PSYCHIATRY.

Psychiatry in Europe around the time of the First World War was torn between psychotherapeutic and biological approaches. It is important to locate these traditions in earlier developments. Psychiatry as a discipline had begun around the time of the French Revolution. It was centered in mental hospitals and emphasized the somatic, or physical, treatment of patients with such remedies as hydrotherapy and sedatives. European psychiatrists in the nineteenth century stressed the genetic sources of illness, with particular emphasis on "degeneration," meaning a worsening of illness from one generation to the next. Asylum psychiatrists attached particular importance to brain anatomy and believed that mental illness could be associated with lesions in the physical structure of the brain. Of course, psychiatric illness existed outside of the mental hospital, yet it was treated in the community not by psychiatrists but by neurologists or physiatrists, specialists in physical treatments who generally practiced in spas under the guise of treating "nervous," not mental illness.

Around 1880 this biological approach began to be challenged by psychiatrists who believed in the efficacy of psychotherapy, not hydrotherapy and sedatives. Prominent among these early psychotherapists were Hippolyte Bernheim at the University of Nancy, who in 1883 proposed nonhypnotic suggestion, in addition to hypnosis, as a way of treating lesser nervous illnesses. In 1902 Jules-Joseph Dejerine, a neurologist at the Salpêtrière Hospice in Paris, began sketching out a treatment of the psychoneuroses involving "isolation" of the patients and intensive psychotherapy. Two years later, in 1904, Paul Dubois, professor of neuropathology in Berne, argued that psychoneuroses could best be treated by a kind of "rational" talking therapy emphasizing give-and-take between doctor and patient. First at the Salpêtrière then at Sainte-Anne Mental Hospital, the psychiatrist Pierre Janet in the decade before the First World War continued his efforts to lay out a psychotherapy aimed at reducing "psychological tension" and thus relieving "obsessions and psychasthenia," the title of his 1903 opus. Thus there were numerous attempts in the years before the First World War to construct a psychotherapy that would serve "ambulatory" (nonhospitalized) patients living in the community.

Yet by 1904 these early efforts started to become overshadowed by the kind of psychotherapy that Sigmund Freud (1856–1939) in Vienna introduced, called "psychoanalysis." Beginning in the 1890s, Freud postulated conflicts in the "unconscious" mind as the source of psychoneurosis; he advocated treatment with psychotherapy involving free association (to determine where poorly remembered childhood sexual experiences and fantasized traumas lay) and the analysis of dreams. Among Freud's early publications were Studies in Hysteria, cowritten in 1895 with Vienna family doctor Josef Breuer, and The Interpretation of Dreams in 1899. By 1904 psychoanalysis was on the brink of becoming an international movement and would attain an amplitude that caused such figures as Bernheim, Dubois, and Dejerine to be almost completely forgotten.

Thus, psychiatry before the First World War was divided between a corps of asylum doctors practicing somatic treatments on patients with major illnesses such as schizophrenia and manic-depressive illness, and psychotherapeutically oriented neurologists and family doctors in private practice, who were just beginning to catch Freud's message and to start plumbing their patients' psyches about early childhood experiences and dreams.

FROM 1900 TO THE SECOND WORLD WAR

The asylums continued to grow in population, yet the main trends in psychiatry shifted to university hospitals and to private practice. In academic psychiatry, interest changed from the anatomical concerns of the late nineteenth century to diagnosis and "psychopathology," meaning the study of the patients' actual symptoms (rather than hypothetical "diseases" the patient might have). This was in particular a German story, yet it will be discussed here because of the great influence of German-speaking authorities on international developments. Throughout the second half of the nineteenth century, German authors had puzzled over the various psychiatric diseases and how to classify them.

Emil Kraepelin (1856–1926), professor of psychiatry in Heidelberg, then after 1903 in Munich, is the central figure in the nosology story. (Nosology means the classification of diagnoses.) As a young physician, in 1883 he had brought out a textbook of psychiatry, called simply Psychiatry. Yet ongoing experience made him modify his ideas, and in the fourth edition of the textbook in 1893 he revived the concept of his predecessor, the German physician Karl Kahlbaum (1828–1899), that the best way to classify psychiatric diseases was on the basis of clinical course rather than momentary symptom picture. In this edition, Kraepelin said that there was a special form of psychotic illness (psychotic meaning delusions and hallucinations) in which the patients' personalities and intellects deteriorated irreversibly, ending in "dementia." Kraepelin called it "dementia praecox," or premature dementia, seen often in young people. In the sixth edition of his textbook in 1899, Kraepelin said that there was a second main form of illness, involving such mood disorders as mania and depression, in which the patients experienced a fluctuating course over their lives rather than deteriorating. He called this disease "manic-depressive illness," and the Kraepelinian firewall between dementia praecox and manic-depressive illness dominated psychiatric thinking for the next century. In 1908 the Zurich psychiatry professor Eugen Bleuler rebaptized dementia praecox as "schizophrenia."

The psychiatric clinic at Heidelberg University had proven an especially fruitful source of thought, and it was here that the young psychiatry trainee Karl Jaspers (1883–1969) in 1913 authored the most important book ever written about psychopathology, General Psychopathology, a work that influenced understanding of patients' experience of illness as profoundly as Kraepelin had influenced formal thinking about mental "diseases." The close study of patients' symptoms became a European specialty, and Jaspers's book was not even translated into English until 1963.

Kurt Schneider, a contemporary of Jaspers then in Cologne, stirred up the study of mood disorders in 1921 with his distinction between "vital" and reactive depression. (Vital meant serious depression, often called "endogenous.") In the 1920s Schneider also elaborated a series of diagnostic symptoms he believed characteristic of schizophrenia; today, these symptoms are referred to as "Schneiderian," or first-rank, criteria in diagnosing that illness.

German academic psychiatry also developed a strong interest in the inheritance of mental illness, or psychiatric genetics. Unlike earlier "degeneration" doctrines that relied heavily on anecdote, psychiatric genetics properly understood was a statistical discipline, based on studies of twins and family trees. (In a twin study, the difference between the presence of an illness in monozygotic [one-egg] twins and dizygotic [two-egg)] twins is a measure of the influence of the genes.) In 1928 Hans Luxenburger at the German Psychiatric Research Institute in Munich undertook the first twin study.

Yet the doctrine that swept much of academic and community psychiatry between the two world wars in Europe was psychoanalysis. In 1902 Freud founded his "Psychological Wednesday Society" in Vienna, out of which emerged the first psychoanalytic society. In 1908 the first international psychoanalytic congress convened in Salzburg (the second in Nuremberg in 1910, the third in Weimar in 1911). In 1920 the first psychoanalytic outpatient clinic was opened in Berlin. By the 1920s, psychoanalysis was being avidly discussed everywhere, and even though most psychiatrists did not become analysts, Freud's doctrines certainly became the basis of psychotherapy, remaining so until the 1970s.

The Nazi seizure of power in Germany in 1933, and the Anschluss (annexation) of Austria in 1938, spelled the provisional end of psychoanalysis as a European movement. Freud's books were banned, his Jewish collaborators chased into exile. In 1938 the Freud family fled Vienna for London, where Freud died the following year. Many well-known analysts ended up in the United States and Canada, giving psychoanalysis a new impetus in the New World.

A final important prewar development was the emergence of physical treatments of the brain and mind. These began in Vienna in 1917 as the psychiatry professor Julius Wagner von Jauregg (1857–1940) originated the malarial cure of neurosyphilis (spread of syphilis to the central nervous system; malaria raised the body temperature, thus arresting the growth of the organisms that cause syphilis; the malaria was then cured with quinine). In 1930 Manfred Sakel, a young Austrian physician practicing in a private psychiatric hospital in Berlin, revolutionized the treatment of psychosis ("schizophrenia") with his insulin cure: large doses of insulin put patients into hours-long comas; after a long series of these treatments they often recovered from their psychosis.

In 1935 Ladislaus von Meduna, a young Budapest psychiatrist, developed the first convulsive therapy: deliberately inducing convulsions with a substance such as camphor or pentylenetetrazol (Metrazol, Cardiazol) in order to relieve psychosis (and depression). Despite the unpleasant optics of the convulsions (which had few lasting side effects), the treatment was surprisingly effective, and convulsive therapy began its long trajectory that continues even today. In 1938 the Rome psychiatry professor Ugo Cerletti suggested inducing the convulsions with electricity rather than chemically (patients disliked the latter approach because they felt terrified if the convulsions did not immediately begin after the injection; with electroconvulsive therapy, or ECT, unconsciousness was immediate; the patients had no recollection of the fit when they awoke, and were willing to have additional treatments).

FROM THE 1950S TO 2004

After the Second World War, the principal new development in psychiatry was psychopharmacology, the treatment of symptoms arising from mind and brain with drugs. There had been innovations in pharmacological treatments even before the war, such as the introduction in the 1930s of amphetamines for mild depression. A good deal of research into mental mechanisms was stimulated with the diffusion of lysergic acid diethylamide, "LSD-25," the mental effects of which were discovered in 1943 by the Swiss medicinal chemist Albert Hofmann at Sandoz Limited in Basel.

Yet the true revolution of psychopharmacology—for indeed it was revolutionary to shift the treatment of mental illness from psychotherapy for the mind to pharmacotherapy for the brain—commenced in 1952 with the discovery by several Parisian physicians that a phenothiazine-type anti-histamine called chlorpromazine, made by the Rhône-Poulenc company, effectively improved the symptoms of psychotic illness. The success of chlorpromazine in chronic patients in the back wards of mental hospitals led to the synthesis in the 1950s and 1960s of a whole series of other phenothiazines. In 1958 the butyrophenone class of antipsychotics was initiated by the Janssen company in Belgium (haloperidol being the first); in 1958 as well the thioxanthene series of antipsychotics was launched by the Lundbeck company in Denmark (chlorprothixene the first). These drugs, called "antipsychotics" in North America, "neuroleptics" in Europe, had an incalculable impact on the treatment of schizophrenia and psychosis: it now became possible to discharge large numbers of patients from asylums to the community. The "institutional era" in the history of psychiatry started to end. This was entirely a European story.

Then came drugs for depression. In 1957 the Swiss psychiatrist Roland Kuhn discovered that a compound of the Geigy company in Basel called generically imipramine (trade name Tofranil) was helpful in the treatment of vital depression. It was the first antidepressant for serious, hospital depression. Imipramine spawned a whole series of tricyclic antidepressants (so called because of their ring structure). Simultaneously in the early 1950s, the usefulness of iproniazid, developed in Europe from Geman rocket fuel, and of reserpine, developed in India from a traditional medicinal plant (Rauwolfia serpentina), was being explored.

By the mid-1960s the entire range of serious psychiatric illnesses had become eminently treatable, either with ECT or with pharmacotherapy. Psychiatry started to swing from offering psychotherapy to the provision of medication. It was a great sea change.

DEVELOPMENTS COUNTRY BY COUNTRY

There are great differences from country to country in the level of scientific accomplishment in psychiatry. These differences give rise to reflection about the social and political conditions that make for or hinder progress.

Germany and Austria

There is no doubt that before 1933 psychiatry was dominated by German and Austrian clinicians and scientists. Just as French was once said to be the language of diplomacy, German was the language of psychiatry. The German dominance of the international field commenced with the Berlin psychiatry professor Wilhelm Griesinger in the 1860s, who proposed the modern university psychiatric clinic, founded the premier international scientific journal, the Archive for Psychiatry and Nervous Diseases, and advocated a biological basis for psychiatric illness. By 1904 the German psychiatric tradition had become deeply organic, heavily dependent on autopsy findings, and preoccupied with nosology. The major centers were Heidelberg, Berlin, Munich, and Vienna. Psychoanalysis made only limited inroads into biological thinking at German universities.

A real turning of the page occurred with the Nazi seizure of power in 1933—1938 in Austria—as the Jewish scientists who had formed the backbone of excellence of the German system were driven out. This represented a blow from which German psychiatry never really recovered. Since the Second World War there have been few German contributions to psychopharmacology, psychopathology, or psychotherapy of international significance. In the 1960s a great passion for Freud's doctrines began to sweep German academic psychiatry that had only partly abated by the early 2000s.

In retrospect, between 1933 and 1945 in psychiatry, Germany and Austria went from sixty to zero, as it were, partly because of the loss of so many premier scientific figures from emigration and the Holocaust. A discipline cannot lose many figures such as Franz Kallmann, the Berlin psychiatric geneticist who ended up at Columbia University, without suffering grave harm. The loss of a hundred Kallmanns contributed to the end of the German predominance in psychiatry and to the rise of American predominance.

Switzerland

The Swiss bridle at the notion that they are part of "Germany." There are three Swiss narratives in the psychiatry story. The first begins with the rise of the Zurich cantonal hospital and psychiatric clinic, the "Burghölzli," to world fame in the last quarter of the nineteenth century. In 1904 Eugen Bleuler, of "schizophrenia" fame, was the professor of psychiatry, and he and his son Manfred Bleuler made numerous important contributions, notably Eugen Bleuler's 1910 work on schizophrenia, in which he proposed a much milder version of the disease than Kraepelin's unremittingly downhill concept.

A second Swiss moment of excellence was research on the somatic therapies, such as insulin and Cardiazol, centered on Max Müller in the Münsingen mental hospital in the 1930s and 1940s. A third such moment was Swiss research on psychopharmacology, led by Paul Kielholz and other figures, in Basel and Zurich in the 1960s and after.

In the late 1930s, with the eclipse of Germany and Austria, Switzerland was probably the world's epicenter of research in psychiatry. Swiss clinicians were doubtless aided considerably by contact with the great pharmaceutical companies of Basel: Sandoz, Hoffmann-La Roche, Geigy, and Ciba, three of which by 2004 had merged into Novartis, leaving only Hoffmann-La Roche standing alone.

The United Kingdom

England and Scotland rivaled Germany as a psychiatric great power during the nineteenth century. In 1923 the Maudsley Hospital in London, led by Edward Mapother, opened its doors; it was to become the major British training center for psychiatry. Aubrey Lewis, perhaps the greatest name in mid-twentieth-century English psychiatry, became clinical director of the Maudsley in 1936 (and professor of psychiatry in the University of London in 1946). Lewis and Michael Shepherd led the British charge toward social and community psychiatry between the 1940s and 1960s, which was possibly the most important English innovation in these years. (Social psychiatry emphasizes community care and social rehabilitation rather than individual psychotherapy or psychopharmacology.) Although there had been a lively interest in biological psychiatry ever since Joel Elkes had founded in 1951 the Department of Experimental Psychiatry in Birmingham, it was only in the 1970s that psychiatry as a whole began to shift toward psychopharmacology; in 1974, under the aegis of the Leeds psychiatrist Max Hamilton (creator of the Hamilton depression scale), the British Association of Psychopharmacology was founded.

In psychopharmaceuticals, Britain has always been an international leader. In 1995 Glaxo and Wellcome merged to form Glaxo Wellcome (becoming GlaxoSmithKline in 2000 in a union with the Philadelphia firm SmithKline & Beecham). In 1999 the Swedish firm Astra joined with the English company Zeneca to form a second British pharmaceutical giant, AstraZeneca.

France

In the twentieth century, France lost its status as a center of psychiatric care and research. The land of such nineteenth-century giants as Philippe Pinel and Jean-Martin Charcot did not in the twentieth century produce any great psychiatric figures beyond the rather bizarre Parisian psychoanalyst Jacques Lacan and the circle around Jean Delay, professor of psychiatry in Paris from 1946 to 1970. It was Delay who supervised the clinical trials of chlorpromazine in 1952, aided by Pierre Deniker; Pierre Pichot, who introduced psychological testing to France, was Delay's other famous student. After the 1960s, as in Italy and Germany, French psychiatry became increasingly swept up in psychoanalysis and really vanished from the international stage except for its highly innovative pharmaceutical firms such as Sanofi Synthélabo, formed by a merger in 1998.

Italy

Italian contributions to the international story have really been limited to Ugo Cerletti's electroconvulsive therapy in 1938. In the 1960s, as elsewhere, Italy became caught up in the vogue for psychoanalysis. Simultaneously, psychiatry became highly politicized and various political parties including Democratic Psychiatry (Psichiatria Democratica) demanded the complete closing of all provincial mental hospitals, achieved in a 1978 law. Access to ECT also became highly restricted, indeed unavailable in most parts of Italy. By 2004 Italy had become a kind of psychiatric museum of the 1960s, idolizing countercultural politics, radical deinstitutionalization, and psychoanalysis.

Spain and Portugal

There have been virtually no major contributions from Iberia to modern psychiatry. In 1950 Juan Jose Lopez Ibor, a member of the department of psychiatry of the University of Madrid and a student of the German psychopathological tradition, described "anxious thymopathy" as a distinctive illness, comparable to the "vital depression" of Kurt Schneider. In 1936 the Lisbon neurology professor Egas Moniz proposed the ablation of much of the frontal lobes of the brain as a remedy for psychosis (the procedure was called leukotomy, also lobotomy), a contribution for which he received a Nobel Prize in 1949. It is said that the Nobel Prize committee became subsequently so horrified at having misbestowed this honor that no further Nobel Prizes were conferred in psychiatry.

Denmark

In proportion to its population, Danish contributions to the international narrative of psychiatry have been extraordinary, in the twentieth century beginning with August Wimmer, director of the provincial psychiatric hospital St. Hans in Roskilde, who in 1916 originated the diagnosis "reactive psychosis." In 1954 Mogens Schou at the Aarhus university clinic in Risskov undertook a randomized clinical trial, one of the first in psychiatry, to test the efficacy of lithium in mania, the beginning of Schou's lifelong work on lithium (which he also determined to be an effective maintenance treatment of depression). Erik Strömgren, from 1945 professor of psychiatry at Aarhus, was among the pioneers of the epidemiology of psychiatric genetics, and Ole Rafaelsen, in his Psychochemistry Institute in Copenhagen, trained a generation of Danish and international psychopharmacologists. The Lundbeck company, which around 1945 began targeting the central nervous system, has worked closely with such Danish clinicians as Jorgen Ravn in the development of the thioxanthenes and other drug classes. Danish clinicians were closely involved in the late 1960s and early 1970s with the psychopharmacology training programs of the Copenhagen office of the World Health Organization.

Sweden

Another Nordic psychiatric great power, Swedish psychiatry in the twentieth century has focused around the Karolinska Institute in Stockholm, where in 1979 Marie Asberg, working with Stuart Montgomery in England, devised the "Montgomery-Asberg Rating Scale for Depression," or MADRS, used throughout the world in depression research. In 1957 pharmacologist Arvid Carlsson, then at the University of Lund (later at Gothenburg), discovered the role of dopamine as a neurotransmitter. For his dopamine research, Carlsson received a Nobel Prize in 2000. Working with Carlsson, in 1982 the Astra company introduced zimeldine, the first of the so-called selective serotonin reuptake inhibitors, or Prozac-style remedies that bear the catchy acronym "SSRIs."

Eastern Europe and the Soviet Union

As for Eastern Europe and the Soviet Union, it would be unfortunate to let the political abuses to which psychiatric care was often subject overshadow the real contributions to the international story. Within the framework of conditioned reflexes set by the great Russian neurophysiologist Ivan Pavlov (1849–1936), a physiologically oriented psychiatry flourished in the Soviet Union. B. M. Teplov reviews this work in his book Thirty Years of Soviet Psychology, published in Russian in 1947. V. A. Gilyarovsky, author of a widely used psychiatry textbook, undertook EEG tracking of antropine-induced psychoses. In Hungary, psychiatrist Joseph Knoll, professor of pharmacology in Budapest, synthesized in 1961 the drug selegiline (marketed in the United States as Deprenyl), important in the treatment of Parkinson's disease and possibly useful in the treatment of depression and dementia and in staving off the effects of aging. In Prague, a team of clinicians and pharmacologists led by the psychiatrist Oldrich Vinar, and including the chemist M. Protiva, synthesized in 1962 the popular antidepressant drug dothiepin (Prothiaden in many markets) and generally spearheaded psychopharmacology in Eastern Europe. Numerous important Eastern European contributions to psychiatric drug discovery have remained widely unknown abroad.

CONCLUDING OBSERVATIONS

What makes for excellence in a crossnational context? Three factors emerge as salient. One is the existence of a university system based on the "Humboldtian" model of combining teaching and research, conceived by Wilhelm von Humboldt (1767–1835), the Prussian education minister in Berlin, in Napoleonic times. The Swiss and Scandinavian universities were very much constructed on this German-style model, in contrast to much of Mediterranean university life, where research is done at an often lackadaisical pace and teaching assigned to assistants. Second, international attainment in psychiatry since the Second World War has tracked psychoanalysis inversely: those countries where analysis became all the rage in the 1960s and after simply fell off the research map. Finally, progress in clinical psychiatry and the neurosciences has often occurred in connection with research-oriented pharmaceutical companies, especially in Switzerland, Denmark, and Sweden, that have sought out academics for collaborative research.

See alsoFreud, Sigmund; Jaspers, Karl; Psychoanalysis; War Neuroses.

BIBLIOGRAPHY

Angel, Katherine, Edgar Jones, and Michael Neve, eds. European Psychiatry on the Eve of War: Aubrey Lewis, the Maudsley Hospital, and the Rockefeller Foundation in the 1930s. London, 2003.

Ayd, Frank J., and Barry Blackwell, eds. Discoveries in Biological Psychiatry. Philadelphia, 1970.

Berrios, German. The History of Mental Symptoms: Descriptive Psychopathology since the Nineteenth Century. Cambridge, U.K., 1996.

Berrios, German, and Roy Porter, eds. A History of Clinical Psychiatry: The Origin and History of Psychiatric Disorders. London, 1995.

Healy, David. The Psychopharmacologists: Interviews. 3 vols. London, 1996–2000.

——. Let Them Eat Prozac: The Unhealthy Relationship between the Pharmaceutical Industry and Depression. New York, 2004.

Howells, John G., ed. World History of Psychiatry. New York, 1975.

Pichot, Pierre. A Century of Psychiatry. Paris, 1983.

Shorter, Edward. A History of Psychiatry: From the Era of the Asylum to the Age of Prozac. New York, 1997.

——. A Historical Dictionary of Psychiatry. New York, 2005.

Edward Shorter