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Thelunatic asylum,insane asylum ormental asylum was an institution where people with mental illness were confined. It was an early precursor of the modernpsychiatric hospital.
Modern psychiatric hospitals evolved from and eventually replaced the older lunatic asylum. The treatment of inmates in early lunatic asylums was sometimes brutal and focused on containment and restraint.[1][2] The discovery of anti-psychotic drugs and mood-stabilizing drugs resulted in a shift in focus from containment in lunatic asylums to treatment in psychiatric hospitals. Later, there was further and more thorough critique in the form of thedeinstitutionalization movement which focuses on treatment at home or in less isolated institutions.
In the Islamic world, theBimaristans were described by European travellers, who wrote about their wonder at the care and kindness shown to lunatics. In 872,Ahmad ibn Tulun built a hospital inCairo that provided care to the insane, which included music therapy.[3] Nonetheless, British historian of medicineRoy Porter cautioned against idealising the role of hospitals generally in medieval Islam, stating that "They were a drop in the ocean for the vast population that they had to serve, and their true function lay in highlighting ideals of compassion and bringing together the activities of the medical profession."[4]: 105
In Europe during the medieval era, a small subsection of the population of those considered mad were housed in a variety of institutional settings. Mentally ill people were often held captive in cages or kept up within the city walls, or they were compelled to amuse members of courtly society.[5] Porter gives examples of such locales where some of the insane were cared for, such as in monasteries. A few towns had towers where madmen were kept (calledNarrentürme in German, or "fools' towers").[citation needed] The ancient Parisian hospitalHôtel-Dieu also had a small number of cells set aside for lunatics, whilst the town ofElbing boasted a madhouse, theTollhaus, attached to the Teutonic Knights' hospital.[6] Dave Sheppard'sDevelopment of Mental Health Law and Practice begins in 1285 with a case that linked "the instigation of the devil" with being "frantic and mad".[7]
In Spain, other such institutions for the insane were established after the ChristianReconquista; facilities included hospitals inValencia (1407),Zaragoza (1425),Seville (1436),Barcelona (1481) andToledo (1483).[4]: 127 InLondon, England, thePriory of Saint Mary of Bethlehem, which later became known more notoriously asBedlam, was founded in 1247. At the start of the 15th century, it housed six insane men.[4]: 127 The former lunatic asylum,Het Dolhuys, established in the 16th century inHaarlem, theNetherlands, has been adapted as a museum of psychiatry, with an overview of treatments from the origins of the building up to the 1990s.
The level of specialist institutional provision for the care and control of the insane remained extremely limited at the turn of the 18th century. Madness was seen principally as a domestic problem, with families and parish authorities in Europe and England central to regimens of care.[8]: 154 [9]: 439 Various forms of outdoor relief were extended by the parish authorities to families in these circumstances, including financial support, the provision of parish nurses and, where family care was not possible, lunatics might be 'boarded out' to other members of the local community or committed to private madhouses.[9]: 452–56 [10]: 299 Exceptionally, if those deemed mad were judged to be particularly disturbing or violent, parish authorities might meet the not inconsiderable costs of their confinement in charitable asylums such asBethlem, in Houses of Correction or in workhouses.[11]: 30, 31–35, 39–43
In the late 17th century, this model began to change, and privately run asylums for the insane began to proliferate and expand in size. Already in 1632 it was recorded thatBethlem Royal Hospital, London had "below stairs a parlor, a kitchen, two larders, a long entry throughout the house, and 21 rooms wherein the poor distracted people lie, and above the stairs eight rooms more for servants and the poor to lie in".[12] Inmates who were deemed dangerous or disturbing were chained, but Bethlem was an otherwise open building. Its inhabitants could roam around its confines and possibly throughout the general neighborhood in which the hospital was situated.[13] In 1676, Bethlem expanded into newly built premises atMoorfields with a capacity for 100 inmates.[8]: 155 [14]: 27
A second public charitable institution was opened in 1713. Known as the Bethel inNorwich, it was a small facility which generally housed between twenty and thirty inmates.[8]: 166 In 1728 atGuy's Hospital, London, wards were established for chronic lunatics.[15]: 11 From the mid-eighteenth century the number of public charitably funded asylums expanded moderately with the opening ofSt Luke's Hospital in 1751 in Upper Moorfields, London; the establishment in 1765 of the Hospital for Lunatics atNewcastle upon Tyne; the Manchester Lunatic Hospital, which opened in 1766; theYork Asylum in 1777 (not to be confused with theYork Retreat); theLeicester Lunatic Asylum (1794), and theLiverpool Lunatic Asylum (1797).[14]: 27
A similar expansion took place in theBritish American colonies. ThePennsylvania Hospital was founded inPhiladelphia in 1751 as a result of work begun in 1709 by theReligious Society of Friends. A portion of this hospital was set apart for the mentally ill, and the first patients were admitted in 1752.[16]Virginia is recognized as the first state to establish an institution for the mentally ill.[17]Eastern State Hospital, located inWilliamsburg, Virginia, was incorporated in 1768 under the name of the "Public Hospital for Persons of Insane and Disordered Minds" and its first patients were admitted in 1773.[16][18]
There was no centralised state response to “madness” in society in centuryBritain until the 19th century, however private madhouses proliferated there in the 18th century on a scale unseen elsewhere.[8]: 174 References to such institutions are limited for the 17th century but it is evident that by the start of the 18th century, the so-called 'trade in lunacy' was well established.[15]: 8–9 Daniel Defoe, an ardent critic of private madhouses,[19]: 118 estimated in 1724 that there were fifteen then operating in the London area.[20]: 9 Defoe may have exaggerated but exact figures for private metropolitan madhouses are available only from 1774, whenlicensing legislation was introduced: sixteen institutions were recorded.[20]: 9–10 At least two of these,Hoxton House and Wood's Close,Clerkenwell, had been in operation since the 17th century.[20]: 10 By 1807, the number had increased to seventeen.[20]: 9 This limited growth in the number of London madhouses is believed likely to reflect the fact that vested interests, especially theCollege of Physicians, exercised considerable control in preventing new entrants to the market.[20]: 10–11 Thus, rather than there being a proliferation of private madhouses in London, existing institutions tended to expand considerably in size.[20]: 10 The establishments which increased most during the 18th century, such as Hoxton House, did so by acceptingpauper patients rather than private, middle class, fee-paying patients.[20]: 11 Significantly, pauper patients, unlike their private counterparts, were not subject to inspection under the1774 legislation.[20]: 11
Fragmentary evidence indicates that some provincial madhouses existed in Britain from at least the 17th century and possibly earlier.[8]: 175 [15]: 8 A madhouse atKingsdown, Box, Wiltshire was opened during the 17th century.[8]: 176 [20]: 11 Further locales of early businesses include one atGuildford in Surrey which was accepting patients by 1700, one atFonthill Gifford in Wiltshire from 1718, another atHook Norton in Oxfordshire from about 1725, one atSt Albans dating from around 1740, and a madhouse atFishponds in Bristol from 1766.[8]: 176 [20]: 11 It is likely that many of these provincial madhouses, as was the case with the exclusiveTicehurst House, may have evolved from householders who were boarding lunatics on behalf of parochial authorities and later formalised this practice into a business venture.[8]: 176 The vast majority were small in scale with only seven asylums outside London with in excess of thirty patients by 1800 and somewhere between ten and twenty institutions had fewer patients than this.[8]: 178
During theAge of Enlightenment, attitudes began to change, in particular among the educated classes in Western Europe. “Mental illness” came to be viewed as a disorder that required some form of compassionate but clinical, “rational” treatment that would aid in the rehabilitation of the patient into a rational being. When the ruling monarch of theUnited Kingdom,George III, who had a mental disorder, experienced aremission in 1789, mental illness came to be seen as something which could be treated and cured. The introduction of moral treatment was initiated independently by the French doctorPhilippe Pinel and the EnglishQuakerWilliam Tuke.[21]
In 1792, Pinel became the chief physician at theBicêtre Hospital inLe Kremlin-Bicêtre, near Paris. Before his arrival, inmates were chained in cramped cell-like rooms where there was poor ventilation, led by a man named Jackson 'Brutis' Taylor. Taylor was then killed by the inmates leading to Pinel's leadership. In 1797, Jean-Baptiste Pussin, the "governor" of mental patients at Bicêtre, first freed patients of their chains and banned physical punishment, although straitjackets could be used instead.[22][23] Patients were allowed to move freely about the hospital grounds, and eventually dark dungeons were replaced with sunny, well-ventilated rooms. Pinel argued that mental illness was the result of excessive exposure to social andpsychological stresses, toheredity and physiological damage.[citation needed]
Pussin and Pinel's approach was seen as remarkably successful, and they later brought similar reforms to a mental hospital in Paris for female patients,La Salpetrière. Pinel's student and successor,Jean Esquirol, went on to help establish 10 new mental hospitals that operated on the same principles. There was an emphasis on the selection and supervision of attendants in order to establish a suitable setting to facilitate psychological work, and particularly on the employment of ex-patients as they were thought most likely to refrain from inhumane treatment while being able to stand up to patients' pleas, menaces, or complaints.[24]
William Tuke led the development of a radical new type of institution inNorthern England, following the death of a fellow Quaker in a local asylum in 1790.[25]: 84–85 [26]: 30 [27] In 1796, with the help of fellow Quakers and others, he founded theYork Retreat, where eventually about 30 patients lived as part of a small community in a quiet country house and engaged in a combination of rest, talk, and manual work. Rejecting medical theories and techniques, the efforts of the York Retreat centred around minimising restraints and cultivating rationality and moral strength.
The entire Tuke family became known as founders of moral treatment.[28] They created a family-style ethos, and patients performed chores to give them a sense of contribution. There was a daily routine of both work and leisure time. If patients behaved well, they were rewarded; if they behaved poorly, there was some minimal use of restraints or instilling of fear. The patients were told that treatment depended on their conduct. In this sense, the patient's moral autonomy was recognised. William Tuke's grandson,Samuel Tuke, published an influential work in the early 19th century on the methods of the retreat; Pinel'sTreatise on Insanity had by then been published, and Samuel Tuke translated his term as "moral treatment". Tuke's Retreat became a model throughout the world for humane and moral treatment of patients with mental disorders.[29]
The York Retreat inspired similar institutions in the United States, most notably theBrattleboro Retreat and the Hartford Retreat (nowthe Institute of Living).Benjamin Rush ofPhiladelphia also promoted humane treatment of the insane outside dungeons and without iron restraints, as well as sought their reintegration into society. In 1792, Rush successfully campaigned for a separate ward for the insane at the Pennsylvania Hospital. His talk-based approach could be considered as a rudimentary form of modern occupational therapy, although most of his physical approaches have long been discredited, such as bleeding and purging, hot and cold baths, mercury pills, a "tranquilizing chair" and gyroscope.
A similar reform was carried out in Italy byVincenzo Chiarugi, who discontinued the use of chains on the inmates in the early 19th century. In the town ofInterlaken,Johann Jakob Guggenbühl started a retreat for mentally disabled children in 1841.[30]
The modern era of institutionalized provision for the care of the mentally ill, began in the early 19th century with a large state-led effort. Public mental asylums were established in Britain after the passing of the1808 County Asylums Act.[31] This empoweredmagistrates to build rate-supported asylums in everycounty to house the many 'pauper lunatics'. Nine counties first applied, and the first public asylum opened in 1811 inNottinghamshire.[32]Parliamentary Committees were established to investigate abuses at private madhouses likeBethlem Hospital – its officers were eventually dismissed and national attention was focused on the routine use of bars, chains and handcuffs and the filthy conditions the inmates lived in.[33] However, it was not until 1828 that the newly appointedCommissioners in Lunacy were empowered to license and supervise private asylums.[34]
TheLunacy Act 1845 was an important landmark in the treatment of the mentally ill, as it explicitly changed the status ofmentally ill people topatients who required treatment. The Act created theLunacy Commission, headed byLord Shaftesbury, to focus on lunacy legislation reform.[35] The commission was made up of eleven Metropolitan Commissioners who were required to carry out the provisions of the Act:[36] the compulsory construction of asylums in every county, with regular inspections on behalf of theHome Secretary. All asylums were required to have written regulations and to have a resident qualifiedphysician.[37] A national body for asylum superintendents – theMedico-Psychological Association – was established in 1866 under the Presidency ofWilliam A. F. Browne, although the body appeared in an earlier form in 1841.[38]
In 1838, France enacted a law to regulate both the admissions into asylums and asylum services across the country.Édouard Séguin developed a systematic approach for training individuals with mental deficiencies,[39] and, in 1839, he opened the first school for the "severely retarded". His method of treatment was based on the assumption that the "mentally deficient" did not suffer from disease.[40]
In the United States, the erection of state asylums began with the first law for the creation of one in New York, passed in 1842. TheUtica State Hospital was opened approximately in 1850. The creation of this hospital, as of many others, was largely the work ofDorothea Lynde Dix, whose philanthropic efforts extended over many states, and in Europe as far asConstantinople. Many state hospitals in the United States were built in the 1850s and 1860s on theKirkbride Plan, an architectural style meant to have curative effect.[41]
Looking into the late 19th and early 20th century history of the Homewood Retreat of Guelph, Ontario, and the context of commitments to asylums in North America and Great Britain,Cheryl Krasnick Warsh states that "the kin of asylum patients were, in fact, the major impetus behind commitment, but their motivations were based not so much upon greed as upon the internal dynamics of the family, and upon the economic structure of western society in the 19th and early 20th centuries."[42]
Based on her study of cases from the Homewood Retreat, Cheryl Krasnick Warsh concludes that "the realities of the household in late Victorian and Edwardian middle class society rendered certain elements—socially redundant women in particular—more susceptible to institutionalization than others."[42]
In the 18th to the early 20th century, women were sometimes institutionalised due to their opinions, their unruliness and their inability to be controlled properly by a primarily male-dominated culture.[43] There were financial incentives too; before the passage of theMarried Women's Property Act 1882, all of a wife's assets passed automatically to her husband.
The men who were in charge of these women, either a husband, father or brother, could send these women to mental institutions, stating that they believed that these women were mentally ill because of their strong opinions. "Between the years of 1850–1900, women were placed in mental institutions for behaving in ways the male society did not agree with."[44] These men had the last say when it came to the mental health of these women, so if they believed that these women were mentally ill, or if they simply wanted to silence the voices and opinions of these women, they could easily send them to mental institutions. This was an easy way to render them vulnerable and submissive.[45]
An early fictional example isMary Wollstonecraft's posthumously published novelMaria: or, The Wrongs of Woman (1798), in which the title character is confined to an insane asylum when she becomes inconvenient to her husband. Real women's stories reached the public through court cases:Louisa Nottidge was abducted by male relatives to prevent her committing her inheritance and her life to live in a revivalist clergyman'sintentional community.Wilkie Collins based his 1859 novelThe Woman in White on this case, dedicating it toBryan Procter, the Commissioner for Lunacy. A generation later,Rosina Bulwer Lytton, daughter of the women's rights advocateAnna Wheeler, was locked up by her husbandEdward Bulwer-Lytton and subsequently wrote of this inA Blighted Life (1880).
In 1887, journalistNellie Bly had herself committed to theBlackwell's Island Insane Asylum in New York City, in order to investigate conditions there. Her account was published in theNew York World newspaper, and in book form asTen Days in a Mad-House.
In 1902,Margarethe von Ende [de], wife of the German arms manufacturerFriedrich Alfred Krupp, was consigned to an insane asylum byKaiser Wilhelm II, a family friend, when she asked him to respond to reports of her husband's gay orgies on Capri.[46]
Incontinental Europe, universities often played a part in the administration of the asylums.[47] In Germany, many practising psychiatrists were educated in universities associated with particular asylums.[47] However, becauseGermany remained a loosely bound conglomerate of individual states, it lacked a national regulatory framework for asylums.
Although Tuke, Pinel and others had tried to do away with physical restraint, it remained widespread in the 19th century. At theLincoln Asylum in England,Robert Gardiner Hill, with the support ofEdward Parker Charlesworth, pioneered a mode of treatment that suited "all types" of patients, so that mechanical restraints and coercion could be dispensed with—a situation he finally achieved in 1838. In 1839 Sergeant John Adams and Dr.John Conolly were impressed by the work of Hill, and introduced the method into theirHanwell Asylum, by then the largest in the country. Hill's system was adapted, since Conolly was unable to supervise each attendant as closely as Hill had done. By September 1839, mechanical restraint was no longer required for any patient.[48][49]
William A. F. Browne (1805–1885) introduced activities for patients including writing, art, group activity and drama, pioneered early forms ofoccupational therapy andart therapy, and initiated one of the earliest collections of artistic work by patients, atMontrose Asylum.[50]
By the end of the 19th century, national systems of regulated asylums for the mentally ill had been established in mostindustrialized countries. At the turn of the century,Britain andFrance combined had only a few hundred people in asylums,[51] but by the end of the century this number had risen to the hundreds of thousands. The United States housed 150,000 patients in mental hospitals by 1904. Germany housed more than 400 public and private sector asylums.[51] These asylums were critical to the evolution of psychiatry as they provided places of practice throughout the world.[51]
However, the hope that mental illness could be ameliorated through treatment during the mid-19th century was disappointed.[52] Instead, psychiatrists were pressured by an ever-increasing patient population.[52] The average number of patients in asylums in the United States jumped 927%.[52] Numbers were similar in Britain and Germany.[52] Overcrowding was rampant in France, where asylums would commonly take in double their maximum capacity.[53] Increases in asylum populations may have been a result of the transfer of care from families andpoorhouses, but the specific reasons as to why the increase occurred are still debated today.[54] No matter the cause, the pressure on asylums from the increase was taking its toll on the asylums and psychiatry as a specialty. Asylums were once again turning into custodial institutions[55] and the reputation of psychiatry in the medical world had hit an extreme low.[56]
In the 1800s, middle class facilities became more common, replacing private care for wealthier persons. However, facilities in this period were largely oversubscribed. Individuals were referred to facilities either by the community or by the criminal justice system. Dangerous or violent cases were usually given precedence for admission. A survey taken in 1891 inCape Town, South Africa shows the distribution between different facilities. Out of 2046 persons surveyed, 1,281 were in private dwellings, 120 in jails and 645 in asylums, with men representing nearly two-thirds of the number surveyed.[57]
Defining someone as insane was a necessary prerequisite for being admitted to a facility. A doctor was only called after someone was labelled insane on social terms and had become socially or economically problematic. Until the 1890s, little distinction existed between the lunatic and criminal lunatic. The term was often used to policevagrancy as well as paupers and the insane. In the 1850s, lurid rumours that medical doctors were declaring normal people "insane" in Britain, were spread by the press causing widespread public anxiety. The fear was that people who were a source of embarrassment to their families were conveniently disposed of into asylums with the willing connivance of the psychiatric profession. Thissensationalism appeared in widely readnovels of the time, includingThe Woman in White.[57][58]
A series of radical physical therapies were developed in central and continental Europe in the late 1910s, the 1920s and most particularly, the 1930s. Among these, we may note theAustrian psychiatristJulius Wagner-Jauregg'smalarial therapy forgeneral paresis of the insane (orneurosyphilis) first used in 1917, and for which he won a Nobel Prize in 1927.[59] This treatment heralded the beginning of a radical and experimental era in psychiatric medicine that increasingly broke with an asylum-based culture of therapeutic nihilism in the treatment of chronicpsychiatric disorders,[60] most particularlydementia praecox (increasingly known asschizophrenia from the 1910s, although the two terms were used more or less interchangeably until at least the end of the 1930s), which were typically regarded ashereditary degenerative disorders and therefore unamenable to any therapeutic intervention.[61] Malarial therapy was followed in 1920 bybarbiturate-induceddeep sleep therapy to treat dementia praecox, which was popularised by theSwiss psychiatristJakob Klaesi. In 1933 theVienna-based psychiatristManfred Sakel introducedinsulin shock therapy, and in August 1934Ladislas J. Meduna, a Hungarian neuropathologist and psychiatrist working inBudapest, introducedcardiazol shock therapy (cardiazol is the tradename of the chemical compoundpentylenetetrazol, known by the tradenamemetrazol in the United States), which was the first convulsive or seizure therapy for a psychiatric disorder. Again, both of these therapies were initially targeted at curing dementia praecox. Cardiazol shock therapy, founded on the theoretical notion that there existed a biological antagonism betweenschizophrenia andepilepsy and that therefore inducing epileptiform fits in schizophrenic patients might effect a cure, was superseded byelectroconvulsive therapy (ECT), invented by the Italian neurologistUgo Cerletti in 1938.[62]
The use ofpsychosurgery was narrowed to a very small number of people for specific indications.Egas Moniz performed the first leucotomy, orlobotomy inPortugal in 1935, which targets the brain's frontal lobes.[7] This was shortly thereafter adapted byWalter Freeman and James W. Watts in what is known as Freeman–Watts procedure or the standard prefrontal lobotomy. From 1946, Freeman developed the transorbital lobotomy, using a device akin to an ice-pick. This was an "office" procedure which did not have to be performed in a surgical theatre and took as little as fifteen minutes to complete. Freeman is credited with the popularisation of the technique in the United States. In 1949, 5,074 lobotomies were carried out in the United States and by 1951, 18,608 people had undergone the controversial procedure in that country.[63] One of the most famous people to have a lobotomy was the sister ofJohn F. Kennedy,Rosemary Kennedy, who was rendered profoundly intellectually disabled as a result of the surgery.[64]
In modern times, insulin shock therapy and lobotomies are viewed as being almost as barbaric as the Bedlam "treatments", although the insulin shock therapy was still seen as the only option which produced any noticeable effect on patients. ECT is still used in the West in the 21st century, but it is seen as a last resort for treatment of mood disorders and is administered much more safely than in the past.[65] Elsewhere, particularly in India, use of ECT is reportedly increasing, as a cost-effective alternative to drug treatment.[citation needed] The effect of a shock on an overly excitable patient often allowed these patients to be discharged to their homes, which was seen by administrators (and often guardians) as a preferable solution to institutionalisation. Lobotomies were performed in the thousands from the 1930s to the 1950s, and were ultimately replaced with modernpsychotropic drugs.
Theeugenics movement of the early 20th century led to a number of countries enacting laws for the compulsory sterilization of the "feeble minded", which resulted in the forced sterilization of numerous psychiatric inmates.[66] As late as the 1950s, laws in Japan allowed the forcible sterilization of patients with psychiatric illnesses.[67]
UnderNazi Germany, theAktion T4euthanasia program resulted in the killings of thousands of the mentally ill housed in state institutions. In 1939, the Nazis secretly began to exterminate the mentally ill in a euthanasia campaign. Around 6,000 disabled babies, children and teenagers were murdered by starvation or lethal injection.[68]
Psychiatrists around the world have been involved in the suppression of individual rights by states wherein the definitions of mental disease had been expanded to include political disobedience.[69]: 6 Nowadays, in many countries, political prisoners are sometimes confined to mental institutions and abused therein.[70]: 3 Psychiatry possesses a built-in capacity for abuse which is greater than in other areas of medicine.[71]: 65 The diagnosis of mental disease can serve as proxy for the designation of social dissidents, allowing the state to hold persons against their will and to insist upon therapies that work in favour of ideologicalconformity and in the broader interests of society.[71]: 65
In a monolithic state, psychiatry can be used to bypass standard legal procedures for establishing guilt or innocence and allow political incarceration without the ordinary odium attaching to such political trials.[71]: 65 InNazi Germany in the 1940s, the 'duty to care' was violated on an enormous scale: A reported 300,000 individuals were sterilised and 100,000 killed in Germany alone, as were many thousands further afield, mainly in Eastern Europe.[72]
From the 1960s up to 1986,political abuse of psychiatry was reported to be systematic in theSoviet Union, and to surface on occasion in other Eastern European countries such asRomania,Hungary,Czechoslovakia andYugoslavia.[71]: 66 A "mental health genocide" reminiscent of the Nazi aberrations has been located in the history of South African oppression during theapartheid era.[73] A continued misappropriation of the discipline was subsequently attributed to the People's Republic of China.[74]
The 20th century saw the development of the first effectivepsychiatric drugs.
The firstanti-psychotic drug,chlorpromazine (known under the trade nameLargactil in Europe andThorazine in the United States), was first synthesized in France in 1950.Pierre Deniker, a psychiatrist of the Saint-Anne Psychiatric Center in Paris, is credited with first recognising the specificity of action of the drug in psychosis in 1952. Deniker traveled with a colleague to theUnited States and Canada promoting the drug at medical conferences in 1954. The first publication regarding its use in North America was made in the same year by the Canadian psychiatristHeinz Lehmann, who was based inMontreal. Also in 1954 another antipsychotic,reserpine, was first used by an American psychiatrist based inNew York, Nathan S. Kline. At a Paris-based colloquium onneuroleptics (antipsychotics) in 1955 a series of psychiatric studies were presented by, among others,Hans Hoff (Vienna), Dr. Ihsan Aksel (Istanbul), Felix Labarth (Basle),Linford Rees (London), Sarro (Barcelona),Manfred Bleuler (Zurich), Willi Mayer-Gross (Birmingham), Winford (Washington) and Denber (New York) attesting to the effective and concordant action of the new drugs in the treatment of psychosis.[citation needed]
The new antipsychotics had an immense impact on the lives of psychiatrists and patients. For instance,Henri Ey, a French psychiatrist at Bonneval, related that between 1921 and 1937 only 6% of patients with schizophrenia and chronic delirium were discharged from his institution. The comparable figure for the period from 1955 to 1967, after the introduction of chlorpromazine, was 67%. Between 1955 and 1968 the residential psychiatric population in the United States dropped by 30%.[76] Newly developedantidepressants were used to treat cases ofdepression, and the introduction ofmuscle relaxants allowedECT to be used in a modified form for the treatment of severe depression and a few other disorders.[7]
The discovery of themood stabilizing effect oflithium carbonate byJohn Cade in 1948 would eventually revolutionise the treatment ofbipolar disorder, although its use was banned in the United States until the 1970s.[77]
From 1942 to 1947,conscientious objectors in the US assigned to psychiatric hospitals underCivilian Public Service exposed abuses throughout the psychiatric care system and were instrumental in reforms of the 1940s and 1950s. The CPS reformers were especially active at thePhiladelphia State Hospital where fourQuakers initiatedThe Attendant magazine as a way to communicate ideas and promote reform. This periodical later becameThe Psychiatric Aide, a professional journal for mental health workers. On 6 May 1946,Life magazine printed an exposé of the psychiatric system by Albert Q. Maisel based on the reports of COs.[78] Another effort of CPS, namely theMental Hygiene Project, became the nationalMental Health Foundation. Initially skeptical about the value of Civilian Public Service,Eleanor Roosevelt, impressed by the changes introduced by COs in the mental health system, became a sponsor ofthe National Mental Health Foundation and actively inspired other prominent citizens includingOwen J. Roberts,Pearl Buck andHarry Emerson Fosdick to join her in advancing the organization's objectives of reform and humane treatment of patients.[citation needed]
By the beginning of the 20th century, ever-increasing admissions had resulted in serious overcrowding. Funding was often cut, especially during periods of economic decline, and during wartime in particular many patients starved to death. Asylums became notorious for poor living conditions, lack of hygiene, overcrowding, and ill-treatment andabuse of patients.[79]
The first community-based alternatives were suggested and tentatively implemented in the 1920s and 1930s, although asylum numbers continued to increase up to the 1950s. The movement for deinstitutionalisation came to the fore in various Western countries in the 1950s and 1960s.
The prevailing public arguments, time of onset, and pace of reforms varied by country.[79]Class action lawsuits in the United States, and the scrutiny of institutions throughdisability activism andantipsychiatry, helped expose the poor conditions and treatment. Sociologists and others argued that such institutions maintained or created dependency, passivity, exclusion and disability, causing people to beinstitutionalised.
There was an argument that community services would be cheaper. It was suggested that new psychiatric medications made it more feasible to release people into the community.[80]
There were differing views on deinstitutionalization, however, in groups such as mental health professionals, public officials, families, advocacy groups, public citizens and unions.[81]
In Japan, the number of hospital beds has risen steadily over the last few decades.[79]
In Hong Kong, a number of residential care services such as half-way houses, long-stay care homes, and supported hostels are provided for the discharged patients. In addition, a number of community support services such as Community Rehabilitation Day Services, Community Mental Health Link, Community Mental Health Care, etc. have been launched to facilitate the re-integration of patients into the community.
Countries where deinstitutionalisation has happened may be experiencing a process of "re-institutionalisation" or relocation to different institutions, as evidenced by increases in the number ofsupported housing facilities,forensic psychiatric beds and rising numbers in the prison population.[83]
New Zealand established areconciliation initiative in 2005 in the context of ongoingcompensation payouts to ex-patients of state-run mental institutions in the 1970s to 1990s. The forum heard of poor reasons for admissions; unsanitary and overcrowded conditions; lack of communication to patients and family members; physical violence and sexual misconduct and abuse; inadequate complaints mechanisms; pressures and difficulties for staff, within anauthoritarianpsychiatric hierarchy based on containment; fear and humiliation in the misuse ofseclusion; over-use and abuse ofECT,psychiatric medication and other treatments/punishments, includinggroup therapy, with continuedadverse effects; lack of support on discharge; interrupted lives and lost potential; and continued stigma, prejudice and emotional distress and trauma.
There were some references to instances of helpful aspects or kindnesses despite the system. Participants were offered counselling to help them deal with their experiences, and advice on their rights, including access to records and legal redress.[84]
In severalSouth American countries,[which?] the total number of beds in asylum-type institutions has decreased, replaced by psychiatric inpatient units in general hospitals and other local settings.[79]
At the beginning of the 19th century, there were, perhaps, a few thousand "lunatics" housed in a variety of disparate institutions; but, by the beginning of the 20th century, that figure had grown to about 100,000. This growth coincided with the development of "alienism," now known as psychiatry, as a medical specialty.[8]: 14
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The United States has experienced two waves ofdeinstitutionalization. Wave one began in the 1950s and targeted people with mental illness.[85] The second wave began roughly fifteen years after and focused on individuals who had been diagnosed with adevelopmental disability (e.g. intellectual disability).[85]
A process of indirectcost-shifting may have led to a form of "re-institutionalization" through the increased use of jail detention for those with mental disorders deemed unmanageable and noncompliant.[86] In summer 2009, author and columnistHeather Mac Donald stated inCity Journal, "jails have become society's primary mental institutions, though few have the funding or expertise to carry out that role properly... atRikers, 28% of the inmates require mental health services, a number that rises each year."[87]
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