Introduction to Psychiatric Nursing SM Raju
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Evolution and History of Mental Illness and Mental Health Care1

Social change brings in structural and cultural evolution of society that varies between constant and at times erratic. The driving forces behind social change are economic and productivity factors. At times the social change could be the by-product of revolutionary ideas—political, religious, philosophical, or scientific, or social change could even be a combination of all of these.
Throughout history, mental disorders are believed to have caused by interplay of biologic, spiritual, and environmental factors that include social changes.
 
 
Pre-moral Treatment
During ancient times (up to 800 BC) mental sickness was thought to be an indication of displeasure of the Gods, a form of punishment inflicted by demonic or divine for sins and wrongdoings.
Greek and Roman (800 BC-1 AD)
During this period (460–357 BC) Hippocrates related mental illnesses to disturbances in the brain and physiology.
Aristotle (382–322 BC) later proposed the theory of four humors that corresponded to excesses or imbalances in main temperaments.
  1. Sanguine—Cheerful, hopeful2
  2. Phlegmatic—Passive, lethargic, calm
  3. Choleric—Angry, irritable
  4. Melancholic—Sad, depressed
The treatment included purging, starving, and bloodletting.
Early Christian Periods (1 to 1000 AD)
During which the power of Christian church grew, when St. Augustine pronounced that all diseases are ascribed to demons. That was the return to primitive beliefs and superstitions, when mental illness generated fear, ignorance, and cruelty. The mentally ill were incarcerated in dungeons, beaten and starved.
Medieval Period (1000 to 1300 AD)
The establishment of Feudal system in England offered economic stability—more tolerance for those in rural communities, and the Spirit of inquiry died. Mentally ill persons were incarcerated in dungeons, beaten and starved. This is also the period when the first Asylum was build by Moslems and the mentally ill people were treated as sick.
Renaissance (1300 to 1600 AD)
The term “Lunatics” (from full moon) came into use to describe the mentally ill.
In England insane were considered different from criminal.
Mild form of lunatics were housed in institutions and hospitals, whereas the violent lunatics were chained and imprisoned.
In Bethlehem Asylum wealthy lunatics were hospitalized.
Mental patients (1403) who were allowed to beg for charity were called Bedlam beggars (Bedlam means madness and chaos).3
Colonies – Mental illness caused by demonic possession and witch hunts.
The Colonial Period (1700 to 1790 AD)
In the year 1751, Ben Franklin established a hospital at Pennsylvania, which was the first institution to receive those with mental disease for treatment and cure.
In 1773, the first public freestanding asylum at Williamsburg, Virginia was established.
In 1783, Benjamin Rush categorized mental illnesses and began to treat mental disorders with medical interventions. That was the beginning of mental diseases being viewed as illness to be treated.
 
Moral Treatment Era (1790–1900 AD)
Period of changing ideas, about mental illness and mounting political pressure, for increased economic resources.
Moral treatment advocates kindness, compassion, and a pleasant environment for mentally ill.
In 1792, Philippe Pinel removed chains, and stopped abuses.
In 1796, William Tuke and Friends raised funds for New York Retreat.
In 1821, Thomas Eddy and Quaker elimination of corporal punishment, chains, and cruel treatment.
In 1840, Dorothea Dix crusaded for human treatment of mentally ill. Helped to establish state hospital for mentally ill in United States and Canada.
In 1873, Linda Richards graduated from NE Hospital for Women and Children.
In 1882, she organized training school at McLean Hospital for Mentally Ill. That was the beginning of Psychiatric Nursing.
In 1890, Adolph Meyer proposed psychobiological approach.4
 
Institutionalization of Public Responsibility (1900–1955 AD)
In early 1900s, Sigmund Freud put forth Psychoanalytic.
Theories: During the same period Emil Kraepelin started correlating symptoms vs causes.
1920s described as the period of Great Depression with increase in number of mentally ill. World War II (1940–1945), established legitimacy of treated mental disorders as an illness that could happen to anyone.
In 1946, National Mental Health Act was passed. Research and speciality training required to establish clinics and treatment centers, which established the National Institute of Mental Health (NIMH).
 
Period of Deinstitutionalization and Community Mental Health Movement (1955 to 1990 AD)
Thorazine (antipsychotic drug) was introduced in 1955.
In USA, in 1963, mental retardation facilities and community mental health centers' construction Act (MRCMH) was signed by Kennedy to develop community mental health centers, which provided—Inpatient services, outpatient services, partial hospitalization services, 24 hours emergency services, and consultation and educational services for community agencies and professional personnel.
In 1975, MRCMH Act was amended to expand services such as—Follow-up care, transitional services, services for children and adolescents, services for the elderly, screening services, alcohol abuse services, and drug abuse services.
In 1980, Community Mental Health Systems Act was passed. Act focused on coordinating services
In 1980, Descriptive Taxonomy vs Neurosis or Psychosis was published.5
 
Decade of the Brain
Cost-effective mental health care becomes a priority.
Managed behavioral health becomes health care delivery model.
In 1990, Healthy People 2000.
Discovery of new neurotransmitter receptors.
Development of new antipsychotic antidepressant medications.
Evolution of scientific thought and practice.
Theoretical arguments consistent with thinking of the times were proposed.
Psychosocial theory proposed that mental disorders resulted from environmental and social deprivation. Moral management was the answer but was not enough.
Biologic theory proposed that mental illnesses had a biologic cause and could be treated with physical interventions, but was not developed.
Psychiatric pluralism theory by Adolph Meyer—Integration of human biologic functions with environment.
Psychoanalytic theory developed a personality theory, based on unconscious motivations for behavior or drives. As gained in popularity, ideas of the mind-body relationship were lost.
Primary causes of mental illnesses are now viewed as psychological and any physical manifestations or social influences are considered secondary.
  • Biological treatments
  • Psychosurgery
  • Insulin coma6
  • Electroconvulsive therapy
  • Psychopharmacology
  • Primary causes of mental illness are now viewed as biological
  • Environmental stressors may trigger pre-existing condition
  • Genetic markers are being investigated.
We have gone full circle from Greek times.
 
COMMUNITY MENTAL HEALTH SYSTEM
 
Epidemiology of Mental Disorders
It includes the study of disease pattern and distribution in time and space.
Focuses on health status of population groups or aggregates rather than individuals.
Studies are descriptive, analytic, or experimental.
 
Risk Factors
  • Genetic
  • Biologic
  • Environmental
  • Cultural
  • Occupational
  • Some risk factors can be changed others cannot
 
Terms to know in Community Mental Health
  • Rate
  • Prevalence
  • Incidence
  • Prevention
  • Decision analysis approach