 BC, along with ancient ayurvedic texts, describe episodes of melancholy, mood swings and dementia.
Ancient Greece and Rome also believed that external, supernatural forces contributed to disease. Hippocrates took a different approach (~400BC). He was one of the first to theorize that physiological imbalances may be related to illness vs supernatural forces. He introduced the humoral theory and made significant behavioral observations. Hippocrates used “hysteria” to describe a cluster of symptoms observed specifically in women and unknowingly introduced a term that for centuries has been used to discriminate and stigmatize mental illness. Although this time period was labeled Athens Golden Age, it also perpetuated themes of persecution and discrimination as related to “madness”. Treatments consisted of purification rituals, special diets, and music along with harsher, violent treatments for those who did not improve.
In the Middle Ages, any deviation away from religion was cited as the root of insanity. Since sin was central to mental illness, religious activity became essential to cure. Treatments occurred in religious buildings and included masses, exorcisms, incantations, potions, pilgrimages, prayer, counsel and bible reading. Often the afflicted person did not improve. Ultimately, there was no relief for the ill, who continued to live with persecution and discrimination.
Medieval Islam was several steps ahead of European ideology. In the Middle East and Islamic world, sickness was a normal part of life and spiritual cleansing for the ill was important. The first known psychiatric hospital was established in the Middle East, with a focus on humane treatment. These hospitals were known to create a soothing atmosphere with fountains, gardens, music and special diets. For those with limited access to care, traveling clinics were utilized. Psychiatric “hospitals” are documented in medieval Europe from the 13th century, but with no specific treatments, and served to confine patients.
The 17th century was a time for rejecting the supernatural views and religion, and substituting with science and logical reasoning. Enlightenment attitudes encouraged more sensitivity towards the mentally ill, rather than treating them as “outcasts” and “fools”. With the 18th and 19th century, the nervous system and psyche became focus points. The Lunacy Act (1845) was an important landmark in treatment, as it explicitly changed the status of mentally ill people to patients who required treatment.
With the Industrial Revolution, a shift towards institutionalization was seen in many sectors, including psychiatry. There was an increase in asylums/hospitals throughout Europe and the US, with a focus on reform and humane treatment. Institutionalization of patients occurred at a rapid rate and eventually drew significant criticism. This change was heavily influenced by societal focus on human rights post-World War II.
By the late 1950s, medications such as chlorpromazine became the new “breakthrough” in treatment, followed by other psychotropic medications, ultimately leading to deinstitutionalization. In the 1970s, civil rights and libertarian movements began in the United States and Europe, increasing advocacy for individual civil liberties and least restrictive alternative of care.
Today, treatments that were “breakthrough” even 50 years ago are now considered controversial. As documented by history, in an effort to diagnose and treat, patients have been stigmatized and persecuted (e.g. the poor, women, various ethnic groups, varying sexual identities). It's important to reflect how our perspectives have shifted, focusing on biases so these patterns aren’t repeated. Understanding our history and critically viewing ourselves will ultimately help better serve our patients.
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