In 1861 Benedikt Morel, a physician in France, described a terrifying new illness. It involved young people in their late teens or early twenties about to enter what should have been the prime of their lives who instead sank into a profound and seemingly incurable state of what he termed precocious dementia. Morel painted a picture of a terrifying and seemingly close to incurable loss of cognitive function.
In short order all around Europe, there were similar reports of the new illness. Some called it adolescent insanity, others hebephrenia, and later dementia praecox.
A short while before, the English, French and Germans had begun to build the first specialist hospitals for any set of medical disorders. They were designed to promote recovery from mental illness by offering a focus on hygiene and a behavioral approach that would build up the morale of the affected person.
Very soon after opening however the beds filled so that fresh wards had to be built which in turned filled rapidly. Asylum superintendents in their annual reports asked whether insanity was increasing. Those who thought it was, put the changes down to urbanization or industrialization and the increasing pace of modern life.
In mid-nineteenth century, the patients who came into the asylums mostly had melancholia or acute and transient disorders. Very few patients had dementia praecox. But by the end of the century, dementia praecox accounted for by far the largest number of admission.
The early asylums were geared for patients who were expected to recover but few recovered from dementia praecox. Some of these new young mad patients only stayed in hospital for a short time. Three to five years after admission, the women in particular caught tuberculosis and died from it. But among those who did not die from tuberculosis, some were there 10, 20, 30 and in some cases 60 years later. The mission of the asylums changed from recovery to warehousing. The reputation grew that you only ever came out in a box.
Briefly around 1920 soon after its name switched to schizophrenia, the illness became popular. Artists, and others like Carl Jung who thought creatively might be allied to madness were happy to brand their struggles as schizophrenic.
But it is almost impossible to interest the media in schizophrenia now. Nobody wants to have anything to do with this graveyard of hope.
In 1980 a controversy blew up in the ivory towers. Some argued that schizophrenia had only appeared in the nineteenth century and if so we should redouble our efforts to pinpoint a cause – especially as the antipsychotics were definitely not the cure. Indeed worryingly, dementia paralytica (tertiary syphilis – General Paralysis of the Insane/GPI) looked very similar to dementia praecox. If we had had the antipsychotics when patients with GPI came into hospitals they would have controlled these patients just as much as they control schizophrenia making it harder to recognize that penicillin rather than antipsychotics were the cure for GPI.
Most of psychiatry dismissed this idea, as did I. The increase in insanity was apparent rather than real – most argued. We were warehousing awkward patients. Doctors had a conflict of interest – the more patients the more powerful they were.
Then the data on admissions to the North Wales asylum fell into my hands. Yes there was an increase in first admissions for insanity in line with increases in the population. But beyond this there was a tripling of first admission rates for schizophrenia between 1875 and 1905 over and above the increases linked to population change, while the rates of admission for other disorders remained constant.
These findings cannot be explained by industrialization, urbanization, or culture change as North West Wales did not urbanize, or industrialize and had no shift in ethnic mix.
All the old textbooks from 1900 say schizophrenia affected men and women equally. All the textbooks from 2000 say it affects 2 or more men for every woman. In our records the figures for 1875-1924 show almost exactly the same number of women and men but the figures for 1994 to 2010 show 2 men for every woman. (See Healy et al, 2012).
But even more surprising, starting in 2005, perhaps a good deal earlier for women, first admission rates for schizophrenia have plummeted. Other surveys which look at admission rates for schizophrenia will miss this as first admissions only account for 15% of admissions. The figures have dropped from 15-20 new cases per year to 5 per year – figures not seen in North Wales since 1876.
A ward has closed. This is the kind of thing that speaks louder than academic articles.
What’s going on? The drop cannot be explained by early intervention services or home treatment teams or any other change in service because there has been no change of service in North Wales during this time.
The North Wales nineteenth century figures nail down for the first time a specific increase in schizophrenia reinforcing calls to pinpoint what might have caused it. The modern data add to the urgency of these calls. While the factors that led to this increase in schizophrenia may not be the same as those leading to its decrease now, it would be very satisfying to find something that might both account for some of the increase and some of the decrease.
Two strong candidates come to mind. In the nineteenth century we began to use lead for more and more purposes. Lead pipes carried our water. Lead solder closed the tin cans in which food was increasingly put. Lead was added to food and even to the medicines we took. The paint we coated our houses in had high concentrations of lead. The paint on bars of cots that teething babies gnawed on were impregnated with lead. Our children wrote with lead pencils in school. When the automobile arrived, we put lead in gasoline and concentrations of lead in urban air grew rapidly.
Lead is neurotoxic to children in particular. If the brain damage it can cause is what made some psychoses chronic in later life, then to see a drop in admission rates around 2005 in North Wales, where lead was once mined, we would want to see a fall in lead concentrations around 1980. And in 1980 lead was being removed from water-pipes, paint, gasoline, and had already been removed from food and medicines. The soil concentration of lead in North Wales began falling fast at this time. Elsewhere in the USA in particular, rates of admission for schizophrenia track lead levels and those admitted have higher levels of lead than controls.
Another possibility lies in changing childbirth practices. In mid-nineteenth century we introduced anesthesia and this led male obstetricians to ever greater feats of heroism with forceps and other instruments, delivering blue and sometimes close to black babies from “mid-cavity”. Around 1980 there were major changes in practice with increased rates of Caesarean Sections and the active management of labor aimed at delivering pink babies.
It would be wonderful to pinpoint a cause. We are probably though looking for a cause for chronicity rather than a cause for schizophrenia. What may be happening is that what might have been acute and transient psychoses against a background of subtle brain insults turn into chronic psychoses. The question then will be what the original conditions look like – are they in fact acute and transient psychoses?
Some reviewers of our findings have been intensely hostile. They seem to hear a message that mental illness is disappearing. It isn’t. In same way that we will have respiratory illnesses as long as we have respiratory systems, but respiratory disorders like tuberculosis rise and fall – this is what happens to real medical disorders, so also as long as we have brains we will have mental disorders but specific disorders like dementia paralytica and dementia praecox can come and go.
There is good news here for anyone interested in recovery in mental disorders. The patients we see in future may be much more likely to recover. This opens up the possibility of reconfiguring services. But if something like lead poisoning once made some psychoses chronic we need to keep an eye out for other things that might do this in future. For example we should track what the outcomes are when we save intensely premature babies – in so doing do we cause the kind of damage that might lead on to chronic psychosis.
There is a message for anyone treating chronic psychoses. The patients are right when they say the drugs don’t cure. The antipsychotics can be helpful if used judiciously but realizing that a cure is not going to appear if we just hammer the dopamine system a little bit harder might let us devise more sensitive and nuanced treatment approaches.
We need more sensitive and nuanced approaches because at present more patients are dying earlier than they should and these deaths are linked to the way we are using antipsychotics.