The bicentennial volume of the British Journal of Psychiatry: the winding pathway of mental science

Summary

The Asylum Journal, first published in 1853, is now, as the British Journal of Psychiatry, in its 200th volume. It has changed greatly in its breadth and scope, but its core values and concerns – professional respect, removal of stigma, delivery of care, understanding of pathology, and informed treatment – have remained at its heart throughout. We predict some changes for the future, but not dramatic ones, and conclude that the impinging advances of science will elucidate and refine, but not remove, the need for a journal that is proud to represent psychiatry or, in the words of John Bucknill, its first editor, ‘to render prominent its characteristics and to stamp it as a specialty’.

Today we launch the first issue of the 200th volume of the British Journal of Psychiatry (the Journal); this landmark offers an opportunity, some might say an excuse, to take the longer view of our history, our present and our prospects. The Asylum Journal was first published on 15 November 1853 and John Bucknill was its first editor. It subsequently changed its name to the Journal of Mental Science in 1858, and the British Journal of Psychiatry in 1963. This makes it the third oldest psychiatric journal in the world after the Annales Médico-Psychologiques (1843) in France and the American Journal of Insanity, subsequently American Journal of Psychiatry (1844). By taking what epidemiologists sometimes call a rolling average over the 158 years of the Journal’s existence we hope to identify trends that tell us where we have been, how well we are doing now, and where we may be going. What we do not intend to do is to make this a self-congratulatory exercise, and have no intention of being impressed by mere history. Longevity is not necessarily a mark of excellence, merely of persistence.

The origins of the Journal are closely linked to the association that published it and have been written about in some depth. ^1–3 Samuel Hitch, the Physician Superintendent of Gloucester County Asylum, was the founder of the Association of Medical Officers of Asylums and Hospitals for the Insane, subsequently renamed the Medico-Psychological Association in 1841, and it is clear that without this stimulus, the Journal would not have been created. Nevertheless, it was not until the delayed 7th annual meeting of the Association in Oxford in 1852 that the members thought about publishing a journal. According to Dr Outterson Wood (1843–1930), who recalled the early history of the Association in 1896, ⁴ the key figure in setting up the Journal was Dr William Ley of the County Asylum in Oxford. The meeting, with its 14 participants listed but with no record of its actions, was recorded in a single paragraph in the British Medical Journal in 1852 (www.bmj.com/content/s2-4/44/783.full.pdf) but from Dr Wood’s account it was clear that Ley, who later became Treasurer, ³ was the main inspiration behind the Journal’s generation:

‘Mr. Ley ably advocated the establishment of a Journal for the use of the members of the Association, and submitted to the meeting several propositions connected therewith. […] Dr. Bucknill addressed the meeting at considerable length on behalf of Mr. Ley’s propositions, in which he was supported by Mr. Conolly. An interesting discussion ensued, and it was finally resolved, on the motion of Mr. Ley, seconded by Dr. Thurnam, that the Journal be undertaken and that Dr. Bucknill be appointed the Editor.’ (pp. 258–259) ⁴

Dr Bucknill, to whom Dr Wood spoke in the preparation of his article, gave particular praise to Dr Ley ‘for the disinterested manner in which he worked for the good of the Association’ (p. 260). ⁴

So a group of only 14 men‡ made the executive decision to publish a new journal and within an astonishingly short time (18 months) the first issue had appeared.

A rival journal, the Journal of Psychological Medicine and Mental Pathology, already existed under the editorship of Dr Forbes Winslow of Hammersmith, and Dr Winslow may have been at first peeved at a competitor appearing, ¹ even though he was present at the Oxford meeting. Perhaps he had too much to eat and drink following the conspicuous hospitality of Dr Ley in Oxford after their momentous decision, but in any case he was swiftly reconciled afterwards. Although the Journal of Psychological Medicine and Mental Pathology only lasted until 1860, it was resurrected by Michael Shepherd as Psychological Medicine in 1969 and has continued to thrive and expand its influence, remaining a genuinely friendly competitor. Although the Asylum Journal perhaps was not expected at first to be a major element of the Medico-Psychological Society, it quickly became its most important mouthpiece, largely due to the influence of its first editor, John Bucknill, the son of a surgeon from Market Bosworth, who became the first Medical Superintendent of the Devon County Asylum at Exminster. He was Editor until 1862 and during his 9 years of editorship he expanded the role and influence of the Journal enormously. His career was illustrious; he was later knighted and made a Fellow of the Royal Society, and also had time, with Hughlings Jackson and others, to found a new journal, Brain, in 1870. This points to Dr Bucknill’s own orientation in psychiatry, and right from the beginning in the Asylum Journal he indicated his own belief, first propounded by Hippocrates but often forgotten, that insanity is primarily a disease of the brain. ⁵ His place of birth, close to the site of the battle of Bosworth Field, was also apposite, as he was a doughty soldier in these early days of our discipline, when asylum doctors had to show both a measure of aggression and a planned strategy to rattle the cages of medicine so they could not be ignored in their isolated outposts in rural Britain. He maintained his military profile later in life when he founded the first Exeter and Devonshire Rifle Volunteers; a statue commemorating him and this achievement stands in Northernhay, Exeter.

What Bucknill did in these early days was to set the philosophy of the Journal. Not for him the aggressive cut and thrust of the flamboyant Lancet, first published 30 years earlier by Thomas Wakley, but a sober, eclectic, pragmatic and topical journal that was very clear in its purpose, to establish the ground rules for this new discipline of mental science. He made this clear in the very first issue, when he wrote,

‘Since the public in all civilized countries have recognized the fact, that Insanity lies strictly within the domain of medical science, new responsibilities and new duties have devolved upon those who have devoted themselves to its investigation and treatment. Many circumstances have tended, not indeed to isolate cerebro-mental disease from the mainland of general pathology; but to render prominent its characteristics and to stamp it as a specialty.’ ⁶

The range of papers in the first issue set the standard and contents for the future. There were practical articles on management in asylums (the acreage of land attached to asylums – an early venture into health economics – and the prevention of dysentery and cholera), phenomenology and forensic psychiatry (the diagnosis of monomania), psychopharmacology and perinatal psychiatry (chloroform in childbirth to prevent puerperal mania), interest in patients and stigma (the head dress of pauper lunatic men), neuropathology (on the grey substance of the brain after excessive mental exertion) and opinions on non-restraint in Germany, showing right from the beginning that the Journal had an international perspective.

The Journal became widely read. Whereas in 1861 the Association founded by Hitch had only 152 members, the Journal had a circulation of over 400, ⁷ so it was attracting interest far beyond its core subscribers. It gave an image of psychiatric illness and its treatment, like a well-constructed mirror, sometimes distorting a little, but reflecting as accurately as possible the different elements of the discipline and its related subjects in all their forms. These contributions appeared often as original articles but equally often as reviews of other works, particularly from continental Europe, where Germany was the most active, ⁸ but very few from America. Although the title of the Journal of Mental Science may suggest a journal like Biological Psychiatry, its contents showed admirable balance between those who felt that the best form of advance is to promote sciences based on psychiatry and others who were inclined to promote the services based on psychiatry, an argument that still exercises us today. ⁹ At the end of the day, someone must decide, and the present Editor considers his position to be the last remaining bastion of true dictatorship.

Although there was vigorous debate and disagreement, the early issues of the Journal of Mental Science saw a surprising lack of editorial dogmatism or control. This might have been because, in a day when books rather than articles were the main conveyance of new knowledge, many of the early luminaries chose to produce their major ideas in the form of books. Indeed, the book format is perhaps more appropriate for writers who enjoyed long-windedness and a mild degree of pomposity, and so controversy generally escaped the Journal. Bucknill resigned in 1862 when he became Lord Chancellor’s Visitor in Lunacy, and Lockhart Robertson was elected Editor, with Henry Maudsley as Co-Editor. Later Maudsley became Senior Editor and was one of the few editors to have a fiery course in this role. He resigned in 1877, partly because of the attractions of private practice, but also after being put under pressure for his sceptical views about some of the conventional wisdom at the time. ¹⁰ After John Bucknill was briefly courted again, Daniel Hack Tuke of the famous Tuke family, and Thomas Clouston, a Scot from Orkney who became a celebrated teacher in Edinburgh, took over as Editors.

In the early 20th century the Journal widened its interests, particularly after the First World War when the issue of shellshock brought psychology, psychiatry and neurology closer together. It was also during this period that the Journal developed a general scepticism about new psychodynamic treatments, with its general attitude towards what is perceived as good psychotherapy as an intervention that was ‘simple in its language and deeply suspicious of suspect, degenerate continental techniques that contradicted the accepted principles of the nervous reflex’. ¹¹ This approach was unsurprising, given the underlying biological orientation of British psychiatry. But it also reflected Bucknill’s original suspicion of fancy ideas and a preference for pragmatism, which protected the Journal from the wild swings of fashion in psychiatry and psychotherapy that characterised psychiatric journals in the USA and some European countries in the middle years of the 20th century, and which we like to think, with some supportive data, ¹² has been maintained until the present day. There was a period after 1945 when the Journal seemed to go to sleep a little. But in 1963, when the British Journal of Psychiatry took over from the Journal of Mental Science under the editorship of Eliot Slater, ¹³ followed by the strong stimulus generated by the formation of the Royal College of Psychiatrists in 1971, it enjoyed an invigorating recrudescence that has been maintained by its following editors, Edward Hare, John Crammer, Hugh Freeman and Greg Wilkinson.

Where are we now?

One of the benefits of a long past is that it offers a perspective on almost all the issues with which we grapple on a daily basis. Although some issues turn out to be of passing importance only, other themes will likely preoccupy psychiatrists when volume 400 is published – the bread and butter issues of the delivery of psychiatric services, the need for coercion, drug and psychological treatments, how we classify mental disorders, and stigma and discrimination. Some sense of the changes that have occurred can be gained by browsing the titles of articles in the Journal (available at http://bjp.rcpsych.org/content/) spread through the 200 volumes. But here, three examples will suffice. In the 19th century about 20% of all in-patients were suffering with ‘general paralysis of the insane’: the central nervous system effects of syphilis infection. Now most readers will never see a case. A second example is the dramatic broadening of the palette of active psychotropic agents that occurred in the middle of the 20th century. Our discipline has long known psychoactive medications, beginning with opium, chloral hydrate (introduced clinically in 1869), and the barbiturates and amphetamines from the early 20th century. Yet the golden age of psychotropics in the 1950s saw the introduction of new anxiolytics, antidepressants, anti-psychotics and lithium, agents that gave rise to a new discipline of psychopharmacology. ¹⁴ The third example, not entirely unconnected with the second, is the welcome move to deinstitutionalisation, which proceeded most rapidly in the second half of the 20th century, together with the better appreciation of the rights of patients. ⁸

At the dawn of the new millennium, the outgoing President of the Royal College of Psychiatrists, Professor Robert Kendell, speculated about the next 25 years of psychiatry in an editorial in the Journal. ¹⁵ Given that this 200th volume is being published exactly half way through Kendell’s quarter century of speculation, we might reflect on the extent to which his predictions are holding and consider whether any new big issues are current.

Kendell identified several subjects that would be our constant companions. As he predicted, the high prevalence and disabling consequences of mental illness ¹⁶ have been increasingly recognised and acknowledged by the general public, politicians and the media. There have been high-profile campaigns to raise awareness by voluntary organisations (e.g. the Time to Change campaign in England), ¹⁷ media exposure (including high-profile celebrities speaking out about mental illness) ¹⁸ and political interest (e.g. the recent public mental health initiative). ¹⁹ This trend seems set to continue and should be beneficial for mental health improvement and reduction of stigma.

Predicting the future

Kendell’s prediction of better understanding of aetiology has been supported, but to a lesser extent than he might have wanted. For example, over the past 5 years replicated reports of large-scale (tens of thousands of participants) molecular genetics studies in samples have demonstrated the importance of both common and rare genetic variation in influencing susceptibility to mood and psychotic illness. ^20–22 Importantly, such studies are starting to point to the role of specific biological pathways and mechanisms in illness and helping to reveal the relationships between the major psychiatric disorders that have hitherto been classified on purely descriptive grounds. ^23,24 This represents the next stage in mental science’s long journey of discovery and will need all the resources of imaging, cognitive neuroscience, epidemiology, psychology and sociology as well as molecular biology and genetics. ²³

The effective psychotropic drugs that transformed psychiatry in the 1950s were found serendipitously rather than being based on understanding of disease. ¹⁴ One might think that recent progress in understanding aetiology provides opportunities to develop new therapies more logically, ²⁵ but to date these expectations have been largely dashed. We still await the flood of revelations of neuroscience to open the cornucopia of drug development – and the reason for the failure of industry to come up with significant new drug classes in psychopharmacology may be related to something that Professor Kendell did not highlight, namely, the limitations imposed by our current purely descriptive diagnostic classification. Some very broad categories such as ‘major depression’ apply to highly heterogeneous patient populations that overlap with normal mood variation, and almost certainly do not map simply onto underlying brain function and dysfunction. In addition, the marketing of the so-called atypical antipsychotic drugs has not been a praiseworthy episode in the history of psychopharmacology, ²⁶ and reinforces the need for genuinely novel drugs ²⁷ that will change patient care. ²⁵

Patients’ wishes and rights have come to the fore to a much greater extent than any of our Victorian forefathers would have expected. This is exemplified by the fundamental place of patients in new health legislation in England (and the other UK jurisdictions), including the important principle of shared decision-making. These apply across medicine but psychiatry has the difficult task in accommodating and engaging with consumer groups who are often highly vocal in their criticisms. There seems to be plenty of work to do in explaining the importance of psychiatry and psychiatrists, ⁹ as well as better discussion with patients about the various treatment options so that truly informed shared decisions can be made. ²⁸ It seems inevitable that we will move towards increasing emphasis on placing the patient at the heart of services. This can only be good for patients and for psychiatry.

Economics of mental health

One issue not anticipated by many 20–30 years ago is the growth of mental health economics. This is highly important in the current global economic situation and has a major impact on services ²⁹ as well as other aspects of life. Kendell ¹⁵ rightly identified increasing financial constraints on services as a big issue and, although the present economic downturn is expected to be time-limited, it seems inevitable that financial constraints will loom well into the future; this explains the need to choose treatments that are truly cost-effective. The challenge for psychiatrists will be to advocate for treatments and services for psychiatric patients ^29,30 to ensure they are not disadvantaged compared with non-psychiatric patients and also to maintain the expertise and professional confidence to prescribe treatments that differ from guidelines when that is in the best interests of the patient. ³¹ It is comforting that many drugs now available in their inexpensive generic forms are equal, if not superior, to a number of expensive patent-protected agents. Choosing these safe and effective generics will also help keep costs down.

The final issue that Kendell presciently predicted is that of increased competition between professions. Psychiatrists are expensive and therefore are attractive targets for service managers to cut. There are a variety of non-psychiatric professionals whose work overlaps that of psychiatrists and who, to a greater or lesser extent, have interest in taking over some (or all) of that work. Indeed, the question as to whether the psychiatrist is an ‘endangered species’ has recently been debated. ³² Ultimately the issue will, rightly, be decided according to what is in the best interests of patients. To date, many of the voices tilting against psychiatry have been more vocal and active than the responding voice of the profession. ^28–30 It seems inevitable that the issue of competition between professions will continue and be intensified by financial pressures. There will be an ongoing need for evidence about the cost-effectiveness of psychiatrists and it will be vital to ensure that patients, public and politicians truly understand the role and value of psychiatrists in services. A vanishing of our discipline is unlikely, as no other medical specialty or healthcare profession is adept in the diagnosis and treatment of patients with serious mental illnesses: this is what we do, not just better than anyone else, but uniquely. This role clarity is also essential in recruiting, training and retaining the next generation of psychiatrists. ²⁷

Psychiatry’s relationship to medicine

In one major respect Kendell’s prediction has not yet proved to be correct, and that is the prediction that psychiatry would become more biological and less isolated from medicine. ¹⁵ Although there has been increased emphasis on biological research, there has been a complete disconnect between research and clinical practice, with a relentless tendency over many years to downplay the medical and biological aspects of mental healthcare. In the opening years of the new millennium the trend towards demedicalisation in services has continued, an issue that has been debated within the pages of the Journal. ^9,27,33,34 Questionnaire studies suggest that some of the recent morale, recruitment and retention problems in psychiatry relate to perceived (as well as actual) lack of biological and medical perspective and lack of clarity about the role of psychiatry. ³⁵ There continues to be argument over the scope of increased access to a broad range of evidence-based psychological and social treatments and whether this, despite being important and desirable, has been accompanied by a reduction in the access to and the quality of basic medicine, such as accurate prescribing of medication and attention to physical and biological aspects of care. ^9,27 Progress in understanding of aetiology and pathogenesis will make such attention increasingly important. Only time will tell whether psychiatry in its current form will refocus to deliver what is desired or whether it will end up being built up again from one or more of the other medical disciplines. ³⁶

One other topic of relevance to the long view of psychiatry is the imminent revision of the major classification systems. DSM-5 is due to be published in 2013 and ICD-11 a year later. Diagnosis guides treatment, and classification systems influence the perception and understanding of a field as well as clinical practice and research. Despite plenty of discussion and debate, it is unlikely that there will be any major changes to the diagnostic categories, although a dimensional approach is likely to be added to supplement categories in DSM-5. ³⁷ The changes are largely cosmetic and the systems will continue to be based on operationalised lists of descriptive clinical symptoms. Research data are accumulating that show the shortcomings of the current systems. Although acknowledging the scale of the challenges and the difficulties in predicting the rate of progress, it can be expected that in later versions of DSM and ICD it will be possible to move towards systems, like those in other branches of medicine, that are based more closely on underlying brain function and dysfunction rather than purely descriptive clinical syndromes.

Ultimately, psychiatry exists to play its important and particular role in diagnosis and treatment of mental illness to benefit patients. Much has improved over the period marked by the first 200 volumes of the Journal, although many of the big issues – stigma, professional respect, and the delivery of care – that preoccupy us today have not changed much over the last 150 years. Where our Journal, and like-minded ones elsewhere, can help is to make sure that we present the important new evidence from research and practice as honestly and accurately as possible, not being afraid of controversy over contentious issues where evidence is relatively weak, proud of our connection with the Royal College of Psychiatrists but also maintaining complete independence, and true to the principles of psychiatry and mental science.