It is now difficult to believe that the last of the Victorian asylums was shut only in the 1990s. It marked the end of a period of reassessment for the mental health sector, resulting in the acceptance that mental health patients are not ill for ever and do not need to be locked away.
Many treatments that were applied in the asylums have also been phased out. And the efficacy of those that do remain are liable to be challenged by experts.
Electro-convulsive therapy ceased being widely used in the 1970s, although it is still administered with an anaesthetic on older patients to treat severe depression. Which is where the doubts arise.
Sophie Corlett, policy director at Mind, says: “It is not clear that older people have more instances of treatment-resistant
depression. We are also uneasy with ECT being used forcibly on people who have the capacity to refuse.”
Although the closure of the asylums was welcomed, few doubt that something more socially inclusive should have been put in place. Corlett says: “We have shut the long-stay wards but not fully backed up the commitment to community provision with good quality services.”
Insulin shock therapy (IST) was introduced in the 1930s as a treatment for schizophrenia and psychosis. A massive quantity of insulin would be injected into a patient to reduce blood sugar and bring on a coma. After about an hour, the patient would be revived with injections of glucose.
This treatment was used well into the 1950s when it was replaced by tranquillising and anti-psychotic drugs. IST was dangerous if the coma induced was too deep or the quantity was misjudged. Lobotomies, which had been used to treat schizophrenia, clinical depression and various anxiety disorders, also began to lose favour.
Mental health care now involves a complex system of assertive outreach, crisis resolution, early intervention and community mental health teams. Andrew McCulloch, chief executive of Mental Health Foundation, says: “Treatments have not been eliminated but the care regime has changed. Some things in the old institutions were good – the horticultural aspects and open spaces. The Victorians were right to build asylums to provide refuge for people who would otherwise be on the street.”
However, he says, treatments and drugs were sometimes administered experimentally. Mostly, life in an asylum was one of
separation from the community. Care in the community varies from best practice, where there is social inclusion in terms of “work, church, leisure”, to worst practice, where people are rejected by the community and isolated in flats.
“The benefits of community care are realised only if the care is of a sufficient quality,” says McCulloch. “We thought that closing the institutions had solved the problem. Then we realised that some people require intensive ongoing care and we were slow to put that in place, which led to community care scandals. We haven’t fully implemented the system the government has put forward. Access to psychotherapy is still poor.”
Gil Hitchon, head of Together, finds the focus on cognitive behavioural therapy useful because it directs attention to talking treatments. These, with the growth of the service user movement, will lead to what he calls a “well-being agenda”. He says mental health care is often treated as a public safety matter by politicians, no more so than in its plans to amend current legislation.
Corlett says: “Sixty years ago we probably didn’t know that much about mental health and the right treatment. We’ve moved dramatically in terms of what we know but slowly in terms of what we provide.”
This article appeared in the 5th October issue, pages 30 & 31 under the headline “It wouldn’t happen today”