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The evolution of mental health care

From insane asylums to lobotomies to antidepressants.

The evolution of mental health careThe mentally ill have been demonized, categorized, lobotomized, psychoanalyzed…and medicated.

The early days:  Dungeons and dragons
In the Middle Ages, mental illness was regarded as demonic possession. For centuries, the afflicted were often shackled and shunned and, later, warehoused. French physician Phillippe Pinel, in the late 1700s, took over Bicêtre insane asylum and forbid the use of chains and shackles, removing inmates from dungeons and providing them with sunny rooms. But mistreatment continued in other parts of Europe and the United States.

Revolution by an American heroine:  Demure dynamo, powerful persuader
Beginning in 1841, American heiress and early social worker Dorothea Dix spent fifteen years in the United States and Europe investigating mistreatment in mental institutions: inmates being housed with criminals, unclothed, beaten and kept in darkness. She advocated for reform and had a lasting impact on legislation.

Classifications of mental illness: No more one-size-fits-all
In the late 1800s, Emil Kraepelin distinguished differences between types of mental illness: manic-depressive psychosis, schizophrenia, etc. Patients were no longer seen as simply “insane.”

Freud and psychoanalysis: It all began with my mother.
Psychoanalytic therapies (“talking cures”) were developed by Sigmund Freud, Carl Jung and others around the turn of the century. They focused on identity, memory, childhood, sexuality, and meaning.

Lobotomies: Just a little off the top.
Various methods of lobotomies were used for decades beginning in the late 1930’s, sometimes involving drilling into the brain to sever nerves thought to be capable of regenerating into healthy connections. But, the most renowned was Doctor Walter Freeman’s technique, in which an ice pick-like object was inserted through the eye socket and tapped into the brain with a rubber mallet.

At least fifty thousand people, including “the mentally ill,” “delinquent” young adolescents and unhappy housewives were lobotomized by various techniques through the early 1960s. Some were severely disabled by the procedures.

Electroconvulsive therapy (ECT): Shocking!
ECT, introduced in the 1930s, used a brief electrical stimulus to induce a cerebral seizure. In the early years, according to the Mayo Clinic, “electroconvulsive therapy could be painful and downright dangerous. It was administered with neither anesthetics nor muscle relaxants, and the electrical current was much higher than today. Powerful seizures racked the body with a force that could break bones.” The procedure is still used, in more humane ways, but can have complications, such as memory loss and confusion.

Lithium: Mental metal
Australian psychiatrist J. F. J. Cade in 1949 introduced the use of lithium to treat psychosis. Lithium gained wide use from the mid-1960s to treat those with manic depression, now known as bipolar disorder. Lithium is a naturally occurring mineral that is similar to sodium and potassium. It affects chemical messengers by which nerves communicate with each other.

The drug revolution: “He’s sooo much calmer now.”
Several successful anti-psychotic drugs were introduced in the 1950s, including the powerful chlorpromazine (Thorazine). Studies show that 70 percent of patients with schizophrenia clearly improve on anti-psychotic drugs. Later in this decade came the discovery of the monoamine oxidase inhibitors (MAOIs) and the tricyclic antidepressants.

Behavior therapy: And how does that make you feel?
Developed in the mid-1950s, behavior therapy has become a widely used method to help people replace distorted thoughts and beliefs with those that help them feel and function better. Working with a therapist, they can use it to learn to deal with emotions, relate to others in different ways and solve problems. It has been shown to be highly effective and in over a relatively short time.

One Flew Over the Cuckoo’s Nest: Maybe we’re all crazy.
This popular 1975 movie based on Ken Kesey’s famed 1962 novel, starred a young Jack Nicholson. Set in a state mental hospital in 1965, Nicholson portrays the rebellious Randall Patrick McMurphy who challenges the tyrannical Nurse Ratched. The book and movie raise the possibility that some “mental patients” are simply people who behave in socially unacceptable ways.

De-institutionalization: There’s the door.
In the 1960s, thousands of patients formerly housed in mental institutions were released to be directed toward decentralized clinics for new medications and social services. However, many have had problems accessing services and some are now living on the streets without medications or assistance. Approximately one-third of homeless people are estimated to be untreated mentally ill.

National advocacy: Power to the people!
In the 1980s, national organizations, such as the National Alliance for the Mentally Ill, the National Mental Health Association (now Mental Health America) and others, were formed to protect, support, educate, and advocate for the mentally ill.

Prozac and its descendants: Better living through chemistry
The late 1980s and 1990s introduced new and more effective antidepressants, starting with the very popular fluoxetine (Prozac). These selective serotonin reuptake inhibitors (SSRIs) did not have the side effects of the MAOIs or the tricyclics.

Drugs such as SNRIs and NRIs: venlafaxine (Effexor), duloxetine (Cymbalta), nefazodone and mirtazapine (Remeron) followed. New drugs that do not fit into any of these categories, such as Wellbutrin are now popular. Numerous antidepressants, mood stabilizers and anti-anxiety drugs are used today, along with medications designed to treat the side effects they cause.

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