Concern about increasing rates of severe psychiatric disorders in the United States dates back to the early 19th century. In 1817, for example, an unknown writer in the September issue of North American Review facetiously suggested that "instead of a hospital for the insane, this [proposed] establishment be exclusively appropriated to the use of the sane," since the sane would soon be a small minority. By 1833, one observer noted, "Insanity was once a rare occurrence" but "is no longer rare" (Fuller, 1833, as cited in Jimenez, 1987). State hospitals were built, despite substantial resistance from the taxpayers, at an increasing rate to accommodate the increasing numbers, but the hospitals were filled as quickly as they opened. Dorothea Dix urged state legislatures to build more hospitals, and in 1840 the federal government added an enumeration of insane people to the decennial census.
Edward Jarvis, a prominent psychiatrist of the 1800s, presented a paper to his fellow asylum superintendents in which he asserted, "Insanity is an increasing disease" and that this "corroborates the opinion of nearly all writers" (Jarvis, 1852). In the January 1845 issue of North American Review, a review of I. Ray, M.D.'s, book A Treatise of Medical Jurisprudence of Insanity also noted the "great prevalence of the disease of insanity, and especially its remarkable apparent increase of late years." Between 1880 and 1887, an additional 15 state asylums opened. Most of the existing asylums had been enlarged, some multiple times. In 1870, there had been just two asylums with more than 1,000 patients each; by 1890, there were 17 such asylums, and by 1910 there were 75. Asylum superintendent William Godding, in an 1890 address to his colleagues, reflected on "the rising tide of indiscriminate lunacy pouring through the wards, filling every crevice, rising higher and higher until gradually most distinctions and landmarks have been blotted out."
The increasing prevalence of severe psychiatric disorders, as measured by hospitalization rates, continued steadily until the mid-20th century. The increase was unaffected by World War I, Prohibition, the Great Depression or World War II. Much discussion took place, both among psychiatrists and among the lay public, regarding what might be causing the increase in insanity. Proposed causes included genetics, increasing alcohol(Drug information on alcohol) use, urbanization, industrialization, increased immigration and various concomitants of civilization that might have caused an overload on the brain. In 1916, North American Review called rising insanity "the Apocalyptic Beast" but reassured readers, "Let us be tranquil. The human race is not all going mad" (Harvey, 1916).
A century ago, rising insanity was a major public issue. Yet today, despite the fact that studies suggest the prevalence of severe psychiatric disorders is much higher than a century ago, the issue is never raised. Historians such as David Rothman (1971) assured us, "The rate of insanity in this country has remained constant from before the Civil War to the present," and this assumption, implicit or explicit, is included in every psychiatric textbook. Why did this important issue disappear?
There are several reasons. In the first half of the 20th century, the issue of increasing insanity was rendered irrelevant by beliefs in eugenics and mental hygiene. Insofar as insanity was caused by genetics, restricting reproduction and sterilizing psychiatric patients would solve the problem. Insofar as insanity was caused by bad parenting and early childhood experiences, education for parents and psychotherapy for those afflicted would solve the problem. Despite eugenics and mental hygiene, however, insanity continued to relentlessly increase.
In 1953, Herbert Goldhamer and Andrew Marshall published Psychosis and Civilization, which claimed, "There has been no long-term increase during the last century in the incidence of psychoses of early and middle life." They further noted that their conclusion that no increase had taken place was consistent with psychoanalytic theories "that view the functional psychoses as resulting from repression of basic human drives." The conclusion of Psychosis and Civilization was subsequently widely quoted by textbooks of psychiatry despite the fact that its data appear to contradict the authors' interpretation of it. In an incisive analysis, William Eaton (1980) showed that the authors had used highly selective figures "to support the hypothesis that the rates have not changed."
From the 1960s on, the question of increasing insanity was explained in sociological and Marxist terms. Michel Foucault's influential 1961 Madness and Civilization was followed by books by Andrew Scull, Rothman and a host of other writers who claimed that insanity had not increased. Instead, they said that the 19th-century insane asylums had been built to rid society of "the non-able-bodied poor" (Scull's phrase) or "the deviant and the dependent" (Rothman's phrase). Despite having no factual basis, these views have been remarkably influential. When one examines the historical records, it is clear that the asylums were built in response to the rising tide of insanity, that there was considerable resistance by taxpayers to building them, and that the individuals being hospitalized as insane were, in fact, severely mentally ill and not merely "the non-able-bodied poor." As Edward Shorter noted when discussing the Foucault-Scull-Rothman thesis in his book A History of Psychiatry (1997): "It is astonishing that this interpretation could have achieved such currency as there is virtually no evidence on its behalf."
The final reason why there is no current discussion of the increasing incidence of severe psychiatric disorders is that reports from Scotland, England and Denmark in the 1980s indicated that the incidence of schizophrenia was in fact decreasing. Subsequent studies in Scotland found that the apparent decrease was due to diagnostic changes (Allardyce et al., 2000). Recent reports from Denmark (Tsuchiya and Munk Jòrgensen, in press) and England (Brewin et al., 2002) even suggest that first-admission rates for schizophrenia have increased in recent years.