In the 1800s there was widespread concern over the increase in the number of individuals with severe mental illnesses. Evidence from the 20th and 21st centuries is building that shows a similar trend. Why, then, is this increase not being currently addressed?
Evidence is accumulating that the occurrence of severe psychiatric disorders, especially schizophrenia and bipolar disorder, may be increasing. The most visible manifestation of this is the increasing number of severely mentally ill individuals among the homeless population and in the nation's jails. Multiple studies have reported that at least one-third of the approximately 600,000 homeless individuals have a severe psychiatric disorder, and there are suggestions that the problem is getting worse.
Similarly, a 1999 U.S. Department of Justice study reported that 16% of inmates in local jails and state prisons -- 275,900 individuals -- had been treated psychiatrically (Ditton, 1999). There are, therefore, five times more psychiatric patients in jails and prisons than the 55,000 remaining patients in state psychiatric hospitals. Headlines are increasingly proclaiming statements such as: "Mental Illness Behind Bars: A Tragic Situation Getting Worse" (Kupers, 2000).
Another measure of the increasing number of individuals with severe psychiatric disorders is the number of these individuals on supplemental security income (SSI) and social security disability insurance (SSDI), the two federal programs for the support of disabled individuals. The number of individuals in the category "mental disorders other than mental retardation" increased from 1.1 million in 1985 to 2.9 million in 1998, a 164% increase during a time in which the U.S. population increased only 13%. The "mental disorders" category is both the largest and the fastest-growing diagnostic category for both the SSI and SSDI programs.
Increasing numbers of individuals with severe psychiatric disorders are also suggested by the experience of managed care companies assuming responsibility for state psychiatric programs. In state after state, managed care companies have underestimated the number of individuals with severe psychiatric disorders who require services, with dire fiscal consequences. Typical is a statement from the press regarding the January report from the state of Maryland discussing the failed managed care program for Maryland's mentally ill Medicaid patients: "But the state greatly underestimated demand, and the system was soon overwhelmed" (Becker and Hedgpeth, 2002).
The strongest evidence that severe psychiatric disorders may be increasing comes from the Epidemiologic Catchment Area (ECA) study, carried out in the early 1980s, and the National Comorbidity Survey (NCS), carried out in the early 1990s. In a 1999 discussion, Darrel Regier, M.D., co-author of the ECA study, said the study found that, after accounting for duplicate diagnoses, 2.2% of adults (ages 18 years and over) met diagnostic criteria for schizophrenia or bipolar disorder over a one-year period. A recent reanalysis of this study revised this estimate to 1.7% (Narrow et al., 2002). This translates into a prevalence rate of 12 to 16 per 1,000 total population, not including any mentally ill adults with other severe psychiatric disorders such as major depression or severe obsessive-compulsive disorder. The NCS study reported that 2.6% of adults had a "severe and persistent mental illness [SPMI]," defined as including schizophrenia; bipolar disorder; severe forms of depression, panic disorder and obsessive-compulsive disorder; and autism (Kessler et al., 1996). This translates into 19 adult individuals with SPMI per 1,000 total population.
Although comparisons of rates over time are fraught with diagnostic and other methodological pitfalls, the 12 to 19 per 1,000 rate contrasts sharply with prevalence surveys done in earlier years. For example, the 1958 Hollingshead and Redlich study of New Haven, Conn., one of the ECA study sites, reported a rate of 4.2 individuals who were being treated for schizophrenia and affective psychoses per 1,000 total population. Similarly, a census study of Baltimore, another ECA study site, found a rate of 7.1 individuals with psychosis or with psychotic traits, both treated and untreated, per 1,000 total population (Lemkau et al., 1942).
The most complete enumeration of severe psychiatric disorders ever carried out by the U.S. Census Office was done in 1880. Because of widespread fears at the time that insanity was increasing, census enumerators were given special forms and extra pay to identify all severely mentally ill people, including querying neighbors of the person in question. In addition, all 100,000 physicians in the United States were asked to report "all idiots and lunatics within the sphere of their personal knowledge," and over 80% did so. Insanity was classified by seven subtypes using definitions supplied by the New England Psychological Association. All duplication between the enumerator and physician lists was eliminated.
A total of 91,997 insane people were identified. Of these, 38,047 were in asylums, an increase of 115% in hospitalized insane since the 1870 census. The prevalence of insane people, both hospitalized and living in the community, was 1.83 per 1,000 total population. In 1880, asylum superintendent Foster Pratt called that increase an "important and alarming facta great question of public health that demands careful study" (as cited in Grob, 1980). And yet the ECA study from 1980 reported a prevalence rate for schizophrenia and bipolar disorder that was almost 10 times higher than the 1880 prevalence rate.
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 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 Jrgensen, in press) and England (Brewin et al., 2002) even suggest that first-admission rates for schizophrenia have increased in recent years.
What, then, are we left with? We are left with an epidemic of schizophrenia and bipolar disorder that presently affects 4 million Americans, four times more than are infected with HIV. An epidemic that slowly kills by suicide 15% of those afflicted (Goodwin and Jamison, 1990) and that costs the nation over $110 billion each year in direct and indirect costs (Wyatt and Henter, 1995; Wyatt et al., 1995). An epidemic that is so insidious and ingratiating that it is barely noticed, an invisible plague. An epidemic that increased as much as 10-fold over the last century and that appears to still be increasing.
Allardyce J, Morrison G, Van Os J et al. (2000), Schizophrenia is not disappearing in southwest Scotland. Br J Psychiatry 177:38-41.
Becker J, Hedgpeth D (2002), Montgomery moves to help mentally ill. Washington Post, Jan. 30, pB01.
Brewin J, Lloyd T, Tarrant J et al. (2002), Increasing incidence of psychoses in Nottingham 1978-1999. Schizophr Res 53(3 suppl):32-33.
Ditton PM (1999), Bureau of Justice Statistics Special Report. Mental Health and Treatment of Inmates and Probationers. Washington, D.C.: U.S. Department of Justice.
Eaton WE (1980), The Sociology of Mental Disorders. New York: Praeger, pp174-176.
Godding WW (1890), Progress in provision for the insane. American Journal of Insanity 39:129-150.
Goldhamer H, Marshall AW (1953), Psychosis and Civilization: Two Studies in the Frequency of Mental Disease. Glencoe, Ill.: Free Press.
Goodwin FK, Jamison KR (1990), Manic Depressive Illness. New York: Oxford University Press Inc.
Grob GN, ed. (1980), Immigrants and Insanity: Dissenting Views, 1883-1914. New York: Arno Press.
Harvey G (1916), The race is not going mad. North American Review 204:16-20.
Hollingshead AB, Redlich FC (1958), Social Class and Mental Illness: A Community Study. New York: John Wiley & Sons.
Jarvis E (1852), On the supposed increase of insanity. American Journal of Insanity 8:333-364.
Jimenez MA (1987), Changing Faces of Madness: Early American Attitudes and Treatment of the Insane. Hanover, N.H.: University Press of New England, p120.
Kessler RC, Berglund PA, Zhao S et al. (1996), The 12-month prevalence and correlates of serious mental illness (SMI). In: Mental Health, United States, 1996, Manderscheid RW, Sonnenschein MA, eds. DHHS publication No. 96-3098. Washington, D.C.: U.S. Government Printing Office.
Kupers TA (2000), Mental illness behind bars: a tragic situation getting worse. Psychiatric News. Oct. 6, p18.
Lemkau P, Tietze C, Cooper M (1942), Mental hygiene problems in an urban district. Mental Hygiene 26:100-119.
Narrow WE, Rae DS, Robins LN, Regier DA (2002), Revised prevalence estimates of mental disorders in the United States: using a clinical significance criterion to reconcile 2 surveys' estimates. Arch Gen Psychiatry 59(2):115-123.
Rothman DJ (1971), Discovery of the Asylum: Social Order and Disorder in the New Republic. Boston: Little, Brown and Co.
Shorter E (1997), A History of Psychiatry: From the Era of the Asylum to the Age of Prozac. New York: John Wiley & Sons.
Tsuchiya KJ, Munk JÃ²rgensen P (in press), First-admission rates of schizophrenia in Denmark, 1980-1997: Have they been increasing? Schizophr Res.
United States Census Office, 10th Census (1880), Vol. XXI: Report on the Defective, Dependent, and Delinquent Classes of the Population of the United States. Washington, D.C.: U.S. Government Printing Office.
Wyatt RJ, Henter I (1995), An economic evaluation of manic-depressive illness -- 1991. Soc Psychiatry Psychiatr Epidemiol 30(5):213-219.
Wyatt RJ, Henter I, Leary MC, Taylor E (1995), An economic evaluation of schizophrenia -- 1991. Soc Psychiatry Psychiatr Epidemiol 30(5):196-205.