A brief history of mental health

Mara: Hello everyone! Welcome, or welcome back, to the Mental Health for Romania podcast! I’m Mara, a volunteer with Mental Health for Romania, and today, together with Andrada, my colleague, we’ll be talking about mental health — but not in the way you’re used to hearing from us.

Andrada: We thought it would be interesting to discuss mental health from a historical perspective — to trace the evolution of the concept of mental illness over time, the way it was approached, and how we arrived at modern treatments. We think it’s important to see where we started, where we are now, and how we made this journey, which was by no means a simple one. If we think mental health is a taboo subject now, things were far more extreme in the past. People with mental health conditions used to be marginalised and considered responsible for their condition.

Mara: Indeed, those people were treated as outcasts from society — they were excluded from their communities and isolated. In fact, the concept of mental illness emerged later. For much of history, mental health problems were considered congenital and incurable, personality disorders caused by an internal imbalance or by demonic spirits.

Andrada: Yes, in many ancient cultures, mental disorders were believed to have supernatural origins. For example, people believed that those suffering from a mental illness had violated the will of the gods and were therefore being punished. There were, of course, other explanations for the origins of ideas about mental illness, and in general, they depended on the culture we’re discussing. In ancient China, for example, Confucius and other philosophers believed that these conditions were caused by an excess of feelings and emotions, particularly in the case of mania. But where does the idea that mental illnesses are the result of divine anger originate?

Mara: Well, it all began in Ancient Greece, a hub of scientific thought that has left its mark to this day. Greek physicians rejected supernatural explanations for mental illness. Around 400 BC, Hippocrates, now known as the father of medicine, attempted to separate superstition and religion from medicine. Thus, alongside Galen and Socrates, great thinkers of their time, he adopted the theory of the four humours, or essential bodily fluids, which helped them identify causes and then establish treatments. These humours were blood, yellow bile, black bile, and saliva. A person’s personality was thought to be associated with the balance between the four humours.

Andrada: Thus, a person who was overly temperamental or impulsive was thought to have an excess of blood, so treatment involved bloodletting. Similarly, melancholia, or what we would call depression today, was thought at the time to be caused by an excess of black bile. Interestingly, also in Antiquity, manic episodes were associated with the phases of the Moon, which is where the term we still use today, “lunatic”, comes from.

Mara: All of this shows that this was the period when the first ideas about mental health began to emerge. Hippocrates classified mental disorders into four categories: epilepsy, mania, melancholia, and brain fever. Like other physician-philosophers of the time, he did not believe that mental illness was a cause for shame or that those affected were to blame for their behaviour.

Andrada: In other words, this is exactly what we promote today. However, for much of history, all those wise thinkers of Antiquity, whether European or Asian, were contradicted by the way people with mental disorders were treated during the Middle Ages and for much of the modern era, specifically between the 15th and 18th centuries.

Mara: This period that Andrada is referring to was, in fact, the era of asylums. In asylums across Europe, people with mental illnesses were not treated as patients, but as prisoners, being incarcerated and subjected to brutal treatment. The asylums were places of true horror, from isolation in cells and abuse to torture. Because mental illnesses were considered incurable, they were treated through isolation from society or through immoral and inhumane practices. The presumed causes were imbalances in bodily fluids or the influence of demonic forces, as I mentioned in the introduction. As a result, the supposed cures were horrific: bloodletting and the removal of other bodily fluids in an attempt to restore the body’s moral balance; exorcism, torture and other forms of severe trauma to drive out the demons — all of these ideas drawing, in part, on theories developed by the ancient Greeks.

Andrada: Before we continue, you should know that many of the “treatments” — in quotation marks, of course — that we’re going to talk about are cruel and may be emotionally distressing. The first psychiatric asylum was built in Valencia in 1406. This asylum, like those that followed, offered patients neither real treatment nor any form of comfort. Patients were subjected to inhumane conditions and horrific abuse. These facilities were, in fact, prisons, merely disguised by the name “asylum”. I think that, at times, they were even more brutal than penal institutions. There was no concept of caring for people with mental illnesses, only of separating them from their families and from society. All they achieved was confining patients, nothing more. The belief was that this would minimise the harm they might cause to the community, particularly because there was very little understanding of what a contagious disease was or how such illnesses worked.

Mara: Exactly. The so-called treatments involved forms of suffering intended to restore the patients’ minds to a healthy state, as asylum staff believed that mental disorders were a choice and therefore used physical restraints in an attempt to cure them. For example, they used forms of torture that we now see in history museums as examples of the conditions in medieval prisons, which goes to show that asylums were essentially just that — prisons. Medication was only used occasionally, and only in cases considered more dangerous or difficult.

Andrada: Among the best-known asylums were Maison de Charenton in Paris and Narrenturm in Vienna. People with mental illnesses were considered the responsibility of the local authorities, and asylums continued to be established from the 19th century onwards. They existed in Britain and outside Europe as well. Although the number of asylums increased, the conditions in which patients lived did not improve until much later.

Mara: It was not until the end of the 18th century that attitudes towards mental illness began to change. In 1793, the French doctor Philippe Pinel pioneered a humane, moral approach to mental health problems in the asylums of Paris. From then on, prisoners became patients, and living conditions in asylums began to improve. Pinel insisted that mental disorders were not moral failings, but medical conditions. He argued that they had scientific causes, such as heredity or excessive stress. In doing so, he helped establish psychiatry as a branch of medicine.

Andrada: Until the French Revolution, the Salpêtrière hospital in Paris was the largest asylum in the world, with a capacity of more than 10,000 patients. However, it had no medical function until Pinel arrived and introduced what were known as “moral treatments”. He ordered the facilities to be cleaned and the patients to be freed from their chains, placing them in well-lit rooms. Patients were also allowed to walk around the hospital grounds. Although this may seem perfectly normal to us, at the time it represented a huge step forward.

Mara: Exactly, it was a major leap forward in the way mental health was understood. Another revolutionary figure worth mentioning in this field is Emil Kraepelin, who pioneered modern scientific psychiatry and psychopharmacology at the end of the 19th century. He based his diagnoses on clinical observations, such as symptoms and how the illness progressed over time, and divided mental disorders into two broad groups—the disorders of thought, which he called “dementia praecox” (what we would now classify as schizophrenia and bipolar disorder), and mood disorders, which he called “manic-depressive illnesses” (what we would now call depression). He also argued that mental illnesses were strictly biological and had a genetic basis, an idea that is still taken into account in psychiatric research today. Mental disorders are now understood as the result of an accumulation of biological, social and psychological factors, although genetic factors remain particularly important.

Andrada: And since we’ve started talking about the pioneers of modern psychiatry, we can’t leave out Karl Jaspers. In his works on psychopathology from the early 1900s, he divided mental illnesses into three groups, basing his approach largely on what could be observed in a patient’s anatomy, which he saw as an organic substrate on which certain illnesses could develop and grow. It was very similar to the way soil can either support the growth of certain plants or not. Conditions with a demonstrable organic substrate — in other words, those with what we would now call a clear underlying pathology — were considered mental illnesses. Alongside these, there were also mental illnesses for which no clear organic substrate could yet be demonstrated, the so-called endogenous psychoses. And let’s not forget the abnormal psychological variations in intelligence or personality, as well as normal reactions to life events. In this way, Jaspers laid the foundations for a diagnostic approach based on clear evidence.

Mara: Jaspers’ role in the history of mental health is very interesting as well. In the 19th century, new branches of medicine emerged, with neurology and psychiatry becoming separate fields. Neurology thus became the study of the nervous system from both a structural and functional perspective, initially focusing on conditions with clearly defined diagnoses. Neurological disorders can also involve psychiatric symptoms, for example in cases of brain tumours or Alzheimer’s disease, but they generally have a strong anatomical basis. The distinction between the two fields was established under the influence of the French physician Jean-Martin Charcot, who later specialised in neurology.

Andrada: You’re right, Mara. It’s very important to distinguish between neurology and psychiatry. Psychiatry, on the other hand, deals with mental and behavioural disorders, which are most often not anatomically visible. Patients don’t necessarily have physical symptoms, as they can with neurological conditions, where, for example, paralysis may occur, but they most often present with specific behaviours. It is often difficult to establish an exact psychiatric diagnosis, as conditions are constantly evolving and their symptoms can sometimes overlap, while treatment is generally aimed more at managing the symptoms than curing the underlying conditions.

Mara: For practical reasons, patients are admitted to psychiatric wards when mental health disorders are the main concern or when they appear suddenly. There are also conditions that fall into both fields, such as dementia. So the distinction is often a very fine line. Sometimes, treating these conditions involves both a neurologist and a psychiatrist, which helps us to better understand the symptoms.

Andrada: As we can see, even today, the distinction between neurology and psychiatry is not entirely clear-cut, which shows just how complex the field of mental health is. It was not until the late 19th century that the idea that mental illnesses could have psychological causes became more widespread, implying that they could also be treated psychologically.

Mara: And so, little by little, we arrive at the concept of psychotherapy, which brings us to the famous Sigmund Freud, a key figure in the history of mental health, whom we’ve all surely heard of. A contemporary of Kraepelin, he is considered the father of psychoanalysis, a theory of psychotherapy that has had a major influence across a wide range of fields.

Andrada: Indeed, our discussion couldn’t leave out Freud, who made a major contribution to the way mental disorders were understood and treated. He argued that although mental illnesses affect the brain, they are acquired as a result of traumatic experiences, so they are not purely anatomical in nature. As many of you probably already know, Freud compared the human psyche to an iceberg, with instincts hidden in the subconscious and the ego within the realm of conscious thought.

Mara: Among his areas of study were hypnosis and the meaning of dreams, with some of his most famous work carried out together with Breuer. The two studied a condition known as hysteria, following the case of a patient known as Anna O. She was hypnotised and encouraged to talk about significant events and the emotions they had brought up, leading Freud to conclude that the unconscious has a major influence on human behaviour.

Andrada: In addition to this, he developed the technique of free association, which replaced hypnotic treatment, which had been very popular up to that point. The free association method is at the heart of psychoanalytic therapy, and the process is as follows: the patient lies on a couch, which encourages a certain state of relaxation, and speaks freely about whatever comes to mind, without deliberately focusing on any particular subject or previously established topic. The flow of thoughts is allowed to unfold freely and is followed without any conscious intervention. The important thing is that the critical mind does not step in to censor spontaneous thoughts. We do, in fact, tend to censor our thoughts according to various criteria, whether moral, ethical, narcissistic, cultural or even spiritual. But the free association method requires us to set aside intellectual censorship for a while and speak freely about whatever comes to mind. Essentially, Freud’s approach was based on the idea that by expressing our problems and bringing them into the open, we can get to the root of them. The “talking cure” thus became the key to treating his patients and uncovering the causes of their suffering.

Mara: This was another very important step Freud took in the history of mental health, paving the way towards psychotherapy. We could talk at length about his work, but it’s worth mentioning that Freud also developed psychoanalysis, which is still used in psychotherapy today. He encouraged patients to keep a journal in which they would write down what their subconscious was revealing to them through their dreams. He would then analyse the contents of these journals, looking for messages that could help him understand their mental disorders. Traces of this approach can still be found in cognitive behavioural therapies today, with psychologists using so-called “talk therapy” with their patients. This is now a very common practice in psychology. Patients are encouraged to write down their feelings and thoughts in a journal, in a way creating a dialogue with themselves, which helps the psychologist better understand what they are experiencing.

Andrada: Fortunately, nowadays, patients have access to a wide range of increasingly modern treatments. For many people, psychotherapy remains an essential form of treatment, but there have also been revolutionary developments in the field of psychotherapy. For example, in the 20th century, convulsive therapy was introduced in Hungary as a treatment for schizophrenia.

Mara: It’s also worth mentioning electroconvulsive therapy, which is an older treatment but is still useful today. It works by inducing controlled seizures to treat symptoms of depression. Like psychoanalysis, electroconvulsive therapy is still used, although generally as a last resort for mental health conditions that do not respond to standard treatments, for example in cases of severe depression with psychotic symptoms.

Andrada: Conventional psychology no longer focuses as much on psychoanalysis. Through their popularity, Freud’s works opened the door to new approaches to treatment, such as psychosurgery, electroconvulsive therapy and psychopharmacology, which we’ve already mentioned. These approaches stem from the biological model of mental illness, which is based on the idea that mental health conditions are caused by biochemical imbalances in the body.

Mara: Indeed, we’ve reached a point where modern psychology is developing further and further, branching out into an ever-growing number of fields. So, we can see a clear evolution from the four humours of Antiquity. According to the modern model, these conditions should be treated like physical, somatic illnesses. This is the rationale behind psychosurgery, for example—essentially, neurosurgery applied to mental disorders rather than neurological or neuroanatomical conditions.

Andrada: As I’ve already mentioned a few times, these conditions can also be treated with medication, which led to the development of the psychopharmacology industry from the modern era to the present day. The earliest medications affecting the nervous system date back to the 19th century, when chemical forms of sedatives began to emerge. Substances such as chloral hydrates, bromides and barbiturates were used as sedatives to treat mental disorders as early as the 1800s, but doctors were dissatisfied with them because their effects did not last very long. Treatments with these medications could be effective, but they did not provide long-term benefits. It’s also worth mentioning that these medications were prescribed somewhat arbitrarily, without a clear understanding of the best way to administer them depending on the patient or the condition.

Mara: However, this changed in 1949, when an Australian psychiatrist introduced lithium as a treatment. It did not cure psychosis, but it proved to be more effective at controlling symptoms than any other method that had been tried previously. Lithium marked the beginning of modern psychopharmacology, which changed the way mental illnesses were treated.

Andrada: And so, lithium became a standard treatment for these conditions. Other medications were then developed throughout the 20th century, including chlorpromazine, also known as Thorazine, Valium and Prozac. You’ve certainly heard of these when it comes to treating conditions such as depression or bipolar disorder.

Mara: There are now hundreds of psychoactive medications for a wide range of conditions, giving patients a high degree of comfort and privacy throughout their treatment, which is, in fact, the main aim of psychopharmacology. On the other hand, this field has also had some unfortunate consequences when it comes to addiction, as many people have developed a dependence on the substances used in treatment. Medications such as barbiturates and opioids have become drugs in their own right, as we know. That’s why dosages need to be carefully monitored by a psychiatrist, to avoid disrupting biochemical processes and to prevent dependence or the effects of not following the prescribed treatment.

Andrada:In other words, one of the biggest problems with medication for many mental health conditions is that it can often lead to dependence. Despite these adverse side effects, we can still see real progress in the way mental health conditions are treated compared with the past. Modern treatments provide genuine help and give people the chance to lead a life that is as close to normal as possible.

Mara: Absolutely! The evolution from inhumane treatments to recognising that people living with these disorders need support, just like any other patients, is clear. This is far more important than any medication or treatment method ever discovered. The difference is that, unlike physical illnesses, mental health conditions require psychotherapy, which makes them more difficult to treat, because the human mind is, in fact, far more complex than any other biological mechanism.

Andrada: That’s right! But more than that, alongside modern medication, which is certainly useful, as well as therapy and other forms of treatment, people with mental health conditions also need emotional support. That’s why the support and encouragement of their loved ones is so important. They need to feel heard, to be encouraged to seek treatment, and to be included in society.

Mara: And we’ve certainly learnt from history that isolating people doesn’t help; it only makes treatment more difficult. Yet the idea of mental illness still frightens us today and, at least in our country, it remains a taboo subject, just as it was hundreds and thousands of years ago. To understand and address mental health conditions more effectively, we need to raise awareness. People need to be better informed. In fact, that was what people lacked most in the past—information, health education and openness.

Andrada: You put that really well, Mara! We’ve certainly come a long way to get to where we are today when it comes to treating mental health conditions and tackling the strong stigma associated with them. However, as you said, stigma is still widespread, despite all the sources of information that have emerged over the past century. If we don’t want to wait decades or even hundreds of years for a new chapter to be written in the history of mental health, we all need to play our part in raising awareness of its importance. As a first step, you can share our podcasts and articles with those close to you and support our initiatives to educate young people. Thank you for listening! See you soon!