History of Psychiatry

HISTORY of the MENTAL HEALTH CARE SYSTEM IN KANSAS
Roy W. Menninger MD, Topeka KS

 

ORIGINS of PSYCHIATRY

      Psychiatry has had no linear course of development from its earliest forms as have other disciplines (e.g., alchemy to chemistry; astrology to astronomy). Our origins are scattered: in primitive medicine, mythology, hypnotism, theology, philosophy, law, anthropology, literature, & popular lay healing.

      No stable & consensual theoretical vantage point has developed. Rather: competing, bitterly opposing schools the rule. The primary contemporary example: the bitter debate between somatic & mentalist philosophies of mind. (Micale & Porter 1994. p. 2)

 

EVOLUTION OF PSYCHIATRY & PSYCHIATRIC TREATMENT

      Asylums have existed since the Middle Ages but were solely custodial. Oldest: Bethlem (“bedlam”) in 13th century as the Priory of St. Mary of Bethlehem but by 1815 had only 122 patients. On Sundays patients were exhibited to the public as entertainment. Mentally ill usually confined at home, often in dreadful conditions.

      Presumed causes of illness: devils à treatment by exorcism, witches à treated by burning; disturbance of bodily humors (black bile, yellow bile, phlegm & blood) à treatment by bleeding, purging, emetics, restraints

 

18th Century – European Enlightenment generated a progressive social philosophy and encouraged idea that reason would improve therapeutics—produced a new spirit of optimism & belief that institutions could cure.

      1729 – 1st psychiatric ward in US (Boston); 1773 – 1st US psychiatric hospital: Williamsburg VA, but entirely custodial

      Leading 18th C reformers:

            1751 – Wm. Battie – St. Luke’s Hospital, London; emphasized the curability of mental disorder

            1788 – Vincenzio Chiarugi – opened Bonifazio mental hospital in Florence, Italy; he argued that asylums were therapeutic and could heal mental illness

            1793 – Philippe Pinel – Salpêtrière & Bicêtre Hospitals, Paris – promoted better care; struck off the chains of the mentally ill; believed that asylums were places where psychological therapy could be carried out

            1796 –  William Tuke, a Quaker, founded York Retreat, a private asylum in England using  “moral treatment” based on “care & judicious kindness;” spread to US à opening of Pennsylvania Hospital for the Insane in Philadelphia

 

19th Century – Rise of science established new theories about mental illness – that they were brain-based & genetic. Treatment still primitive and limited. Few hospitals. Therefore many mentally ill persons ended up in jails.

      First state hospital: State Lunatic Asylum at Worcester (1833), created by Rev. Louis Dwight to deal with the mentally ill in jails

      The asylums movement is a story of good intentions gone bad. Asylums initially begun by volunteers (not gov’t.) and were based on a moral philosophy of healthy, caring environment. Began with high hopes for cure and initially saw high discharge rates. With markedly increased numbers of patients (1840s), enthusiasm waned & hospitals deteriorated into human warehouses.

      Intended to fulfill a dual purpose: rehabilitate the inmates and then, by virtue of its success, set an example of right action for the larger society. A Utopian flavor. [Rothman xix]

      Social reformer Dorothea Lynde Dix (1841-47) focused on sad plight on the mentally ill in jails & prisons and was directly responsible for the opening of at least 30 more state hospitals. Total of 75 public hospitals by 1880. First census of “insane persons”: à 91,959 “insane” – ½ at home, ½ in hospital, 0.7% (397) in jails. (Torrey 1997, Chap. 3)

      In 1992, by contrast, jail population of schizophrenics increased 10x to 7-10% and in some places, 25%.There were 283,800 people with mental illness in the nation’s prisons and jails. Approximately 23% of individuals in prison and 16% of persons in jails reported a mental illness. (Huss & Grinage 2003). As many as 40% of those who come in contact with the corrections system have a mental illness.

      In the US, the number of mentally ill in jails now surpass numbers of patients in psychiatric hospitals in New York, Austin TX, Dallas Country, Seattle, and San Diego. In the Los Angeles County Jail, 3,300 of 21,000 inmates “require MH services on a daily basis…” – it is the largest mental institution in the country. (Torrey 1997, Chap. 3)

      In Kansas: currently 2/3rds of prison population (9,000) have Axis I (clinical disorders) or Axis II (personality disorders & MR) diagnoses (Huss & Grinage 2003). The increase of persons with mental illness in jails & prisons is clearly a direct result of deinstitutionalization.

      Notable: society has only 2 ways of handling deviants: labeling them either sick or criminal. Depending on the label, individuals are shifted from one to the other, illustrating the “Balloon Phenomenon” – reducing mental hospital census produces an increased jail census & vice versa.

 

20th Century – Diagnosis and treatment pursued parallel (but separate) tracks: biological (“nerves”) & psychological theories & treatment; intensely competitive & often mutually exclusive and divisive

      New hope for cure came with accidental discovery that fever cured neurosyphilis (1917), tried w/ other psychoses using malaria; unsuccessful

      Other biological treatments tried and (usually) abandoned:                                 

            Total tooth extraction (to eliminate “bacterial poisons”
Convulsions à improvement in severe depression leading to use of metrazol and later, electric shock
Insulin therapy
Lobotomies

            Early drugs:
Laxatives
Opium à morphine
Sedatives (chloral hydrate, paraldehyde, barbiturates)

Other physical treatments for “nerves” (some of which are still used):
Hydrotherapy                                                      rest cure       
Cold wet packs                                                   spas
Sleep therapy                                                     diet

                                                     
1896-1912 -- Freud developed psychoanalysis. Widely accepted in US.

                  ·    it offered theories of causation
·    it provided a means of treatment à psychotherapy à encouraged emergence of private practice
·    it emphasized therapeutic role of MD-patient relationship

Popularity and professional influence of psychoanalysis peaked in 1960s

 

      1909 – founding of National Committee for Mental Hygiene, stimulated by book, “A Mind That Found Itself” written by Clifford Beers and published in 1908. A beginning of the consumer movement

      1920-30s – Center of gravity of American psychiatry was in the mental hospitals, but they were totally custodial—virtually without treatment of any kind. Population by 1933: 366,000, w/ some hospitals >8,000 patients (Milledgeville GA)

      1925 – Menninger Sanitarium opened in Topeka

 

WORLD WAR II

      Successful treatment of psychiatric casualties à new atmosphere of enthusiasm & hope for successful treatment (Menninger 2000, pp. 1-2)

      Lessons (many of which had been discovered during WW I, forgotten, and re-learned in WW II)

            1 – community and outpatient treatment of disturbed persons was possible and effective

            2 – psychodynamic & psychoanalytic theories emphasizing life experiences and socio-environmental factors proved useful

            3 – early intervention essential for rapid improvement and preventing subsequent hospitalization

            4 – stimulated the (false) belief that psychiatry could identify & ameliorate social & environmental factors in etiology of mental illnesses. Formed the backdrop of active social reform efforts in the 1960s.

            5 – new psychological and biological therapies (including but not limited to psychotropic drugs) introduced, offering fresh hope for normal existence outside of mental hospitals

            6 – promoted enhanced social health and welfare role of the federal government, evident in the creation of the Natl. Institutes of Health and Mental Health

Post-war public reaction: an upsurge of interest in mental health; increased number of applicants for training. In 1946, some 108 physicians started psychiatric residency at the Menninger School of Psychiatry (ultimately responsible for training 7% of nation’s psychiatrists).

            Initially, most graduates went into public psychiatry. Later, the trend shifted to academic centers or into private practice. Still largely true.

      1946 – National MH Act created Natl. Institute of Mental Health, charged with promoting psychiatric research, training MH personnel, awarding grants to states to assist in establishment of clinics, and funding demonstration studies dealing with prevention, diagnosis & treatment of neuropsychiatric disorders (Grob p. 53)

 

      1952 – Publication of first organized taxonomy of mental illnesses: Diagnostic and Statistical Manual: Mental Disorders (DSM-I), followed by DSM-II in 1968, DSM-III in 1980, DSM-III-R in 1987, DSM-IV in 1994 and DSM-IV-R in 2000.

 

      1955 – American Medical Association and American Psychiatric Association created the Joint Commission on Mental Illness and Health, produced report “Action for Mental Health.”

 

      1961 – Report sent to Congress and released to the public. Critical of state hospitals. Had broad but controversial recommendations. Promoted a community-oriented perspective.

 

      1963, 1965, 1967  – Community MH Centers Acts, proposed by JFK, were products of “Action for Mental Health.” They initiated the community mental health movement and the creation of CMHCs but decreed federal & local county funding for them without state involvement. (Grob 2000)

 

DEINSTITUTIONALIZATION [1955-1970] – outcome of a confluence of many factors  (Lamb 2000; Torrey 1997, Chap 3)

            a – Public outrage over the appalling conditions in state hospitals

                  Albert Deutsch published Shame of the States (1948), reflecting the horrors of state hospitals, primarily Byberry in Philadelphia: patients flung into misery and seemingly forgotten. But it was intended as a call for reform, not censure or closure. Further exposure of state hospital conditions in movie of MJ Ward’s novel, “The Snake Pit,” (1949) starring Olivia de Havilland; on the cover of Time magazine

            b – Parallel trends –

                  1 – Antipsychiatry movement: preached that mental hospitals were wicked and repressive, and that there was no such thing as mental illness, just social rejection, labeling and ostracism.

                  2 – Rise of civil rights movements, extended to psychiatric patients. Civil rights were seriously truncated by the then-employed commitment & institutionalization proceedings. (RWM’s experience as a 1st yr. resident: incarceration with a single signature)

            c – Introduction of the antisychotic drugs (1954) – initially chlorpromazine [Thorazine] & reserpine [Serpasil] followed by many other psychotropic meds; this facilitated planning for extra-hospital treatment       

            d – Emergence of the community mental health concept and “social treatment” – belief that persons would receive better and more humanitarian treatment in their community rather than in state hospitals far from home.

            e – Financial considerations: state government wished to shift the cost burden to the federal & local governments: to federal Supplemental Security Income (SSI) and Medicaid, and local law enforcement agencies, emergency health and mental health services. Maintenance of patients in community is considerably cheaper than in hospital.

            BUT – the community mental health center system was totally unprepared to deal with such severely ill patients, i.e., they could not provide basic care (food, clothing, shelter) or the support mechanisms to enable severely ill persons to cope with their environment.

                  CMHCs initially primarily provided psychotherapy for the walking (worried) well with virtually no provision for services to the actively ill persons pushed out of the state hospitals. Closing state hospital beds eliminated major services for severely ill—still true today.

            Deinstitutionalization reduced state hospital population from 559,000 in 1955 to 338,000 in 1970, to 107,000 in 1988, to 71,619 in 1994 – a decrease of 88% in nearly 40 years. (Torrey 1997, Chap. 3)

                  Population increase since 1955 would have meant some 885,000 patints in state hospitals today, that is, 92% of people who would have been living in public psychiatric hospitals in 1955 were not living there in 1994—a 92% reduction. Some 50-60% were schizophrenic;             10-15% manic-depressive & depression, & 10-15% organic brain disease. (Torrey 1997, Chap 3)

                  At the same time, a 5-fold expansion in total volume of care (from 1.7 million episodes in 1955 to 8.6 million in 1990)

                  Deinstitutionalization was the true “shame of the states”. One-third became homeless; many transferred to other institutions lacking treatment capabilities: nursing homes, boarding houses, etc. and especially jails. In short, it was transinstitutionalization, not deinstitutionalization

 

      1970-80s –

            Continuing neuroscience advances: progressively better understanding of neurochemistry & brain localization à development of increasingly effective medications (“2nd generation meds”) & precision neurosurgery (Parkinson’s, brain tumors)

            Increased awareness of mental illness and its treatability, though stigma still rampant; development of psychiatric units in general hospitals & increased numbers of private psychiatric hospitals (from 150 in 1970 to 444 in 1988)

            But this trend produced steadily increasing costs (esp. psych hospital), leading to cost-containment methods (managed care, HMOs, restricted benefits, policy exclusions of mental illness) à

                  ·    diminished role of in-patient treatment, with shorter lengths-of-stay, and major change in role of hospital (from treatment to diagnosis and stabilization)

                  ·    and increasing emphasis on out-patient treatment and community treatment services

            Mental Health centers underfunded from the beginning, and extended, expected to provide 12 “core services” to anyone who applied. Some new funding in 1982, but still grossly insufficient until Medicaid & Medicare funds became available (1986, 1987).

 

KANSAS MENTAL HEALTH SYSTEM HISTORY

      1949 – death of a legislator’s wife à mobilized determination to change things; Gov. Carlson invited Dr. Karl to assist; KAM agreed, asking (and receiving) $21 million for staff & training. Result: marked improvement of state hospital care with transformation of Topeka State from a custodial into a teaching institution. Continued until its closure in 1997

            At its peak, KS state hospitals had approximately 5,000 beds.

      1987 – Rapp (KU) report: “Toward an Agenda for MH in Kansas” à major finding: extreme incongruence between MH program policy and financing policy. Kansas was ranked #42 & moving backwards.

            Funding differences: CMHCs funded by federal money & county levies; hospitals by state General Fund. Two separate systems. Absolutely no coordination or collaboration.

      1990 – MH Reform legislation introduced major changes: all patients referred for hospitalization were first screened by CMHCs, either admitted or assigned a case manager and diverted to community programs. SH bed utilization was sharply limited to reduce SH costs. Result: the beginning of coordination between CHMCs and SHs.

            Over 6 yr period (1990-96), KS General Fund expenditures for community services increased from 18% to 51% of the MH budget; state hospital expenditures declined from 82% to 49%. Avg. daily state hospital census in Kansas declined by 50%; community caseloads increased by 222%. (Chamberlin, Zebley et al 1998, p. 1)

            Kansas state hospital beds decreased from 1,003 in 1990 to 340 in FY2004 [275 adults, 35 adolescents & 30 children] (Hammond 2005)

            CMHC system: majority of persons are indigent or low income: adults with severe persistent mental illness (SPMI) and children with serious emotional disturbance (SED). Virtually no private pay patients

            Other results of Kansas Mental Health Reform (Chamberlain 1995):

                  ·    Specialized community services to target populations increased

                  ·    Majority of adult consumers of community service programs are living independently; over half involved in work or educational activity

                  ·    [Some] specialized children’s services have been developed in many areas of the state

                  ·    Consumer-Run Organizations (CROs) increased in size and number (to 20 by 2005).

            Further recommendations:

·    Address inadequate capacity of community service programs to deliver appropriate levels of service to more consumers. What is needed: aggressive outreach.

·    Address statewide gaps & make services & opportunities for consumers more equitable across catchment areas, esp. for children

                  ·    Nursing Facilities for Mental Health (NFMH) should be covered by a gatekeeping system to prevent costly & unnecessary institutionalization

                  ·    Develop standards to address consumer empowerment issues, such as representation on governing boards

 

      1997 – Topeka State Hospital closed. Heavily impacted Topeka & Shawnee County because of considerable previous in-migration of psychiatric patients seeking treatment from the substantial supply of psychiatric services—but there were Insufficient alternative community services available

 

      1998-2003 – decreasing 3rd party reimbursement for psychiatric patients since psychiatry briefly viewed as the most expensive medical service, à increased restrictions on utilization & reimbursement (chiefly decr. LOS). Other psychiatric hospitals (private) closed or moved (e.g., Menninger); number of in-patient beds for acute services decreased dramatically: >150 pvt beds & 400+ NFMH beds; 53% nationwide

            Recent trends: SH admissions are increasing (Osa - 994 in FY00 to 2,191 in FY05; Larned - 870 in FY00 to 1,943 in FY05), LOS are decreasing, readmission rates are higher than the national average. Some 50% of 1st admissions to KS hospitals are persons connecting with the mental health system for the first time.

            State hospitals increasingly used their beds for acute, short-term stabilization rather than treatment per se. Emphasis on “efficiency” measured by short lengths-of-stay and rapid return to the community and the CMHC. “Efficiency” is not equivalent to good treatment: patients cannot remain long enough to become stabilized or allow for discharge planning. KS has next to lowest hospital beds / 10,000 popln: 1.3 (MO has 0.9; CO – 1.6, OK - 2.0, NE - 3.0)

            State hospitals are the safety net to accommodate indigent patients. too sick or too disturbed to be able to utilize the extensive community resources developed to avert hospitalization. It is seriously overstrained.

            Target population numbers using CMHCs are increasing: from 17K in 1994 to 36K now (paid by Medicaid), and the non-target population is increasing: >70K today (not covered).

            Result: increased burden on supplemental community services without increased funding. Serious need for transitional/supported living programs.

 

      2003 – Report from the President’s New Freedom Commission – their recommendations:

                  ·    to address stigma
·    to deal with unfair treatment limitations and financial requirements placed on mental health benefits in private health insurance, and
·    to deal with the fragmented mental health service delivery system.
·    to insure that services & treatments are consumer- and family-centered
·    to focus care on increasing consumers’ ability to cope successfully with life’s challenges, on facilitating recovery, and on building resilience

 

      2004 – Our response in Kansas: to organize a series of “summit meetings” (ultimately 8) with consumers, families, providers and administrators to discuss relevance and importance of each of the Commission Goals to Kansas. This collection of thoughts and ideas has been forwarded to the Governor’s Mental Health Services Planning Council for its efforts to create a vision and a long-term strategic plan for the Kansas mental health system.
Freedom Commission Goals –

                  I – Americans Understand that Mental Health is Essential to Overall Health –

                        ·    Expand mental health awareness & public education
·    Develop a MH screening system w/ primary care MDs                           
·    Create a state-wide suicide prevention program

II --      Mental Health Care is Consumer- and Family-Driven
·    Provide consumers & families with understandable information about treatment options and MH public policy, and enable their desires must drive both. They must be in control of their lives and their destinies

                  III – Disparities in MH Services are Eliminated
·    Address needs of cultures living in frontier communities who  are unintentionally but systematically underserved by the state MH system.
·    Develop standards for cultural competence, recruit, train & retain a workforce that is culturally competent, and adopt a policy of ongoing culturally competent practices.

                  IV – Early MH Screening, Assessment, and Referral to Services are Common Practice
·    Primary need to build on capacity for inter-systemic screening, assessment & service provision for young children, schools, persons w. co-occurring disorders and all individuals across the life-span.

                  V – Excellent MH Care is Delivered & Research is Accelerated
·    Develop an infrastructure that provides a full array of broad, equitable and evidence-based services, and
·    A structure supportive of recovery and resilience

                  VI – Technology is Used to Access MH Care and Information
·    Concerted effort to use technology in several ways:
1 – disseminate information based on technological infrastructure and system
2 – information about available services to increase access to and coordination of services
3 – coordinate the sharing of medical records, and
4 – maintain confidentiality of personal health information

 

SUMMARY:  CURRENT TREATMENT CONCEPTS –

      Good treatment now means both psychopharmacology & psychosocial treatment (psychotherapy + environmental support of groups, case managers, family, social agencies, wrap-around services, work), based on thorough assessment & diagnosis

      Emphasis of care has shifted from symptom suppression and cure to recovery, resilience & successful management of illness

      Patients and their families must have a more central role in the decision-making processes of care and treatment

      Major service issues:

            ·    services are still insufficient in many places for many persons, creating great difficulty for mentally ill persons to get the help they need, especially in rural & frontier areas where services are v. limited and transportation a huge issue, and

            ·    the absence of a mechanism to prevent patients from drifting out of the system.

      Essential truth: our guiding philosophy should be a commitment to doing what is needed to enable mentally ill individuals to live and work in their communities. Doing this requires --

            ·    ready access to information about quality medical/psychiatric or social psychological services, and the services themselves, especially for children and their families, plus

            ·    accessing many other resources and services such as housing, transportation, education, vocational training, & job opportunities

            But, these critical services are not medical, they are not reimbursed by medical insurance payment systems, they are not readily accessible by persons with mental illness, there are no mental health funds available to pay for these services, they are located in other departments of government, and there is no super-ordinate authority to enable even minimal coordination with mental health services.

            If effective integration of these various disciplines of knowledge and service from separate departments of government with the mental health system were possible, that would indeed be a true transformation of the MH System in Kansas.

      In sum, Kansas has a better-than-average mental health system that needs significant improvement, especially in regard to greater patient and family involvement and more broadly available services with easier access.

      “Kansas has a reputation for cultivating innovative programs, like new flowers from seed broadcast on the ground; but, no one ever goes back and weeds the garden.” Otherwise put, we start many good programs, but we seldom pause to review what ones worked and what ones didn’t, to see what ones should be sustained and what ones not. We should this become a pattern of the past.

 

REFERENCES

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History of this paper:

      League of Women Voters policy meetings - Sep. 24, 2005 & Apr. 4, Aug 24 & Oct 7, 2006