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Monday, 22.10.2018

Hanfried Helmchen: The role of psychopharmacotherapy in the early development of social psychiatry in Germany1

 

Not the least as a reaction to the collectivistic ideology and the biological reductionism of National Socialism, humanitarian aspects such as the personal history and social context of the individual gained influence on psychiatric thinking after the war in Germany. This development became manifest in anthropological psychiatry. It came into being with the “understanding anthropology” around Jürg Zutt (1893-1980), professor of psychiatry and head of the Department of Psychiatry at the Frankfurt University (1950-1967), as well as with Walter v. Baeyer (1904-1987), professor of psychiatry and head of the Department of Psychiatry at Heidelberg University (1955-1972) and later on vice president of the World Psychiatric Association (WPA) (1966-1971), who already in 1955 directed with his “concept of encounter” (Begriff der Begegnung) the view on the essential therapeutic factor of bringing about a relationship with the ill individual.    

As early as in 1947 his experience as chief physician of the psychiatric department in the large general hospital at Nuremberg caused him to speak about “social psychiatry” (Kretz 2004); this concept was then elaborated in the 1960s by his pupils Heinz Häfner and Karl-Peter Kisker (Häfner 1965)2 and was institutionalized by the “Psychiatry-Enquéte of the German Parliament (Deutscher Bundestag) for the reform of psychiatry (1971-1975)” through the reorganization of psychiatric care. The chairman of the Enquéte-Commission was Caspar Kulenkampff, who had established a Department of Social Psychiatry at the Frankfurt University Hospital in 1959. These ideas developed further in the late 1950s and 1960s particularly in southwestern Germany via the psychotherapeutically engaged professor Hanns Ruffin (1902-1979) in Freiburg (1951-1967) and asylum-experienced3 professor Walter Schulte (1910-1972) in Tübingen (1960-1972), as well as through a network of young psychiatrists (the so-called Rhein-Main-Kreis) from these university departments (Söhner, Becker and Fangerau 2017). Finally, the “brutal reality” of the insane asylums neglected and left in miserable condition by the National Socialist crimes and the dire need of the postwar years (Kersting and Schmuhl 2004) motivated young psychiatrists to a movement for reform that resulted in the “Mannheim circle” and, in 1971, the German Society of Social Psychiatry. Thus, the impression is justified that the inhumane conditions of insane asylums and a new anthropologically reasoned view of the mentally ill resulted in a social psychiatric reform of German psychiatry (Thoma 2012).

However, the question has been scarcely elaborated systematically of how the almost simultaneously developing psychopharmacotherapy4 influenced this development. Initially it was looked at as “one of the most important requirements of the acceleration of social psychiatric efforts” (Dörner and Plog 1999), but with diverse relevance and justifications in different contexts (Dörner and Plog 1999; Lauter 1968; Hippius 1968), all the way to only small, questionable or no significance at all (Häfner 1968; Odegard 1964; Smith, Bower and Wignal 1965; Niemann 2008). Therefore, attention will be drawn to interactions between the biological and social dimension from my own knowledge of historical data from Berlin.

Reports of the impressive effects of chlorpromazine on acute psychotic conditions, which were published in 1952 by Jean Delay (1907-1987), professor of psychiatry in Paris, and his collaborators Pierre Deniker et al., immediately excited strong interest in some assistants of German psychiatric hospitals, e.g., in Heidelberg (Janzarik 1954) and Munich (Kolle and Mikorey 1953), and also in the Psychiatric Department of the Free University of Berlin.

            As early as 1954, a first publication (“hibernation therapy of acute psychoses”) from this department was published (Hiob 1954), followed in 1955 by a comprehensive report “comparing the psychopathology of the shock and phenothiazine effects” (Hartmann, Hiob and Hippius 1955), as well as publications on side-effects of the phenothiazine therapy (Hiob and Hippius 1955). In 1988 Hanns Hippius5 described retrospectively the related remarkable improvement of psychiatric treatment “from the impact on psychopathological symptoms through the humanization of the ward atmosphere to the possibilities of outpatient and prophylactic treatment against relapses instead of long-term institutionalization” (Hippius 1988).

The pharmacotherapeutically induced quick and augmented accessibility of the patient opened the view more than to date toward his living conditions, his familiar environment and his social situation (Freyhan 1966). Soon the question arose whether a long-term drug treatment might prevent relapses and recurrences and could support social rehabilitation. “Today the difficulties of the treatment of psychoses are increasingly shifting from the treatment of psychotic symptoms to the re-entrance of the remitted person into his profession and family… As a consequence, problems from the social sphere of influence frequently become more meaningful than the purely medical ones. If these factors are overlooked or neglected, the risk exists that the boost might trickle away that the psychiatric therapy received by the introduction of the psychotropic drugs. The impulses of pharmacopsychiatry must be taken up by social psychiatry” (Enss and Hippius 1964). Thereby the perspective of a rehabilitatively oriented long-term outpatient treatment arose.

These experiences with long-term, drug-treated patients developed toward the demand “to reintegrate the remitted patient without disturbance into his social milieu …to meet the requirements of a gradual social and psychiatric rehabilitation.” Consequently Hanns Hippius, together with some colleagues, particularly Hildegard Enss, tried to implement these demands. Thus, he contacted Dr. Dietrich Blos, the president of the Berlin Red Cross Association, who in 1956 established the Phoenix House (Haus Phönix) for admission of discharged schizophrenic patients, as the first half-way house in the Federal Republic and West-Berlin – supported by the Berlin lottery (Enss and Hippius 1964).

Before then the existing (somatic shock-) treatments could improve the prognosis of acute schizophrenic episodes but not the long-term prognosis. "Thus, the search for a therapeutic method the application of which would be effective for a long or even permanent duration continued to remain one of the urgent tasks of psychiatric therapy. A long-term applicable mode of treatment is most likely to raise the hope of improving the long-term prognosis of schizophrenics” (Enss, Hartmann, Hippius et al. 1960).

Therefore, “…on July 1, 1957, the first catamnesis began with 241 schizophrenic patients; after completion of their inpatient first treatment they were transferred systematically from two closed wards into a long-term treatment with perazine for an average of 6-12 weeks’ duration” (Enss, Hartmann, Hippius et al. 1960). It was to be tested whether the ambulatory drug treatment with perazine (Enss, Hartmann, Hippius H et al. 1958), a drug with only few side effects, would reduce significantly the number of relapses after five years (Helmchen, Hippius and Tiling 1967). 6  It became apparent that the adherence of a patient to the conduct of a long-term treatment was determined not only by individual and medical staff, but also by social factors” (Richter 1961). Not only the obtained grade of remission but “also decisive for the reliability in the long-term treatment are the living condition, the atmosphere at home as well as the attitude of related persons with regard to the illness and therapy of the patient”  (Richter 1961). Therefore, the care of patients was fostered by a gradual process of rehabilitation and institutionalized by a social department in 1960.

The intensive medical and caring support of the long-term drug treatment led to different modifications of interventions in order to prevent or attenuate impending recurrences, not only by adaptations of the dosage executed sometimes by experienced patients themselves, but by overnight admissions for adjustment of the medication and for talks with the psychiatrist. Those patients not yet fit for work but almost for discharge stayed only during the day in the hospital but with their families during the night. For institutionalization of these interventions, in 1962 the Phoenix House was extended to a “half-way house with a day and night hospital” (Hippius 2017).7

His own experiences and increasing discussions on necessary changes in the structures of psychiatric care8 motivated Hanns Hippius to call for a department of psychiatric epidemiology and social psychiatry (in his negotiations for refusing a call to the university in Hamburg in 1968); the faculty and academic senate of the Free University of Berlin decided in favor of this in 1970 (Hippius 2006) and established it in 1972 with Gregor Bosch as head; Bosch had gained his social psychiatric expertise, among other experience, with the setup of the social psychiatric institution initiated by Caspar Kulenkampff in Frankfurt.

Summary

Early experiences are reported that psychopharmacotherapy, particularly the relapse-preventing long-term medication, has led to an increased recognition of social determinants of the course of illness, especially in schizophrenic patients. As a result, social psychiatric institutions developed, e.g., in Berlin from half-way house (Übergangsheim) “Phoenix” in 1956; through a catamnesis for long-term outpatient treatment of schizophrenic patients in 1957; a social service in 1960; a day and night hospital in 1962; all the way to a university department of social psychiatry in 1972 with a rich spectrum of institutions for a gradual rehabilitation of mentally ill patients.

In comparison with well-known humanistic sources of German psychiatric reform we discuss here some less well-known sources based on psychopharmacotherapeutic experiences that need further historical elaboration. Some questions are: 1. how has psychiatric pharmacotherapy influenced the development of social psychiatry in Germany?; 2. has the pioneering spirit of the 1950s, initiated by the new treatments with psychotropic drugs, fostered the development of social psychiatry, although in Germany this development was delayed 9 (Hippius 1968) in comparison with England, France, and Canada until the end of the 1960s; and 3. has (possibly related to the post-war international isolation of German psychiatry) the retardation of the development of social psychiatry in Germany been overcome, not the least by the new scientific development of psychopharmacology that encouraged international contacts and thus increased knowledge among German psychiatrists of social psychiatric institutions in other countries? In any case, the possible influence of psychopharmacotherapy should not be mis­sed in an overall view of the development of social psychiatry in Germany.

 

Author’s Notes:

1     The title of this essay is based on: Helmchen H (2017) Zur Rolle der Psychopharmakotherapie in der Entwicklung der Sozialpsychiatrie. Nervenarzt 89 (1) 88-91 DOI:10.1007/s00115-017-0464-2.

2   Heinz Häfner’s 1965 memorandum initiated a development that resulted in the Central Institute of Mental Health in Mannheim, which opened in 1975.

3     Walter Schulte was the leading physician from 1947-1954 in the German psychiatric asylum Bethel (1954-1960) Bethel, 1954-1960 of the psychiatric asylum Gütersloh.

4    Psychiatric drug therapy was not only a new basis for the treatment of patients, but also became a tool for research into biological mechanisms of mental disorders and led to the term “biological psychiatry” (Helmchen and Hippius 1975).

5     Hanns Hippius, an assistant at the Berlin hospital since 1952, was interested in psychopharmacology; in 1955 he participated in the first Colloque International de Chlorpromazine in Paris; in 1957 he was invited by the Basel pharmacologist Ernst Rothlin as a representative of the young generation of German scientists to the founding of the Collegium Internationale Neuropsychopharmacologicum (CINP) in Zürich; and in 1974 he was elected CINP president.

6    Helmchen, Hippius and Tiling in 1967 reported that after three years, 59% of the drug-treated patients remained free of recurrences, but only 20% of the patients were without long-term treatment.

7     In his personal correspondence of August 27, 2017, Hippius stated that he reported to Caspar Kulenkampff his impressions from his visits of social psychiatric institutions in Canada; after this Kulenkampff visited Hippius in Berlin, visited the social psychiatric institutions around the half-way house “Phoenix” – and published about the night hospital that he had implemented in Frankfurt (Kulenkampff 1961).

8      Hippius was also influenced by a “social psychiatric working group Berlin” (SPAK), which was founded in 1970 mainly by assistants of the university psychiatry department and presented in 1972 a “pink paper” (Lehmkuhl 2008).

       Since 1967 social psychiatric services based on 1920 models of reform were established at the administrative offices of the Berlin burroughs by the decisive initiative of Dr. Ruth Mattheis from the Berlin Senate (Lehmkuhl 2007). Previously, Dr. Barbara v. Renthe-Fink from the Berlin Senate commented: “really successful was only a long-term planned development of social psychiatric services. Long before the Enquète of the Federal Government for the psychiatric care in the Federal Republic of Germany this model of decentralized psychiatry was established” (Renthe-Fink 1982).

9    As printed in “Psychiatry - Proceedings of the IV World Congress of Psychiatry, Madrid 1966,” Hippius wrote: “Today (1966) in Germany social psychiatric concepts are only very reluctantly gaining acceptance. Thus, in the Federal Republic of Germany and West-Berlin up to now only three of the 21 psychiatric university hospitals offer some years of experience with a social psychiatric aftercare unit with day- and night services. Prerequisite and inducement for the development of such an institution in Berlin were the encouraging successes of the long-term drug treatment.”

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April 5, 2018