G lob al Mental Health

1. Global Mental Health A brief history Alex Cohen London School of Hygiene & Tropical Medicine

2. The term • 1982: First use of the term: • Are We for Mental Health as Well as Against Mental Illness? The Significance for Psychiatry of a Global Mental Health Coalition (Brody 1982) • Prior to 2001: • GMH used to denote overall level of stress in an individual • 2001: • Global Mental Health: Its Time Has Come(Satcher) • 2007: • The Lancet series • 2010: • A New Global Health Field Comes of Age(Patel & Prince) • 2014: • Why Mental Health Matters to Global Health(Patel)

3. Why Mental Health Matters to Global Health • Burden • 300 to 400 million people affected by psychosis, intellectual disability, dementia, drug and alcohol dependence, or severe depression • Great majority in low-income countries • Excess mortality • Life expectancies ≈20 years shorter • Worldwide, suicide a leading cause of death among young adults • Disability

4. Mental Health Matters… • Lack of treatment • In high income countries, up to 50% go without treatment • As high as 90% in low-income countries • Abuse • Often in the very institutions that are responsible for care. • Lack of global evidence • Lack of resources

5. Is Global the New Part? Concerns about mental disorders have been circulating the globe for thousands of years

6. Egyptian texts – 16th century BCE “He huddled up in his clothes and lay, not knowing where he was. His wife inserted her hand under his clothes and said ‘no fever in your chest, it is the sadness of the heart.’ Now death is to me like health to the sick, like the smell of a lotus, like the wish of a man to see his house after years of captivity.”

7. China • 12th to 4th centuries BCE: texts describing mental illness • Discussions of the legal status and responsibility of persons who were mentally ill • Yellow Emperor’s Classic of Internal Medicine • circa 1000 BCE • An imbalance of the life forces (Yin and Yang) may result in insanity

8. India • Caraka Samhita (circa 600 BCE) • A seminal work in Ayurvedic medicine • Two categories of insanity • Imbalances in three humours • wind, bile and phlegm • Possession by good or evil spirits • Treatments included: • Medication (e.g., herbs) • Physical therapies (e.g., massage & Yoga) • Magico-religious methods (e.g., talismans & prayer) • ‘Shock therapy’ (e.g., life-threatening acts) also employed in difficult cases

9. Ancient Greece • From the 5th Century BCE to the 5th Century CE, Greek (and Roman) physicians generally agreed that the brain was the organ in which mental functions were based • “Men ought to know that our pleasures, joys, laughter and jests arise from the brain alone, as do also pains, sorrows, sadnesses and tears.” – On the Sacred Disease, 400 BCE

10. Ancient Greece, continued. • Believed that humoural imbalances accounted for disease, in general, and mental illnesses, in particular • Blood, phlegm, and black and yellow bile • Could be disturbed by internal or external forces • Diet • Exercise • Climate • Religious pollution

11. Parallels • We do not know the extent to which the scholars and physicians of ancient China, India, and Greece communicated, but it is striking that their explanatory models were similarly based on the idea that imbalances in life forces were the causes of disease: • Yin and Yang of traditional Chinese medicine • Humoural theories of disease in Ayurvedic medicine • Hippocratic traditions of ancient Greece.

12. Parallels, continued • Similar explanatory models gave rise to the development of similar, physiologically-based treatments: • Traditional Chinese medicine • Herbal potions and acupuncture • Ayurveda • Massage and Yoga • Hippocratic tradition • Massage, baths, balanced diet, and exercise

13. The Rise of Institutional Care • From the time of the oldest written accounts of mental disorders (ca. 20th Century BCE) to the establishment of the first general hospitals by Islamic physicians in the 8th Century CE, care of persons with mental disorders was the responsibility of families • ‘Institutional’ care only took place when families brought ill members to temples, churches, or other places of religious or spiritual importance • In ancient Greece, people worshipped at the ‘grave sites of…mythological and mythohistorical figures’ in the belief that this would cure illnesses • St Dymphna • Islamic dargahs • Hindu temples • Christian religious healers

14. The Rise of Institutional Care, continued • Accounts from as early as the 3rd Century CE of the confinement of mentally ill people in Syrian Catholic Churches • But true institutional (i.e., hospital) care appeared somewhat later in the Islamic world of the Middle East and North Africa • The special provision for the insane [was] a remarkable aspect of the medieval Islamic medical tradition. (Dols 1987) • In contrast to the Christian custom of exorcism, Islamic physicians followed Greek medical teachings and focused on the physical causes of mental disorders and emphasized physiological treatments

15. The Rise of Institutional Care, continued • Disagreement about when and where the first institutional care for persons with mental disorders was established • By some accounts, the first asylums were established in the 8th Century in Fez and Bagdad • Other accounts claim that the earliest institutional care took place in Cairo in 872 CE • By the 13th Century, institutional care could be found from Damascus to Fez • Not clear whether treatment took place in institutions devoted exclusively to the care of persons with mental disorders, in divisions within general hospitals, or both

16. The Rise of Institutional Care, continued • Nevertheless, even with the establishment of hospitals, care remained the responsibility of families and took place at home • Hospital care was intended for poor families that could not afford maintaining an ill person at home

17. The Rise of Institutional Care, continued • General agreement that the Islamic hospitals were distinguished by ‘relaxed atmospheres’ • Fountains and gardens • Treatments that included baths, bloodletting, leeches, cupping, and a variety of drugs • Psychosocial interventions were also employed • Dancing, singing, theater • Careful attention to diet

18. The Rise of Institutional Care, continued • 16th Century account of a facility in Constantinople describes patients being beaten, chained, and displayed for ‘public amusement’ • The harsh conditions of the asylum should not be misconstrued…The chains and irons…were simply necessary devices to prevent harm to the insane or to others-- (Dols 1987) • Whether such practices were forms of abuse or benign protection remains an open question

19. A Rake’s Progress – Hogarth Sir John Soane’s Museum Lincoln’s Inn Fields, London

20. The Rise of Institutional Care, continued • Institutional practices entered Europe with the Moorish invasion of Spain in the 8th Century • Establishment of institutional care first recorded in the 14th Century in Granada • Similar Catholic institutions were founded beginning in the 15th Century

21. Parallel Developments • 1100: Metz, France • 1111: Milan, Italy • 1191: Ghent, Belgium • 1305: Uppsala, Sweden • 1326: Elbing, Germany • 1377: Charing Cross, London • 1400: Bethlem, London Stone House at Charing Cross contained, ‘distraught and lunatike people…but it was said, that sometime a King of England, not liking such a kind of people to remaine so neere his Palace, caused them to be removed…to Bethlem without Bishops gate…and to that Hospitall the said house of Charing Crosse doth yet remaine.’

22. Parallel Developments, continued • The extent to which the model for these hospitals was based on a tradition of Christian charity or was a product of Islamic practices in Spain – or some combination of both – remains to be determined • Central and South America: • Aztecs, Incas, Mayas • Little information • Evidence of trephination, use of hallucinogens • Sub-Saharan Africa: • No written records • Ethnographic evidence of biological and psychosocial interventions

23. Going Global • 1567: psychiatric hospital established in Mexico • First institution of its kind in the Western Hemisphere • First instance of colonial psychiatry • First global expansion of institutional mental health care

24. Europe • Institutional care in England can be traced to the 14th Century (and earlier). • Private institutions first developed in the 18th Century • Expansion of public asylums in England began in 1808 with the County Asylums Act • 1838: France established a state-run system of asylums • Between 1830 and 1850 religious orders in Belgium opened 18 asylums

25. Bethlem Hospital – 1828

26. Bethlem Hospital / Imperial War Museum

27. West Riding Pauper Lunatic Asylum One of a great number of establishments erected in various counties throughout England, for the reception and treatment of those unfortunate people who, drinking a two-fold portion of the cup of affliction, are suffering under both abject poverty and mental alienation. – Pliny Earle 1839

28. Europe, continuedSalpétrière, Paris

29. Europe, continued • Institutions were not founded in Scandinavia until the 18th Century • A ‘madhouse’ was established in Sweden and a Norwegian royal ordinance decreed that hospitals must set aside beds for the purpose of treating mentally ill persons

30. North America • 1773: First asylum opened in Virginia • Followed in the first half of the 19th Century with the establishment initially of private and then later, state-run psychiatric hospitals throughout the United States • In Canada, a hospital in Quebec may have started admitting mentally ill persons in 1714, but the establishment of psychiatric asylums in most provinces only took place after 1840

31. Maclean Hospital, Belmont, MA

32. State Lunatic Hospital at Northampton

33. Looking for an Alternative Flemish Village of Geel

34. GeelSaint Dymphna • Martyred in 600 AD • Veneration began as early as 8th Century • 11th or 12th Century: shrine famous for miraculous cures of various health conditions • Canonized in mid-13th Century • Guest house built for pilgrims: 1286 AD • About same time as Bethlem Hospital

35. Geel, continued • Church of St. Dymphna: 1349 • Sick room built: 1480 • End of 15th Century: patients boarded out with families close to Church • 17th Century: boarding system expanded to other districts of Geel • 1797: France closes Church temporarily • boarding out system becomes secular • 200 boarders in 1800

36. Geel, continued • 1803: • Brussels transfers its patients • Antwerp and other communities do the same • Cities and central government appoint inspectors to monitor care • But attempts to address abuses are repeatedly blocked by the town government

37. Geel, continued • Remoteness: • …considered beyond the pale of civilization, and but little known even by residents of adjacent provinces • No trains until the 1830's • Equivalent of a leper colony? • 1850-52: ‘Foster care’ in Geel comes under the regulation of the central government of Belgium • Jules Parigot appointed as first medical superintendent of Rijkskolonie (State Colony) of Geel • He becomes one of the most passionate and vocal advocates of l'airlibre, the free air system of care

38. The Great Debate • 1850s & 1860: Debate on merits of Geel • Prompted by concerns about increasing need for services and concerns about increasing costs • Those who saw abuses • Those who saw an alternative • Future of the asylum decided in 1860s & 70s • France, Great Britain, United States • Cottage System loses • Possibility of community care did not re-emerge, for all practical purposes, until the 1950s. • Continued expansion of large asylums

39. Colonial Psychiatry • With Colonialism came the spread of Western psychiatry and the establishment of mental asylums across much of the globe • For example, beginning toward the end of the 18th Century and continuing until the early 20th Century, British authorities established asylums in India, Singapore, South Africa, and Nigeria • Colonial psychiatry meant that the essential feature of the mental health systems of Europe – the large, custodial asylum – became the dominant feature of the mental health systems in the colonies

40. Mental Hospital, Angoda, Sri Lanka

41. St Ann’s Hospital, Trinidad

42. Colonial Psychiatry • The end of colonialism, in the late 1950’s and early 1960’s, took place at the same time that community-based mental health systems were being developed in Western Europe and North America. • This alternative did not have an opportunity to become established in the former colonies. • Thus, the legacy of mental asylums continues to dominate many mental health systems in low-income countries. • Exception: development of community psychiatry beginning in the late 1940’s in Madras, India

43. Deinstitutionalization • The paramount place of institutional care for persons with mental disorders, a practice that had begun more than a 1,000 years before, effectively came to an end, at least in many of the industrialized nations of the West, in the 1950’s. • Impetus came about as the result of several factors: • Increased belief in the efficacy of community care • Attention to civil and human rights of people with mental disorders • Abuses in many psychiatric facilities • Growing awareness of the negative effects of long-term institutionalization • Expense of institutional care • Discovery (1954) of chlorpromazine, the first effective anti-psychotic medication • Effects of deinstitutionalization and varying consequences according to diagnosis

44. Deinstitutionalization, continued • Deinstitutionalization has resulted in a steep decline in the number of psychiatric inpatient beds and the closing or downsizing of psychiatric facilities in many Western industrialized countries, as well as several countries of South America. • In contrast, the number of hospital beds has continued to increase in Japan and South Korea. • Institutional care remains dominant in many LMICs.

45. Mixed results • Patients discharged without planning or sufficient resources to live in the community. • Transinstitutionalization • Forensic hospitals • Prisons • Adults homes • Homelessness • The neglect and abuses that characterized institutional care of the past have been replaced by neglect and abuse in the community

46. Skid Row, Los Angeles

47. Community-based Mental Health Services • As effective, if not more so, than hospital-based services • Though not necessarily less expensive • In keeping with principle of least restrictive care • Least effect on personal freedom, status and privileges in the community • Citizenship

48. Foundations of Global Mental Health • Comparative psychiatry • Emil Kraepelin’s visit to Java in 1904 • Is psychopathology: • the product of universal biological / psychological processes? • Or ultimately shaped by culture? Buitenzorg Hospital, Java

49. Cross-Cultural Epidemiology

50. International Pilot Study of Schizophrenia (IPSS) • 9 countries • Late 1960s • Possible to a conduct a valid and reliable cross-cultural studies of schizophrenia • Suggested that the prognosis for schizophrenia was better in ‘developed’ vs. ‘developing’ settings