History of psychiatric institutions

The story of the rise of the lunatic asylum and its gradual transformation into, and eventual replacement by, the modern psychiatric hospital, is also the story of the rise of organized, institutional psychiatry. While there were earlier institutions that housed the 'insane,' the arrival at the answer of institutionalisation as the correct solution to the problem of madness was very much an event of the nineteenth century. To illustrate this with one regional example, in England at the beginning of the nineteenth century there were, perhaps, a few thousand "lunatics" housed in a variety of disparate institutions but by 1900 that figure had grown to about 100,000. That this growth should coincide with the growth of alienism, now known as psychiatry, as a medical specialism is not coincidental.

Medieval era
In the Islamic world, the Bimaristans were described by European travelers, who wrote on their wonder at the care and kindness shown to lunatics. In 872, Ahmad ibn Tulun built a hospital in Cairo that provided care to the insane. Nonetheless, medical historian Roy Porter cautions against idealising the role of hospitals generally in medieval Islam stating that "They were a drop in the ocean for the vast population that they had to serve, and their true function lay in highlighting ideals of compassion and bringing together the activities of the medical profession."

In Europe during the medieval era, a variety of settings were employed to house the small subsection of the population of the mad who were housed in institutional settings. Porter gives examples of such locales where some of the insane were cared for, such as in monasteries. A few towns had towers where madmen were kept (called Narrentürme in German, or "fools' towers"). The ancient Parisian hospital Hôtel-Dieu also had a small number of cells set aside for lunatics, whilst the town of Elbing boasted a madhouse, Tollhaus, attached to the Teutonic Knights' hospital.

Other such institutions for the insane were established after the Christian Reconquista, including hospitals in Valencia (1407), Zaragoza (1425), Seville (1436), Barcelona (1481), and Toledo (1483). The Priory of Saint Mary of Bethlehem, which later became known more notoriously as Bedlam, was founded in 1247. At the start of the fifteenth century it housed just six insane men. The former lunatic asylum Het Dolhuys from the 16th century in Haarlem, the Netherlands is now a museum of psychiatry with an overview of treatments from the origins of the building up to the 1990s.

17th century
In France, the governments under Ancien Régime,  created the Hôpital général de Paris, that the beginning of "le Grand Renfermement".

Domestic care
In England at the beginning of the eighteenth-century the level of specialist institutional provision for the care and control of the insane was extremely limited. Rather, madness was still seen principally as a domestic problem, with families and parish authorities central to regimens of care. Various forms of outdoor relief were extended by the parish authorities to families in these circumstances including financial support, the provision of parish nurses and, where family care was not possible, lunatics might be 'boarded out' to other members of the local community or committed to private madhouses. Exceptionally, if those deemed mad were judged to be particularly disturbing or violent, parish authorities might meet the not inconsiderable costs of their confinement in charitable asylums such as Bethlem, in Houses of Correction or in workhouses.

Public asylums
At the start of the eighteenth century London's historical Bethlem, which had been reopened in new buildings at Moorfields in 1676 with a capacity for 100 inmates, was the only public asylum then operating in England. A second public charitable institution was opened in 1713, the Bethel in Norwich. It was a small facility which generally housed between twenty and thirty inmates. In 1728 at Guy's Hospital, London, wards were established for chronic lunatics. From the mid-eighteenth century the number of public charitably funded asylums expanded moderately with the opening of St Luke's Hospital in 1751 in Upper Moorfields, London, the establishment in 1765 of the Hospital for Lunatics at Newcastle upon Tyne, the Manchester Lunatic Hospital, which opened in 1766, the York Asylum in 1777 (not to be confused with the York Retreat), the Leicester Lunatic Asylum (1794), and the Liverpool Lunatic Asylum (1797).

The trade in lunacy
Due, perhaps, to the absence of a centralised state response to the social problem of madness until the nineteenth-century, private madhouses proliferated in eighteenth-century England on a scale unseen elsewhere. References to such institutions are limited for the seventeenth-century but it is evident that by the start of the eighteenth-century the so-called 'trade in lunacy' was well established. Daniel Defoe, an ardent critic of private madhouses, estimated in 1724 that there were fifteen then operating in the London area. Defoe may have exaggerated but exact figures for private metropolitan madhouses are only available from 1774 when licensing legislation was introduced and sixteen institutions were recorded. At least two of these, Hoxton House and Wood's Close, Clerkenwell, had been in operation since the seventeenth-century. By 1807, the number had only increased to seventeen. It is conjectured that this limited growth in the number of London madhouses is likely to reflect the fact that vested interests, especially the College of Physicians, exercised considerable control in preventing new entrants to the market. Thus, rather than a proliferation of private madhouses in London, existing institutions tended to expand considerably in size. The establishments which increased most during the eighteenth-century, such as Hoxton House, did so by accepting pauper patients rather than private, middle-class, fee-paying patients. Significantly, pauper patients, unlike their private counterparts, were not subject to inspection under the 1774 legislation.

Fragmentary evidence indicates that some provincial madhouses were in existence in England from at least the seventeenth-century and possibly earlier. A madhouse at Box, Wiltshire was opened during the seventeenth-century. Further locales of early businesses include one at Guildford in Surrey which was accepting patients by 1700, one at Fonthill Gifford in Wiltshire from 1718, another at Hook Norton in Oxfordshire from about 1725, one at St Albans dating from around 1740 and a madhouse at Fishponds in Bristol from 1766. It is likely that many of these provincial madhouses, as was the case with the exclusive Ticehurst House, may have evolved from householders who were boarding lunatics on behalf of parochial authorities and later formalised this practice into a business venture. The vast majority were small in scale with only seven asylums outside of London with in excess of thirty patients by 1800 and somewhere between ten and twenty institutions had fewer patients than this.

United States
In the United States, the Pennsylvania Hospital was founded in 1751 as a result of work begun in 1709 by the Religious Society of Friends. A portion of this hospital was set apart for the mentally ill, and the first patients were admitted in 1752. Virginia is recognized as the first state to establish an institution for the mentally ill. Eastern State Hospital, located in Williamsburg, was incorporated in 1768 under the name of the “Public Hospital for Persons of Insane and Disordered Minds” and its first patients were admitted in 1773. Along with the first institution in America, Virginia also founded the first Colored Asylum in 1870. Their land was given to them by the House of Burgesses in 1769.

Moral treatment
Phillipe Pinel (1793) is often credited as being the first in Europe to introduce more humane methods into the treatment of the mentally ill (which came to be known as moral treatment) as the superintendent of the Bicêtre Hospital in Paris. Pinel credited his friend Jean-Baptiste Pussin, the Bicêtre's unschooled manager, for removing patient shackles (though he occasionally used straightjackets). Both spread reforms such as categorising disorders, as well as methods of cure based on observing and talking to patients. Samuel Hahnemann, a fellow medical translator now considered the founder of homeopathic medicine, also lived in Paris at the time and advocated humane treatment of the insane.

Benjamin Rush of Philadelphia also promoted humane treatment of the insane outside dungeons and without iron restraints, as well as sought their reintegration into society. In 1792 Rush successfully campaigned for a separate ward for the insane at the Pennsylvania Hospital. His talk-based approach led to modern occupational therapy and addiction medicine, although most of his physical approaches have long been discredited, such as bleeding and purging (unlike Pinel), hot and cold baths, mercury pills, a "tranquilizing chair" and gyroscope. In Italy, Vincenzo Chiarugi may also have banned chains before this time. Johann Jakob Guggenbühl in 1840 started in Interlaken the first retreat for mentally disabled children.

Around the same time as Pussin and Pinel, British Quakers, particularly William Tuke, pioneered an enlightened approach (moral treatment) at the York Retreat which opened in 1796. The Retreat was not a psychiatric hospital, and in fact abandoned medical approaches of the day in favor of understanding, hope, moral responsibility and occupational therapy. The Brattleboro Retreat and the former Hartford Retreat were named after it.

United States
In 1806 an authorization to a hospital in New York City was granted to erect additions and provide suitable apartments adapted to the various forms and degrees of mental illness. Other important dates in the early part of the 19th century were: the opening of an institution for the care of the mentally ill at Frankfort, Pennsylvania, by the Society of Friends in 1817, the founding of the Hartford Retreat, in Hartford, Connecticut, in 1824, the opening of the South Carolina State Hospital for the Insane in 1824, of the Eastern State Hospital at Lexington, Kentucky, in 1824, of the Western State Hospital at Staunton, Virginia, in 1828, of one of the buildings of the Blockley Almshouse for the dependent insane in Philadelphia from 1830 to 1834, the Maryland Hospital for the Insane in 1832, and the New Hampshire State Hospital for the Insane at Concord in 1842.

From this period on, the erection of state hospitals went rapidly forward in the different states. The first law for the creation of a state hospital in New York was passed in 1842. The Utica State Hospital was opened approximately in 1850. The creation of this hospital, as of many others, was largely the work of Dorothea Lynde Dix, whose philanthropic efforts extended over many states, and in Europe as far as Constantinople. It was through her efforts that institutions were erected in Massachusetts, Pennsylvania, New Jersey, Rhode Island, North Carolina and the District of Columbia. According to her biographers, some 30 institutions in the United States owe their existence, in whole or in part, to her efforts.

Trends
Reformers such as Dix began to advocate a more humane and progressive attitude towards the mentally ill. Some were motivated by a Christian duty to mentally ill citizens. In the United States, for example, the numerous state mental health systems established were paid for by taxpayer money, and often money from the relatives of those institutionalized inside them. These centralized institutions were often linked with loose governmental bodies, though oversight and quality consequently varied. They were generally geographically isolated as well, located away from urban areas because the land was cheap and there was less political opposition.

Many state hospitals in the United States were built in the 1850s and 1860s on the Kirkbride Plan, an architectural style meant to have curative effect. States made large outlays on architecture that often resembled the palaces of Europe, although operating funding for ongoing programs was more scarce. Many patients objected to transfers from private hospitals to state facilities. Some Brattleboro Retreat patients tried to hide when state officials arrived to transfer them to the new Waterbury State Hospital. This decline in patient census led to the collapse of many private institutions, which still accepted indigent patients even when state reimbursement for private hospitals dropped in the face of rising state hospital costs.

In the 1800s middle-class facilities became more common, replacing private care for wealthier persons. However, facilities in this period were largely oversubscribed. Individuals were referred to facilities either by the community or by the criminal justice system. Dangerous or violent cases were usually given precedence for admission. A survey taken in 1891 in Cape Town, South Africa shows the distribution between different facilities. Out of 2046 persons surveryed, 1,281 were in private dwellings, 120 in jails, and 645 in asylua, with men representing nearly two thirds of the number surveyed. In situations of scarcity of accommodation, preference was given to white men and black men (who's insanity threatened white society by disrupting employment relations and the tabooed sexual contact with white women).

Defining someone as insane was a necessary prerequisite for being admitted to a facility. A doctor was only called after someone was labelled insane on social terms and had become socially or economically problematic. Until the 1890s, little distinction existed between the lunatic and criminal lunatic. The term was often used to police vagrancy as well as paupers and the insane. In the 1858–59, the Lunacy Panic occurred in Victorian England that medical doctors were declaring people "insane" that were actually sane. These people were perhaps awkward or embarrassing to families, thus meriting convenient disposal into asylums. This sensationalism was pronounced in novels such as The Woman in White.

Non-restraint movement
In Lincoln (Lincolnshire, England) Robert Gardiner Hill, with the support of Edward Parker Charlesworth, developed a mode of treatment that suited 'all types' of patients, whereby the reliance on mechanical restraints and coercion could be made obsolete altogether – a situation he finally achieved in 1838. By the following year of 1839 Sergeant John Adams and Dr. John Conolly were so impressed by the work of Hill, that they immediately introduced the method into their Hanwell Asylum, which was by then the largest in the kingdom. The greater size required Hill's system to be developed and refined. This was necessary as it was beyond Conolly to be able to supervise each attendant as closely as Hill had done. By September 1839, mechanical restraint was no longer required for any patient.

Radical politics
In February 1919, the first soviet in the British Isles was established at Monaghan Lunatic Asylum, in Monaghan, Ireland. This led to the claim by Joseph Devlin in the House of Commons that "that the only successfully conducted institutions in Ireland are the lunatic asylums"

Physical therapies
A series of radical physical therapies were developed in central and continental Europe in the late 1910s, the 1920s and, most particularly, the 1930s. Among these we may note the Austrian psychiatrist Julius Wagner-Jauregg's malarial therapy for general paresis of the insane (or neurosyphilis) first used in 1917, and for which he won a Nobel Prize in 1927. This treatment heralded the beginning of a radical and experimental era in psychiatric medicine that increasingly broke with an asylum based culture of therapeutic nihilism in the treatment of chronic psychiatric disorders, most particularly dementia praecox (increasingly known as schizophrenia from the 1910s, although the two terms were used more or less interchangeably until at least the end of the 1930s), which were typically regarded as hereditary degenerative disorders and therefore unamenable to any therapeutic intervention. Malarial therapy was followed in 1920 by barbiturate induced deep sleep therapy to treat dementia praecox, which was popularized by the Swiss psychiatrist Jakob Klaesi. In 1933 the Viennese based psychiatrist Manfred Sakel introduced insulin shock therapy and in August 1934 Ladislas J. Meduna, a Hungarian neuropathologist and psychiatrist working in Budapest, introduced cardiazol shock therapy (cardiazol is the tradename of the chemical compound pentylenetetrazol, known by the tradename metrazol in the United States), which was the first convulsive or seizure therapy for a psychiatric disorder. Again, both of these therapies were initially targeted at curing dementia praecox. Cardiazol shock therapy, founded on the theoretical notion that there existed a biological antagonism between schizophrenia and epilepsy and that therefore inducing epiletiform fits in schizophrenic patients might effect a cure, was superseded by electroconvulsive therapy (ECT), invented by the Italian neurologist Ugo Cerletti in 1938. In 1935 the Portuguese neurologist Egas Moniz devised the leucotomy, a surgical procedure targeting the brain's frontal lobes. This was shortly thereafter adapted by Walter Freeman and James W. Watts in what is known as Freeman-Watts procedure or the standard prefrontal lobotomy. From 1946, Freeman developed the transorbital lobotomy, using a device akin to an ice-pick. This was an "office" procedure which did not have to be performed in a surgical theatre and took as little as fifteen minutes to complete. Freeman is credited with the popularisation of the technique in the United States. In 1949, 5074 lobotomies were carried out in the United States and by 1951, 18,608 people had undergone the controversial procedure in that country.

In modern times, insulin shock therapy and lobotomies are viewed as being almost as barbaric as the Bedlam "treatments", although the insulin shock therapy was still seen as the only option which produced any noticeable effect on patients. ECT is still used in the West, but it is seen as a last resort for treatment of mood disorders, and is administered much more safely than in the past. Elsewhere, particularly in India, use of ECT is reportedly increasing, as a cost-effective alternative to drug treatment. The effect of a shock on an overly excitable patient often allowed these patients to be discharged to their homes, which was seen by administrators (and often guardians) as a preferable solution to institutionalization. Lobotomies were performed in the hundreds from the 1930s to the 1950s, and were ultimately replaced with modern psychotropic drugs.

Compulsory sterilization of the "feeble-minded"
The eugenics movement of the early 20th century led to a number of countries enacting laws for the compulsory sterilization of the "feeble minded", which resulted in the forced sterilization of numerous psychiatric inmates. As late as the 1950s, laws in Japan allowed the forcible sterilization of patients with psychiatric illnesses.

Germany and occupied Europe: Nazi euthanasia program
Under Nazi Germany, the Aktion T4 euthanasia program resulted in the killings of thousands of the mentally ill housed in state institutions. In 1939, the Nazis secretly began to exterminate the mentally ill in a euthanasia campaign. Around 6,000 disabled babies, children and teenagers were murdered by starvation or lethal injection.

Drugs
The twentieth century saw the development of the first effective psychiatric drugs.

The first antipsychotic drug, chlorpromazine (known under the trade name Largactil in Europe and Thorazine in the United States), was first synthesised in France in 1950. Pierre Deniker, a psychiatrist of the Saint-Anne Psychiatric Centre in Paris, is credited with first recognising the specificity of action of the drug in psychosis in 1952. Deniker travelled with a colleague to the United States and Canada promoting the drug at medical conferences in 1954. The first publication regarding its use in North America was made in the same year by the Canadian psychiatrist Heinz Lehmann, who was based in Montreal. Also in 1954 another antipsychotic, reserpine, was first used by an American psychiatrist based in New York, Nathan S. Kline. At a Paris based colloquium on neuroleptics (antipsychotics) in 1955 a series of psychiatric studies were presented by, among others, Hans Hoff (Vienna), Aksel (Istanbul), Felix Labarth (Basle), Linford Rees (London), Sarro (Barcelona), Manfred Bleuler (Zurich), William Mayer-Gross (Birmingham), Winford (Washington) and Denber (New York) attesting to the effective and concordant action of the new drugs in the treatment of psychosis.

The new antipsychotics had an immense impact on the lives of psychiatrists and patients. For instance, Henry Ey, a French psychiatrist at Bonneval, related that between 1921 and 1937 only 6 per cent of patients suffering from schizophrenia and chronic delirium were discharged from his institution. The comparable figure for the period from 1955 to 1967, after the introduction of chlorpromazine, was 67 per cent. Between 1955 and 1968 the residential psychiatric population in the United States dropped by 30 per cent. Newly developed antidepressants were used to treat cases of depression, and the introduction of muscle relaxants allowed ECT to be used in a modified form for the treatment of severe depression and a few other disorders.

The discovery of the mood stabilizing effect of lithium carbonate by John Cade in 1948 would eventually revolutionize the treatment of bipolar disorder, although its use was banned in the United States until the 1970s.

The use of psychosurgery was narrowed to a very small number of people for specific indications. New treatments led to reductions in the number of patients in mental hospitals.

United States: Reform in the 1940s
From 1942 to 1947, conscientious objectors in the US assigned to psychiatric hospitals under Civilian Public Service exposed abuses throughout the psychiatric care system and were instrumental in reforms of the 1940s and 1950s. The CPS reformers were especially active at the Philadelphia State Hospital where four Quakers initiated The Attendant magazine as a way to communicate ideas and promote reform. This periodical later became The Psychiatric Aide, a professional journal for mental health workers. On 6 May 1946, Life magazine printed an exposé of the psychiatric system by Albert Q. Maisel based on the reports of COs. Another effort of CPS, namely the Mental Hygiene Project, became the National Mental Health Foundation. Initially skeptical about the value of Civilian Public Service, Eleanor Roosevelt, impressed by the changes introduced by COs in the mental health system, became a sponsor of the National Mental Health Foundation and actively inspired other prominent citizens including Owen J. Roberts, Pearl Buck and Harry Emerson Fosdick to join her in advancing the organization's objectives of reform and humane treatment of patients.

Psychiatric internment as a political device
Psychiatrists around the world have been involved in the suppression of individual rights by states wherein the definitions of mental disease had been expanded to include political disobedience. Nowadays, in many countries, political prisoners are sometimes confined to mental institutions and abused therein. Psychiatry possesses a built-in capacity for abuse which is greater than in other areas of medicine. The diagnosis of mental disease can serve as proxy for the designation of social dissidents, allowing the state to hold persons against their will and to insist upon therapies that work in favour of ideological conformity and in the broader interests of society. In a monolithic state, psychiatry can be used to bypass standard legal procedures for establishing guilt or innocence and allow political incarceration without the ordinary odium attaching to such political trials. In Nazi Germany in the 1940s, the 'duty to care' was violated on an enormous scale: A reported 300,000 individuals were sterilized and 100,000 killed in Germany alone, as were many thousands further afield, mainly in eastern Europe. From the 1960s up to 1986, political abuse of psychiatry was reported to be systematic in the Soviet Union, and to surface on occasion in other Eastern European countries such as Romania, Hungary, Czechoslovakia, and Yugoslavia. A "mental health genocide" reminiscent of the Nazi aberrations has been located in the history of South African oppression during the apartheid era. A continued misappropriation of the discipline was subsequently attributed to the People's Republic of China.

Deinstitutionalization
By the beginning of the 20th century, ever-increasing admissions had resulted in serious overcrowding. Funding was often cut, especially during periods of economic decline, and during wartime in particular many patients starved to death. Asylums became notorious for poor living conditions, lack of hygiene, overcrowding, and ill-treatment and abuse of patients.

The first community-based alternatives were suggested and tentatively implemented in the 1920s and 1930s, although asylum numbers continued to increase up to the 1950s. The movement for deinstitutionalization came to the fore in various countries in the 1950s and 1960s.

The prevailing public arguments, time of onset, and pace of reforms varied by country. Class action lawsuits in the United States, and the scrutiny of institutions through disability activism and antipsychiatry, helped expose the poor conditions and treatment. Sociologists and others argued that such institutions maintained or created dependency, passivity, exclusion and disability, causing people to be institutionalized.

There was an argument that community services would be cheaper. It was suggested that new psychiatric medications made it more feasible to release people into the community.

There were differing views on deinstitutionalization, however, in groups such as mental health professionals, public officials, families, advocacy groups, public citizens, and unions.

Asia
In Japan, the number of hospital beds has risen steadily over the last few decades.

In Hong Kong, a number of residential care services such as half-way houses, long-stay care homes, and supported hostels are provided for the discharged patients. In addition, a number of community support services such as Community Rehabilitation Day Services, Community Mental Health Link, Community Mental Health Care, etc. have been launched to facilitate the re-integration of patients into the community.

New Zealand
New Zealand established a reconciliation initiative in 2005 in the context of ongoing compensation payouts to ex-patients of state-run mental institutions in the 1970s to 1990s. The forum heard of poor reasons for admissions; unsanitary and overcrowded conditions; lack of communication to patients and family members; physical violence and sexual misconduct and abuse; inadequate complaints mechanisms; pressures and difficulties for staff, within an authoritarian psychiatric hierarchy based on containment; fear and humiliation in the misuse of seclusion; over-use and abuse of ECT, psychiatric medication and other treatments/punishments, including group therapy, with continued adverse effects; lack of support on discharge; interrupted lives and lost potential; and continued stigma, prejudice and emotional distress and trauma.

There were some references to instances of helpful aspects or kindnesses despite the system. Participants were offered counseling to help them deal with their experiences, and advice on their rights, including access to records and legal redress.

Africa

 * Uganda has one psychiatric hospital.
 * South Africa has several psychiatric hospitals. These hospitals are spread throughout the country. Some of the most well-known institutions are: Weskoppies Psychiatric Hospital, colloquially known as Groendakkies ("Little Green Roofs") and Denmar Psychiatric Hospital in Pretoria, TARA  in Johannesburg, and Valkenberg Hospital in Cape Town.

Europe
Countries where deinstitutionalization has happened may be experiencing a process of "re-institutionalization" or relocation to different institutions, as evidenced by increases in the number of supported housing facilities, forensic psychiatric beds and rising numbers in the prison population.

Some developing European countries still rely on asylums.

United States
The United States has experienced two waves of deinstitutionalization. Wave one began in the 1950s and targeted people with mental illness. The second wave began roughly fifteen years after and focused on individuals who had been diagnosed with a developmental disability (e.g. mentally impaired). Although these waves began over fifty years ago, deinstitutionalization continues today; however, these waves are growing smaller as fewer people are sent to institutions.

A process of indirect cost-shifting may have led to a form of "re-institutionalization" through the increased use of jail detention for those with mental disorders deemed unmanageable and noncompliant. In Summer 2009, author and columnist Heather Mac Donald stated in City Journal, "jails have become society’s primary mental institutions, though few have the funding or expertise to carry out that role properly... at Rikers, 28 percent of the inmates require mental health services, a number that rises each year."

South America
In several South American countries, the total number of beds in asylum-type institutions has decreased, replaced by psychiatric inpatient units in general hospitals and other local settings.