• DOI:10.1111/j.1600-0447.2010.01544.x
• Corpus ID: 40941250

Were we all asleep at the switch? A personal reminiscence of psychiatry from 1940 to 2010

@article{Eisenberg2010WereWA,
  title={Were we all asleep at the switch? A personal reminiscence of psychiatry from 1940 to 2010},
  author={Leon Eisenberg and Laurence B. Guttmacher},
  journal={Acta Psychiatrica Scandinavica},
  year={2010},
  volume={122}
}

• L. Eisenberg, L. Guttmacher
• Published 1 August 2010
• Psychology, Medicine
• Acta Psychiatrica Scandinavica

Just how extraordinary those changes have been, was not fully apparent to me until I sat down to prepare this memoir. While we were occupied with debates about issues internal to our field, changes in organization and financing of care proved to be decisive in its evolution. In 1956 the United States had 550 000 mental hospital beds (2). The prediction was that the number of hospitalized mental patients would climb to 700 000 by the year 2000, yet the reverse occurred. By 1998 the supply of inpatient beds as measured by beds per capita was a quarter of that in 1956. The predominant venue of care shifted to the outpatient department, to chronic disease hospitals and nursing homes for geriatric patients, and to jails. When I entered the field, the university psychiatric departments in the leading medical schools were predominantly psychoanalytic in orientation, and most of the residents undertook a didactic psychoanalysis in the course of their training. By the 1960s, treatment had been medicalized. The first psychotropic drugs were discovered by serendipity and introduced into psychiatry. The symptom relief they brought was so startling and persuasive that there was a major shift from psychologic to pharmacological treatment. The financing of medical education during World War II was through the federal government. Male medical students (and 95% were male) were automatically drafted into the Armed Forces, provided with tuition, books, meals, dormitory facilities, and marched off to the cafeteria and classrooms! We had no financial indebtedness! With the end of the War, the doctor draft ended and tuition became a personal responsibility. By 2009, mean student indebtedness is $156 456! (3) As World War Two dawned, it became clear that the number of psychiatrists in the United States (about 2500 in 1940) was far short of the total needed and rapid, short training programs were introduced to gear up internists to function as neuropsychiatrists. Some of them found the field attractive enough to undertake formal psychiatric training after the War. The large number of returning veterans with psychiatric disorders spurred the veteran s administration (VA) to finance expanded psychiatric residency training slots. The result was that the number of psychiatrists rose from 2500 in 1940 to about 6500 in 1960. Outpatient psychiatrists, often psychoanalytically oriented, tended to cluster in large cites with analytic institutes. In 1954, 20% of practicing psychiatrists in the US were located in Manhattan (4). As recently as 1977, 64% of psychiatric visits were exclusively for psychotherapy with no prescription provided; in 2002 this was true for <10% of visits to psychiatrists. A survey of office-based psychiatrists looking only at visits over half an hour found that only 19.1% of psychiatrists provided psychotherapy to all of their patients in 1997; this further declined to 10.8% by 2005. Inclusion only of outpatient visits more than 30 min undoubtedly inflated the prevalence of psychotherapy (5). Training in psychotherapy, once abundant, now is neglected. This is the last paper that my stepfather, Leon Eisenberg, worked on before his death on September 15, 2009. Revisions were well on their way. I have tried to complete the paper for him. When the manuscript is in the first person singular it is Leon Eisenberg speaking. All felicitous phrases and insights are his; any problems with the paper undoubtedly rest with me. Laurence B. Guttmacher, MD. Acta Psychiatr Scand 2010: 122: 89–102 All rights reserved DOI: 10.1111/j.1600-0447.2010.01544.x 2010 John Wiley & Sons A/S