Keri Phillips: You're listening to Rear Vision with Keri Phillips. Today a look at mental illness and how our ideas about what it is have changed over time.

Journalist [archival]: The fifth version of the AmericanDiagnostic and Statistical Manual of Mental Disorders, or DSM-5 as it's better known, has sparked a furore over whether it's turning normal mood swings into pathological conditions.

Journalist [archival]: It's being attacked for medicalising normal human frailties, such as grief when a loved one dies, or children's temper tantrums.

Keri Phillips: When the fifth edition of the Diagnostic and Statistical Manual, published by the American Psychiatric Association—the psychiatrists' 'bible'—came out a year ago it caused an outcry. Some argued that its definitions were so broad that 50% of Western populations could now be diagnosed with a mental disorder. Although we won't buy into that argument today on Rear Vision, we will hear about how modern ideas about mental illness and the way to treat it have evolved.

David Healy is a professor of psychiatry at Bangor University in the UK. Among his books are The Antidepressant Era and Let Them Eat Prozac, which explore the connections between the mental health field and the big pharmaceutical companies.

David Healy: A little bit hinges on what you think mental illness or mental health is. Clearly we've always been nervous, we've always been afraid of things and fearful. The Greeks, the Romans, the ancient peoples of various sorts have all given us fairly good descriptions of people who were what we would now say 'anxious'. But they wouldn't have regarded this as being a mental illness, they would have regarded it as just an appropriate response to life generally and to the whole issue of, well, why are we here. So the idea of treating a thing like this is somewhat controversial.

Aside from that kind of mental health problem, there is a further one which is every culture pretty well for all periods of time have recognised and labelled as mental illness really a state called delirium. This is when people are raving mad. We now recognise this happens when you have been poisoned, when you have a high fever, when you've got a physical illness of one sort or the other that interferes with the way the brain is working. And you get people in a state of being literally raving mad. They are often disoriented, they don't know where they are even. And in states like this they can be dangerous to themselves and dangerous to others. Pretty well all cultures and all periods of time have recognised this and regarded it as a mental illness.

Keri Phillips: Sander Gilman is Professor of Psychiatry at Emory University, Atlanta.

Sander Gilman: From the earliest medical texts that we have, in the so-called Hippocratic Corpus which is 3,000 years old, mental illness is treated by physicians. However, physicians and priests are very, very closely aligned, and mental illness is understood oftentimes in terms of violations of taboos, things that might have a, can we say, moral overlay. What you're talking about is modern medicine, and modern medicine, starting really in the 17th and 18th century, starts to think about mental illness as a disease of (to use an 18th-century word) the faculties, of mind rather than morals. And so what happens in the Enlightenment, first of all in Britain then in France, right around the time of the French revolution, then in Germany by the 1830s is the notion that the therapies for mental illness are therapies to correct antisocial behaviours, but it means that it can be corrected.

So the asylum…we always think about Bedlam Asylum in London…goes from some place where people are restrained, literally restrained with shackles, to places by the 1830s and 1840s where the asylum is seen as a big family, people in asylums grow their own food, there are dances on the weekends. The head of the asylum is seen as almost the father of the asylum and that term is used over and over again. And so that's a big shift from the idea of un-treatability to the idea of treatability, from moral failing to behavioural change.

Keri Phillips: What kinds of therapies were available in the asylums of the 19th century?

Sander Gilman: Some of the therapies were social therapies, things like dances on the weekends. Some of therapies were shock therapies, water therapy for example where people were wrapped in wet sheets and basically strapped into a chair and they were held. So some of the therapies we would think of as kind of odd; dances? Some of the therapies we would think of as kind of mean; things like restraints.

Keri Phillips: And what kinds of behaviours would have led to somebody being put into one of these institutions?

Sander Gilman: You know, one of the things that is easy to talk about is to say people did things that we today might think is normal, and therefore they got put into institutions. Some of that might have happened. The very famous case of Mrs Packard in the United States who didn't want to obey her husband and her husband had her committed. But that was a cause célèbre in the day in the 1870s when it happened, that is it was a scandal.

Most of the time people were put into asylums, these large asylums that grew up in the course of the 19th century, because of actions against people's own best interests. People being unable to function in the world, attempted suicide, severe depression, all of the kind of behaviour that made it impossible…and I will use Freud's term because I like it a great deal, he said 'you are ill when you are unable to work and love'. And people in the asylums for the most part were there because they were unable to work and love.

Now, some of things that they were in for today we understand as neurological diseases. The most common disease in the 19th century asylum was called general paralysis of the insane, GPI. By 1904 when we had a test for syphilis, it turned out that most of the people with GPI had a neurological deficit, they had tertiary syphilis.

Woman [archival]: What you are about to hear is the only known recording of the voice of Sigmund Freud.

Sigmund Freud [archival]: I discovered some important new facts about the unconscious in psychic life, the role of instinctual urges, and so on. Out of these findings grew a new science, psychoanalysis, a part of psychology.

Keri Phillips: Sigmund Freud was an Austrian neurologist and the founder of psychoanalysis, a set of psychological and therapeutic theories and associated techniques. Controversial at the time and criticised today as pseudoscience, Freud's ideas continue to influence our understanding of mental illness.

David Healy: Freud was one of the key people in pulling the domain of anxiety into the mental health field. Where before, all the way back for eons people had been scared from time to time, they had been fearful and maybe unduly fearful from time to time, Freud was the person who began to argue; well, this isn't just a normal response to being alive, this can be a disorder in its own right. And that led to various talking cures in an effort to try to get to grips with what the underlying problems might be.

There's a few consequences to that. One of the consequences is that it has led to an understanding that all mental problems are just, in one form or the other, just an abnormal response to life's stresses, and all the person, even people who've got severe mental illnesses need to do is to just learn how to cope with life's stresses, and if they do this they won't need physical treatments. And that's an extreme point of view but it's one that a lot of people have.

What we need is some way to legitimise the idea that there possibly are some mental illnesses, real illnesses in there that aren't simply a condition that is the person's abnormal response to handling stress. It's extraordinarily important to be able to distinguish a physical illness of that sort, of which there may not be very many, from the huge range of ways in which we handle stress at times inappropriately and at times potentially also to a psychotic proportions. That is, there can be people with acute and transient psychosis who can look just like they've got schizophrenia.

So Freud introduced a shifting boundary, and the struggle ever since Freud has been to know just where the right place to draw the line is between those conditions that require us to try and understand what's going on, and then those conditions where it's not really about trying to understand in the sense of getting to grips with where the person is at but much more a case of trying to look at the person and see what the illness is that they have.

Keri Phillips: You're listening to Rear Vision with Keri Phillips on RN, online, on mobile and by podcast. Today we're looking at mental illness and how our ideas about what it is and how to treat it have changed over time.

In the middle of the 20th century a drug called chlorpromazine was developed that was so successful at treating mental illness that it looked like it might be possible to close all the mental hospitals.

David Healy: Back in the 1950s, 1954 or thereabouts, the first of the drugs that really made a big difference, chlorpromazine, was introduced, and this really did fuel an extraordinary explosion of new drugs that led to us getting the antipsychotic group of drugs that we have now and the antidepressant group of drugs and the tranquillisers and stimulants and other drugs. Almost all the drugs that we use now in one way or the other stem from that period during the 1950s. And this period led to great expectations that the drugs would be tools for us to learn how the mind worked, how the brain worked, and also treatments. If we could catch people early and put them on treatment early, that they wouldn't go on to have the kinds of problems that they had had before that, and that we would be able to empty out the large old hospitals.

Journalist [archival]: Over the next nine months some 4,000 mentally ill patients will start moving out of institutions in New South Wales into community hostels and group homes.

Woman [archival]: They really live like you and I. They are able to have dinner together as a family or a group of people, they are able to watch television, they are able to choose when they go to bed and get up at night, choose what clothes they wear. We take these things for granted, but that's not the case when they live in an institution. The institution operates for itself rather than looking at individual client needs or individual patient needs. An alternative community based service focuses on client needs rather than on the needs of the institution.

Sander Gilman: In the 1960s there is a kind of reaction to ideas of mental illness that had become part of the establishment structure. People responded to these large asylums and they said they were terrible places. By the way, some of them were terrible places. But the other thing we have to understand was that these large asylums gave asylum (that word is really important)…gave asylum to people who could not function in society.

So the idea was that…I must admit I was part of this, I was very much active in deinstitutionalisation in New York during the 1960s and 1970s…was that we were going to create much smaller hospitals, we were going to create day hospitals where people could go home at night, we were going to create night hospitals where people could work during the day and come to the hospital in the evening, we were going to create halfway houses. In other words, we were going to take these big asylums with 5,000, 6,000, 7,000 people and we were going to make it possible for the people to be better integrated in the society.

The difficulty was that it was easier to close the big asylums than it was to create large numbers of smaller structures. And what really happened between 1960 and 1980 was the asylums dumped…and I really use that word…dumped their inmates onto the streets of the city. And if you ask today, 2014, in the United States, in Canada, in Australia, in Britain—where is the structure in society where the severe mentally ill are housed?—it winds up being the jail, it winds up being the prison.

As part of that rethinking there were lots of theories about what a mental illness really was. Tom Szasz said there is no such thing as mental illness, it's simply people trying to get a free ride, they're just acting. Some people talked about mental illness in a family where the mentally ill were the healthy person and the family was in point of fact crazy. Some people talked about mental illness as if mental illness was a kind of societal label for people who really should be tolerated because they were kind of eccentrics.

Keri Phillips: While this debate over the very existence of mental illness was going on, chlorpromazine and other new drug therapies were augmented by developments in neuroscience, the study of the nervous system, according to Professor Philip Mitchell from the School of Psychiatry at the University of New South Wales.

Philip Mitchell: Around that same time in the 1950s, which was really when our modern approach to drug treatment and mental illness began, there was also the discovery of the antidepressants. Now, nobody in the late '40s or early '50s would have believed that we ever could have treatments, medications for depression. This was conceptualised very much in psychological terms or personality terms. What happened was that there was a molecule that was derived from chlorpromazine that a drug company in Europe was studying. They were used on some patients with schizophrenia in some private hospitals in Switzerland. One of the researchers decided to try it on his severely depressed patients, and much to his surprise it actually changed their behaviour. So for the first time we saw a medication actually changing depression, and this was remarkable.

Now, what came out of this and the discovery of chlorpromazine for schizophrenia was that scientists started to look at how do these drugs work. With chlorpromazine we found that this acted on dopamine. That took quite a while to become apparent. And this was very aligned with some basic research about neurones and how neurones communicate with each other. Around that time there was a lot of debate about whether neurones connected by electrical impulses or whether it was by chemical transmission setting off electrical impulses in the next cell. And it became apparent around that time that it was chemical transmission.

So the understanding of the antidepressants was very tied into this. What was found was that the antidepressants in fact reduced the reuptake of these neurochemicals back into the neurones, amplifying the signal. So it became apparent that they were working on a number of neurochemicals. These are fairly widely known these days—serotonin and noradrenaline—and that there was a clear chemical effect on reducing the reuptake, so, in a sense, sucking these back into the neurones to strengthen the electrical impulse. So we became aware very quickly of how these new antidepressants were working. So these were very exciting developments at the time.

Keri Phillips: Looking back over the modern history of mental illness in the West, you can see that ideas about what constitutes a mental illness change over time. Some illnesses disappear, new ones are identified, and some mental illnesses are redefined as normal behaviour; homosexuality, for example. Even symptoms change over time.

Sander Gilman: One of the things that's so remarkable about mental illness is that its symptoms, its presentation to the world shifts based on where you are, who you are, what culture you're at. That is, it shifts based on expectations.

I'll give you an example. In the 19th century asylum, you and I are going to walk in the front door and we are going to come into a big room which is a kind of a day room and there are going to be lots of patients in this asylum in 1895. A large number of these patients are going to be frozen in space. They're going to have a symptom called waxy flexibility. They're going to stand in the same position, oftentimes an uncomfortable one for hours, sometimes for days if they are not interrupted. This is a very typical symptom of severe mental illness in the 19th century.

Spool ahead 100 years. We go into a hospital for the mentally ill in Sydney today and we see no cases of waxy flexibility. And so people say to me, well, if the symptoms changed don't think the disease has changed? And the answer is no because mental illness has underlying structures and we pretty much understand these underlying structures, not 100% but I would say pretty well at this point. We don't always understand what causes them. We sometimes understand how we can treat them, but their presentation in the world changes over time. So, for example, today if I wanted to look at the equivalent to waxy flexibility in 2014, it is a symptom which is, let us say, so present that we think of it as almost a commonplace.

We would think of self-harm, of cutting. It is such a common symptom today in a whole range of mental illnesses that it's somehow or other a symptom of the late 20th and early 21st century. Yes, you had self-cutting in the 19th century asylum but of a very different type. We can talk about self-mutilation, and it was very, very, very rare. Today many, many, many teenagers present with some type of self-harm, with some type of cutting. And we immediately say, oh, we know that there's a problem there.

Keri Phillips: In recent decades, while research into brain imaging, genetics, and molecular and cellular biology has continued to explore the idea that mental disorders are related to disturbances in brain function, debate over whether or not we are catching up too much of life's normal experiences and behaviour in the mental illness net has continued.

David Healy: Well, I think in many respects we've gone backwards and forwards. I think it might be a mistake to think that we've progressed. There has been a shift in views over time, and it's not necessarily clear that these shifts have always been based on progress in our understanding of the illnesses, they've often been based on the interests of the people who can earn a living out of treating the illness.

For instance, the pharmaceutical companies recently have clearly stood to gain from persuading people that there is a lot of depression around the place and more recently a lot of bipolar disorder around the place, and the doctors who prescribe these drugs also stand to gain from seeing things that way. And it has looked at times over the last 150 years or so that it has often been the interests of people who stand to make a living out of the conditions that has been the primary driver in the way things appear to change. That holds true for Freud also in that what you had was a bunch of people from Freud onwards who stood to make a living out of persuading people that the anxieties they had were disorders that, through understanding and talk and therapy, that they could help them with.

One other thing to bear in mind that might be of interest here is that when we do make progress, often by accident, it's not recognised. We've got very interesting data from North Wales here showing that schizophrenia, while it rose in frequency during the 19th century and remained extraordinarily high during the 20th century, in the last 10 years or so in North Wales has shown a very marked drop. And by a marked drop I mean we are only getting new cases here at a quarter of the rates that were used to get them before. So something profound is going on here.

But our experience is that when we try to give this news to people most people are just uninterested. They don't want to hear what should be a good news story. It's the kind of story that should generate an awful lot more interest in terms of people trying to work out, well, now that we have evidence that this illness increased in frequency during the 19th century and is perhaps decreasing now, can we work out what the common factors were that might have led to the increase back then and might be leading to a drop now. These are the kinds of things that if there was more interest in them we'd be able to move further forward a lot more quickly.

Philip Mitchell: I think it's fair to say that despite the fact that there has now been 40 or 50 years of research in terms of understanding what those essential differences are in the brains of people with serious psychiatric disorders, that we haven't had the advances that we want to have. In the '60s there was incredible optimism that because we knew the antidepressants worked through serotonin and noradrenaline and that the antipsychotics worked through dopamine, that this would be a simple answer to the question, that these would be simple neurochemical abnormalities.

The story hasn't played out that simply. I think that optimism was too simplistic and I think, in retrospect, naive, that complex disorders like severe depression, bipolar and schizophrenia could be ascribed to simple changes in single neurone transmitters or neurochemicals. The brain has been the most difficult organ of the body to study. It's our most complex organ, and it's clearly the least accessible.

So the major technologies that are relevant to understanding psychiatric disorders are being able to visualise the brain, both in terms of its structure and its function, but also to be able to understand the genetics. These are strongly genetic conditions. Schizophrenia and bipolar, 80% of the cause of these conditions is genetic. And it's only in recent years that we've had the capacity to investigate the subtleties and complexities of genetics.

So I have enormous optimism that we will go from this position of really very limited understanding of these conditions to profound understanding of the biology, and then developing targeted or personalised treatments. The pharmaceutical industry had essentially lost interest in psychiatric disorders over the last five years. Our understandings were so poor that they have retreated. And it's only in the last year or so that you can see interest re-emerging that there are potential targets for new drug developments.

Sander Gilman: One of the things that one has to say is that there will never be a consensus about what mental illness is and where the boundaries are. Where there can be a consensus is where we identified very specific causes, whether they are environmental, things like lead poisoning, whether or not they are neurological, such as Alzheimer's. And then they are not mental illnesses anymore, right?

But certainly for the foreseeable future, one of the things that we really do have to understand is that we are going to be dealing with mental illnesses with, can we say, vague boundaries that include people who may have, for example, a spectrum disorder, a mild form of a mental illness, which enables them to function. And the question is are they truly mentally ill? A person with mild depression. And it strikes me that those are the cases that we look at individually.

What we are really talking about are those people with severe mental illnesses. And, by the way, I would say also severe developmental disabilities. We're talking about things like autism, where we as a society have an obligation to provide succour, to provide asylum for people, and to provide the best possible treatment for them. And yes, there are going to be expanding categories. Autism has grown in the United States greatly, ADHD has grown greatly. But these expanding categories over time self-correct.

That's one of the nice things about being a historian of mental illness is that we really do see this kind of attempt to create bigger categories which then, in a sense, over time self-correct. And we simply therefore can't throw (pardon the cliché) the baby out with the bathwater, which is what we try to do in the '60s and '70s by saying either the mental illness doesn't exist or that it's simply normal behaviour not recognised or eccentric behaviour. Mental illness is illness, it's pain, it creates in people an inability for them to love and work. And in this world, loving and working, having relationships with human beings and having a productive way in the world, are the things that define us.

Keri Phillips: Sander Gilman, Professor of Psychiatry at Emory University, Atlanta. On Rear Vision today you also heard David Healy, a professor of psychiatry at Bangor University, and Professor Philip Mitchell from the School of Psychiatry at the University of New South Wales. I spoke to my overseas guests by Skype.

If you're interesting in finding out more, I've put up a link on the Rear Vision website to a good account of the debate over the fifth edition of the Diagnostic and Statistical Manual on the ABC's Health and Wellbeing website.

Phil McKellar is the sound engineer for Rear Vision today. Bye from Keri Phillips.