Historical perspectives on the theories, diagnosis, and treatment of mental illness

Attitudes and views toward psychopathology in the medical and larger social community have undergone drastic transformation throughout history, at times progressing through a rather tortuous course, to eventually receive validation and scientific attention. Departing from a simplistic view centred on supernatural causes, modern theories in the early 20th century began to recognize mental disorders as unique disease entities, and two main theories of psychodynamics and behaviorism emerged as potential explanations for their causes. With the increasing acceptance of mental illness as a unique form of pathology, official diagnostic classification systems were adopted, new avenues of research spawned, and modern approaches to treatment incorporating pharmaacotherapy and psychotherapy were established. Although much scientific progress has been made in the fields of diagnosing and treating mental illness, at a societal level the recent psychiatric deinstitutionalization movement has been met with mixed success, calling into question how to most effectively implement into clinical practice the knowledge that has been gained over the previous centuries.

The prevailing views of early recorded history posited that mental illness was the product of supernatural forces and demonic possession, and this often led to primitive treatment practices such as trepanning in an effort to release the offending spirit.[1] Relatively little in the way of improvements were achieved throughout the European Middle Ages, and the oppressive sociopolitical climate saw many sufferers of mental illness being submitted to physical restraint and solitary confinement in the asylums of the time.[2] It was not until the late 19th and early 20th centuries that modern theories of psychopathology began to emerge.

Around this time, two main theoretical approaches began to inform our understanding of mental illness: the psychodynamic theory proposed by Austrian neurologist Sigmund Freud (1856–1939), and the theory of behaviorism advanced by American psychologist John B. Watson (1878–1958).[2] Freud’s theory of psychodynamics centred on the notion that mental illness was the product of the interplay of unresolved unconscious motives, and should be treated through various methods of open dialogue with the patient.[2] Behaviorism, on the other hand, suggested that psychopathology was more closely related to the effects of behavioral conditioning, and that treatment should focus on methods of adaptive reconditioning, using the same principles of classical conditioning elucidated by the Russian physiologist Ivan Pavlov (1849–1936).[2]

Against the backdrop of these broad theoretical frameworks, modern approaches to the diagnosis and treatment of psychopathology began to emerge and, along with these, the need to systematically categorize mental illness became apparent. In post–Second World War North America a need for a formal classification system was recognized in order to provide more efficient and targeted mental health services for veterans.[3] This led to the creation of the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1952, which was largely drawn from the World Health Organization’s sixth edition of the International Classification of Diseases (ICD-6).[3] Early editions of the DSM described mental disorders in terms of “reactions,” postulating that such illnesses should be classified with reference to antecedent socio-environmental and biological causative factors.[3] However, in 1980 with the publication of the third edition, the DSM shifted its focus and intentionally remained neutral on the potential etiological causes of the various forms of mental illness. This position was maintained in subsequent editions, including the current DSM-5, published in 2013.[3]

With theoretical frameworks and a classification system in place, the study and treatment of mental illness began to expand significantly in the mid-20th century. Important developments in this period laid the foundation for modern pharmacologic and psychotherapeutic approaches aimed at addressing mental illness. From a pharmacological perspective, the catecholamine hypothesis, published in the 1950s, was an influential milestone although perhaps overly simplistic. Following research into the actions of drugs like reserpine and monoamine oxidase inhibitors, the catecholamine hypothesis proposed that depression and other affective disorders were likely caused by decreased levels of catecholamines such as norepinephrine.[4]

The field of psychotherapy, with its early roots in Freud’s psychodynamic theory, also saw new developments in this period. In particular, individuals such as American psychologist Albert Ellis (1913–2007) and American psychiatrist Aaron T. Beck (b. 1921) began adopting treatment approaches aimed at addressing the maladaptive cognitions and emotions underlying mental disorders.[5,6] When combined with principles of behaviorism, this approach led to the eventual development of cognitive-behavioral therapy (CBT), the current gold standard psychotherapeutic approach in the treatment of anxiety disorders.[7] Taken together, the catecholamine hypothesis and the development of CBT have had a substantial impact on the modern treatment of depression and anxiety, the two disorders accounting for the highest proportion of disability-adjusted life years among mental illnesses across the globe.[8]

In the latter half of the 20th century, various factors gave rise to the more recent psychiatric deinstitutionalization movement in North America, including the advent of antipsychotic drugs and the recognition that mental health expenses could be reduced by using community-based outpatient settings in favor of inpatient care in psychiatric hospitals.[9] In response to the recommendations of the Canadian Mental Health Association in the 1960s,[10] deinstitutionalization was adopted in Canada and is ongoing today.[2] Unfortunately, throughout Canada, the increase in community-based mental health services has not kept pace with the closure of psychiatric hospitals,[11] contributing to problems of homelessness and crime among many sufferers of mental illness.[2] The closure of Riverview Hospital, a mental health facility in Coquitlam, serves as a poignant local example. Amid debates about how to best deal with addiction and mental health problems in BC, Riverview Hospital is currently slated to reopen by 2019,[12] and it will be interesting to see how other regions across the country respond to the ongoing challenges of mental health care. 

Western civilization’s relationship with mental illness has had a complex and varied history, characterized by periods of relative scientific inertia and ostracism of those afflicted, as well as periods of great theoretical insight and progressive thinking. Following the abandonment of supernatural explanations/theories and with the emergence of logical thought and experimental reasoning after the Middle Ages, the stage was set for a transition to a humane method of treating mental illness. This shift led to the advent of modern theories of mental illness, dedicated classification systems, as well as theoretical approaches to treatment based on clinical evidence. Despite such progress, there remain ongoing public health concerns with respect to effectively implementing the most appropriate model of mental health care for society, and these will likely serve as major themes in the next chapter of the history of mental illness.

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This article has been peer reviewed.

References

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2.    Butcher JN, Mineka S, Hooley JM, et al. Abnormal psychology, first Canadian edition. Toronto, ON: Pearson Education Canada; 2010.
3.    American Psychiatric Association. DSM history. Accessed 17 January 2017. www.psychiatry.org/psychiatrists/practice/dsm/history-of-the-dsm.
4.    Schildkraut JJ. The catecholamine hypothesis of affective disorders: A review of supporting evidence. Am J Psychiatry 1965;122:509-522.
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8.    Murray CJ, Vos T, Lozano R, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: A systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012;380(9859):2197-2223.
9.    Lesage AD, Morissette R, Fortier L, et al. Downsizing psychiatric hospitals: Needs for care and services of current and discharged long-stay inpatients. Can J Psychiatry 2000;45:526-532.
10.    Tyhurst JS, Chalke FCR, Lawson FS, et al. More for the mind: A study of psychiatric services in Canada. Toronto, ON: Canadian Mental Health Association; 1963.
11.    Sealy P, Whitehead PC. Forty years of deinstitutionalization of psychiatric services in Canada: An empirical assessment. Can J Psychiatry 2004;49:249-257.
12.    BC Housing. A vision for renewing Riverview. 2015. Accessed 26 January 2017. http://renewingriverview.com/wp-contentuploads/2015/12/A-Vision-For-Rene....

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Mr Jutras is a third-year medical student at the University of British Columbia.