“What is Wrong with the Patient?”
Part III
Treatment Approaches:
“What can/should be done for the Patient?”
Overview of Different Treatment Eras
The 1st Biological Psychiatry: 1880s-1920s
The Psychoanalytic Hiatus: 1920s-1960s
The Rise of the 2nd Biological Psychiatry: 1950s-1980s
The Rise of (Cosmetic) Psychopharmacology: 1990s-present
The 1st Biological Psychiatry
• Industrialization and the necessary “medicalization” of mental
health and psychiatry in late 1890s and early 1900s
• major advances in understanding biological origins of many
several mental illnesses first occurred in Europe (France,
Britain, and especially Germany) . . . definitely not in America
e.g., neurosyphilis and “madness”
- end stage of neurosyphilis was treated in public asylums and clinics
- “shameful” disease meant most people did not receive treatment for it
- evolution of disease took on mental symptoms of increasing severity
The
st
1
Biological Psychiatry
• neurosyphilitic madness
No other disease in which primarily
middle-aged men (mainly whites)
suddenly became demented and then
died paralyzed with terminal convulsions.
• flooded European mental asylums in the 19th century,
along with an extraordinary increase in patients with
severe alcoholism and those with schizophrenia
The
st
1
Biological Psychiatry
• Advanced link between neurology and psychiatry found in
European mental asylums by clinicians who tracked the
progression and resolution of these mental diseases
Emil Kraepelin (1856-1926)
- kept data cards on each patient
- “discovered” schizophrenia and
manic-depression
worked with Aloys Alzheimer at the Heidelberg Clinic
- they began to spot distinct and predictable patterns of disease progression
by virtue of both mental and physiological symptoms
The
st
1
Biological Psychiatry
Kraepelin’s ultimate dichotomy of insanity:
(1) those with an affective component (had better
prognosis)
- mood disorder: depressed, manic, anxious
“manic-depressive illness”
(2) those without an affective component (had worse
prognosis)
- psychotic in the absence of an affective component
“schizophrenia”
The 1st Biological Psychiatry
Kraepelin’s structure insisted that there were a number of discrete
psychiatric illnesses, or diseases, each separate from the next.
• Depression, schizophrenia, and so forth were different just as
mumps and pneumonia were different.
“medical model” of mental illness temporarily
adopted by America’s “Kraepelin”: Adolph Meyer
returned to Worcester State Hospital/Asylum
and then moved to Johns Hopkins (1910-1941)
Meyer ultimately rejected Kraepelin’s model
Psychiatrist Adolf Meyer sailing to Europe.
The Psychoanalytic Hiatus
• Asylum practice came to be seen as “dead end,” even as the
numbers of patients admitted to them continued to increase.
American psychiatrists wanted to shift the focus of their work
to private practice and attract a middle-class clientele.
• Freud to the rescue (trained as a neurologist)
Freud: repressed childhood sexual memories and fantasies
caused neurosis (or psychosis) when reactivated in adult life.
Leisurely introspection became the form of treatment.
The Psychoanalytic Hiatus
American origins: 1909 visit by Freud to Clark University
• Key catalyst: “The Arrival of the Europeans” in the 1930s
Years of triumph: late 1940s to late 1960s
• Symptoms were meaningless because disease entities didn’t mean anything
when it came to mental illness
Practically everyone had some measure of mental maladjustment.
Question: What else made psychoanalytic and dynamic psychiatry so popular?
The Psychoanalytic Hiatus
deep insulin coma therapy, ECT
Metrozol shock therapy, lobotomy
The Rise of the 2nd Biological Psychiatry
1949 - Lithium* (not FDA-approved until 1970)
1954 - Chlorpromazine (Thorazine)
Reserpine
1955 - Meprobamate (Miltown)
1957 - Haloperidol (Haldol)
1958 - Imipramine (Tofranil)
Iproniazid (MOAI)
1960 - Librium (Valium)
1961 - Methylphenidate (Ritalin)
Leo Sternbach, inventor of Valium,
died on September 28, 2005, aged 97
The Rise of the 2nd Biological Psychiatry
• Deinstitutionalization en masse from early 1960s to early 1980s
• Community Mental Health Centers Act (1963)
• turmoil in the 1970’s and the publication of the DSM-III (1980)
The Rise of Psychopharmacology
Type of Coverage
Indemnity (fee-for-service)
Managed Care (HMO, PPO)
1988
71%
29%
1993
49%
51%
1995
30%
70%
Managed Behavioral Health (“Carve Outs”)
Because “supply drives demand” in health care ->
Number of Acute Care Hospital Beds/per 1,000 Residents
Source: Dartmouth Atlas of Virginia
Number of Hospital Discharges for all Medical Conditions (DRGs)
Source: Dartmouth Atlas of Virginia
Average number of physician visits per patient during last six months
of life who received most of their care in one of 77 “best” US hospitals
80.0
NYU Medical Center
76.2
Cedars-Sinai Medical Center
66.2
Mount Sinai Hospital
53.9
UCLA Medical Center
NY Presbyterian Hospitals
43.9
40.3
UCSF Medical Center
Stanford University Hospital
27.2
22.6
70.0
60.0
50.0
40.0
30.0
20.0
10.0
Source: John Wennberg (2005)
Empiricism Driving Managed Care
Researchers’ and Insurers’ Conclusions:
(1.) Physician practice styles vary considerably, especially regarding
diagnoses for which treatment decisions are not driven by consensus
on appropriate care and it is not possible to obtain evidence-based
guidelines from reading journals or consulting textbooks.
e.g., back surgery rates (the #/per 1,000 Medicare beneficiaries):
- 7/per 1,000 in Naples, FL
- 2/per 1,000 in Hanover, NH
- 4.5/per 1,000 national average
(2.) In medicine, supply generally creates its own demand
(e.g., # of hospital beds/per capita, technology available, # of specialists/per capita).
Rates of four orthopedic procedures among
Medicare enrollees in 306 Hospital Referral Regions (2000-01)

Standardized ratio (log scale)
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0.2
Hip
Fracture
Source: John Wennberg (2005)
Knee
Replacement
Hip
Replacement
Back
Surgery
Association between cardiologists and visits per person to
cardiologists among Medicare enrollees (1996): 306 HRRs
Visits to Cardiologists per enrollee
2.5
2.0
1.5
1.0
0.5
R2 = 0.49
0.0
0.0
2.5
5.0
7.5
10.0
12.5
15.0
Number of Cardiologists per 100,000 residents
Source: John Wennberg (2005)
Association between # of hospital beds per 1,000 residents (1996) and
discharges per 1,000 (1995-96) among Medicare enrollees in 306 HRRs
400
Discharges for
all Medical
Conditions
R2 = 0.54
350
Discharge Rate
300
250
200
150
100
50
0
1.0
Source: John Wennberg (2005)
2.0
Discharges for
Hip Fracture
R2 = 0.06
3.0
4.0
5.0
# of Hospital Beds/per 1,000 Residents
Dilemma & Running Debate
• Type 1 errors (fear of “medical malpractice” cases and “self-medicating”)
(person has a mental disorder but is not diagnosed)
• Type 2 errors (fear of “cosmetic psychopharmacology”)
(person does not have a mental disorder, but is diagnosed with one)
Kate Russell for The New York Times
Sarah Couch, who has bipolar disorder,
opposes the effort to force treatment on the mentally ill.
De'Nora Hill: "I am living in fear and I want it to end."
Andrea Yates & Post-Partum Depression w/psychosis