Kaplan and Sadock’s Comprehensive Textbook of Psychiatry (2 Volume Set)

Book Preface

Psychiatry has a long and complex history with substantial impact on today’s society. The extent and complexity is covered by this remarkable book. Psychiatry has come a great distance from the time when people thought psychiatric conditions may be due to demons in the brain or some other exotic force. Bleuler and Kraeplin worked, studied, and categorized psychiatric illness. Freud introduced psychodynamics and psychoanalytic theory, the backdrop for psychotherapeutic approaches beginning in the late 19th and early 20th centuries.

Globally countries are faced with large populations dysfunctional because of psychiatric problems. In the early 20th century, most patients were hospitalized in chronic state psychiatric hospitals. Treatment was limited. Electroconvulsive and other convulsive therapies were used; psychotherapies were used for people less blatantly psychotic. It was not until the 1950s that major psychiatric medications started to be introduced to address symptomatically many of the symptoms that afflict people with such illnesses. At the high point there were close to 600,000 people in state hospitals around the country in the 1950s. Most care was provided in inpatient settings.

And then, many factors—new medications, patient’s rights, budgetary implications of maintaining large numbers of psychiatric institutions, criticism that they were nontherapeutic—combined into a movement to change psychiatric care. Some heroes have tried to humanize care over the years with mixed success.

Patients with more modest symptomatology were treated in out-patient offices by psychiatrists and other mental health professionals. Stigma was universal and destructive.

President Kennedy fostered legislation making mental health care more visible, accessible, and patient centered. This generated the Community Mental Health program in the 1960s and 1970s. This federal plan involved bringing mental health to the community with the intended construction of 1,500 community mental health centers. Assuming 200,000 patients would be assigned to each center, the projection was 300 million people could be served. The intention to move patients out of the chronic hospitals led to the deinstitutionalization era of psychiatric patients launched in the 1960s and continuing for decades. Some argued patients were discharged from hospitals only to find themselves in other institutions like nursing homes, prisons, or as part of the homeless community.

In the evolution of mental health programs, World War II was important. Recruitment by the armed forces revealed the large numbers that had psychiatric illness. This excluded them from service. Beyond that, the large numbers of soldiers who during their war service had personal psychiatric challenges referred to as “battle fatigue,” contributed to the rallying cry to have a national focus on mental health. In the late 1940s, the federal government established the National Institute of Mental Health (NIMH) charged with conducting research, clinical care through the community mental health centers, and education to generate a national clinical mental health workforce. The latter included psychiatrists, clinical psychologists, nurses, and social workers, as well as paraprofessionals. Medicines such as Thorazine, antidepressants, and lithium became available. Enthusiasm regarding discharging patients from chronic hospitals and putting them out in the community strengthened. Given the promise and need for the workforce charged to care for psychiatric patients, there was great interest among physician trainees for psychiatry as a career. This was sustained through the early 1960s. Possibly because of the diminishing assessment of the therapeutic impact of psychodynamic approaches, there was a drop in recruits to psychiatry from about 10% in the early 1960s to about 2 to 3 percent of graduating medical students by the beginning of the 1970s. Mental health was a particularly low priority during the republican national administrations in the late 1960s and early 1970s. Money for support of the programs at NIMH was sharply curtailed, while other areas such as cancer and heart disease were increased. Lack of reimbursement rose as a major insidious issue for those trying to promote mental health services.

Important in the evolution of mental health and of psychiatry was the Carter Commission of the late 1970s. This Commission recommended major changes in mental health care. The “Mental Health Systems Act” passed in 1980 was intended to increase federal involvement in mental health and focus on underserved populations such as children, minorities, elderly, chronically mentally ill, and psychiatric patients in nonpsychiatric medical settings. But after working several years and actually passing that legislation, the Carter Administration was replaced by the Reagan Administration. It challenged sharply the budgets of the NIMH, and the National Institute on Alcohol Abuse and Alcoholism, and National Institute on Drug Abuse conducting programs that dealt with alcohol and drug abuse, respectively. The late 1970s witnessed an improvement in the congressional view regarding NIMH. The Reagan Administration was impressed by findings such as the demonstration by Lou Sokoloff of the value of 2-deoxyglucose used in PET scanning for visualization of activity in the brain. This was enhanced by the Nobel Prize awarded to Roger Sperry, an NIMH research psychologist grantee which led to the understanding that there are major differences in the functions of the two halves (left and right) of the brain. These advances from biological research were accompanied by a vigorous effort by the mental health community leading to revaluing of mental health programs. Productive studies emanated from Seymour Kety regarding genetic contributions to psychiatric disorders. Others produced increasingly systematic studies of brain and behavior. These developments improved the regard in which mental health programs were held during the 1980s. The Reagan Administration began recommending increases in the NIMH budget more comparable to the size of increases allocated to other federal medical areas—heart disease, cancer, among others