Throughout history, there have been several changes in how people suffering from mental illness have been seen and treated.
In ancient cultures, such as Persian, Egyptian, Indian, Greek and Roman, mental disorders were believed to be caused either by demons or by deities. There is evidence that in the 5000 B.C. one of the treatments for mental illness was drilling holes in the skull in order to release the evil spirits.
It was only after the 5th century B.C. that in Greece a different approach to mental illness was adopted. A greek philosopher named Hippocrates started talking about mental illness as a problem of the body rather than a punishment sent by the god. Hippocrates’ treatment focused on changing the patient’s environment or occupation, administering certain substances as medications, and using different other techniques, such as phlebotomies, bloodletting, purging, and diets. The principle that the body was affected by the mind or, more commonly called “soul”, became common by the time Galen was writing in the second Century A.C.
Unfortunately, the vast majority of cultures still believed in supernatural causes of mental illnessness and used treatments such as amulets, talismans, and sedatives to “ease the torment” of the afflicted. In countries that had strong ties to family honour, such as China, people suffering from mental illness were hidden by their families so that the society would have not thought that the condition was the result of an immoral behaviour displayed by the individual or the family.
During the Middle Ages, people suffering from mental disorders were believed to be possessed or in need of religion. Negative attitudes towards mental illness persisted throughout the 18th Century, which led to stigmatisation and confinement of patients. As a result of the social stigma, many people were forced to either live in confinement or on the street. Any of those that were abandoned to live on the street, were also considered dangerous, and were often put in jail or dungeons, “out of the public eye”.
The arrival in the Western world of institutionalisation as a solution to the problem of mental disorders was very much an event of the 19th 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 “pauper lunatics”. The first public asylum opened 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. The treatment of people in the early “lunatic asylums” was sometimes very brutal and focused on containment and restraint.
Late in the 19th Century views were influenced by the evolutionary theories of Charles Darwin and Herbert Spencer. Francis Galton, who coined the term “nature versus nurture”, developed theories of inherited disease which held that mental and physical conditions were caused by organic abnormalities that might be transmitted across generations. Collectively, these ideas had in turn been influenced by the apparent failure of asylums and “moral therapy”.
The influence of gender on the presentation and understanding of mental illness is longstanding. In the late 19th Century, the views of Darwin and Spencer emphasised core differences between men and women. Men were considered to be rational while women were, in contrast, considered biologically inferior to men, dominated by their reproductive system and prone to irrationality.
The new term Hysteria was coniated to indicate various symptoms, often associated to women. Women who spoke out were seen as the “shrieking sisterhood”, and were advised to withdraw and rest. Symptoms of hysteria included: convulsions, paralysis, sensation of respiratory obstruction, speech and mood disorders. By the late 19th Century, the influential French neurologist Jean Martin Charcot proposed that hysteria was an inherited disease of the nervous system triggered by trauma in vulnerable people. Although he promoted a neurological cause, he still focused largely on women and especially their ovaries.
Early psychological theories of hysteria came from Pierre Janet who worked under Charcot. He believed that emotional trauma weakened or injured an individual’s psyche. However, it was Sigmund Freud’s psychoanalytical theories that became most influential. Freud proposed that hysteria was a psychological illness caused by the repression of traumatic memories and that traumatic memories were often sexual in nature, and the trauma would be converted into somatic manifestations, such as hysteria. Freud also proposed psychotherapeutic intervention as main treatment.
Before the First World War, Psychiatry did not have its own clinical/medical recognition to the point that symptoms of mental illness were frequently confused and associated to a broad range of problems like crime, alcoholism and homelessness. Psychiatric patients were being managed in the asylums together with people presenting with other conditions or circumstances. Some of the reasons for admission to an asylum included: alcohol dependence; frigidity, homosexuality and masturbation; late stages of syphilis; unmarried pregnant women; epilepsy; and disables.
Soon after the onset of the First World War (1914–18), soldiers started exhibiting unspecified somatic and psychological symptoms, which were initially explained as a result of damage to the central nervous system from heavy artillery explosions. Symptoms included blindness, deafness, palpitations, paralysis, muscle tremor and anxiety, and were gathered together in the term “Shell shock”. This condition seriously challenged previously accepted views about the causes of mental illness and talking therapies. There was also considerable official and public concern about the number of executions for cowardice. The Report of the War Office Committee of Enquiry into shell shock in 1922 aimed to examine the nature and treatment of the condition. The committee consisted of doctors, military men and parliamentarians. The outcome of the report reflected in shifting ideas about mental illness as it was accepted that the origin of the condition was “a war trauma” and psychological therapies would have been beneficial.
During World War II, the term shell shock was replaced with “battle fatigue” or “combat exhaustion”. Approximately one million men suffering from battle fatigue were admitted to hospitals and a large number of them were returned to battle afterwards. Their military leaders consequently received accolades for this success. The somatic features of battle fatigue shifted to gastrointestinal symptoms. Mirroring a rise in ulcers in the general public, and concerns about the risks of gastrectomy (the only cure at the time), historians suggest that conversion disorders were influenced by popular health fears and the limits of medical science.
During the 1950s and ‘60s, asylum care was gradually replaced by mental healthcare in the community. Prior to the 1960s, it was difficult to accurately gauge the number of people suffering from depression and anxiety, and any cases remained undiagnosed in the community. The gender distribution of mental disorders continued to be more common in women, being approximately 2:1 female to male.
During the Post-war period, a strong cultural association developed between neurotic and depressive illnesses and middle-class married women. Feminist authors and commentators in Britain and the United States began to suggest that, for women, new suburban housing estates built following the Second World War were causing a range of psychological and psychosomatic disorders. The image of the “desperate housewife” began to resonate in our culture where the isolation, boredom and banality of domestic life was increasingly portrayed as pathogenic.
Suicide statistics from the mid-20th Century onwards have repeatedly showed that men are more likely to end their own lives and they are more likely to fail seeking help. Historically, ideas about masculinity and the association between weakness and psychological disorders have been suggested as an underlying explanation for men’s reluctance to visit their doctor. Men were more likely to present with physical or psychosomatic symptoms affecting, for example, the stomach, digestion, musculoskeletal system, sleep and general wellbeing compared to a more typical presentation seen in women, i.e. lack of motivation, sadness etc. Physicians writing in the medical literature during the 1960s and 1970s reported that many male patients maintained a defensive denial of mood disturbances. GPs noted that somatic symptoms were a mask and an “excuse with which to come to the doctor”, because they were viewed as more acceptable to the patient, his family and employer. Alcohol abuse appeared to be more prevalent in men than women: one explanation was that men “self-medicated” when suffering from mental illness. Alcohol problems were under-diagnosed and often presented in the late stages of liver disease. Stigma about alcoholism prevented official diagnosis and accurate recording of the illness on sickness certification.
During the Post-war period, General Practitioners were usually male physicians who were themselves influenced by prevailing attitudes towards masculinity and inclined to identify psychosocial problems more readily in women. Physicians were also socialised into a culture of heavy social drinking at medical school and a significant problem with alcohol, drugs and mental illness existed in the profession. By 1982, the standardised mortality ratio for cirrhosis in doctors was three times that of the general population.
From the 1950s onwards, the field of psychopharmacology developed rapidly as new antidepressants and tranquillisers were discovered, developed and introduced into clinical practice. These developments are often referred to as the pharmacological revolution in psychiatry. Echoing earlier associations between femininity and mental disorders, tranquilliser use became strongly identified with women, particularly housewives, who, it was argued, were prescribed drugs in order to adjust them to a role with which they were dissatisfied.
Unfortunately, in our society mental illness is still stigmatised. People often feel ashamed of talking about how they feel and about psychiatric symptoms they may experience. Somehow, we still feel personally responsible and guilty if we suffer from mental disorders. We think they are less real than any other clinical condition and we (optimistically? fantastically?) believe we can control them and move on. The truth is that there is still a lot of disinformation around mental illness and its treatment. Psychiatric medications are often rejected by patients that are prone to think they may become “zombies”, addicted, or for some magical reason, their personality may change. One of the reasons for it is that old fashioned psychotropic drugs used to cause unwanted side effects and some of them still do. Generally speaking, psychiatric medications are not any different from other medications used in clinical practice. The vast majority of drugs in medicine cause side effects. However, these can be controlled and minimised, and different medical options can be considered. A good compromise between clinical effectiveness and reduced side effects can and needs to be found. It is important to maintain a scientific and biological approach.
Mental disorders likewise other disorders need treatment and the goal is always to get better. If there are doubts in regards to what the best approach to treat an illness is, the optimal attitude is to discuss it with a doctor. Google, Yahoo are not good sources of information as there are far too many articles, people express opinions rather than facts and it is difficult to know what we can trust. Psychiatric symptoms and conditions can be treated. People do get better and they take their life back.
Image by Nicoletta Ceccoli