Deinstitutionalization

  The number of psychiatric beds in the West has shrunk to less than a third of what it was in 1955. Nearly every large mental hospital in the UK and most in the US have closed. The few remaining house only a fraction of the patients they once did. Chronic wards where long-stay patients lived out their lives have virtually disappeared. In the mid-1950s there were 500,000 psychiatric inpatients in the USA and 160,000 in the UK. Now there are less than 100,000 in the USA and less than 30,000 in the UK. This trend is virtually worldwide. This process, inelegantly entitled ‘deinstitutionalization’ started by reducing overcrowding and then closing wards. The last 15 years has finally seen the closure of whole mental hospitals.

  It is usual to attribute this emptying of the asylums to the discovery of antipsychotic drugs in the early 1950s. This was clearly the major force but it is not the whole story. Fundamental changes in social attitudes towards the mentally ill were afoot before these drugs were introduced. The impact of the new drugs varied enormously – from wholesale discharges in some countries, to almost no effect in others. Social attitudes and radical rethinking within psychiatry also exerted powerful influences. Later, financial considerations entered the picture. But let us start with the drugs.

 

  6. A ‘bag lady’: a homeless, mentally ill woman with her few possessions – an increasingly common sight in cities throughout the world during the 1990s and often blamed on the rapid closure of mental hospitals

The drug revolution

  Like so many important discoveries chlorpromazine’s antipsychotic effect was found by pure chance. A French navy anaesthetist researching trauma and shock noted how it calmed patients post-operatively without sedating them. Two psychiatrists, Delay and Deneke, tried the drug in St Anne’s hospital in Paris in 1952 and were astounded by the results. By the tenth patient they knew they had a breakthrough. Over the next four years chlorpromazine became the front-line treatment in psychotic illnesses and the atmosphere in psychiatric wards was totally transformed.

  At its most immediate the drugs humanized the wards. Staff could begin to get to know their patients rather than just controlling them. Episodes of illness were both shorter and less disturbed so that rehabilitation and early discharge (before family relationships and jobs were lost for good) became realistic possibilities. Initially the drugs were used only for treating acute episodes but by the 1970s it was realized that staying on them reduced the risk of further breakdowns. This ‘maintenance therapy’ has become the cornerstone of long-term treatment of schizophrenia and other psychoses.

  Over the last 50 years a whole range of antipsychotics has been developed. Most are about equally effective but their side effects are very different. The original chlorpromazine-like drugs often made patients stiff and lethargic. Newer drugs avoid the stiffness but can cause weight gain and diabetes. Some of these drugs became available as long-acting injections which means the patient can forget about taking them as long as they get their injection every two to four weeks.

  The drug revolution was not restricted to antipsychotics. The first of the antidepressants (imipramine) was introduced in 1958. These had a longer lasting effect than ECT and were more acceptable to many more patients – by the early 1980s US physicians were writing 10 million antidepressant prescriptions a year. Lithium carbonate (a naturally occurring substance) was noted in 1949 to have a calming effect. It was introduced as a long-term ‘mood-stabilizing’ treatment for manic depressive disorder in 1968 and has substantially reduced the risk of further breakdowns.

  This is not the place to detail the developments in modern psychiatric drugs but just to note that the progress has been accelerating. We now have a wide range of drugs for most recognized disorders. However, these are not ‘magic bullets’. No drug will completely cure all patients with a specific disorder but, carefully chosen, drug treatments can make a real difference to the vast majority of patients with mental illnesses. The very success of these newer drugs poses risks for overuse and ethical dilemmas which will be picked up in Chapter 6.