Controversies about psychiatry

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Freeing the mad from chains

 

"The Extraction of the Stone of Madness". Art between 1488 and 1516

As long as psychiatry has existed it has been subject to controversy. Psychiatric treatments are sometimes seen to be ultimately more damaging than helpful to patients. Psychiatry is often thought to be a benign medical practice, but at times is seen by some as a coercive instrument of oppression. Psychiatry is seen to involve an unequal power relationship between doctor and patient, and critics of psychiatry claim a subjective diagnostic process, leaving much room for opinions and interpretations. In 2013, psychiatrist Allen Frances said that "psychiatric diagnosis still relies exclusively on fallible subjective judgments rather than objective biological tests". Every society permits compulsory treatment of mental patients.

Psychiatry's history involves what some view as dangerous treatments. Electroconvulsive therapy is one of these, which was used widely between the 1930s and 1960s and is still in use today. The brain surgery procedure lobotomy is another practice that was ultimately seen as too invasive and brutal. The term anti-psychiatry was coined by psychiatrist David Cooper in 1967 and is understood in current psychiatry to mean opposition to psychiatry's perceived role in many aspects of treatment.

Background

Too often it is felt institutions have too much power, concerns of patients or their relatives are ignored. Psychiatric nurses impose decisions, are reluctant to share information and feel they know best. Only a minority of staff involve patients in decision making. Client empowerment can improve power imbalance. Psychiatrically ill patients are at risk of abuse and discrimination in the mental health system and also the primary care sector. Studies are needed to determine whether power imbalance leads to abuse. Some degree of power imbalance appears inevitable since some patients lack decision making capacity but even then patients benefit from being impowered within their limits. For example, a patient felt lethargic in mornings due to medication she was required to take. She was allowed to stay in bed and miss breakfast as she wanted.

 Multidisciplinary teams benefit patients to the extent that professionals with a range of different expertise are caring for them. There is also a problem because patients who complain about the way they are treated face a group rather than one individual opposing them.

Vienna's Narrenturm — German for "fools' tower" — was one of the earliest buildings specifically designed as a "madhouse". It was built in 1784.

Since the 1960s there have been many challenges to the concept of mental illness itself. Thomas Szasz wrote The Myth of Mental Illness (1960) which said that mental illnesses are not real in the sense that cancers are real. Except for a few identifiable brain diseases, such as Alzheimer’s disease, there are "neither biological or chemical tests nor biopsy or necropsy findings" for verifying or falsifying psychiatric diagnoses. There are no objective methods for detecting the presence or absence of mental disease. Szasz argued that mental illness was a myth used to disguise moral conflicts. He has said "serious persons ought not to take psychiatry seriously -- except as a threat to reason, responsibility and liberty".

Sociologists such as Erving Goffman and Thomas Scheff said that mental illness was merely another example of how society labels and controls non-conformists; behavioural psychologists challenged psychiatry's fundamental reliance on unobservable phenomena; and gay rights activists criticised the APA's listing of homosexuality as a mental disorder. A widely publicised study by Rosenhan in Science was viewed as an attack on the efficacy of psychiatric diagnosis.

These critiques targeted the heart of psychiatry:

They suggested that psychiatry's core concepts were myths, that psychiatry's relationship to medical science had only historical connections, that psychiatry was more aptly characterised as a vast system of coercive social management, and that its paradigmatic practice methods (the talking cure and psychiatric confinement) were ineffective or worse.

Medicalization

Conversation between doctor and patient.

For many years, some psychiatrists (such as David Rosenhan, Peter Breggin, Paula Caplan, Thomas Szasz) and outside critics (such as Stuart A. Kirk) have "been accusing psychiatry of engaging in the systematic medicalization of normality". More recently these concerns have come from insiders who have worked for and promoted the APA (e.g., Robert Spitzer, Allen Frances). In 2013, Allen Frances said that "psychiatric diagnosis still relies exclusively on fallible subjective judgments rather than objective biological tests".

Medicalization (or medicalisation) is the process by which human conditions and problems come to be defined and treated as medical conditions, and thus become the subject of medical study, diagnosis, prevention, or treatment. Medicalization can be driven by new evidence or hypotheses about conditions; by changing social attitudes or economic considerations; or by the development of new medications or treatments.

The concept of medicalization was devised by sociologists to explain how medical knowledge is applied to behaviors which are not self-evidently medical or biological. The term medicalization entered the sociology literature in the 1970s in the works of Irving Zola, Peter Conrad and Thomas Szasz, among others. These sociologists viewed medicalization as a form of social control in which medical authority expanded into domains of everyday existence, and they rejected medicalization in the name of liberation. This critique was embodied in works such as Conrad's "The discovery of hyperkinesis: notes on medicalization of deviance", published in 1973 (hyperkinesis was the term then used to describe what we might now call ADHD). Nevertheless, opium was used to pacify children in ancient Egypt before 2000 BC.

These sociologists did not believe medicalization to be a new phenomenon, arguing that medical authorities had always been concerned with social behavior and traditionally functioned as agents of social control (Foucault, 1965; Szasz,1970; Rosen). However, these authors took the view that increasingly sophisticated technology had extended the potential reach of medicalization as a form of social control, especially in terms of "psychotechnology" (Chorover,1973).

In the 1975 book Limits to medicine: Medical nemesis (1975), Ivan Illich put forth one of the earliest uses of the term "medicalization". Illich, a philosopher, argued that the medical profession harms people through iatrogenesis, a process in which illness and social problems increase due to medical intervention. Illich saw iatrogenesis occurring on three levels: the clinical, involving serious side effects worse than the original condition; the social, whereby the general public is made docile and reliant on the medical profession to cope with life in their society; and the structural, whereby the idea of aging and dying as medical illnesses effectively "medicalized" human life and left individuals and societies less able to deal with these natural processes.

Marxists such as Vicente Navarro (1980) linked medicalization to an oppressive capitalist society. They argued that medicine disguised the underlying causes of disease, such as social inequality and poverty, and instead presented health as an individual issue. Others examined the power and prestige of the medical profession, including use of terminology to mystify and of professional rules to exclude or subordinate others.

Some argue that in practice the process of medicalization tends to strip subjects of their social context, so they come to be understood in terms of the prevailing biomedical ideology, resulting in a disregard for overarching social causes such as unequal distribution of power and resources. A series of publications by Mens Sana Monographs have focused on medicine as a corporate capitalist enterprise.

Political abuse

Psychiatrists have been involved in human rights abuses in states across the world when the definitions of mental disease were expanded to include political disobedience. As scholars have long argued, governmental and medical institutions code menaces to authority as mental diseases during political disturbances. Nowadays, in many countries, political prisoners are sometimes confined and abused in mental institutions. Psychiatric confinement of sane people is a particularly pernicious form of repression.

Psychiatry possesses a built-in capacity for abuse that is greater than in other areas of medicine. The diagnosis of mental disease allows the state to hold persons against their will and insist upon therapy in their interest and in the broader interests of society. In addition, receiving a psychiatric diagnosis can in itself be regarded as oppressive. 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. The use of hospitals instead of jails prevents the victims from receiving legal aid before the courts, makes indefinite incarceration possible, discredits the individuals and their ideas. In that manner, whenever open trials are undesirable, they are avoided.

Examples of political abuse of the power, entrusted in physicians and particularly psychiatrists, are abundant in history and seen during the Nazi era and the Soviet rule when political dissenters were labeled as “mentally ill” and subjected to inhumane “treatments.” In the period from the 1960s up to 1986, abuse of psychiatry for political purposes was reported to be systematic in the Soviet Union, and occasional in other Eastern European countries such as Romania, Hungary, Czechoslovakia, and Yugoslavia. The practice of incarceration of political dissidents in mental hospitals in Eastern Europe and the former USSR damaged the credibility of psychiatric practice in these states and entailed strong condemnation from the international community. Political abuse of psychiatry also takes place in the People's Republic of China and in Russia. Psychiatric diagnoses such as the diagnosis of ‘sluggish schizophrenia’ in political dissidents in the USSR were used for political purposes.

Electroconvulsive therapy

Electroconvulsive therapy (ECT) was one treatment that the anti-psychiatry movement wanted eliminated. Their arguments were that ECT damages the brain, and was used as punishment or as a threat to keep the patients "in line". Since then, ECT has improved considerably, and is performed under general anaesthetic in a medically supervised environment.

The National Institute for Health and Care Excellence recommends ECT for the short term treatment of severe, treatment-resistant depression, and advises against its use in schizophrenia. According to the Canadian Network for Mood and Anxiety Treatments, ECT is more efficacious for the treatment of depression than antidepressants, with a response rate of 90% in first line treatment and 50-60% in treatment-resistant patients. On the other hand, a 2010 literature review concluded that ECT had minimal benefits for people with depression and schizophrenia.

The most common side effects include headache, muscle soreness, confusion, and temporary loss of recent memory. There is strong evidences that ECT causes structural brain damages, observable on MRI. Before these advanced brain imaging techniques, some researchers said that ECT doesn't cause physical damage. The observation on MRI of objective lesions in the brain is consistent with research on cognitive impairments.

Marketing of antipsychotic drugs

Psychiatry has greatly benefitted by advances in pharmacotherapy. However, the close relationship between those prescribing psychiatric medication and pharmaceutical companies, and the risk of a conflict of interest, is also a source of concern. This marketing by the pharmaceutical industry has an influence on practicing psychiatrists, which affects prescription. Child psychiatry is one of the areas in which prescription has grown massively. In the past, it was rare, but nowadays child psychiatrists on a regular basis prescribe psychotropic drugs for children, for instance Ritalin.

Joanna Moncrieff has argued that antipsychotic drug treatment is often undertaken as a means of control rather than to treat specific symptoms experienced by the patient. Moncreiff has further argued that the evidence for antipsychotics from discontinuation-relapse studies may be flawed, because they do not take into account that antipsychotics may sensitize the brain and provoke psychosis if discontinued, which may then be wrongly interpreted as a relapse of the original condition.

Use of this class of drugs has a history of criticism in residential care. As the drugs used can make patients calmer and more compliant, critics claim that the drugs can be overused. Outside doctors can feel under pressure from care home staff. In an official review commissioned by UK government ministers it was reported that the needless use of antipsychotic medication in dementia care was widespread and was linked to 1800 deaths per year. In the US, the government has initiated legal action against the pharmaceutical company Johnson & Johnson for allegedly paying kickbacks to Omnicare to promote its antipsychotic risperidone (Risperdal) in nursing homes.

There has also been controversy about the role of pharmaceutical companies in marketing and promoting antipsychotics, including allegations of downplaying or covering up adverse effects, expanding the number of conditions or illegally promoting off-label usage; influencing drug trials (or their publication) to try to show that the expensive and profitable newer atypicals were superior to the older cheaper typicals that were out of patent. Following charges of illegal marketing, settlements by two large pharmaceutical companies in the US set records for the largest criminal fines ever imposed on corporations. One case involved Eli Lilly and Company's antipsychotic Zyprexa, and the other involved Bextra. In the Bextra case, the government also charged Pfizer with illegally marketing another antipsychotic, Geodon. In addition, Astrazeneca faces numerous personal-injury lawsuits from former users of Seroquel (quetiapine), amidst federal investigations of its marketing practices.^[51] By expanding the conditions for which they were indicated, Astrazeneca's Seroquel and Eli Lilly's Zyprexa had become the biggest selling antipsychotics in 2008 with global sales of $5.5 billion and $5.4 billion respectively.

Harvard medical professor Joseph Biederman conducted research on bipolar disorder in children that led to an increase in such diagnoses. A 2008 Senate investigation found that Biederman also received $1.6 million in speaking and consulting fees between 2000 and 2007 — some of them undisclosed to Harvard — from companies including makers of antipsychotic drugs prescribed for children with bipolar disorder. Johnson & Johnson gave more than $700,000 to a research center that was headed by Biederman from 2002 to 2005, where research was conducted, in part, on Risperdal, the company's antipsychotic drug. Biederman has responded saying that the money did not influence him and that he did not promote a specific diagnosis or treatment.

In 2004, University of Minnesota research participant Dan Markingson committed suicide while enrolled in an industry-sponsored pharmaceutical trial comparing three FDA-approved atypical antipsychotics: Seroquel (quetiapine), Zyprexa (olanzapine), and Risperdal (risperidone). Writing on the circumstances surrounding Markingson's death in the study, which was designed and funded by Seroquel manufacturer AstraZeneca, University of Minnesota Professor of Bioethics Carl Elliott noted that Markingson was enrolled in the study against the wishes of his mother, Mary Weiss, and that he was forced to choose between enrolling in the study or being involuntarily committed to a state mental institution. Further investigation revealed financial ties to AstraZeneca by Markingson's psychiatrist, Dr. Stephen C. Olson, oversights and biases in AstraZeneca's trial design, and the inadequacy of university Institutional Review Board (IRB) protections for research subjects. A 2005 FDA investigation cleared the university. Nonetheless, controversy around the case has continued. Mother Jones resulted in a group of university faculty members sending a public letter to the university Board of Regents urging an external investigation into Markingson's death.
Pharmaceutical companies have also been accused of attempting to set the mental health agenda through activities such as funding consumer advocacy groups.

In an effort to reduce the potential for hidden conflicts of interest between researchers and pharmaceutical companies, the US Government issued a mandate in 2012 requiring that drug manufacturers receiving funds under the Medicare and Medicaid programs collect data, and make public, all gifts to doctors and hospitals.

Prisoner experimentation

Prisoners in psychiatric hospitals have been the subjects of experiments involving new medications. Vladimir Khailo of the USSR was an individual exposed to such treatment in the 1980s. However, the involuntary treatment of prisoners by use of psychiatric drugs has not been limited to Khailo, nor the USSR.

ADHD

ADHD, its diagnosis, and its treatment have been controversial since the 1970s. The controversies involve clinicians, teachers, policymakers, parents, and the media. Positions range from the view that ADHD is within the normal range of behavior to the hypothesis that ADHD is a genetic condition. Other areas of controversy include the use of stimulant medications in children, the method of diagnosis, and the possibility of overdiagnosis. In 2012, the National Institute for Health and Care Excellence, while acknowledging the controversy, states that the current treatments and methods of diagnosis are based on the dominant view of the academic literature. In 2014, Keith Conners, one of the early advocates for recognition of the disorder, spoke out against overdiagnosis in a New York Times article. In contrast, a 2014 peer-reviewed medical literature review indicated that ADHD is underdiagnosed in adults.

With widely differing rates of diagnosis across countries, states within countries, races, and ethnicities, some suspect factors other than the presence of the symptoms of ADHD are playing a role in diagnosis. Some sociologists consider ADHD to be an example of the medicalization of deviant behavior, that is, the turning of the previously non-medical issue of school performance into a medical one. Most healthcare providers accept ADHD as a genuine disorder, at least in the small number of people with severe symptoms. Among healthcare providers the debate mainly centers on diagnosis and treatment in the much larger number of people with less severe symptoms.

As of 2009, 8% of all United States Major League Baseball players had been diagnosed with ADHD, making the disorder common among this population. The increase coincided with the League's 2006 ban on stimulants, which has raised concern that some players are mimicking or falsifying the symptoms or history of ADHD to get around the ban on the use of stimulants in sport.

Schizophrenia diagnosis

Underlying issues associated with schizophrenia would be better addressed as a spectrum of conditions or as individual dimensions along which everyone varies rather than by a diagnostic category based on an arbitrary cut-off between normal and ill. This approach appears consistent with research on schizotypy, and with a relatively high prevalence of psychotic experiences, mostly non-distressing delusional beliefs, among the general public. In concordance with this observation, psychologist Edgar Jones, and psychiatrists Tony David and Nassir Ghaemi, surveying the existing literature on delusions, pointed out that the consistency and completeness of the definition of delusion have been found wanting by many; delusions are neither necessarily fixed nor false, and need not involve the presence of incontrovertible evidence.

Nancy Andreasen has criticized the current DSM-IV and ICD-10 criteria for sacrificing diagnostic validity for the sake of artificially improving reliability. She argues that overemphasis on psychosis in the diagnostic criteria, while improving diagnostic reliability, ignores more fundamental cognitive impairments that are harder to assess due to large variations in presentation. This view is supported by other psychiatrists. In the same vein, Ming Tsuang and colleagues argue that psychotic symptoms may be a common end-state in a variety of disorders, including schizophrenia, rather than a reflection of the specific etiology of schizophrenia, and warn that there is little basis for regarding DSM’s operational definition as the "true" construct of schizophrenia. Neuropsychologist Michael Foster Green went further in suggesting the presence of specific neurocognitive deficits may be used to construct phenotypes that are alternatives to those that are purely symptom-based. These deficits take the form of a reduction or impairment in basic psychological functions such as memory, attention, executive function and problem solving.

The exclusion of affective components from the criteria for schizophrenia, despite their ubiquity in clinical settings, has also caused contention. This exclusion in the DSM has resulted in a "rather convoluted" separate disorder—schizoaffective disorder. Citing poor interrater reliability, some psychiatrists have totally contested the concept of schizoaffective disorder as a separate entity. The categorical distinction between mood disorders and schizophrenia, known as the Kraepelinian dichotomy, has also been challenged by data from genetic epidemiology.

Deep sleep therapy

Controversial Australian psychiatrist Harry Bailey treated mental patients via deep sleep therapy and other methods at Chelmsford Private Hospital, a Sydney mental hospital. He has been linked with the deaths of 85 patients, including 19 who committed suicide.

The resultant scandal broke in the early 1980s, following two 60 Minutes programs in 1980 and 1982, and closed down Chelmsford entirely. In 1985, the "legal and medical investigative machinery finally co-ordinated their actions and Bailey was facing committal proceedings over the death of Miriam Podio in 1977". The Chelmsford Royal Commission under the Greiner government from 1988 to 1990, headed by Justice John Slattery of the New South Wales Supreme Court, produced findings concerning Chelmsford's treatment program that ran to twelve volumes and described deplorable conditions, fraud, and misconduct and medical negligence. Bailey committed suicide by ingesting barbiturates at Mount White.

Anti-psychiatry

Controversy has often surrounded psychiatry, and the anti-psychiatry message is that psychiatric treatments are ultimately more damaging than helpful to patients. Psychiatry is often thought to be a benign medical practice, but at times is seen by some as a coercive instrument of oppression. Psychiatry is seen to involve an unequal power relationship between doctor and patient, and advocates of anti-psychiatry claim a subjective diagnostic process, leaving much room for opinions and interpretations. Every society, including liberal Western society, permits compulsory treatment of mental patients. The World Health Organization (WHO) recognizes that "poor quality services and human rights violations in mental health and social care facilities are still an everyday occurrence in many places", but has recently taken steps to improve the situation globally.

Psychiatry's history involves what some view as dangerous treatments. Electroconvulsive therapy is one of these, which was used widely between the 1930s and 1960s and is still in use today. The brain surgery procedure lobotomy is another practice that was ultimately seen as too invasive and brutal. In the US, between 1939 and 1951, over 50,000 lobotomy operations were performed in mental hospitals. Valium and other sedatives have arguably been over-prescribed, leading to a claimed epidemic of dependence. Concerns also exist for the significant increase in prescription of psychiatric drugs to children.

Three authors have come to personify the movement against psychiatry, of which two are or have been practicing psychiatrists. The most influential was R.D. Laing, who wrote a series of best-selling books, including; The Divided Self. Thomas Szasz rose to fame with the book The Myth of Mental Illness. Michael Foucault challenged the very basis of psychiatric practice and cast it as repressive and controlling. The term "anti-psychiatry" itself was coined by David Cooper in 1967.

Divergence within psychiatry generated the anti-psychiatry movement in the 1960s and 1970s, and is still present. Issues remaining relevant in contemporary psychiatry are questions of; freedom versus coercion, mind versus brain, nature versus nurture, and the right to be different.

Psychiatric survivors movement

The psychiatric survivors movement arose out of the civil rights ferment of the late 1960s and early 1970s and the personal histories of psychiatric abuse experienced by some ex-patients rather than the intradisciplinary discourse of antipsychiatry. The key text in the intellectual development of the survivor movement, at least in the USA, was Judi Chamberlin's 1978 text, On Our Own: Patient Controlled Alternatives to the Mental Health System. Chamberlin was an ex-patient and co-founder of the Mental Patients' Liberation Front. Coalescing around the ex-patient newsletter Dendron, in late 1988 leaders from several of the main national and grassroots psychiatric survivor groups felt that an independent, human rights coalition focused on problems in the mental health system was needed. That year the Support Coalition International (SCI) was formed. SCI's first public action was to stage a counter-conference and protest in New York City, in May, 1990, at the same time as (and directly outside of) the American Psychiatric Association's annual meeting. In 2005 the SCI changed its name to Mind Freedom International with David W. Oaks as its director.

Pro-Psychiatry

There has always been a major concern regarding psychiatric care; however, it can be argued that the mental health care of millions of individuals is needed. The biggest economic problem around the world at the moment is that of mental illness, due to the "disability and job loss", costing the world, in 2010, $2.3 trillion, and is projected to jump to $6 trillion by 2030. Although the methods that are used differ from one psychiatric professional to another, and may be questionable by some, it is even more evident in the numbers that are reflecting a global mental crisis that mental illness needs to be addressed humanely to help individuals with mental illnesses gain their independence.

Psychiatric hospital

From Wikipedia, the free encyclopedia

Traverse City State Hospital, Traverse City, Michigan

Psychiatric hospitals, also known as mental hospitals, mental health units, mental asylums or simply asylums, are hospitals or wards specializing in the treatment of serious mental disorders, such as clinical depression, schizophrenia, and bipolar disorder. Psychiatric hospitals vary widely in their size and grading. Some hospitals may specialize only in short-term or outpatient therapy for low-risk patients. Others may specialize in the temporary or permanent care of residents who, as a result of a psychological disorder, require routine assistance, treatment, or a specialized and controlled environment. Patients are often admitted on a voluntary basis, but people whom psychiatrists believe may pose a significant danger to themselves or others may be subject to involuntary commitment. Psychiatric hospitals may also be referred to as psychiatric wards (or "psych" wards) when they are a subunit of a regular hospital.

Modern psychiatric hospitals evolved from, and eventually replaced the older lunatic asylums. The treatment of inmates in early lunatic asylums was sometimes brutal and focused on containment and restraint. With successive waves of reform, and the introduction of effective evidence-based treatments, most modern psychiatric hospitals provide a primary emphasis on treatment, and attempt where possible to help patients control their own lives in the outside world, with the use of a combination of psychiatric drugs and psychotherapy. An exception is in Japan, where many psychiatric hospitals still use physical restraints on patients, tying them to their beds for days or even months at a time.

A crisis stabilization unit is in effect an emergency department for psychiatry, frequently dealing with suicidal, violent, or otherwise critical individuals. Open units are psychiatric units that are not as secure as crisis stabilization units. Another type of psychiatric hospital is medium term, which provides care lasting several weeks. In the United Kingdom, both crisis admissions and medium term care is usually provided on acute admissions wards. Juvenile or adolescent wards are sections of psychiatric hospitals or psychiatric wards set aside for children or adolescents with mental illness. Long-term care facilities have the goal of treatment and rehabilitation back into society within a short time-frame (two or three years). Another institution for the mentally ill is a community-based halfway house.

History

The York Retreat (c.1796) was built by William Tuke, a pioneer of moral treatment for the mentally ill.

Modern psychiatric hospitals evolved from, and eventually replaced the older lunatic asylums. The development of the modern psychiatric hospital is also the story of the rise of organized, institutional psychiatry.

Hospitals known as bimaristans were built throughout Arab countries beginning around the early 9th century, with the first in Baghdad under the leadership of the Abbasid Caliph Harun al-Rashid. While not devoted solely to patients with psychiatric disorders, they often contained wards for patients exhibiting mania or other psychological distress. Because of cultural taboos against refusing to care for one's family members, mentally ill patients would be surrendered to a bimaristan only if the patient demonstrated violence, incurable chronic illness, or some other extremely debilitating ailment. Psychological wards were typically enclosed by iron bars owing to the aggression of some of the patients.

Western Europe would adopt these views later on with the advances of physicians like Philippe Pinel at the Bicêtre Hospital in France and William Tuke at the York Retreat in England. They advocated the viewing of mental illness as a disorder that required compassionate treatment that would aid in the rehabilitation of the victim. The arrival in the Western world of institutionalisation as a solution to the problem of madness was very much an event of the nineteenth century. The first public mental asylums were established in Britain; the passing of the County Asylums Act 1808 empowered magistrates to build rate-supported asylums in every county to house the many 'pauper lunatics'. Nine counties first applied, the first public asylum opening in 1812 in Nottinghamshire. In 1828, the newly appointed Commissioners in Lunacy were empowered to license and supervise private asylums. The Lunacy Act 1845 made the construction of asylums in every country compulsory with regular inspections on behalf of the Home Secretary. The Act required asylums to have written regulations and to have a resident physician.

At the beginning of the nineteenth century there were a few thousand "sick people" housed in a variety of disparate institutions throughout England, but by 1900 that figure had grown to about 100,000. This growth coincided with the growth of alienism, later known as psychiatry, as a medical specialism. The treatment of inmates in early lunatic asylums was sometimes very brutal and focused on containment and restraint.

In the late 19th and early 20th centuries, terms such as "madness," "lunacy" or "insanity"—all of which assumed a unitary psychosis—were split into numerous "mental diseases," of which catatonia, melancholia and dementia praecox (modern day schizophrenia) were the most common in psychiatric institutions.

In 1961 sociologist Erving Goffman described a theory of the "total institution" and the process by which it takes efforts to maintain predictable and regular behavior on the part of both "guard" and "captor," suggesting that many of the features of such institutions serve the ritual function of ensuring that both classes of people know their function and social role, in other words of "institutionalizing" them. Asylums was a key text in the development of deinstitutionalization.

With successive waves of reform, and the introduction of effective evidence-based treatments, modern psychiatric hospitals provide a primary emphasis on treatment, and attempt where possible to help patients control their own lives in the outside world, with the use of a combination of psychiatric drugs and psychotherapy. These treatments can be involuntary. Involuntary treatments are among the many psychiatric practices which are questioned by the mental patient liberation movement. Most psychiatric hospitals now restrict internet access and any device that can take photos. In the U.S. state of Connecticut, involuntary patients must be examined annually by a court-appointed psychiatrist. Patients may also apply for release at any time and receive a full hearing on the application.

Types

The Republican Vilnius Psychiatric Hospital in Naujoji Vilnia (Parko g. 15), is one of the largest health facilities in Lithuania; built in 1902, official opening on 21 May 1903

There are a number of different types of modern psychiatric hospitals, but all of them house people with mental illnesses of widely variable severity.

Crisis stabilization

Vienna's Narrenturm—German for "fools' tower"—was one of the earliest buildings specifically designed for mentally ill people. It was built in 1784.

The crisis stabilization unit is in effect an emergency department for psychiatry, frequently dealing with suicidal, violent, or otherwise critical individuals.

Open units

Open units are psychiatric units that are not as secure as crisis stabilization units. They are not used for acutely suicidal persons; the focus in these units is to make life as normal as possible for patients while continuing treatment to the point where they can be discharged. However, patients are usually still not allowed to hold their own medications in their rooms, because of the risk of an impulsive overdose. While some open units are physically unlocked, other open units still use locked entrances and exits depending on the type of patients admitted.

Medium-term

Another type of psychiatric hospital is medium term, which provides care lasting several weeks. Most drugs used for psychiatric purposes take several weeks to take effect, and the main purpose of these hospitals is to monitor the patient for the first few weeks of therapy to ensure the treatment is effective.

Juvenile wards

Juvenile wards are sections of psychiatric hospitals or psychiatric wards set aside for children or adolescents with mental illness. However, there are a number of institutions specializing only in the treatment of juveniles, particularly when dealing with drug abuse, self-harm, eating disorders, anxiety, depression or other mental illness.

Long-term care facilities

In the UK long-term care facilities are now being replaced with smaller secure units (some within the hospitals listed above). Modern buildings, modern security and being locally sited to help with reintegration into society once medication has stabilized the condition are often features of such units. An example of this is the Three Bridges Unit, in the grounds of St Bernard's Hospital in West London and the John Munroe Hospital in Staffordshire. However these modern units have the goal of treatment and rehabilitation back into society within a short time-frame (two or three years) and not all patients' treatment can meet this criterion, so the large hospitals mentioned above often retain this role.

These hospitals provide stabilization and rehabilitation for those who are having difficulties such as depression, eating disorders, other mental disorders, and so on.

Halfway houses

One type of institution for the mentally ill is a community-based halfway house. These facilities provide assisted living for patients with mental illnesses for an extended period of time, and often aid in the transition to self-sufficiency. These institutions are considered to be one of the most important parts of a mental health system by many psychiatrists, although some localities lack sufficient funding.

Political imprisonment

In some countries the mental institution may be used in certain cases for the incarceration of political prisoners, as a form of punishment. A notable historical example was the use of punitive psychiatry in the Soviet Union and China.

Secure units

In the UK, criminal courts or the Home Secretary can order the admission of offenders to be detained in hospital under various sections of the Mental Health Act, although the term "criminally insane" is no longer legally or medically recognized. Secure psychiatric units exist in all regions of the UK for this purpose; in addition, there are a small number of Specialist Hospitals which offer care and treatment within conditions of high security. These facilities are run by the National Health Service, which undertake psychiatric assessments and can also provide treatment and accommodation in a safe, hospital environment where patients can be prevented from absconding and there is a reduction in their risk of harm to others and themselves.

These secure hospital facilities are divided into three main categories and are referred to as High, Medium and Low Secure. Although it is a phrase often used by newspapers, there is no such classification as "Maximum Secure". Low Secure units are often incorrectly referred to as "Local Secure" as patients are detained there frequently by local criminal courts for psychiatric assessment before sentencing.

Community hospital utilization

Community hospitals across the United States regularly see mental health discharges. A study of community hospital discharge data from 2003-2011 showed that mental health hospitalizations were increasing for both children (patients aged 0–17 years) and adults (patients aged 18–64). Compared to other hospital utilization, mental health discharges were the slowest increasing hospitalizations for children, but the most rapidly increasing hospitalizations for adults under 64. Some units have been opened to provide "Therapeutically Enhanced Treatment" and so form a subcategory to the three main ones.

The general public are familiar with the names of the High Secure Hospitals due to the frequency that they are mentioned in the news reports about the people who are sent there. Those in England include, Ashworth Hospital in Merseyside; Broadmoor Hospital in Crowthorne, Berkshire and Rampton Secure Hospital in Retford, Nottinghamshire and in Scotland is The State Hospital, Carstairs. Northern Ireland and the Isle of Man have their own Medium and Low Secure units but use the mainland faculties for High Secure, which smaller Channel Islands also transfer their patients to as Out of Area (Off-Island Placements) Referrals under the Mental Health Act 1983. Of the Medium Secure units, there are many more of these in number scattered throughout the UK. As of 2009 there were 27 women only units in England alone. Irish units include those at prisons in Portlaise, Castelrea, and Cork.

Criticism

American psychiatrist Thomas Szasz insisted that psychiatric hospitals are like prisons, not proper hospitals, and that psychiatrists who subject others to coercion function as judges and jailers, not physicians. The French historian Michel Foucault is widely known for his comprehensive critique of the use and abuse of the mental hospital system in Madness and Civilization. He argued that Tuke and Pinel's asylum was a symbolic recreation of the condition of a child under a bourgeois family. It was a microcosm symbolizing the massive structures of bourgeois society and its values: relations of Family–Children (paternal authority), Fault–Punishment (immediate justice), Madness–Disorder (social and moral order).

Erving Goffman coined the term "Total Institution" for mental hospitals and similar places which took over and confined a person's whole life. Goffman placed psychiatric hospitals in the same category as concentration camps, prisons, military organizations, orphanages, and monasteries. In his book Asylums Goffman describes how the institutionalisation process socialises people into the role of a good patient, someone "dull, harmless and inconspicuous"; in turn, it reinforces notions of chronicity in severe mental illness. The Rosenhan experiment of 1973 demonstrated the difficulty of distinguishing sane patients from insane patients.

Franco Basaglia, a leading Italian psychiatrist who inspired and was the architect of the psychiatric reform in Italy, also defined the mental hospital as an oppressive, locked and total institution in which prison-like, punitive rules are applied, in order to gradually eliminate its own contents, and patients, doctors and nurses are all subjected (at different levels) to the same process of institutionalism. American psychiatrist Loren Mosher noticed that the psychiatric institution itself gave him master classes in the art of the "total institution": labeling, unnecessary dependency, the induction and perpetuation of powerlessness, the degradation ceremony, authoritarianism, and the primacy of institutional needs over those of the persons it was ostensibly there to serve-the patients.

The anti-psychiatry movement coming to the fore in the 1960s has opposed many of the practices, conditions, or existence of mental hospitals. The psychiatric consumer/survivor movement has often objected to or campaigned against conditions in mental hospitals or their use, voluntarily or involuntarily. The mental patient liberation movement emphatically opposes involuntary treatment but generally does not have any issue with any psychiatric treatments that are consensual, provided that both parties are free to withdraw consent at any time.

History of psychiatry

From Wikipedia, the free encyclopedia

Ancient

Specialty in psychiatry can be traced in Ancient India. The oldest texts on psychiatry include the ayurvedic text, Charaka Samhita. Some of the first hospitals for curing mental illness were established during the 3rd century BCE.

During the 5th century BCE, mental disorders, especially those with psychotic traits, were considered supernatural in origin, a view which existed throughout ancient Greece and Rome. The beginning of psychiatry as a medical specialty is dated to the middle of the nineteenth century, although one may trace its germination to the late eighteenth century.

Some of the early manuals about mental disorders were created by the Greeks. In the 4th century BCE, Hippocrates theorized that physiological abnormalities may be the root of mental disorders. In 4th- to 5th-century BCE Greece, Hippocrates wrote that he visited Democritus and found him in his garden cutting open animals. Democritus explained that he was attempting to discover the cause of madness and melancholy. Hippocrates praised his work. Democritus had with him a book on madness and melancholy.

Religious leaders often turned to versions of exorcism to treat mental disorders, often utilizing methods that many consider to be cruel and/or barbaric.

Middle Ages

A number of hospitals known as bimaristans were built throughout Arab countries beginning around the early 9th century, with the first in Baghdad. They sometimes contained wards for mentally ill patients, typically those who exhibited violence or suffered from debilitating chronic illness.

Physicians who wrote on mental disorders and their treatment in the Medieval Islamic period included Muhammad ibn Zakariya al-Razi (Rhazes), the Arab physician Najab ud-din Muhammad, and Abu Ali al-Hussain ibn Abdallah ibn Sina, known in the West as Avicenna.

Specialist hospitals were built in medieval Europe from the 13th century to treat mental disorders but were utilized only as custodial institutions and did not provide any type of treatment.

Early modern period

Plan of the Bethlem Royal Hospital, an early public asylum for the mentally ill.

Founded in the 13th century, Bethlem Royal Hospital in London was one of the oldest lunatic asylums. In the late 17th century, privately run asylums for the insane began to proliferate and expand in size. Already in 1632 it was recorded that Bethlem 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". Inmates who were deemed dangerous or disturbing were chained, but Bethlem was an otherwise open building for its inhabitants to roam around its confines and possibly throughout the general neighborhood in which the hospital was situated. In 1676, Bethlem expanded into newly built premises at Moorfields with a capacity for 100 inmates.

In 1713 the Bethel Hospital Norwich was opened, the first purpose-built asylum in England, founded by Mary Chapman.

In 1621, Oxford University mathematician, astrologer, and scholar Robert Burton published one of the earliest treatises on mental illness, 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. Burton thought that there was "no greater cause of melancholy than idleness, no better cure than business." Unlike English philosopher of science Francis Bacon, Burton argued that knowledge of the mind, not natural science, is humankind's greatest need.

In 1656, Louis XIV of France created a public system of hospitals for those suffering from mental disorders, but as in England, no real treatment was applied.

Humanitarian reform

Dr. Philippe Pinel at the Salpêtrière, 1795 by Tony Robert-Fleury. Pinel ordering the removal of chains from patients at the Paris Asylum for insane women.

During the Enlightenment attitudes towards the mentally ill began to change. It came to be viewed as a disorder that required compassionate treatment that would aid in the rehabilitation of the victim. In 1758 English physician William Battie wrote his Treatise on Madness on the management of mental disorder. It was a critique aimed particularly at the Bethlem Hospital, where a conservative regime continued to use barbaric custodial treatment. Battie argued for a tailored management of patients entailing cleanliness, good food, fresh air, and distraction from friends and family. He argued that mental disorder originated from dysfunction of the material brain and body rather than the internal workings of the mind.

Thirty years later, then ruling monarch in England George III was known to be suffering from a mental disorder. Following the King's remission 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 doctor Philippe Pinel and the English Quaker William Tuke.

In 1792 Pinel became the chief physician at the Bicêtre Hospital. In 1797, Jean-Baptiste Pussin first freed patients of their chains and banned physical punishment, although straitjackets could be used instead.

Patients were allowed to move freely about the hospital grounds, and eventually dark dungeons were replaced with sunny, well-ventilated rooms. 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 (1772–1840), 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 pleading, menaces, or complaining.

The York Retreat (c.1796) was built by William Tuke, a pioneer of moral treatment for the insane.

William Tuke led the development of a radical new type of institution in northern England, following the death of a fellow Quaker in a local asylum in 1790. In 1796, with the help of fellow Quakers and others, he founded the York 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 centered around minimizing restraints and cultivating rationality and moral strength. The entire Tuke family became known as founders of moral treatment.

William Tuke's grandson, Samuel Tuke, published an influential work in the early 19th century on the methods of the retreat; Pinel's Treatise 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 suffering from mental disorders. The York Retreat inspired similar institutions in the United States, most notably the Brattleboro Retreat and the Hartford Retreat (now The Institute of Living).

Although Tuke, Pinel and others had tried to do away with physical restraint, it remained widespread into the 19th century. At the Lincoln Asylum in England, Robert Gardiner Hill, with the support of Edward 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 their Hanwell 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.

Phrenology

William A. F. Browne was an influential reformer of the lunatic asylum in the mid-19th century, and an advocate of the new 'science' of phrenology.

Scotland's Edinburgh medical school of the eighteenth century developed an interest in mental illness, with influential teachers including William Cullen (1710–1790) and Robert Whytt (1714–1766) emphasising the clinical importance of psychiatric disorders. In 1816, the phrenologist Johann Spurzheim (1776–1832) visited Edinburgh and lectured on his craniological and phrenological concepts; the central concepts of the system were that the brain is the organ of the mind and that human behaviour can be usefully understood in neurological rather than philosophical or religious terms. Phrenologists also laid stress on the modularity of mind.

Some of the medical students, including William A. F. Browne (1805–1885), responded very positively to this materialist conception of the nervous system and, by implication, of mental disorder. George Combe (1788–1858), an Edinburgh solicitor, became an unrivalled exponent of phrenological thinking, and his brother, Andrew Combe (1797–1847), who was later appointed a physician to Queen Victoria, wrote a phrenological treatise entitled Observations on Mental Derangement (1831). They also founded the Edinburgh Phrenological Society in 1820.

Institutionalization

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 the 1808 County Asylums Act. This empowered magistrates to build rate-supported asylums in every county to house the many 'pauper lunatics'. Nine counties first applied, and the first public asylum opened in 1812 in Nottinghamshire. Parliamentary Committees were established to investigate abuses at private madhouses like Bethlem 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. However, it was not until 1828 that the newly appointed Commissioners in Lunacy were empowered to license and supervise private asylums.

Lord Shaftesbury, a vigorous campaigner for the reform of lunacy law in England, and the Head of the Lunacy Commission for 40 years.

The Lunacy Act 1845 was an important landmark in the treatment of the mentally ill, as it explicitly changed the status of mentally ill people to patients who required treatment. The Act created the Lunacy Commission, headed by Lord Shaftesbury, to focus on lunacy legislation reform. The Commission was made up of eleven Metropolitan Commissioners who were required to carry out the provisions of the Act; the compulsory construction of asylums in every county, with regular inspections on behalf of the Home Secretary. All asylums were required to have written regulations and to have a resident qualified physician. A national body for asylum superintendents - the Medico-Psychological Association - was established in 1866 under the Presidency of William A. F. Browne, although the body appeared in an earlier form in 1841.

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, 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.

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. The Utica State Hospital was opened approximately in 1850. The creation of this hospital, as of many others, was largely the work of Dorothea Lynde Dix, whose philanthropic efforts extended over many states, and in Europe as far as Constantinople. Many state hospitals in the United States were built in the 1850s and 1860s on the Kirkbride Plan, an architectural style meant to have curative effect.

At the turn of the century, England and France combined had only a few hundred individuals in asylums. By the late 1890s and early 1900s, this number had risen to the hundreds of thousands. However, the idea that mental illness could be ameliorated through institutionalization was soon disappointed. Psychiatrists were pressured by an ever-increasing patient population. The average number of patients in asylums kept on growing. Asylums were quickly becoming almost indistinguishable from custodial institutions, and the reputation of psychiatry in the medical world had hit an extreme low.

Scientific advances

Emil Kraepelin studied and promoted ideas of disease classification for mental disorders.

In the early 1800s, psychiatry made advances in the diagnosis of mental illness by broadening the category of mental disease to include mood disorders, in addition to disease level delusion or irrationality. The term psychiatry (Greek "ψυχιατρική", psychiatrikē) which comes from the Greek "ψυχή" (psychē: "soul or mind") and "ιατρός" (iatros: "healer") was coined by Johann Christian Reil in 1808. Jean-Étienne Dominique Esquirol, a student of Pinel, defined lypemania as an 'affective monomania' (excessive attention to a single thing). This was an early diagnosis of depression.

The 20th century introduced a new psychiatry into the world. Different perspectives of looking at mental disorders began to be introduced. The career of Emil Kraepelin reflects the convergence of different disciplines in psychiatry. Kraepelin initially was very attracted to psychology and ignored the ideas of anatomical psychiatry. Following his appointment to a professorship of psychiatry and his work in a university psychiatric clinic, Kraepelin's interest in pure psychology began to fade and he introduced a plan for a more comprehensive psychiatry. Kraepelin began to study and promote the ideas of disease classification for mental disorders, an idea introduced by Karl Ludwig Kahlbaum. The initial ideas behind biological psychiatry, stating that the different mental disorders were all biological in nature, evolved into a new concept of "nerves" and psychiatry became a rough approximation of neurology and neuropsychiatry. However, Kraepelin was criticized for considering schizophrenia as a biological illness in the absence of any detectable histologic or anatomic abnormalities. While Kraepelin tried to find organic causes of mental illness, he adopted many theses of positivist medicine, but he favoured the precision of nosological classification over the indefiniteness of etiological causation as his basic mode of psychiatric explanation.

Following Sigmund Freud's pioneering work, ideas stemming from psychoanalytic theory also began to take root in psychiatry. The psychoanalytic theory became popular among psychiatrists because it allowed the patients to be treated in private practices instead of warehoused in asylums. By the 1970s the psychoanalytic school of thought had become marginalized within the field.

Otto Loewi's work led to the identification of the first neurotransmitter, acetylcholine.

Biological psychiatry reemerged during this time. Psychopharmacology became an integral part of psychiatry starting with Otto Loewi's discovery of the neuromodulatory properties of acetylcholine; thus identifying it as the first-known neurotransmitter. Neuroimaging was first utilized as a tool for psychiatry in the 1980s. The discovery of chlorpromazine's effectiveness in treating schizophrenia in 1952 revolutionized treatment of the disorder, as did lithium carbonate's ability to stabilize mood highs and lows in bipolar disorder in 1948. Psychotherapy was still utilized, but as a treatment for psychosocial issues. In the 1920s and 1930s, most asylum and academic psychiatrists in Europe believed that manic depressive disorder and schizophrenia were inherited, but in the decades after World War II, the conflation of genetics with Nazi racist ideology thoroughly discredited genetics.

Now genetics are once again thought by some prominent researchers to play a large role in mental illness. The genetic and heritable proportion of the cause of five major psychiatric disorders found in family and twin studies is 81% for schizophrenia, 80% for autism spectrum disorder, 75% for bipolar disorder, 75% for attention deficit hyperactivity disorder, and 37% for major depressive disorder. Geneticist Müller-Hill is quoted as saying "Genes are not destiny, they may give an individual a pre-disposition toward a disorder, for example, but that only means they are more likely than others to have it. It (mental illness) is not a certainty.” Molecular biology opened the door for specific genes contributing to mental disorders to be identified.

Deinstitutionalization

Asylums: Essays on the Social Situation of Mental Patients and Other Inmates (1961), written by sociologist Erving Goffman, examined the social situation of mental patients in the hospital. Based on his participant observation field work, the book developed the theory of the "total institution" and the process by which it takes efforts to maintain predictable and regular behavior on the part of both "guard" and "captor". The book suggested that many of the features of such institutions serve the ritual function of ensuring that both classes of people know their function and social role, in other words of "institutionalizing" them. Asylums was a key text in the development of deinstitutionalisation. At the same time, academic psychiatrist and psychoanalyst Thomas Szasz began publishing articles and books that were highly critical of psychiatry and involuntary treatment, including his best-known work The Myth of Mental Illness in 1961.

In 1963, US president John F. Kennedy introduced legislation delegating the National Institute of Mental Health to administer Community Mental Health Centers for those being discharged from state psychiatric hospitals. Later, though, the Community Mental Health Centers focus shifted to providing psychotherapy for those suffering from acute but less serious mental disorders. Ultimately there were no arrangements made for actively following and treating severely mentally ill patients who were being discharged from hospitals. Some of those suffering from mental disorders drifted into homelessness or ended up in prisons and jails. Studies found that 33% of the homeless population and 14% of inmates in prisons and jails were already diagnosed with a mental illness.

In 1973, psychologist David Rosenhan published the Rosenhan experiment, a study with results that led to questions about the validity of psychiatric diagnoses. Critics such as Robert Spitzer placed doubt on the validity and credibility of the study, but did concede that the consistency of psychiatric diagnoses needed improvement.

Psychiatry, like most medical specialties, has a continuing, significant need for research into its diseases, classifications and treatments. Psychiatry adopts biology's fundamental belief that disease and health are different elements of an individual's adaptation to an environment. But psychiatry also recognizes that the environment of the human species is complex and includes physical, cultural, and interpersonal elements. In addition to external factors, the human brain must contain and organize an individual's hopes, fears, desires, fantasies and feelings. Psychiatry's difficult task is to bridge the understanding of these factors so that they can be studied both clinically and physiologically.