Treatment of mental disorders: Has it actually changed over the years?

Recent times have witnessed increased awareness about mental health and more people are talking about it. It is not that mental health and related issues did not exist earlier, if we look back, mental health issues have been observed throughout history.  How one perceived and conceptualized mental health, its importance and how it’s been treated has evolved over time. 

The factors contributing to the understanding of mental health have influenced the treatment approaches and how they have changed over time.

Perception of mental health

Now it is widely accepted that mental health is not a separate entity in fact along with other aspects of health it is important for overall well-being and functioning. WHO's definition of health states “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. Mental health can be understood as emotional, psychological and social well-being. Earlier, mental health issues would mean gross changes in behaviours (being psychotic or aggressive). Now an entire spectrum of symptoms (anxiety, depression, adjustment issues) are included and are being addressed.

Aetiology of mental illnesses

Understanding the causative factors for mental illness has a great influence over the choice and place of care one would receive and also the willingness of an individual to seek help.

Supernatural

During the 18th century, mental illnesses were believed to be due to evil possessions, the displeasure of gods, eclipses, planetary gravitation, curses, and sins. This led to treatment that was more based on exorcisms and isolation.

Somatogenic theories

These theories identify disturbances in regular mental functioning as a result of biological changes like illness, genetic inheritance or brain damage/imbalance. The basis of pharmacological treatment (medications) is the biological evidence for mental health issues.

Psychogenic theories 

It emphasized the change in behaviours as a consequence of traumatic or stressful experiences, negative cognitions, and maladaptive coping behaviours. These theories explain the role of therapies in the management of mental health issues.

Information 

Recent advances and evidence-based studies of the causative factors and effectiveness of various treatments in addressing mental health issues have greatly influenced the treatment modalities and choice of treatment. 

Cultural variations

The delineation between normal and abnormal behaviours varies according to the context, and cultural & spiritual beliefs. Culture-bound syndromes are widely prevalent in different parts of the world (run amok, dhat syndrome, possession syndrome). The regional beliefs greatly influence how the behaviour change is perceived and their inclination to seek medical help.

Stigma and prejudice

The notion of a person with mental illness being weak, and labelling them to be aggressive and harmful, often led to people being sent to asylums. Shame and stigma against the person and their family members also affected their willingness to seek professional help. With more acceptance and shifts in attitudes, treatment choices have changed significantly. Now, more people are talking more about issues like anxiety at workplace, depression and childhood traumas, and are reaching out for help.

Evolution of psychological treatment approaches

Treatments in the 18th century

• Intensely invasive surgeries were earlier performed on persons who were considered "mentally ill". People were forced to take part in exorcisms, were imprisoned, or even executed!

• Later, asylums were built to house the "mentally ill". However, the patients often received little or no treatment, and the methods were cruel and dehumanizing.

• The "De-institutionalization Movement" led to the shift from asylums to hospitals, where patients could go back home and receive treatment within their community when needed. 

Treatments in the 19th and 20th century

"Talking cure"

It is also referred to as Psychotherapy. Such therapies are still part of current management strategies, either as a singular form of treatment or in combination with pharmacotherapy.

Electro Convulsive Therapy (ECT)

Fears and stigma are associated with ECT, based on early treatment wherein using high doses of electricity without anaesthesia caused significant side effects like memory problems and fractured bones. Compared to earlier methods, ECT is much safer now. ECT seems to cause changes in brain biochemistry that can quickly reverse symptoms 

of mental health conditions. There are certain indications where, even today, it is considered the first line of treatment.

Medications

Biological theories of the causation of mental health issues have led to the usage of medications which address the imbalance of neurotransmitters. Since their introduction, medications have been made available with more efficacy and lesser side effects as time goes on.

Neuromodulation

These are emerging non-pharmacological therapeutics for psychiatric illness. It includes procedures that change brain activity by directly stimulating brain regions in several ways. It helps improve symptoms of mental illness and includes procedures such as Transcranial Magnetic Stimulation, Deep Brain Stimulation and Vagal Nerve Stimulation.

Psychosurgeries

The evidence of psychosurgical procedures can be traced back to prehistory.  The evolution of effective psychopharmacological treatments eliminated the need and desire for these procedures. However, there has been a recent resurgence of non-ablative procedures.

Other non-pharmacological management techniques like practising yoga, deep breathing, art therapy, music therapy and aroma therapy, and focusing on lifestyle modifications have now also been integrated into mental health management options.

How far we have come

Currently, there is a comprehensive assessment and multimodal approach to address mental health issues:

• Evolution of sub-branches such as  Child and Adolescent Psychiatry, Geriatric Psychiatry,  Rehabilitation Psychiatry, and Addiction Psychiatry

• Addressing comorbid illnesses & medical conditions, and working in close liaison with other branches of medicine

• There has been an improvement in accessibility to services

• Training and increased reach of mental health professionals like counsellors, psychologists, and social workers can be catered to as required

Looking to the future

Mental illness is yet to be as normalized as physical illness. Currently, mental health acts and regulatory bodies ensure patients are not exploited and human rights are respected.

In closing

With newer understanding come newer methods and strategies to address mental health issues. A comprehensive, individualized and targeted treatment plan has to be formulated for effective results. Increased awareness, acceptance and evidence can help reduce the morbidity and burden of mental health issues.

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