Published by Oxford University Press on behalf of the International Epidemiological Association International Journal of Epidemiology 2010;39:1417–1425 The Author 2010; all rights reserved. doi:10.1093/ije/dyq222 Commentary: Sir Arthur Mitchell—pioneer of psychiatric epidemiology and of community care Ezra Susser,* Joy Noel Baumgartner and Zena Stein Department of Epidemiology, Mailman School of Public Health, New York, NY, USA *Corresponding author. Mailman School of Public Health, 722 West 168th Street, New York, NY 10032, USA. E-mail: ess8@columbia.edu Accepted 19 October 2010 In Scotland in the 19th century, Sir Arthur Mitchell in the community, from both a high-income country (1826–1909) laid conceptual foundations for the (the UK) and a low-income country (Nigeria). In use of epidemiology in wide-ranging areas, from retrospect, we see significant continuities between family-based genetic studies to ‘clinical’ or ‘natural the concepts put forward by Mitchell and by pioneers history’ cohort studies to studies of the prevalence in subsequent generations who were not aware of his 2–5 and care of mental disorders in the community. A work. Finally, we discuss the implications of these recent article in IJE drew attention to these contribu- continuities for global mental health today. tions and the subsequent neglect of his work. He also made contributions in many other fields, from Medical Meteorology to Archeology, and was a The Insane in Private Dwellings Professor of Ancient History. A large part of Mitchell’s work was devoted to what ‘Boarding out’ was a traditional form of care in we would now call psychiatric epidemiology and psy- Scotland, which dated back to before Mitchell. In chiatric care in the community. With respect to psy- practice, the Poor Laws of Scotland were applied flex- chiatric epidemiology, Mitchell’s study of people with ibly and variably across parishes, and in many mental illness living in the community is described instances ‘insane’ persons were supported in the here, and his study of mortality rates among psychi- homes of relatives, and sometimes of strangers, in- atric patients is in the reprint that precedes this com- stead of being institutionalized in poorhouses or asy- mentary. These studies compare favourably with the lums. Boarding out was used not only for insane community survey done by Edward Jarvis and the people but also for orphans and other people with analysis of mortality rates done by William Farr at disabilities. 8,9 around the same time. Yet Jarvis and Farr are con- Following the Scottish Royal Lunacy Commission’s 21 22 sidered to be forefathers of psychiatric epidemiology, report of 1855, the Lunacy Act of 1857 established whereas Mitchell’s work has been forgotten. The work a General Board of Lunacy, which was made respon- of John Snow was also neglected over a long period, sible for monitoring the condition of all insane per- until it was resurrected by Wade Hampton Frost. sons in UK. The Act called for the expansion of the Mitchell merits a similar resurrection, especially in asylum system, which was less developed in Scotland psychiatric epidemiology and public mental health, than in England. But it also explicitly endorsed the as a ‘giant’ on whose shoulders the next generations systematic use of boarding out, and introduced new could have stood. provisions to facilitate the expansion of boarding out. We discuss here one of Mitchell’s signal contribu- Mitchell was appointed in 1857 as a Deputy tions entitled ‘The Insane in Private Dwellings’. This Commissioner of the Board of Lunacy (later he was report proposed that most ‘insane’ people could be Commissioner 1870–95) and charged with leading an cared for outside of asylums. Mitchell’s work on this investigation into the conditions of insane persons topic was influential in many countries during his living outside asylums. Based on this investigation, time, and in his home country of Scotland well into in 1864 he published ‘The Insane in Private 12–19 11 the 20th century. Next, we offer examples of Dwellings’, which was innovative in so many ways work carried out 100 years later on psychiatric care that we cannot do full justice to it here. We limit our 1418 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY comment to two components: his findings on the is the reverse, can only be thoroughly appreciated by numbers and living conditions of insane people in those who have had much dealing with this class of the community, and his proposal for a system of the insane.’ (p. 67) care for insane people. For historical accuracy, we Regarding the considerable number of homeless adhere to terms such as ‘insane’, which were used insane people, he writes: ‘They were called inveterate by Mitchell, though these terms are offensive in cur- wanderers, and it was said that the habits ... (were) a rent parlance. source of pleasure ... (But it) was generally found that the vagabond life was associated with begging, and that it was pursued as a means of subsistence, and Insane People in the Community not because it afforded enjoyment ... ’. The case of Mitchell’s investigation attempted to identify all J.L. will illustrate these remarks. ‘She is said to insane persons living in private dwellings in have lost her reason some thirty years ago in conse- Scotland. The purpose was not only to count them, quence of a love disappointment ... she wanders over but to assess their living conditions and gain insight a district sixty or seventy miles long, and often sleeps into how these conditions could be improved. This in the open air ... . This woman has a nominal home was no small challenge. To meet it, he used methods with her sister ... a little mud hovel on the that went well beyond the practices of his own time, hillside ... She has no bed there ... she has no alter- and, in some respects, were better than the methods native but to beg, or to starve ... five shillings quar- used in such investigations today. terly being the allowance which the parish gives her, The investigation collected information from many and which her sister, who is in great poverty, can in sources about potential cases. It entailed visits to no degree supplement ... . Let her be kindly treated, people in all kinds of circumstances, living in family comfortably clothed, and provided with a warm bed, homes, as vagrants, in small shacks alone or in vari- and three substantial meals a day in one place, and ous other kinds of arrangements. In all, about 7000 there, without compulsion, she will make her visits were made and a report was written about the home ... ’. Although in this case of J.L., the Board living conditions in each case. Reports were also made could not persuade the parish to increase her allow- on about 2000 people for whom visits were not pos- ance to a sufficient amount, ‘I could furnish many sible or deemed unnecessary. These reports considered excellent illustrations of this, but one will be not only the insane themselves, but also their families enough ... B.C. was for nearly thirty years a confirmed and other caregivers, and took interest in the benefits begging wanderer, rarely more than two nights in one as well as the burdens to caregivers. It was more dif- house, and having a beat which embraced three large ficult to identify the ‘non-pauper’ than the pauper counties ... years ago this woman was placed as a insane, because paupers were registered as recipients boarder, at four shillings a week, with a kindly old of public assistance, but the study nonetheless at- woman, whom she had been in the habit of visiting, tempted a full count of non-paupers as well as and ... all these years she has slept under her guard- paupers. ian’s roof.’ (pp. 42–44). These remarks are still rele- The result was a total estimate for 1 January 1862 vant and poignant for those of us who work today of 3628 insane persons living outside asylums, which with homeless people afflicted by severe mental was nearly equal to the number living within asy- illnesses. lums. These were subdivided in numerous ways. For Most, though not all, caregivers were relatives. example, there were 1741 paupers and 1887 non- Mitchell observes that for indigent non-pauper paupers. Among non-paupers, living conditions were families, the financial burden was such that the categorized as affluent (very few), comfortable (about whole family’s condition tended to deteriorate over one-quarter) or indigent (the great majority), and time. ‘Many of them seem to be just waiting for the types of insanity were categorized as ‘idiot’ (36%), disturbance of some precarious arrangement, ere they ‘imbecile’ (37%) or ‘acquired insanity’ (27%). take one step further down and pass to the pauper Many of Mitchell’s insights derived from the in vivo list.’ (p. 12). He argues that a supplement had to be nature of this investigation. His report describes many provided to these families, so that they could sustain cases in detail, and his empathy as well as his per- their caregiving without draining all the family’s re- ceptiveness shine through these accounts. We only sources. On stigma, he writes of Widow M that ‘... It have space for one general quotation that demon- is painful to have her condition looked at by stran- strates his connection to the lived experience of the gers ... visitors are therefore discouraged ... and the people he studied, and for a few short extracts on the house and family ... isolated from friends and neigh- two specific topics of homelessness and caregiving. bors ... ’ (p. 14). He suggests that many families Mitchell writes: ‘By every little thing the idiot learns encouraged their insane members to lie constantly to do, by so much he is less an idiot; and the width in bed, or even put them in seclusion, out of misun- and importance of the difference between an idiot derstanding rather than malice. He describes a case of who can feed himself and one who cannot, between an idiot who can put on his own clothes and one who solitary confinement where ‘A more judicious treat- cannot, between an idiot who is cleanly and one who ment was recommended, and at the next visit her SIR ARTHUR MITCHELL 1419 case was thus reported on: ‘She now leaves her room caregivers should be expected to take on this task and joins the family circle, occasionally assisting in without any compensation. As noted earlier, he saw household and field work ... seems interested in clearly that in the absence of supplements to indigent what goes on around her ... thinks more of her per- family caregivers (the majority of non-pauper com- sonal appearance ... . Her own enjoyment of life is munity caregivers), those who assumed a caregiving increased ... . And the change will not be felt by her role often found their resources drained, with the alone, but by those also ... who have so long tended result that eventually the entire family became pau- her with unwearied care ... ’. (p. 60) Mitchell was pers. Fourthly, he understood that the provision of aware too, that caregiving in reasonable circum- care in the community depended upon the acceptance stances—which could be made possible by a supple- of insane persons as belonging to the community as ment to the caregivers—could bring emotional fellow human beings. He thought that insane people benefits, not only burdens, to the caregivers. His should be in the company of children, so that from an standard for good caregiving was contextual: ‘In the early age the inhabitants of the community could vast majority of cases, it is enough if the patient is become accustomed to interacting freely with insane really treated as a member of the family in which he people. He also thought that the provision of in vivo lives ... ’. (p. 35) assistance to caregivers would help: ‘... the seed of correct views was being sown in the community ... . Thus a prospective as well as an immediate benefit Proposal for a System of Care was being conferred on the insane poor, or rather, Mitchell’s report is at once a critique of the then cur- I should say, on the insane generally’. (p. 58) rent practices of boarding out in Scotland, an expos´ e The report is explicit in proposing a national of its worst abuses, and a proposal to develop and ‘system’ of care. He knew about the town of Gheel, improve it as the key component of an integrated Belgium, where patients had been boarded for centu- system of care for insane people. Had his proposed ries; to our knowledge the first successful model of system been adopted, it would still represent an im- collaboration among families, patients and commu- provement on the psychiatric care provided in most nity. But he only used it to show that more than countries today. First, he proposed that care provided one patient could be boarded in a dwelling. He did both inside the asylum and outside the asylum not see it as (and it was not) an integrated system (mainly boarding out) should be managed in in which one component was boarding of patients in tandem as part of one system, with both carefully their own home or other familiar environments. monitored for prevention of abuse and for continuing Thus Mitchell envisioned a system in which a cer- improvement. His overarching philosophy was that tain form of boarding out would play a key role. This patients should be living in the least restrictive envir- is reflected in his other writings too. The state of onment (not his words but clearly his meaning). He Massachusetts carried out an experiment in boarding believed that most patients were ‘incurable’ and out that was purportedly based on his proposals, and ‘harmless’ and should live in the community. The it failed. In a sharp critique, Mitchell pointed out that asylum should be used for patients in danger of sui- the experiment had no fidelity to his model, and fur- cide or of harming others or for acute treatment that thermore was not sustainable. It was a diluted and would promote recovery. He writes: ‘The principle timid version of boarding out, which included such which at present regulates admissions and discharges elements as not boarding-out patients to families seems to be this—not easily in, and still less easily with children, avoiding substantial payments to care- out ... the principle ought to be: easily in, and not givers and trying to place patients with caregivers easily detained’. (p. 87) who had experience as asylum employees, all of Secondly, he argued that the system of boarding out which Mitchell opposed. could be widely extended and sustained with good Mitchell used statistics as evidence to suggest that results. This was needed in order to accommodate his model could be implemented and could improve his model. It was not, however, unrealistic. Boarding patient and family outcomes. He showed that the ex- out was in fact extended and sustained over a very tension of boarding out would be less expensive than long period. The cleverness of this approach lay in the extension of asylum care, even with the improve- using what was already a traditional local resource. ments he proposed. He showed that mortality rates Boarding out was an accepted practice in Scotland, were 10% per year for lunatics in asylums and and, therefore, had the potential to be improved and 5% per year for those boarded out. He exhibited the sustained with less resistance than an approach im- statistics for a district where improved boarding out ported from elsewhere. He suggested that boarding along the lines of his proposal had produced good out could be improved by ongoing visits to the results. He drew on various kinds of evidence to homes, so that arrangements could be tailored to show that the supply of caregivers would be suffi- the needs of the individual patients and their families cient, especially if it was possible to board more or other caregivers. Thirdly, he emphasized that the system had to be supported by more generous pay- than one patient in a home as allowed by the ments to caregivers. He ridiculed the idea that Lunacy Act of 1857. 1420 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY Unfortunately, although his model was imple- of care. The Act raised the status of psychiatrists to mented at least in part, and was sustained by others that of their fellow consultants. It also reorganized after his retirement, it eventually did fade. The num- health services into a tripartite system of hospitals, bers boarded out peaked in 1913 and then began to local authorities and general practitioners. Mental decline. An interesting piece written by George Gibson hospitals were grouped with general hospitals and in the 1920s notes the decline and considers various were encouraged to develop outpatient services. The explanations. Gibson concludes that the main ex- local authorities were assigned explicit responsibilities planation was the lack of enthusiasm of the asylum regarding the care of mentally-ill persons. superintendents, who had become dominant in the In these new circumstances, experiment and creativ- public mental-health system. The asylum superin- ity had room to flourish. The introduction of psycho- tendents knew little about the living conditions of tropic medications in the 1950s gave further impetus. patients in the community. They were more comfort- Thus began a period in which new concepts and prac- able keeping patients within the asylum, and especial- tices were introduced. Outpatient clinics sprang up, in ly keen to retain patients who were able to work and both psychiatric and general hospitals, to serve men- contribute to the upkeep of the asylum. If this is true tally disordered patients. The theory as well as the (and it is certainly plausible), then the underlying understanding of the scope and limitations of com- reason for the decline of community care in munity care advanced. A Royal Commission report in Scotland was the failure to fully implement the inte- 1957 and a new Mental Health Act in 1959 rein- gration of community and asylum care. The asylums forced these trends. became dominant rather than being but one cog in a Two of the best-documented projects, one in larger wheel. Chichester in the south of England, and the other Before we proceed to the next sections, we should in Salford in the north offer interesting and contrast- note some of the less-attractive aspects of Mitchell’s ing approaches. In both instances they began, as did report, viewed through the lens of a 21st century Mitchell, by counting and describing the known men- reader. This is not ‘fair’, in the sense that he was, tally ill persons in the areas of interest. The fate of like all of us, a man of his own times. But it is none- these clients was then followed, for a few months in theless important, in order to convey the true history Chichester, for several years in Salford. The resources and also to avoid mere hagiography. Mitchell needed for their care, and especially those provided by believed, like many of his time, that special accom- families, were evaluated. Comprehensive accounts of modations should be available to the better-educated 27–30 both Chichester and Salford are available. We classes, so that they could be treated in conditions to focus here on illustrating how both projects resonated which they were accustomed. This was not a foolish with Mitchell’s vision, despite the fact that they were idea, given the historical context, but clearly not an done without awareness of his work. egalitarian one either. He was uncharacteristically The Chichester project was led by Peter Sainsbury and harsh on insane women who bore illegitimate chil- Jaqueline Grad of the Medical Research Council. They dren, which he believed to be an ‘evil’. His views on sought to understand the impact of the community ser- the matter seem motivated not only by his genuine vices being developed by the Graylingwell mental hos- concern both for insane women who were sexually pital. Like Mitchell, they were especially concerned exploited and for their offspring, but also by moral with caregivers in the community. The patients and prejudice. caregivers in the Chichester area were compared with a designated ‘control’ area, Salisbury, where the trad- itional mental hospital services still prevailed. A cen- One Hundred Years Later: a High- tral question was whether the Chichester services Income Country relieved or accentuated the burden on the family. Reading the Chichester reports, one is impressed by Throughout the economic downturn of the Great the care taken in the measurement of family burden. Depression and the ensuing Second World War, wide- With respect to this question, the results were nuanced, spread poverty and maldistribution of health services neither service being obviously superior across the range were prominent features of British society. It was of clients, although the Chichester system certainly not until the election of a Labour Government near relieved pressure on the hospital. In some ways, the the end of the war, however, that government policies study was most useful in emphasizing the different were directly targeted to redress these inequalities. A needs of the various types of patients, some requiring potent symbol of change was the National Health short-term admissions, the elderly needing social work Service Act of 1948. services, those without the support of relatives having to Mental disorders were not a high priority in the be individually served. This work presaged the notion of National Health Service Act, but nor were they over- ‘balanced hospital and community care’ put forth looked. It was evident that the spectrum of mental disorders was broader than previously recognized, today. and that the traditional pattern of asylum care In contrast, the Salford project was initiated by Dr would have to be supplemented by other forms Lancelot Burn, the Medical Officer of Health of the SIR ARTHUR MITCHELL 1421 local authority. Burn was committed to the inclu- model of community-based treatment for those with sion of mental health in public health and saw that mental illness in a completely different cultural con- the system of health care must embrace those with text. Lambo, among other achievements, was Deputy severe mental illness. This project had a dual focus: Director of the World Health Organization from 1973 one was to actively implement changes in services, to 1988 later in his career; however, it was his village and the other was to build a base for epidemiologic model of boarding-out patients in the community research, which included, but was not limited to, created in the 1950s that established his legacy in measuring the effects of the changes. Very imagina- African psychiatry. Lambo did not have the bene- tively, Burn entered into an alliance with the fit of a community study prior to initiating his Department of Social and Preventive Medicine at programme, but he visited the homes where individ- Manchester University, which appointed Dr Mervyn uals with mental illness were living, and this first- Susser to work part-time in Salford. Susser was a hand knowledge greatly influenced his ideas about South African ´ emigre ´ and a medical practitioner the practice of community psychiatry. (Later, he with a strong public health and community orienta- collaborated with the Leightons on studies of psychi- tion, fresh from directing a South African community atric conditions among the Yoruba population of health centre, and without prior convictions about Nigeria.) how patients with mental illness in Salford should Like most of colonial Africa, Nigeria had asylums for best be served. custodial psychiatric care, although the number of Like Mitchell, the Salford team envisioned an inte- asylum beds per capita was far lower than in the 40,41 grated system of mental-health services (though at industrialized countries. In this context, Lambo the local rather than the national level). Susser developed a now-famous experiment in boarding out began by analysing the barriers between the different for patients in Nigeria—the Aro Village model. In institutions and services involved. He illustrated his 1954, Lambo, having recently completed specialist findings in a diagram (Figure 1), which placed the training at Maudsley Hospital in London, assumed local authority at the centre to emphasize its key responsibility for the Lantoro Asylum, and for the role in integration; portrayed in circles around were Aro Mental Hospital in Abeokuta, Nigeria. The the mental hospital, the general hospital, the general Aro Hospital was intended to be the first modern 34,35 practitioners and the community facilities. Susser psychiatric hospital in Africa, but was still under con- then set himself to smooth the linkages between struction. Prior to completion of the hospital, them. Among the steps taken, first was to develop Lambo, who was anxious to start treating patients, the professional skills of the team members, known developed the Aro Village model whereby patients as mental-health officers, who had a range of experi- could be ‘admitted’ to the village and receive treat- ences and training, but were none well suited to the ment from Lambo and his colleagues. The full village demands of this new service; secondly was to enhance model took shape upon completion of Aro Hospital in the interactions among general practitioners and mental-health officers; and thirdly was to arrange Aro Hospital was built near four villages and after the appointment of a psychiatrist (Hugh Freeman) extensive work establishing community support, with a new cross-cutting role. Patients were regularly Lambo grafted a therapeutic village unit onto these visited by mental-health officers, and new institutions existing villages with the intent of accommodating 42,43 were created in the community, such as a social club, 200–300 patients. Patients admitted to Aro hostels and day-care facilities. To trace the impact of Hospital could stay within the hospital wards that these changes, and also for other purposes, a patient were designed for short-term stays of up to a few registry was established, one of the first to use com- months or they could be boarded out to the neigh- puterized data. bouring villages. Patients lodging in the homes of vil- Finally, we note one further similarity to the work lagers were required to be accompanied by one of Mitchell. The projects in both Chichester and relative who also lodged with the village family and Salford were well known in academic and profession- who was responsible for taking care of the patient al circles in the UK, and attracted attention in the (e.g. cooking, washing clothes, escorting to the hos- USA and elsewhere too. Neither the Chichester nor pital) for the duration of treatment, which could be the Salford models were sustained over the long 56 months. Patients went to the hospital every term, however, and it is not easy to read the effects morning for treatment and returned to the villages of these studies on current practices today. in the afternoon where they could participate in regu- lar village life activities. The model was unique in that it required family caregivers and the host commu- nities to work together. Lambo further developed One Hundred Years Later: a Low- the idea into a comprehensive therapeutic model Income Country that included bringing traditional healers to the vil- During the same period, Nigeria’s first African psych- lages to complement the hospital treatment, an un- 38,44 iatrist, Dr Thomas Adeoye Lambo, designed a village orthodox collaboration at the time. 1422 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY Figure 1 Circle for general practice shows the proportion distributed to the different psychiatric services; all other circles show the proportions of referrals received from different services. The actual numbers of referrals are shown by the figures in the arrows. Psychiatric O.P. refers to psychiatric out-patient clinics. Printed with author’s permission from Susser et al. (p. 4) The Aro Village model was guided by four principles community. Unlike Mitchell’s proposal, however, that resonate with (but did not derive from) boarding out in Aro village was not a long-term ar- Mitchell’s boarding-out model. First, Aro Village was rangement. It was part of a treatment plan whereby meant to be one component of a system of care. eventually patients would return home after some Lambo posited that the Aro Village programme measure of recovery. Lambo believed that by utilizing could not work without Aro Hospital’s open in-patient and adapting to the existing village infrastructure unit and out-patient clinic, and, according to his con- around Aro Hospital, many Nigerians’ recovery from temporary colleague Dr T. Asuni, also the Lantoro mental illness would be enhanced by living and work- Asylum for patients needing a closed inpatient ing in a rural environment with the traditional 40 42 unit. The Aro model clearly valued a strong, flexible socio-cultural resources of the community. link between hospital and community-based care re- Continuing to live in the community was expected sponsive to individual needs. Secondly, Lambo under- to aid in their reintegration after treatment. Finally, stood from the beginning that compensation for Lambo recognized that reduced stigma could be a community caregiving had to be part of the pro- positive byproduct of living with those with mental gramme. Indeed, he believed not only that the villa- illness. Lambo not only believed in the therapeutic gers who housed those with mental illness should be effects for patients but also that patients could compensated, but also that the entire village should change the community: ‘The community, on the benefit from taking on this unique relationship with other hand, can have the opportunity of watching Aro Hospital. Besides individual payments to villagers the gradual process of recovery of the patients, there- for boarding patients, villages received the added in- by changing their views on the alleged causation and centive of services such as public health clinics and course of mental illness and perhaps exhibiting more piped water systems. Thirdly, Lambo was emphatic tolerance.’ that the model be designed as a culturally appropriate The Aro Village model is a testament to creativity, care option that would be sustainable in the innovation and foresight. Yet this model too proved SIR ARTHUR MITCHELL 1423 unsustainable. One disadvantage of the model was their homes. In Dar es Salaam, this role was taken up that it excluded some urban or more educated pa- by community psychiatric nurses. A few nurses still tients for whom village life and agrarian work was hold these positions; however, the city’s population seen as inappropriate. There were administrative now exceeds 3 million, and far outstrips their ability costs for sustaining the Aro Village, and with changes to visit even a small fraction of the patients who in political leadership and increasing urbanization, could benefit. There is also an unfilled need for 38,40 boarding out with non-relatives when living with the model has largely disappeared. family is not a feasible or appropriate arrangement. A limited number of patients are served by the Vikuruti rehabilitation village—a village within a vil- Implications for Global Mental lage community with self-sustaining agriculturally based rehabilitation activities, established in the Health early 1980s near Dar es Salaam and fashioned on Many of us in the global mental-health field share a the principles underpinning the Aro Village model. vision of community-based psychiatric care for indi- However, similar to what Mitchell cogently described viduals with severe mental illness and their full inte- in 19th century Scotland, families in Dar es Salaam gration in communities. We are still far short of this who struggle to care for their ill relatives without ad- vision. The barriers we face have been portrayed elo- equate support can be drained of resources over time, quently by Saraceno et al. and the affected individuals may also suffer (e.g. In all countries, as we confront these challenges, being tied up in their homes or left homeless when there is much to learn from our predecessors. Like family resources dissipate). Mental-health care in Dar the few examples described here, some of these pre- es Salaam could be greatly improved if there were decessors achieved international recognition in their appropriate levels of financing to support patients own time. Others, especially in developing countries, and their carers, and regular guidance from commu- had mainly local or regional influence, but with nity mental-health workers who could support and modern technology, their work is now being made monitor community living arrangements, including accessible to a global audience. the rehabilitation village, and ease access to hospital The works described here formulated principles care as needed (Dr Sylvia Kaaya, personal for mental-health services (independently of one communication). another), which are still relevant for the development We have many advantages today that our predeces- of community care today. They recognized that a sors did not have. Our scientific and clinical under- spectrum of community living arrangements is an es- standing of mental illness has been transformed. We sential component of a system of care. They proposed have rigorous methods to design and test new and/or a fluid relationship between hospital and community adapted models of community care and treatment. living arrangements, within which the location of care We can reliably measure many dimensions of out- could differ over time without interrupting the con- comes for patients and their families. We have tinuity of care. They saw the need for a coordinated begun systematic investigations of how to sustain system of care that could encompass medical treat- and disseminate effective services. Families and pa- ment, housing, employment support and other elem- tients (or consumers) are taking a more active role ents. They sought to change the community in shaping formal services and in creating informal environment within which affected individuals services for mutual support. would be living, and to increase their acceptance as Yet we are left with many of the same problems en- part of the community. countered by Mitchell, 150 years ago. In countries with These principles remain useful across a vast range of scarce and plentiful resources alike, significant numbers cultural contexts in the present time. Consider the of mentally ill persons are still wandering the roads, city of Dar es Salaam, in Tanzania, a country with begging, sleeping rough. Others are housed for much one of the more innovative mental-health systems of their lives in institutions, hidden from sight. The 49,50 in Africa. In this city, when families seek out concept of justice and humanity fits neither of these formal psychiatric services, they are often in a state extremes as Mitchell so clearly saw. of crisis after having tried to manage at home, and An especially ubiquitous challenge is to sustain until recently they sometimes went directly to the mental-health services that have proven effective. national referral hospital, Muhimbili National There is no ready answer, and our predecessors did 51,52 Hospital, bypassing the lower echelons of the pri- not fully achieve this goal, but again we can learn mary health-care system. Further, affected individuals from them. They saw that continual monitoring, from other regions often move to stay with relatives evaluation and creative adaptation is essential at in Dar es Salaam in order to access and receive every level. It may be that without these elements, mental-health care at Muhimbili National Hospital. no model can survive in the long term. 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Soc Sci orders among those attending primary care health clinics Med 1998;47:419–28. and traditional healers in urban Tanzania. Br J Psychiatry Schulsinger F, Jablensky A. The national mental health 2003;183:349–55. programme in the United Republic of Tanzania. A report Published by Oxford University Press on behalf of the International Epidemiological Association International Journal of Epidemiology 2010;39:1425–1429 The Author 2010; all rights reserved. doi:10.1093/ije/dyq226 Commentary: A psychiatric epidemiological pioneer—Arthur Mitchell’s follow-up of study of hospitalized patients Gerald N Grob Rutgers University, Institute for Health, Health Care Policy and Aging Research, New Brunswick, NJ 08901, USA. E-mail: ggrob@ifh.rutgers.edu Accepted 17 June 2010 Arthur Mitchell’s ‘Contribution to the statistics of in- hospitals were more akin to welfare institutions that sanity’ is in many ways a unique contribution. At a catered to a variety of dependent and disabled time when there was virtually no interest in following persons. the lives of patients admitted to mental hospitals, Toward the close of the 18th century, the concept of Mitchell undertook a 12-year study to determine the a mental hospital underwent a radical transformation. fate of nearly 1300 persons admitted to mental hos- No individual did more to popularize the faith in pitals for the first time. Such undertakings were vir- asylum care and treatment than Philippe Pinel. He tually unknown in the 19th century (nor are they loathed speculation about the ultimate nature of common at present). Yet, their significance cannot disease and preferred to confine himself to the be overestimated, for they provide a unique insight accumulation and analysis of date. His Traite me´dico- into the workings and outcomes of institutional care philosophique sur L’alie´nation mentale, ou la manie (pub- and treatment. lished in 1801 and translated into English in 1806) To comprehend the significance of Mitchell’s study became the classic justification for making mental requires an understanding of the historical context, hospitals the core of psychiatric practice. He rejected including the origins and subsequent development bleeding, corporal punishment and other traditional of mental hospitals. Appearing in the late 18th cen- practices that were used to treat the insane. He was tury, mental hospitals were regarded as a harbinger of equally opposed to prevailing modes of confinement, progress. Madness, wrote Dr William Battie in 1758, which included seclusion and the use of mechanical was as manageable as other distempers and by no restraints. Rejecting the belief that insanity was solely means incurable. As one of the founders and first the result of physical lesions, he made room for a physician at St Luke’s Hospital for Lunatics in psychologically oriented therapy. Seeking to gain London, he noted the existence of spontaneous recov- the patient’s confidence, he developed what eries. Insisting upon the importance of ‘regimen’, he called traitement moral, which in England and Battie stimulated the founding of lunatic hospitals the USA became known as ‘moral treatment’ or in other English cities. Nevertheless, 18th-century ‘moral management’. It should be understood,
International Journal of Epidemiology – Oxford University Press
Published: Dec 24, 2010