Hanfried Helmchen: The role of psychopharmacotherapy in the early development of social psychiatry in Germany
Shridhar Sharma’s comment

            Dr. Hanfried Helmchen’s paper on “The role of psychopharmacotherapy in the early development of Social Psychiatry in Germany” is interesting and informative. The paper basically deals the historical development after the Second World War and is silent about the early development.

            The term “Social Psychiatry” has a long tradition in Germany. In 1803 Johann Christian Reil introduced the word “Psychiatrie” in Germany (Binder, Schaller and Clusmann2007). After 100years, in 1903,the term “social” was first linked to psychiatry when Georg Ilberg from the Groß-Schweidnitz asylum in Saxony, Germany, wrote a paper entitled simply “Soziale Psychiatrie.” (Ilberg 1913). Ilberg defined Social Psychiatry as a theory of the detrimental influences that affected the mental health of the whole population (Gesamtheit) and as a useful means for their prevention. Ilberg suggested that about 60-70% of all mental diseases exhibited a hereditarian component and thereforethe first task of Social Psychiatry was to prevent intermarriage between healthy and mentally ill persons. The second task concerned the fight against syphilis, which was rampant during this period and caused progressive paralysis and dementia paralytica. Third, he argued for a campaign against excessive alcohol consumption, which was a major health problem. Fourth, he felt that it was essential for several professional groups in the society to become familiar with psychiatric knowledge, among them lawyers, priests and teachers who could play important role.

            In 1912Max Fischer, advocated psychiatric care outside the asylums and called this kind of extramural psychiatry “soziale Psychiatrie” (Fischer 1912). He further stressed thatwithout Social Psychiatry there would be no psychiatry (Fischer 1919). During roughly the same period, Gustav Kolb (1931) stressed that asylum care and extramural psychiatric care were two inseparable and complementary parts of one single system of mental health care. After a cost-benefit analysis, he suggested that this kind of open psychiatric care was “natural progress” because it enabled mental health care to achieve maximum efficacy with minimalexpenditure. Kolb also outlined five specific tasks to meet this objective: first, the reintegration of discharged mentally ill patients with their families and occupations, thus eliminating the disadvantages and dangers they posed for the general public; second, the scientific, statistical and socio-medical registration of all mentally ill and abnormal people outside the asylums; third, the consolidation of all local asylums and other caring institutions according to psychiatric principles; fourth, the publication of psychiatric knowledge and experience of the mentally ill living outside the asylums; and fifth, the publication of knowledge about mental hygiene in order to prepare for preventive intervention in the community.

            It is worth recalling that it was in the Heidelberg Clinic that Kraepelin introduced the methods of experimental psychology for the study of fatigue, dreams and drugs, whileFranz Nissl,Kraepelin’ssuccessor,centered his interestson neuroanatomy and neuropathology. Heidelberg was an important psychiatric center where many eminent young psychiatrists worked,includingAdolf Meyer, Eric Cuttman and Mayer Gross (Lewis 1977; Kraepelin 1918). Similarly, Rüdin (1931),who equated Social Psychiatry with racial hygiene,stated that Kraepelin had also taken a social psychiatric approach, indeed a psychiatric-racial hygienic approach (“sozialpsychiatrisch, ja psychiatrisch-rassenhygienisch”). “Social Psychiatry” was thus reduced to the concept of prevention based on biological interventions, such as sterilization. This approach proved fatal for the Social Psychiatry movement.

            Thus, in 1940 the term Social Psychiatry lost its previous wide spectrum of connotations and was narrowed down to issues in line with National Socialist politics. As early as the First World War, and much more so in National Socialist Germany, the social status of the mentally ill worsened considerably and the ability to work became an obligation for patients. During the Third Reichthis obligation became a criterion for selection that determined whether they would live or die. Between 1939 and 1945 many psychiatrists in Germany participated in the largest systematic program to kill patients known in the history of medicine (Goldberg 2002). According to recent estimates, a total of at least 260,000 patients suffering from mental illnesses and mental retardation were murdered. After 1945 the term “Social Psychiatry” was not used as it was highly stigmatized. Despite the fact that psychiatrists referred to specific historical examples, they preferred the terms “Resozialisierung” and “Rehabilitation” (rehabilitation) in order to describe their endeavors (Hafner, von Bayer and Kisker 1965) and they avoided the term Social Psychiatry for almost a decade after the Second World War.

            Today, Social Psychiatry is concerned with the relationship between disorders of the mind and the human environment(Bachrach 1992; Harpham 1994; Marsella 1998). It studies the forces which act at the interface between individuals and those around them,and which may contribute to the onset, or course and outcome of mental disorders. There is a complex relationship between the molecular biology of the cell and the social environment. The mind is now the domain of the collection of small, sometimes overlapping disciplines ranging from molecular psychiatry, dealing like neurobiology with molecules in a cell, to Social Psychiatry, the final holistic output of the complex interplay of genes and social environment. Molecular events in brain cells have repercussions on aperson’s social environment and that, reciprocally, such molecular events may at times be influenced by happenings in the environment. In this landscape our aim should be for decompartmentalization of scientific boundaries with a more unified and integrated scientific approach to the problems of society at large and the individual minds that comprise our societies. The Social Environment concept is much more abstract and includes constructs such as social cohesion and culture;shared values;economic conditions andglobalization;threat by an enemy;and the expectation of survival(Marsella 1998; Stuckler, Basu, Suhrcke and McKee 2009; Stuckler, Basu, Suhrcke et al. 2009).

            These are macrosocial phenomena, sometimes difficult to define with precision or to measure, but nevertheless attributes of a society which certainly influence behavior in daily life and which may promote suicidal behavior, violence, hysteria or inhibit some types of mental disorder(Stuckler, Basu, Suhrcke M, et al. 2009). What is known about social influences on mental health, and how is this body of knowledge coming to form a coherent pattern, based on contributions which have been accumulating throughout the past century?(Marsella 1998).

Economic and Social Environment Suicide and Homicide Rates

            Recent analysis of European Union data for the past 30 years found that each 1% rise in unemployment was associated with an overall proportionate increase in suicidal rates(Stuckler, Basu, Suhrcke and McKee 2009; Stuckler, Basu, Suhrcke et al. 2009) . Similar trends have been reported in farmers in India and Khan(2011)proposed that in Pakistan the socio-demographic profile of suicide bombers is comprised of young people with a background of poverty, poor education, unemployment and lack of social support. The method of Social Psychiatry reflects its concern with the assessment of the individual and his environment. This is in its simplest form, entails a thorough psychobiological inventory of an individual, his life history and his total life situation. Such an inventory utilizes not only psychological factors, but also utilizes the clinical skills of the psychiatrist and, perhaps, those of the anthropologist or sociologist familiar with the ramifications of the patient’s environment. Recently,Heinz Häfner(2015)published some interesting German data on 25 years of research into schizophrenia.

            Social Psychiatry is a “point of view.” Such a view focuses on the social dimension of mental health, mental illness and mental health care. If it is applied to the wide field of psychiatry, three distinct connotations of Social Psychiatry result:

            First,an area of theoretical and empirical science

            As a scientific specialty, Social Psychiatry uses concepts and methods of social sciences, including psychology and anthropology, to investigate social factors influencing and relevant to occurrence, expression, course and care of mental disorders and may also deal with mental health promotion and other issues relevant to public mental health. Sometimes it is used in combination with other terms. Social Psychiatry might be seen as one of the major scientific specialties in psychiatric research, alongside biological psychiatry and, possibly, a “psychological” or psychotherapeutic psychiatry. 

            Second, a political movement with policy implications

            Since the 1950s, all Western industrialized nations have seen far-reaching reforms of mental health care with a closure or downsizing of former asylums and the establishment of services in the community. To a varying degree, the reforms were politically driven but they were greatly influenced by the introduction of antipsychotic drugs. They were frequently called “social psychiatric” and the advocates were regarded as “social psychiatrists.”

            Third,a way to practice mental health care

            Connotation of Social Psychiatry relates to the practice of mental health care. The underlying attitude was illustrated by the statement “psychiatry is Social Psychiatry or it is no psychiatry.” The term Social Psychiatry does not carry a copyright. 

            The three connotations as outlined above seem equally valid. However, it is useful to be aware of the differences between the connotations and to distinguish between them(Sharma 2004).

            Social Psychiatry is, of course, only one component of a wider body of knowledge about mental disorders. It complements other fields Psychopathology, Biological Psychiatry, Clinical Psychiatry and Environmental Psychiatry. Human disease is more than biopathology.   A biomedical model is based on a “biopathology” concept. Illness implies a biosocial model based on a social-pathology concept. This hypothesis proposes an etiological factor outside the individual, in his social environment. Such a paradigm has long been a mainstay of Social Psychiatry, with its emphasis on extra personal factors as major determinants of mental disorders. The role of individual psycho-social factors, for example, schizophrenia, whose worldwide presence of 1%in most social populations across the world suggests an etiology in which genes are favored over environment. A meta-analysis showed heritability had a liability quotient ranging from 73 to 90% and environmental factors ranging from 3 to 19%. This variation in the latter should be a focus of Social Psychiatry as to what factors in society protected individuals with a genetic liability suffering from this disease.

            The working agenda in Social Psychiatry consists of those experiences taking place between people which may influence their mental health and specifies the three main sets:  the social experiences and other social variables; the characteristics of the persons; and the nature of the psychiatric morbidity. It is also concerned with the way in which environment affects form, distribution, frequency, treatment, management and perpetuation of psychiatric disorders. Much of the concern of Social Psychiatry has been in assessing the pathogenetic significance of broad social currents such as a) migration, b) acculturation, c) industrialization, d) urbanization, e) discrimination and f) automation/technology, g) psychosocial stresses, h) violence,i) to self andj) outside.

            Today, the practice of Social Psychiatry is being increasingly influenced by the growth of science, technology and ideology of economicsalong with ashift in individual and social values suggesting introspection. The practice of Social Psychiatry is related to and depends on a complex of factors encompassing biological sciences and socioeconomic and ethical issues. In every day social psychiatric practice like other disciplines of medicine, science sustains and continually supplements our knowledge. However, it cannot provide the framework whereby sense is made of the data or the values with which to use the data ethically. Social psychiatry has developed into a robust arm of medical research and practice for at least two reasons:forces outside the individual are thought likely to have a powerful effect in causing mental disorders; andit is psychiatry which has made impressive progress in investigating the fabric of the social environment and in harnessing it for treatment. Thus, today Psychopharmacology has a greater relevance to the growth of Social Psychiatry. There is close proximity between the two disciplines.

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October 25, 2018