Greg Eghigian, PhD

As we all try to acclimate ourselves to the rapidly changing circumstances brought about by the 

, comparisons are being made between this pandemic and the so-called 

 was that Spain was one of the only countries at the time to not censor reports of cases, and so it was widely publicized there by late-fall 1918.) The Spanish flu proved to be peculiar for several reasons, most noteworthy of course due to the high morbidity (as many 500 million were infected) and mortality (around 50 million deaths). It also came in waves. In the US, there were four such waves: first in spring 1918, again in August 1918 (epidemiologically the most devastating of the four), yet again in winter 1918/1919, and a final return in early 1920. Finally, the disease was unlike most flus in that it decimated even the traditionally more robust segments of the population (ages 20-40), taking the lives of many within 3 days of showing symptoms.

Since the pandemic of the Spanish flu, researchers dedicated themselves to identifying the origins and nature of the virus. It took decades, however, before virologists succeeded. Starting in the mid-1990s, 

, and his team were able to carry out a sequence and phylogenetic analysis of 1918 influenza virus genes and identified it to be an H1N1 virus of avian origin.

Until around 1970, historical research about the pandemic had been virtually non-existent. Some novels and popular histories appeared over the decades, but it was Alfred Crosby’s 1976 book 

America’s Forgotten Pandemic: The Influenza of 1918

) that paved the way for international research about the subject.

 One of the book’s major achievements was to draw attention to the fact that the pandemic quickly disappeared as a topic of public conversation soon after it was over, ignored by periodicals and textbooks for decades. To many historians, this collective silence is as much a part of the pandemic’s story as the course of the disease itself.

In comparison to other aspects of the pandemic, little research has been done on the long-term impact of the Spanish flu on mental health. One of the few researchers to investigate the subject was historical demographer 

 Looking at asylum hospitalizations in Norway from 1872 to 1929, Mamelund found that the number of first-time hospitalized patients with mental disorders attributed to influenza increased by an average annual factor of 7.2 in the 6 years following the pandemic.

 In addition, he pointed out that Spanish flu survivors reported sleep disturbances, depression, mental distraction, dizziness, and difficulties coping at work, and that influenza death rates in the United States during the years 1918-1920 significantly and positively related to suicide.

Mamelund is among a number of scholars who have noted what many suspect to be a connection between the Spanish flu and a pronounced increase in neurological diseases. By 1919 and 1920, physicians and researchers in Great Britain were already reporting a marked rise in nervous symptoms and illnesses among some patients recovering from influenza infection; among other symptoms, depression, neuropathy, neurasthenia, meningitis, degenerative changes in nerve cells, and a decline in visual acuity were cited.

Encephalitis lethargica: another connection or vulnerability?

 coincided with the Spanish flu; it reached epidemic proportions alongside the Spanish flu. As Hoffman and Vilensky have recently described, the syndrome was characterized by two, often, blended phases:

During the acute phase, patients typically experienced excessive sleepiness, disorders of ocular motility, fever, and movement disorders, although virtually any neurological sign or symptom could be exhibited, with day-to-day, and even hour-by-hour shifts in symptomatology. The chronic phase could occur months to years later and was most commonly characterized by parkinsonian-like signs.

Psychiatrists and neurologists first reported encountering encephalitis lethargica symptoms in 1916 and 1917 in Austria and France. By 1919, cases had become common throughout Europe, the United States, Canada, Central America, and India. All told, approximately 1 million people worldwide were affected by encephalitis lethargica between its outbreak in 1916 until the early 1930s. While many clinicians (both at the time and since then) have surmised an association between encephalitis lethargica and the Spanish flu,

 there is no conclusive evidence of causality.

Some medical and social historians have been tracing connections between the pandemic and the other catastrophic global event of the time-World War I. In this regard, historians have flagged the ways in which the war efforts depleted medical personnel, helped disseminate the virus through the mobilization of troops, and created the conditions for the mutation of an otherwise mild flu virus.

When it comes to mental health, the historical record shows that the pandemic, like the war, took a toll on the emotional resilience of those not (or not yet) in harm’s way. The massive and sudden loss of life plunged many into a chronic state of helplessness and anxiousness. A large portion of the population were affected by the loss of loved ones. Parents had to come to grips with losing a child (or even several children), while some children suddenly found themselves parentless. In November 1918, 31,000 children in New York City alone had lost one or both parents. For others, the experience left them feeling a mix of guilt, anger, confusion, and abandonment. Surviving health professionals were not immune to such sentiments, with many of them noting that they were haunted by a sense of frustration and grief, even years later.

Like all mass encounters with infectious disease, the Spanish flu pandemic had its own unique features. If history teaches us anything, it is that we should always be measured in how we glean lessons from the past. That said, the example of the influenza of 1918-1920 gives us reason to expect that the present pandemic will carry in tow its own set of mental health challenges.

This article was originally posted April 3, 2020, and has since been updated. -Ed

is professor of history at Penn State University. He specializes in the history of psychiatry and mental health and is member of the 

The Origin and Virulence of the 1918 ‘Spanish’ Influenza Virus

Proceedings of the American Philosophical Society

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Effects of the Spanish Influenza Pandemic of 1918-19 on Later Life Mortality of Norwegian Cohorts Born About 1900

https://www.researchgate.net/publication/5097223_Effects_of_the_Spanish_Influenza_Pandemic_of_1918-19_on_Later_Life_Mortality_of_Norwegian_Cohorts_Born_About_1900

Parkinsonism and Neurological Manifestations of Influenza Throughout the 20th and 21st Centuries

Encephalitis Lethargica: 100 Years After the Epidemic

Out in the Cold and Back: New-Found Interest in the Great Flu.

The Recent Wave of ‘Spanish’ Flu Historiography.

American Pandemic: The Lost Worlds of the 1918 Influenza Epidemic

Oxford and New York: Oxford University Press; 2012.

Articles

Have we learned anything? Looking back at the Spanish flu epidemic as the world deals with the COVID pandemic.

The Spanish Flu Pandemic and Mental Health: A Historical Perspective

The DSM has recognized trauma- and stress-related disorders since its third edition in 1980. Historians of psychiatry have shown that the contemporary concept of a traumatic stress disorder first began to take shape in the wake of World War II, when the debilitating effects of Nazi persecution and murder on its victims began to be looked at as health problems for those affected.

 Since then, a wide range of ex-political prisoners-including those from Chile, Iran, Myanmar, Palestine, South Africa, and Vietnam, to name just a few-have been examined and discussed by mental health specialists.

Among the most studied have been former political prisoners of the German Democratic Republic (GDR) or more commonly known as East Germany. The communist state there, founded in 1949, proved to be uncompromising with any citizen who appeared to be out of step with its directives, establishing a relentless state police apparatus (the Stasi) and a system of prisons and youth work camps.

Though the regime came to an end in 1989 with the fall of the Berlin Wall, it is estimated that at its height in the 1980s, the GDR held around 200,000 political prisoners. A 2013 follow-up 

of 93 such inmates found that “results indicate a trauma-related long-term morbidity,” albeit one that is “less stable than previously assumed.”

 now provides us with an intimate look at the toll imprisonment has had on some of these former captives. 

) offers four ex-political prisoners a chance to discuss their experiences frankly and in their own words. In June of this year, I was invited to attend a screening of the film in Berlin, followed by a question and answer session with director JÃ¼rgen Haase and two of the film’s featured subjects.

Karl-Heinz Bomberg was a physician and singer-songwriter, when he was charged with “anti-state agitation” and placed in a Stasi-run jail. Writer and human rights activist Siegmar Faust was also arrested for “anti-state agitation” and sentenced to three and a half years detention. Katrin BÃ¼chel is now a photographer, but after running away from home in her youth, she was placed in reeducation work camps over four years, deemed to be a girl with “authority issues” and “personality abnormalities.” Thomas Hannemann, a mechanic, was given a sentence of four and a half year for attempting to escape the country. Together, they provide a compellingly stark glimpse into the experiences of political detainees there.

The first part of the film chronicles their initial encounters with arrest, interrogation, and detention. Siegmar Faust, for instance, recalls thinking at the time that everything was like out of a movie one sees about the Nazis. “I didn’t do anything. This can’t be happening,” he remembers saying to himself. Most of them also describe an overwhelming sense of helplessness and loneliness, as they were badgered by interrogators, put in dark cells, and isolated from their families and other inmates.

For those having gone through it, the time spent in solitary confinement proved to be the most torturous. Karl-Heinz Bomberg recalls being beset by sweats and panic attacks. Thomas Hannemann found the absence of anyone to talk to and anything to do especially crippling. The experience was arguably even more vexing for Katrin BÃ¼chel, who was still a minor at the time of her confinement. She was sent to the high security youth camp at Torgau at one point, for exhibiting what records show was a dizzying array of red flag indicators, including “deviant behavior,” anxiety, sedition, petulance, bedwetting, thumb sucking, bullying, and feeling insulted. Placed in solitary confinement, wet, cold, afraid, and anxious, she tried to kill herself. While she didn’t succeed, others did.

The lack of personal freedom was not the only brutalizing feature of imprisonment. BÃ¼chel and other youth work camp detainees were forced to take part in reeducation drills, including presenting talks in which they had to recite communist party dogma. Thomas Hannemann’s daughter was given up for adoption following his arrest. And Karl-Heinz Bomberg speaks of coming to the “catastrophic” realization that any number of his fellow inmates were actually operating as informants to the police.

Release from internment brought immediate relief to all of the subjects of the film-but the solace proved short-lived. Each describes how, even now, unforeseen effects of their detention have haunted them. Siegmar Faust recounts how small, mundane things and encounters would prompt him to burst into tears and how he constantly had to remind himself that ordinary conversations were not interrogations. The singer and clinician 

 notes that he still finds himself swept up in a perpetual vigilance, a compulsion to always be on the look-out. BÃ¼chel continues to have trouble sleeping and trusting others. Thomas Hannemann likewise has difficulties with sleep, but he is also plagued by a variety of aches and pains and is easily rattled when hears a heavy door closing. “Everything is still very present,” he laments.

The discussion following the film provided the director JÃ¼rgen Haase along with BÃ¼chel and Bomberg to discuss the making of the film (which was seven years in development) and address comments and questions from the audience. As is frequently the case when life in East Germany is discussed in public forums in Germany, the conversation at times turned into a referendum on the former regime and its legacy. Was the GDR totalitarian? To what extent do former East German citizens deliberately avoid hearing about these kinds of abuses? Why is it that it falls to the victims to raise these matters and demand recognition? Exchanges were sometimes quite heated. And maybe that is to be expected. As historians and mental health professionals both know, in the words of the writer William Faulkner, “the past is never dead. It’s not even past.”

Perhaps the most poignant moment of the evening, however, came when Katrin BÃ¼chel was asked if she ever talked to her parents about this chapter in her life. “No,” she said. She paused. But her daughter at age 21 asked her if her experiences left her ashamed of East Germany. “Unfortunately, I had to say, I am ashamed,” BÃ¼chel admitted with resignation.

Editor's note: There is no link to the film at this time. Some information can be found 

Dr Eghigian is Professor of History, Penn State University, State College, PA. He is the History of Psychiatry Editor for

The War in Their Minds: German Soldiers and Their Violent Pasts in West Germany.

 Ann Arbor, MI: University of Michigan Press; 2017.

Die Politik des Traumas: Gewalterfahrungen und psychisches Leid in den USA, in Deutschland und im Israel/PalÃ¤stina-Konflikt

3. Zajde N. Die Schoah als Paradigma des psychischen Traumas. 

The History of the Stasi: East Germany’s Secret Police, 1945-1990.

5. Maercker A, GÃ¤bler I, SchÃ¼tzwohl M. VerlÃ¤ufe von traumafolgen bei ehemaligen politisch inhaftierten der DDR: Ein 15-Jahres-follow-up [

Course of trauma sequelae in ex-political prisoners in the GDR: A 15-year follow-up study

As historians and mental health professionals both know, in the words of the writer William Faulkner, “The past is never dead. It’s not even past.”

The Legacy of Political Persecution

The 20th century introduced a number of new concepts to psychiatry and clinical psychology. One of the most influential has been the notion of personality. Carl Jung, Gordon Allport, Abraham Maslow, Harry Stack Sullivan, and Carl Rogers are just a few of the early figures who, starting in the 1920s, developed theories and models designed to capture the inner core of human subjectivity (or the “self,” as Rogers put it). But while their names and ideas continue to resonate, time has proven less kind to another psychological project that played out at the same time. This was characterology.

Coined in 1867 by Julius Bahnsen, a student of the philosopher Arthur Schopenhauer, characterology was associated primarily with Germany. It is there that it began to take hold and thrive, with the founding of the field’s two major journals in the mid-1920s: 

Jahrbuch fÃ¼r Charakterologie (Yearbook for Characterology)

Zeitschrift fÃ¼r Menschenkunde (Journal for Human Studies)

Characterology emerged as a type of character analysis following along the lines of the clinical assessment of functional disorders in the 19th century. This was an assessment that involved examining a patient for outward signs indicating a psychopathology or at least a proclivity toward some pathological state of mind. The approach was beholden in no small measure to the work of the France-based psychiatrist BÃ©nÃ©dict Morel (1809-1873), whose theory of degeneration held that most mental disorders were due to corrupt hereditary constitutions and that these corruptions were reflected in observable physical stigmata and behavioral abnormalities.

 Characterology’s innovation was to extend this kind of evaluation to populations beyond those deemed “abnormal,” in order to identify those traits that drove an individual’s will and conduct.

In Germany, characterology’s star began rising in the 1920s and 1930s, when industry and the public sector began seeing the value in applied psychology. Both psychotechnics and vocational counseling were beneficiaries of this growing interest. So too was characterology, whose practitioners at the time placed less emphasis on testing and quantitative measures and more on the observation and interpretation of expressions of virtues, such as patience, independence, love of order, and calmness.

How then did characterologists propose doing this?

One way was developed by psychiatrist Ernst Kretschmer (1888-1964), which he laid out in his influential book 

 in 1921. He argued that two types of constitutions-a cyclothymic and a schizothymic-are at the core of human character to varying degrees. Moreover, human beings are born with one of three basic body types: asthenic, pyknic, and athletic, and these body types are closely associated with contrasting pairs of character features. Individuals of the pyknic variety, for instance, he believed, temperamentally fluctuate between joviality and despair. Thus, if Kretschmer’s model was accurate, it was possible to read character features and predilections by simply inspecting a subject’s physique.

Psychologist Ludwig Klages (1872-1956) offered another technique: graphology. The notion that a bodily movement like handwriting could provide direct insight into the soul or character of a person was not new, having been the subject of treatises dating back to at least the 17th century. What Klages and others did by the early 20th century, however, was to tie handwriting directly to neurology, understanding the activity to be a form of expression that projected facets of a person’s inner core.

Klages’s graphology was hardly an innocuous exercise. Instead, it was bound up in the psychologist’s dark vision of the modern world. Like many of his reactionary contemporaries, Klages considered modernity to be dangerously superficial and chaotic in a way that undermined the ability of human beings (and Germans in particular) to fully realize themselves. The world therefore needed a way to differentiate between authenticity and falsehood, between genuine virtue and corrosive subterfuge. Characterology and graphology were therefore conceived as tools capable of breaking through the veneer of a person and exposing his or her true nature.

As historians Per Leo and Nitzan Lebovic have shown, Klages in particular argued for there being a natural, racial inequality separating groups of human beings, one that penetrated deep into the body and mind. Here characterology intersected with the toxic anti-Semitism of its time, holding to the view that Jews literally embodied this inequality, casting them as perpetual outsiders, but ones who disguised their true selves.

 It therefore should come as no surprise that under the Nazis characterology flourished.

It needs to be pointed out, however, that interest in character was not limited to Germany. During World War II, for instance, a number of American cultural anthropologists volunteered their services and knowledge to aid in the war effort against Nazi Germany and Imperial Japan (and they would go on to continue this work during the early years of the Cold War). They engaged in what was referred to as “studies of culture at a distance,” a form of applied anthropology intended to serve the interests of the US and framed as the study of national characteristics. Japan, Germany, Russia, Britain, and Poland, all became subjects for these kinds of analyses, which were subsequently criticized for simplifying complex communities and relations.

One of the most famous anthropologists engaged in this project was Margaret Mead (1901-1978). Among her tasks was to collaborate on an initiative of the Council on Intercultural Affairs in New York City to study the “national character” of Axis powers and, later on, the assimilation of minorities in the US along with “our American character.” Publishing the results of her analysis in 1942 in the book 

, Mead argued for rejecting racist essentialisms about groups, while also insisting on the consistency of certain traits among ethnic communities: environment and upbringing, not blood, were the formative elements in national character. And while she invariably invoked an idea of “whiteness” indebted to European prejudices, she held that Americans distinguished themselves from Europeans by giving everyone in society a chance to realize their full potential, thus making the US a more adaptable society.

 That said, despite contending that Japanese-Americans were essentially American in their make-up and conduct, she and her colleagues appear to have done nothing to speak out or campaign against the forced detention of Japanese-Americans during World War II.

In Europe, after the war, characterologists continued their work throughout the 1950s and early 1960s. But times were changing. As West German researchers and clinicians increasingly turned to the US for inspiration, they found themselves drawn to “trait-and-factor” methods instead. The idea was no longer to uncover supposedly fixed character traits, but rather to identify the general aptitudes, adaptabilities, and interests of a person.

 As a result, a more dynamic and developmental concept of “personality” replaced “character” in academic and professional circles.

Dr Eghigian is Professor of History, Penn State University.

Faces of Degeneration: A European Disorder

, c. 1848-c. 1918. Cambridge: Cambridge University Press; 1993.

 Meskill D. Characterological psychology and the German political economy in the Weimar period (1919-1933). 

 Stanghellini G, Broome M, Raballo A, et al. 

The Oxford Handbook of Phenomenological Psychopathology

. New York; Oxford: Oxford University Press. 2019.

 SchÃ¤fer A. Graphology in German psychiatry (1870-1930). 

The Philosophy of Life and Death: Ludwig Klages and the Rise of Nazi Biopolitics

 Neiburg F, Goldman M. Anthropology and politics in studies of national character. 

 Hazard Jr, AQ. Wartime anthropology, nationalism, and ‘race’ in Margaret Mead’s 

 Mabee C. Margaret Mead and behavioral scientists in World War II: problems in responsibility, truth, and effectiveness. 

 Meskill D. Psychological testing and the German labor market, 1925 to 1965. 

The 20th century introduced a number of new concepts to psychiatry and clinical psychology. One of the most influential has been the notion of personality.

Before Personality: Character Assessment and Its Troubled History

Dr Eghigian is Professor of Modern History and Former Director of the Science, Technology, and Society Program at Penn State University. He is the History of Psychiatry Editor and an editorial board member of 

A year ago, I edited a collection of articles by some of the world’s leading historians of psychiatry and mental illness.

 The purpose of the collection was to take a snapshot of historical research on mental illness-an assessment of what has been accomplished, how the field is changing, and what some of the new directions for scholarship may be as we forge ahead.

To that end, it seemed important to conceive of the project broadly: consider developments from ancient times to the present, be global in scope, and gain the perspectives of researchers from throughout world. No book can claim to be exhaustive, and this one is no exception. Still, the volume provides a glimpse at some of the work going on in the history of psychiatry. So, then, here are five trends that are shaping historical research today.

1. The stigma associated with mental illness is perennial

In the 1970s and 1980s, many historians of psychiatry found inspiration in the sociology of deviance and so-called labelling theory pioneered by the likes of Howard Becker, Erving Goffman, and Thomas Scheff. This led to studies-such as Klaus DÃ¶rner’s

Madmen and the Bourgeoisie: A Social History of Insanity and Psychiatry

The Female Malady: Women, Madness, and English Culture, 1830-1980

Museums of Madness: The Social Organization of Insanity in Nineteenth Century England

-that explored how asylums served to isolate and discipline socially marginalized populations. The social stigma attached to mental illness appeared to trigger efforts aimed at social control.

Historians continue to find ample evidence dating back to the ancient world that the afflicted have routinely faced ridicule and scorn. That stigma, it appears now, is often superimposed on top of other ones. University of Richmond historian Manuella Meyer,

 for instance, has pointed out that research in Argentina, Bolivia, and Mexico demonstrates that indigenous populations, the poor, and women there have been disproportionately labelled as mad, especially when perceived to be resisting prevailing social hierarchies.

2. Historians are taking another look at spaces and objects

Perhaps it is to be expected that historians of psychiatry would-as they have-tend to focus on clinical concepts, research methods, and doctor-patient relations. After all, these seem to have been the chief preoccupations of healers and investigators. That said, already by the 1980s and 1990s, historians were pointing out that things like asylum architecture and the use of physical restraints also had a profound impact on care. Now some historians are chronicling how a host of other material objects have played important, yet often overlooked, roles in treatment facilities.

 Gates, windows, doors, floors, gardens, clothes, beds, pills, television sets, and cigarettes: all are coming under careful scrutiny, as historical sources show each was considered to have therapeutic, sedative, disciplinary, and symbolic functions.

3. Yes, European and American psychiatry went global, but . . . 

The topic of globalization has drawn considerable attention from historians in recent years, and historians of psychiatry have been no exception. It is becoming clear that the much-cited international influence of the DSM since the 1980s

 is part of a much longer process. Already in the 19th century, psychiatric ideas, techniques, and institutions rooted in Western Europe began spreading to every continent.

This tended to happen in one of two ways. In North and South America and in East Asia, reformers interested in modernizing their societies found inspiration in European models, which they then attempted to emulate. In places like Africa and South Asia, however, colonial regimes were responsible for introducing asylums and psychiatric concepts to the region, often with disastrous consequences. That said, historians like Sally Swartz

 (University of Cape Town) and Waltraud Ernst

 (Oxford Brookes University) have been careful to point out that many of these imperialist efforts were on such a small scale and so hampered by a lack of knowledge about indigenous conditions that their influence was severely limited.

4. Any distinction drawn between biological and psychotherapeutic treatments needs to be qualified

By the 20th century, it had become common throughout the Western world to speak of there being a stark difference between psychological and somatic interventions in mental health. In more recent times, however, the results of epigenetics and research on neuroplasticity have led observers to question the notion of there being a bright line separating life experience and the body. Historians, too, are finding reason to question a clear-cut mind/body distinction, particularly when it comes to forms of treatment.

Records show that ancient, medieval, and early modern healers routinely mixed comforting conversation with dietary and hygienic instructions, often combining them with incantations, prayer, and visits to holy shrines. As historian Jonathan Sadowsky

 (Case Western Reserve University) has pointed out, most societies have treated mental illness eclectically. Ostensibly, physical treatments have always aimed at promoting spiritual or mental well-being, just as psychotherapies have been touted for having somatic effects on clients.

5. Historians remain dubious about retrospective diagnosis

While the Goldwater Rule has largely succeeded in keeping psychiatrists from publicly commenting on the mental health of prominent individuals whom they have not examined, historical figures have generally been considered fair game for evaluation. Biographers and psychoanalytically trained psycho-historians have long taken it upon themselves to assess a host of famous personalities in history, including Martin Luther, Abraham and Mary Todd Lincoln, Adolf Hitler, T.E. Lawrence, Joseph Stalin, and Emily Dickinson. Historians of psychiatry, however, generally express reservations about applying contemporary diagnostic terms to people in the past.

Ancient historians such as Chiara Thumiger

 (University of Warwick) and Madalina Vartejanu-Joubert

 (National Institute for Oriental Languages and Civilizations, Paris) point out that documents from antiquity invoking madness often were intended to serve religious, political, and legal functions and thus cannot be entirely depended on to provide clinically reliable information. At the same time, historians like Laura Hirshbein

 (University of Michigan) and Svenja Goltermann

 (University of ZÃ¼rich) have demonstrated that it is difficult to trace a direct, unbroken link connecting earlier with present-day diagnostic terms: melancholia was not the same as depression, and war neurosis and shellshock cannot be easily subsumed under the rubric of PTSD.

Dr Eghigian reports that he receives royalties for his books, one of which is mentioned in this article.

The Routledge History of Madness and Mental Health. 

Madmen and the Bourgeoisie: A Social History of Insanity and Psychiatry.

The Female Malady: Women, Madness, and English Culture, 1830-1980.

Museums of Madness: The Social Organization of Insanity in Nineteenth Century England.

Reasoning Against Madness: Psychiatry and the State in Rio de Janeiro, 1830-1944.

 Rochester, NY: University of Rochester Press; 2017.

Smoking Privileges: Psychiatry, the Mentally Ill, and the Tobacco Industry in America.

 New Brunswick, NJ: Rutgers University Press; 2015.

Crazy Like Us: The Globalization of the American Psyche.

8. Swartz S. The regulation of British colonial lunatic asylums and the origins of colonial psychiatry, 1860-1864. 

Colonialism and Transnational Psychiatry: The Development of an Indian Mental Hospital in British India, c. 1925-1940.

Electroconvulsive Therapy in America: The Anatomy of a Medical Controversy. 

A History of the Mind and Mental Health in Classical Greek Medical Thought.

 Cambridge and New York: Cambridge University Press; 2017.

American Melancholy: Constructions of Depression in the Twentieth Century.

 New Brunswick, NJ: Rutgers University Press; 2014.

An assessment of what has been accomplished, how the field is changing, and new directions for scholarship as we forge ahead into the next year.

Five Trends in Historical Research on Psychiatry and Mental Health

In 1897, the French sociologist Ãmile Durkheim (1858-1917) published 

Le suicide: Ãtude de sociologie [Suicide: A Study in Sociology]

. With it, Durkheim largely succeeded in achieving one of his main goals-to use an empirical analysis of the subject of suicide to launch the field of modern scientific sociology. Reading the book today, one is still impressed by its innovative methods. For example, its epidemiological approach based on international statistical data and its often surprising findings-for one, that suicide rates rose not during social crises, but rather at times when governing norms were breaking down.

While the work has been hailed as a founding text for the social sciences, historians have shown that Durkheim was perhaps less a pioneer than beneficiary of generations of research. As historian Daryl Lee puts it, the book “marks not the beginning but the culmination of nearly a century of intense anxiety and debate over the subject of suicide.”

 What for centuries had been considered a matter for clergy, theologians, and philosophers alone to comment on became in the 19th century a problem that increasingly drew the attention of psychiatrists and sociologists. Why did things change?

If we look back to ancient Greece and Rome, philosophers there considered it a matter of debate whether it was morally acceptable to end one’s life. Intellectuals such as Socrates and Cato, both suicide completers, continued to enjoy respectable reputations after their passing. Christian Europe, however, expressed a far less tolerant attitude toward self-inflicted death. For over a thousand years, Christian thinkers shared the aversion to suicide of St. Augustine (354–430), who held the act to be an arrogant refusal to submit to God's will; it was widely accepted, He and He alone rightfully decided on when an individual’s life should come to an end. As such, suicide was deemed a crime and the bodies of suicide completers were often desecrated and their possessions confiscated.

A shift in thinking began to take place between 1500 and 1800. While intellectuals of the 16th and early-17th centuries continued to pronounce suicide to be a moral abomination, some Enlightenment figures of the 18th century like Voltaire (1694–1778) and David Hume (1711–1776) argued for its legitimacy under certain situations. Historians examining judicial and church records have shown that in between these 2 periods, local authorities throughout Europe were slowly decriminalizing suicide, believing the penalties imposed on the corpses and estates of victims an unjustified burden on family members. Popular attitudes at the time also appear to have been evolving, as people gradually attributed suicides not to moral failings or the devil, but to deep emotions such as grief.

 This opened the way in the 1700s for reform-minded thinkers to begin pathologizing suicide as an expression of melancholy.

Clinical observers and researchers began taking up the subject in the early 19th century. In 1807, Danish physician Heinrich Callisen (1740–1824) dubbed it a form of illness and others soon followed suit.

 This was not due to the emergence of any new clinical evidence, however. Rather, legal and judicial changes in defining criminal responsibility inspired debate within psychiatry over a range of issues: the possibility of “partial” insanities, the existence of emotional and volitional forms of madness, as well as whether suicide should be treated simply as a symptom of an altered state of mind. On the latter question, some-like the famed French psychiatrist Jean-Ãtienne Esquirol (1772–1840)-generally believed it to be “a disorder of the emotions,” a view a later writer in 1857 would criticize as “. . . a dangerous and serious mistake which can give rise to undesirable moral consequences.”

At the time, the debate within psychiatry represented only one thread of the discussion over suicide. In the early 19th century, there was widespread perception that the incidence of suicide was rising. Whether this was so is difficult to judge. What we do know, however, is that this was exactly the moment when governments began to concertedly collect statistics on suicide as part of a broad effort aimed at developing a more empirically-informed public policy.

While interest in the regularities of birth, marriage, and death rates dated back to the 18th century, during the 1830s the field of what was called “moral statistics” was ever more drawn to deviant acts like crime, alcoholism, and suicide. For moral statisticians, like the Belgian Adolphe Quetelet (1796–1874), the fact that these morally corrupt and seeming irrational actions followed consistent patterns in their incidence, prevalence, and distribution demonstrated that human behavior-like the rest of the natural world-followed certain laws. And these laws, he thought, could be scientifically discovered and analyzed. Here was compelling proof of the need for a social science on par with the physical sciences.

 Thus, 2 lines of research emeged in 2 emerging fields, one rooted in psychiatry, the other in sociology. The 2 paths certainly diverged from one another: psychiatrists remained most interested in the psychopathology and treatment of individuals. Social scientists were drawn to identifying and influencing collective patterns.

Nevertheless, there were points where the interests of the 2 groups overlapped. Both statistician AndrÃ©-Michel Guerry (1802–1866) and physician Brierre de Boismont (1797–1881), for instance, separately took it upon themselves to classify and analyze the motivations of those committing suicide. Pouring over the letters, notes, and writings of thousands of victims, they sought out trends that might be common among those attempting to kill themselves.

But what continued to worry many analysts in both camps, however, was what seemed to be the shockingly high suicide rate in contemporary society. Thomas Masaryk in his 1881 study of the topic put it bluntly: suicide was “the sickness of our time.” It appeared to be not just an epidemic in, but also endemic to the modern world. What was one to make of this?

The growing influence of Darwinian evolutionary theory moved some to search for answers there. The physician and writer Max Nordau (1849–1923) argued that the rising suicide rate reflected a more general pattern of “degeneration,” an evolutionary regression of the human race caused by society’s neglect of the moral and hygienic health of civilized peoples.

Others, however, wondered whether the evolutionary connections between humans and other animals meant that suicide could be found in other species. Scottish alienist William Lauder Lindsay (1829–1880) believed so. A critic of the use of mechanical restraints and an advocate for psychotherapy in asylums, Lindsay argued that evidence showed that animals did commit suicide just like humans, not as “the simple product of malady, but of malady aggravated by mismanagement.” In other words, it was due to neglect and abuse. The famous British psychiatrist Henry Maudsley (1835–1918) begged to differ. He categorically dismissed the notion of animal suicide. Non-humans, he contended, lacked the capacity to deliberately seek their own deaths, and he criticized Lindsay for sacrificing scientific assessment in the service of a “spirit of romance.”

Others saw less value in evolutionary arguments, opting instead to focus on recent historical changes. Durkheim entered the debate, emphasizing the impact modern secular and consumer values had on unmooring individuals from their familiar moral anchors. He was hardly the first to argue along these lines. Almost 2 decades earlier, the Italian physician Enrico Morselli (1852–1929) published Suicide: An Essay on Comparative Moral Statistics (1879), in which he related contemporary suicides to the rise in the unsatisfied desires and unregulated self-gratification characteristic of modern life.

By century's end, many researchers concluded that suicide represented not so much an illness as a symptom–a response by some to the challenges posted by living in the modern world.

is Associate Professor of Modern History and Former Director of the Science, Technology, and Society Program at Penn State University; he is also Section Editor for Psychiatric Times' History of Psychiatry

 Lee D. Accounting for self-destruction: Morselli, moral statistics, and the modernity of suicide. Intellect Hist Rev. 2009;19:337.

 Watt JR. Introduction: toward a history of suicide in early modern Europe. From Sin to Insanity: Suicide in Early Modern Europe. Ithaca: Cornell University Press; 2004: 1-8.

 BÃ¤hr A. Between self-murder and suicide: the modern etymology of self-killing. J Soc Hist. 2013;46:620-632.

 Goldney RD, Schioldann JA, Dunn KI. Suicide research before Durkheim. Health Hist. 2008;10:73-89.

 Berrios GE, Mohanna M. Durkheim and French psychiatric views on suicide during the 19th century: a conceptual history. Br J Psychiatry. 1990;156:1-9.

 Porter TM. The Rise of Statistical Thinking, 1820-1900. Princeton: Princeton University Press; 1986.

 Pick D. Faces of Degeneration: A European Disorder, c 1848-1918. Cambridge: Cambridge University Press; 1989.

 Ramsden E, Wilson D. The suicidal animal: science and the nature of self-destruction. Past Present. 2014;224:201-242.

In 1897, the French sociologist Émile Durkheim (1858-1917) published Le suicide: Étude de sociologie [Suicide: A Study in Sociology]. With it, Durkheim largely succeeded in achieving one of his main goals.

A “Sickness of Our Time”: How Suicide First Became a Research Question

Slideshows

A selection of noteworthy books to add to your reading list. Can you think of others?

5 New Books in the History of Psychiatry to Read for 2018

 I am embarking on what I hope will be a regular feature-namely, interviews with historians of psychiatry about their recently published works. My goal is to introduce readers of 

 to some of the new books by these authors.

Here, I interview Jonathan Sadowsky, PhD, about his book 

Electroconvulsive Therapy in America: The Anatomy of a Medical Controversy

, published late last year by Routledge. Dr. Sadowsky is the Theodore Castele Professor of Medical History at Case Western Reserve University, where he is also Associate Director of the Master’s Program in Medicine, Society, and Culture. His interests include the history of colonial psychiatry, convulsive therapy and other somatic treatments in psychiatry, race and psychiatry, and the history of psychoanalysis. He is the author of 

Imperial Bedlam: Institutions of Madness and Colonialism in Southwest Nigeria

 (University of California Press, 1999) and, more recently, his book on ECT.

, ECT has had-and continues to have-both its champions and detractors. And historians who have written on the subject have largely fallen into the same pattern, seeing it either as a technology of social control or as an instance of unmitigated progress. How does your book differ from these?

There is nothing wrong with historians’ advocating for a point of view. And it would be disingenuous of me to claim that after years of study, I have no opinions of my own about ECT. But I thought we might be better served now by an inquiry into how views of this treatment became so polarized. There is no single answer to this. But one point I can make here is that ECT has been pressed into service as a proxy in wider struggles over the authority of medicine, what kind of psychiatry we should have (“biological” or “talk,” for example), or even if we should have psychiatry at all, since ECT was a main target of the antipsychiatry movement. These debates not only have practical clinical significance, but touch deeply held but often implicit beliefs about the meaning of illness and wellness-and even what a person is.

You acknowledge that throughout the history of ECT, “Patients have both attested to damage it has done and expressed gratitude for the relief and hope it can provide.” How do you explain this seemingly paradoxical disparity in the experiences and opinions of patients?

 The human body is not a mass-produced machine, where given inputs such as therapies produce automatic and predictable results. Most clinicians and lay people know this but often act as if they don’t. One result of this mechanistic conception is resistance to the variability of bodily experience. But this variability is easy to show. Any psychiatrist who reads this knows it is not completely random-a psychiatrist might hesitate to prescribe bupropion to treat depression comorbid with extreme anxiety, for example-but there is a lot of mystery involved.

In the case of ECT, there has been a reluctance by many partisans to recognize that the experience they have had or observed may not be universal or typical. We will have more productive discussions if we are more sensitive to variability.

 One of the claims you make is that ECT does indeed work, but you also point out that historical research shows that the methods of assessing the effectiveness of treatments have changed significantly over time. So, what does the history of ECT and the debate surrounding it tell us about how we might measure progress in psychiatry?

 Historians of medicine have shown that the meaning of whether a therapy “works” changes. It is an appealing idea to historians, because change over time is our sacred specialty. It is short step from there to finding all therapies equal, provided they work in their historical context. I worry there may be costs to taking that step.

The author interviews Jonathan Sadowsky, PhD, historian of psychiatry, about his book Electroconvulsive Therapy in America: The Anatomy of a Medical Controversy.

Author | Greg Eghigian, PhD

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Five Trends in Historical Research on Psychiatry and Mental Health

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