Post-World War II psychiatry: 70 years of momentous change

A large percentage of psychiatrists practicing today are Boomers, and have experienced the tumultuous change in their profession since the end of World War II. At a recent Grand Rounds presentation in the Department of Neurology & Psychiatry at Saint Louis University, participants examined major changes and paradigm shifts that have reshaped psychiatry since 1946. The audience, which included me, contributed historical observations to the list of those changes and shifts, which I’ve classified here for your ben­efit, whether or not you are a Boomer.

Medical advances
Consider these discoveries and developments:
• Penicillin in 1947, which led to a reduction in cases of psychosis caused by tertiary syphilis, a disease that accounted for 10% to 15% of state hos­pital admissions.
• Lithium in 1948, the first pharma­ceutical treatment for mania.
• Chlorpromazine, the first anti­psychotic drug, in 1952, launching the psychopharmacology era and ending lifetime institutional sequestration as the only “treatment” for serious mental disorders.
• Monoamine oxidase inhibitors in 1959, from observations that iproniazid, a drug used in tuberculosis sanitariums, improved the mood of tuberculosis patients. This was the first pharmaco­therapy for depression, which had been treated with electroconvulsive therapy (ECT), developed in the 1930s.
• Tricyclic antidepressants, starting with imipramine in the late 1950s, dur­ing attempts to synthesize additional phenothiazine antipsychotics.
• Diazepam, introduced in 1963 for its anti-anxiety effects, became the most widely used drug in the world over the next 2 decades.
• Pre-frontal lobotomy to treat severe psychiatric disorders. The neurosurgeon-inventor of this so-called medical advance won the 1949 Nobel Prize for Medicine or Physiology. The procedure was rap­idly discredited after the development of antipsychotic drugs.
• Fluoxetine, the first selective sero­tonin reuptake inhibitor, in 1987, revo­lutionized the treatment of depression, especially in primary care settings.
• Clozapine, as an effective treat­ment for refractory and suicidal schizophrenia, and the spawning of second-generation antipsychotics. These newer agents shifted focus from neurologic adverse effects (extrapy­ramidal symptoms, tardive dyskinesia) to cardio-metabolic side effects (obesity, diabetes, dyslipidemia, and hypertension).

Changes to the landscape of health care
Three noteworthy developments made the list:
• The Community Mental Health Act of 1963, signed into law by President John F. Kennedy, revolu­tionized psychiatric care by shifting delivery of care from inpatient, hospital-based facilities to outpatient, clinic-based centers. There are now close to 800 community mental health centers in the United States, where care is dominated by non-physician mental health providers—in contrast to the era of state hospitals, during which phy­sicians and nurses provided care for mentally ill patients.
• Deinstitutionalization. This move-ment gathered momentum in the 1970s and 1980s, leading to clos­ing of the majority of state hospitals, with tragic consequences for the seri­ously mentally ill—including early demise, homelessness, substance abuse, and incarceration. In fact, the large percentage of mentally ill peo­ple in U.S. jails and prisons, instead of in a hospital, represents what has been labeled trans-institutionalization (see my March 2008 editorial, “Bring back the asylums?,” available at CurrentPsychiatry.com).
• Managed care, emerging in the late 1980s and early 1990s, caused a seismic disturbance in the delivery of, and reimbursement for, psychiat­ric care. The result was a significant decline in access to, and quality of, care—especially the so-called carve-out model that reduced payment for psychiatric care even more drastically than for general medical care. Under managed care, the priority became saving money, rather than saving lives. Average hospital stay for patients who had a psychiatric disorder, which was years in the pre-pharmacotherapy era, and weeks or months after that, shrunk to a few days under managed care.

Changes in professional direction
Two major shifts in the complexion of the specialty were identified:
• The decline of psychoanalysis, which had dominated psychiatry for decades (the 1940s through the 1970s), was a major shift in the conceptual­ization, training, and delivery of care in psychiatry. The rise of biological psychiatry and the medical model of psychiatric brain disorders, as well as the emergence of evidence-based (and briefer) psychotherapies (eg, cognitive-behavioral therapy, dialectical behav­ior therapy, and interpersonal therapy), gradually replaced the Freudian model of mental illness.

As a result, it became no longer nec­essary to be a certified psychoanalyst to be named chair of a department of psy­chiatry. The impact of this change on psychiatric training has been profound, because medical management by psy­chiatrists superseded psychotherapy— given the brief hospitalization that is required and the diminishing coverage for psychotherapy by insurers.

• Delegation of psychosocial treatments to non-psychiatrists. The unintended consequences of psychia­trists’ change of focus to 1) consulta­tion on medical/surgical patients and 2) the medical evaluation, diagnosis, and pharmacotherapy of mental dis­orders led to the so-called “dual treat­ment model” for the most seriously mentally ill patients: The physician provides medical management and non-physician mental health profes­sionals provide counseling, psychoso­cial therapy, and rehabilitation.