A history of mental health care

Trepanation — cutting or scraping a hole in the skull — is the oldest known surgical procedure, with securely dated examples from as early as 6500 BCE at a burial site in France.

By around 400 BCE, the Hippocratic text “On the Sacred Disease” argued that epilepsy had a natural, bodily cause rather than a divine one.

Hippocratic medicine, developing in Greece from the 5th century BCE, explained both physical and mental illness as an imbalance among four bodily humors: blood, phlegm, yellow bile, and black bile.

Physician Asclepiades of Bithynia, active in Rome around 124–40 BCE, rejected humoral theory and treated mentally ill patients by freeing them from confinement and using diet and natural remedies instead.

Between roughly 98 and 138 CE, the Greek physician Soranus of Ephesus argued against harsh restraint, recommending soft wrappings, calm surroundings, and conversation instead.

In 805 CE, Caliph Harun al-Rashid founded a hospital, or bimaristan, in Baghdad — widely regarded as the first true general hospital, treating the mentally ill alongside other patients.

Physician al-Razi (Rhazes, 865–925 CE) directed a Baghdad hospital that set aside a ward exclusively for patients with mental illness.

In 1284, Mamluk sultan al-Mansur Qalawun founded Cairo’s al-Mansuri hospital, which treated mental illness among its many services and turned away no patient for inability to pay.

The Priory of St Mary of Bethlehem was founded in London in 1247; its earliest surviving record of mentally ill patients dates to 1403, when a visitation described six inmates as “mente capti.”

From the mid-1200s the Flemish town of Geel became a center of family-based care, after pilgrims to the shrine of Saint Dymphna were taken in as boarders by local households — a tradition that continues today.

Jean-Baptiste Pussin, a former patient who had worked at Paris’s Bicêtre Hospital since 1771, was already using nonviolent, observation-based patient care before physicians took notice of his methods.

In 1797, Pussin instituted a permanent ban on the use of iron chains to restrain patients at Bicêtre.

In 1795 Pinel became chief physician at the Salpêtrière and arranged for Pussin to join him; in 1796 Pinel ordered chains removed from 80 patients.

A Quaker woman named Hannah Mills died in 1790, shortly after admission to the York Asylum, after local Quakers were refused permission to visit her.

Prompted partly by Mills’s death, tea merchant William Tuke opened the Retreat near York in 1796, replacing bloodletting and purging with routine, occupation such as sewing and knitting, and warm baths.

In 1812, physician Benjamin Rush published “Medical Inquiries and Observations upon Diseases of the Mind,” the first American textbook on mental illness.

Between 1841 and her death in 1887, Dix’s advocacy contributed to the establishment or expansion of 32 mental hospitals across the United States and Canada.

Thomas Story Kirkbride’s 1854 treatise set out a design — later called the “Kirkbride Plan” — built around light, fresh air, and wings meant to hold about 250 patients each.

By the 1880s many state asylums held far more patients than designed: New York’s institutionalized population grew from 5,673 in 1870 to 13,538 by 1886.

In 1887, journalist Nellie Bly went undercover for ten days at the Women’s Lunatic Asylum on Blackwell’s Island; her exposé prompted a grand jury investigation and an $850,000 budget increase.

Sigmund Freud’s “The Interpretation of Dreams,” which introduced his theories of the unconscious and dream analysis, was completed in 1899 and published with a 1900 date on its title page.

In September 1909, Freud delivered five lectures on psychoanalysis at Clark University in Worcester, Massachusetts — the only lectures he ever gave in the United States.

German psychiatrist Emil Kraepelin formally distinguished “dementia praecox” (later renamed schizophrenia) from “manic-depressive insanity” in the sixth edition of his psychiatry textbook in 1899.

Clifford Beers published his memoir, “A Mind That Found Itself,” in 1908, describing his mistreatment during confinement in Connecticut and Massachusetts mental institutions from 1900 to 1903.

In 1909, Beers co-founded the National Committee for Mental Hygiene with psychiatrist Adolf Meyer and philosopher William James, launching the mental hygiene movement in the United States.

In 1927, the U.S. Supreme Court ruled 8-1 in Buck v. Bell that Virginia’s forced sterilization of Carrie Buck did not violate the Constitution — a ruling never formally overturned.

An estimated 60,000 to 70,000 Americans were involuntarily sterilized under eugenics laws in more than 30 states, a practice that continued into the 1970s.

In 1935, Portuguese neurologist Egas Moniz developed the prefrontal leucotomy, for which he was awarded the Nobel Prize in Physiology or Medicine in 1949.

In 1946, Walter Freeman introduced the transorbital lobotomy in the United States — about ten minutes, outside an operating room. U.S. lobotomies are estimated at up to 50,000, most between 1949 and 1952.

Chlorpromazine, the first antipsychotic, was introduced in France in 1952 and reached the U.S. as Thorazine in 1954, rapidly displacing insulin coma, metrazol, and lobotomy.

In 1952, Henri Laborit, Jean Delay, and Pierre Deniker, at Sainte-Anne Hospital in Paris, demonstrated chlorpromazine’s calming effect on psychiatric patients — the first effective antipsychotic medication.

On October 31, 1963, President Kennedy signed the Community Mental Health Centers Construction Act — the last bill he signed before his assassination three weeks later.

The Act envisioned roughly 1,500 federally funded community mental health centers nationwide; only about half were ever built.

The U.S. state psychiatric hospital population peaked at about 558,000 to 560,000 patients in 1955 and fell to roughly 137,000 by 1980 as deinstitutionalization accelerated.

The American Psychiatric Association published the first Diagnostic and Statistical Manual of Mental Disorders (DSM-I) in 1952, followed by DSM-II in 1968.

On December 15, 1973, the APA’s Board of Trustees voted to remove homosexuality from the DSM; about 58 percent of roughly 10,000 voting members upheld the decision in a 1974 referendum.

In 1980, DSM-III introduced explicit diagnostic criteria and an atheoretical approach that did not assume a cause for each disorder — a shift led by Robert Spitzer’s task force.

Aaron Beck published his first paper on cognitive therapy, “Thinking and Depression,” in 1963, followed by “Cognitive Therapy and the Emotional Disorders” in 1976.

In 1957, Carl Rogers proposed that a therapist’s empathy, congruence, and unconditional positive regard were necessary conditions for therapeutic change.

NAMI was founded in 1979 in Madison, Wisconsin, by family members frustrated by inadequate care and by being blamed for their relatives’ illnesses — the first large-scale grassroots mental illness advocacy group in the United States.

The Americans with Disabilities Act, signed into law on July 26, 1990, extended civil rights protections to people with psychiatric disabilities, including depression, bipolar disorder, PTSD, and schizophrenia.

In Olmstead v. L.C. (1999), the Supreme Court ruled 6-3 that unjustified institutional segregation of people with disabilities is discrimination under the ADA, and that states must offer community-based services.

The Mental Health Parity and Addiction Equity Act of 2008 required parity in copays, deductibles, treatment limits, and network coverage, and extended protection to substance use disorder treatment.

During the COVID-19 pandemic, outpatient telehealth visits for mental health and substance use care rose from near zero in 2019 to a peak of about 40% of all such visits in mid-2020.

The 988 Suicide & Crisis Lifeline launched in July 2022, replacing the original 10-digit National Suicide Prevention Lifeline with a three-digit number reachable by call, text, or chat.

The Mental Health Parity and Addiction Equity Act of 2008 requires parity in copays, deductibles, treatment limits, and network coverage, and covers substance use disorder treatment.

By 2003, the President’s New Freedom Commission on Mental Health called for transforming U.S. mental health care into a “recovery-oriented system” — building on the peer support movement former patients had been building since the 1970s.

According to SAMHSA and the National Association of Social Workers, professional social workers are the largest single group of mental health service providers in the United States, outnumbering psychiatrists, psychologists, and psychiatric nurses combined.