From Madness to Mental Illness: History of Psychiatry 101


Stone of madness, evil spirits, possessed by the devil—these were common explanations for madness before modern psychiatry. Madness was a term broadly applied to afflictions ranging from schizophrenia to autism to epilepsy to feminism, and was often attributed to a magical or supernatural causes. 

Imagine a medieval doctor using a flint to drill a hole into a patient's skull. This procedure, known as skull trepanation, was intended to create a hole in the patient's head through which an evil spirit could escape, thus curing them of their madness. Skulls over a thousand years old have been found bearing evidence of skull trepanation. Some of these skulls display healing around the bore, indicating that the patient survived long after the procedure!

This supernatural conception of madness extended past Christian Europe. Buddhists in Sri Lanka believed in the healing power of rituals and performed the devil’s dance to evict demons from those afflicted with madness.

Greco-Roman Medicine and the Four Humors

In 770 B.C.E. there were two medical schools in Greece: one in Knidos and one in Kos. Hippocrates, the father of modern medicine, was a doctor at the Kos school. He rejected the notion that diseases were caused by evil spirits and sought a physical explanation. Hippocrates believed that disease was caused by an imbalance of the four major body fluids (i.e. the Four Humors): blood, phlegm, yellow bile, and black bile. In order to restore the correct proportions he used bleedings and vomitive therapies, suction of bile and phlegm, and laxative and dehydrating herbs. He considered madness a disease of the brain and treated patients with baths, rest, diet, and music. 

As in Greece, Roman medicine before Caesar (who brought Hippocratic theory to Rome) was an amalgam of mythology and magic. There were two approaches to madness: the repressive and the therapeutic. One camp viewed madness as the simulation of disease in order to escape social or economic responsibility (sound familiar?), and the other viewed it as the result of tension caused by the patient’s surroundings. For the former, treatment included confinement and torture. For the latter, therapy consisted of rest, music, and pleasant company. This dichotomy of repression and care continues even today.

Shifting Attitudes Toward Mental Illness

Before the rise of modern psychiatry, the mentally ill often weren’t treated at all but were separated from society. Isolation and confinement was the common fate of the economically unprofitable: the mentally ill, the disabled, orphans, and criminals.

The shift from madness to mental illness, that is, the understanding of mental illness as something supernatural to something biological, took off during the Enlightenment. The emphasis on the scientific method and the increased skepticism of religious orthodoxy laid the groundwork for a more scientific approach to mental health and medicine. 

It was during this time that the world began to widely understand mental illness as disease, and thus as something treatable. William Battie, an English physician, was the first to speak of the moral management of the mentally ill. After starting work at St Luke's Hospital for Lunatics, Battie published Treatise on Madness in 1758, in which he critiqued the coercive and barbaric treatment of the mentally ill and advocated for tailored, moral treatment. In France, this shift was led by Philippe Pinel. In his role as superintendent of La Salpêtrière Hospital, he abolished the use of chains for mental patients. In Germany, Johann Reil was the first to use the term “psychiatrie” in 1808. He advanced the idea that madness could be cured and that institutions were the therapeutic means for that treatment. Use of the general term “psychiatry” began in 1816.

Dr. Joseph Guislain, Belgium’s first psychiatrist, brought together two major schools of thought: the theory of  Philippe Pinel and the ideas of Jean-Étienne Esquirol. Pinel thought of madness as a disorder of the intellect and that the cause of madness was the result of the intestines disrupting the brain. (New studies suggest that there actually is a strong connection between the gut and the brain.) His student, Eqsuirol, attached importance to the passions. Esquirol believed that the passions could directly influence the soul and thus madness was a disease of the soul. Guislain argued that insanity is a disorder of the mind and the cause is found in the psyche. He acknowledged the role of biological causes of mental illness, but he placed more importance on fear, sadness, stress, and strong emotions. He also believed that social and cultural factors play a role in the development of mental illness.

Modern Approaches to Mental Health

I often hear people talk about the rise of mental illness, especially in the West, but the treatment of mental illness goes back millennia and extends all over the globe. Madness, neuroses, nerves, melancholia—these all translate to what we today understand as anxiety, depression, and other mental health concerns. I think there is an argument to be made that antidepressants and benzodiazepines are overprescribed, and that the terms "anxiety" and "depression" are misused to describe normal stress and sadness. But the existence and treatment of mental illness is not new.

Today, the rhetoric around mental health is focused on the biological roots of mental disorders. This connection is only strengthened by advancements in brain imaging techniques and genetic sequencing. And as these technologies advance, they can be translated into more precise treatment that is specific to individual patients. Not only are science and medicine advancing, but the conversation around mental illness is changing. There are widespread campaigns to reduce the stigma around mental illness, and the internet provides resources and support to people who might struggle to access it elsewhere.