The first medical model

  The end of the asylum era (Chapter 3) was foreshadowed by the ‘first medical model’ in the 1920s and 1930s. Interest in psychiatry had received a boost during the First World War with the need to treat shell-shocked soldiers, while at the same time the asylums had become even more overcrowded and neglected. It was only from the 1920s onwards that really effective treatments were discovered and introduced. These caused widespread changes in attitudes and restored optimism. ‘Lunatic’ was replaced with ‘mental patient’, ‘asylum’ with ‘mental hospital’, ‘certification’ with ‘involuntary admission’, and voluntary admissions became common for the first time: a truly revolutionary change in perspective.

  There had been a steady improvement in the drugs used to control agitation prior to this time but two new treatments were epoch making – malaria treatment for cerebral syphilis and electro-convulsive therapy.

Julius Wagner-Jauregg (1857–1940) and malaria treatment

  Wagner-Jauregg was the only psychiatrist to be awarded the Nobel Prize for Medicine before Sigmund Freud in 1939. He received it for his 1917 introduction of malaria treatment for cerebral syphilis (then called general paralysis of the insane, GPI). Before effective treatments for syphilis, a small proportion of chronically infected patients went on to develop the disease in the brain with disastrous consequences. It often took 20 years to develop, by which time the patient might be a settled family man. The terror it represented for 19th-century society is vividly captured in Ibsen’s play Ghosts. Onset of mental symptoms was sudden and dramatic. The philosopher Nietzsche inexplicably embraced a horse that was being abused in the street in Turin and within days was confined to a mental hospital; he died 11 years later never having recovered. Deterioration was tragic and humiliating. It was often associated with delusions of grandeur (hence all those cartoons of patients convinced they were Napoleon), and ended in dementia.

  Wagner-Jauregg’s treatment consisted of infecting the patient with malaria parasites and waiting, with careful nursing, while the high fever raged. Over 10–12 cycles this killed the syphilis germs. The malaria could afterwards be treated with quinine. This treatment was difficult and risky but the alternative held no hope. GPI was effectively cleared from mental hospitals long before effective antibiotics arrived. Malaria treatment restored optimism to mental hospitals and strengthened the professional pride of the doctors and nurses who had to manage this difficult, but effective, treatment. It also forged clearer links with general hospitals where the patients often had to go to be treated. In doing this it became clear that involuntary patients would often cooperate with treatment and this stimulated a reassessment of the need for so much compulsion.

Electro-convulsive therapy

  While malaria treatment is purely of historical interest, electro-convulsive therapy (ECT) is still widely used. Psychiatrists knew that epileptic seizures often caused profound changes in mood – either exciting or calming patients in the hours after a fit. It was also thought that epilepsy was uncommon in patients with schizophrenia so the idea developed that perhaps fits protected patients against this disease. Fits were induced in schizophrenia patients from 1935 by getting them to inhale camphor or by injecting a chemical called metrazol. The results were promising, with many patients improving. Unfortunately the experience (in particular the minutes leading up to the fit after the metrazol was injected) were very unpleasant indeed, with mounting dread, so many patients refused the treatments.

  An Italian, Cerletti, came up with the idea of using a weak electric current to initiate the fit and used it on his first patient in 1938 with striking results. Several psychiatrists started to use ECT and its results were truly remarkable. While it did calm very agitated schizophrenic patients, its most dramatic results were with depressed patients, many of whom made sustained recoveries. If this all sounds a bit barbaric it pays to remember that depressed patients in the 1930s (even in very good mental hospitals) often stayed for years and up to one fifth died during the admission.

  Initially ECT was given without anaesthetic and clearly was a frightening experience often with complications of small fractures if the fit was very strong, headache, and memory loss. For the last 50 years patients have received a short-acting anaesthetic and a chemical to block the muscle contractions so there is no fit to see and no risk of fractures. Headache and memory loss are still problems but patients don’t recall the actual seizure.

  The discovery and durability of ECT is typical of many developments in psychiatry. The idea that started it (that epilepsy protected against schizophrenia) was wrong but the treatment worked, although more in depression than schizophrenia. We still don’t know why it works, but it certainly does. It remains one of the most effective treatments in psychiatry and (despite its wider reputation) the one that most patients who have had it say they would want again.