Historian Edward Shorter takes us on a 200 year journey from the age of spa treatments to the birth of psychopharmacology.

KELLIE NEWSOME: Today, Edward Shorter takes us on a 200 year journey from the age of spa treatments to the birth of psychopharmacology.

Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003.

CHRIS AIKEN: I’m Chris Aiken, the editor-in-chief of the Carlat Psychiatry Report. 

KELLIE NEWSOME: And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue.

Edward Shorter has been documenting the history of psychiatry for nearly half a century, sometimes writing alone, sometimes with psychiatrists like Conrad Swartz and Max Fink. We caught up with him from his home in Toronto, Canada, where he shared how the disorders we call depression and anxiety were managed long ago…

CHRIS AIKEN: I take it that there’s been some kind of distress that’s driven people to psychiatrists for many years and maybe the name of it has changed: you know anxiety, depression, neurosis, etc., but it might all be the same condition.

EDWARD SHORTER: The distress itself doesn’t really change. This is probably a constant in human affairs, but the labels for it change, and accordingly the treatments for it. What you just called distress a few moments ago used to be called nerves, nervous illness, nervous disease, okay. And that’s a term now that has gone out of style and has been largely replaced with depression.

Nerves or nervous illness is one of the original diagnoses of psychiatry. And the assumption is that this is an organic problem; your nerves are organic entities and there’s something wrong with these nerves; there’s a physical disorder in the body, in other words. And so what are we going to do about that? Well the treatments for nervous illness were not wonderful in those days, but nonetheless there were treatments. If you were middle class and above you’d be sent to a spa for hydrotherapy, and so bathing in spa water, drinking spa water or having electrotherapy – not ECT but peripheral applications of electricity such as was done at spas – were seen as optimal treatments for nervous disorder. And they were very successful actually! Going to a spa was seen as highly therapeutic even though we look now back at this kind of belneotherapy as it was called or hydrotherapy with disbelief. How could they have imagined that drinking potassium water would make them better, but it did. Or bathing in potassium water would make them better, but it worked. Or they had all kinds of wraps, for example they’d take linen gauze and drip it in spa water and then wrap the affected limbs with it. And it was amazingly effective. We say, “Well what you’re dealing with here is suggestion, and these treatments are suggestive treatments.” But I’m not sure that’s entirely true. 

EDWARD SHORTER: So at the very beginning of psychiatry we have nervous illness, and the basic people who treated nervous illness were not psychiatrists who practiced in asylums and were called alienists. They were neurologists and GPs. So that’s where modern psychiatry starts out is in the hands of neurology treating nervous illness.

CHRIS AIKEN: Can you put a date on this range of time?

EDWARD SHORTER: Sure, the whole concept of nerves arises with the rest of clinical medicine early in the 19th century. And nerves certainly dominate the picture right up until about the First World War. 

And what happens in the First World War - the rise of psychoanalysis. So it’s Freud’s psychoanalysis that takes over psychiatry. And the analysts had no use for nerves at all; they had no use for any kind of organic concept in psychiatry. For psychoanalysts, the only meaningful entity was the unconscious mind or conflicts within the unconscious mind. And so you could see this would be a dramatic paradigm shift; we don’t need nerves anymore; we don’t need spas or hydrotherapy anymore; all that is just nonsense. Come to the office, lie down on the couch and we’ll treat you with free association and dream analysis. 

And that – it seems amazing now to look back over the history of psychiatry and say that this once dominated psychiatry, but after the 1920s it did. Psychiatry was dominated by psychoanalysis right up until the 1970s.

CHRIS AIKEN: Was there something about World War I that spurred this?

EDWARD SHORTER: Not really. I use World War I as a convenient kind of marker, but the rise of psychoanalysis, the psychoanalytic idea is diffused in the United States, for example, after the First World War and they certainly ruled the roost in Europe even before the First World War, so there’s nothing particularly causative about the war itself, but it’s at that point in history that psychoanalysis wipes out the rest of psychiatry, wipes out what you might think of in retrospect.

It’s the first biological psychiatry. It was based on nerves, based on the idea of heredity is what makes people ill, and if you’re really sick we’ll put you in an asylum. So that would have been the first biological psychiatry.

CHRIS AIKEN: Can you explain how an asylum is different from a spa?

EDWARD SHORTER: Well it’s very different because in a spa the treatment modalities are basically water, so spas are based on top of mineral springs which are a source of the water and they tend to be in lovely settings where you just respond to nature as such. An asylum by contrast makes no use of hydrotherapy at all. In fact they offer very little in the way of therapy. In an asylum the idea is that admitting you to this treatment facility will, in and of itself, make you better, and if it doesn’t well hey, that’s okay, you’ll stay here.

CHRIS AIKEN: But they did have “moral therapy” in the asylums is that right?

EDWARD SHORTER: Moral therapy is a contemporary term going back to about 1800 for what we call psychotherapy; it doesn’t mean you’re treating peoples’ morals, but the idea of moral therapy means you’re treating the mind. In other words it’s psychotherapy. And that starts out in England actually late in the 18th century, but the whole world of nervous illness shoved moral therapy more or less aside. If you have a nervous problem then you don’t really have a mental problem; you have a problem with your nerves.

CHRIS AIKEN: And you go to spas for the nerves.

EDWARD SHORTER: Yes.

CHRIS AIKEN: If I understand you right, more mild depression and anxiety as we see it today would go to spas perhaps directed by a neurologist or a primary care doc and the more severe cases would go to asylums where alienists were?

EDWARD SHORTER: The spas refused to accept people with frank psychotic illness. They said that in their publicity, but in fact they accepted just about everybody because they wanted the money. But yeah if you had a frank psychosis or melancholic depression then you’d be a candidate for an asylum and you’d give everybody in the spa the creeps. They discouraged admitting these patients who would just sit and cry all day.

KELLIE NEWSOME: Did spa treatments really work? Some of them featured lithium water, like Lithia Springs in Georgia. 100 years ago there was no stigma around lithium – it was seen as a health elixir and president Warren Harding had it shipped up to the White House. But while low doses of lithium may prevent mental health problems – suicide, crime, and dementia are all lower in places that have lithium in the water – we are aware of no evidence that those low doses actually treat anything. Even in the anti-viral studies, where lithium treated Herpes and COVID – they used the same doses we use in mood disorders.

But maybe just sitting in the spas water had some healing effects? Hot and cold baths do have antiinflammatory and other health benefits, and that idea inspired one of the most unusual studies we’ve seen in psychiatry. 

In 2016, Charles Raison and colleagues published a small randomized trial of Whole-Body Hyperthermia for depression in JAMA Psych. Patients sat inside this infrared heating device for about an hour, until their body temperature reached 38.5 degrees Celsius, 101.3 degrees Fahrenheit. The control group received a sham treatment, and most patients were not able to tell if they got the placebo sham or the real mccoy. 

After just one treatment, patients experienced significant improvement in depression within a week, and those improvements continued for 6 weeks without further treatment, with a large effect size of 1-2 (Janssen CW et al,  JAMA Psychiatry. 2016;73(8):789-795). 

CHRIS AIKEN: Heating the body like this reduces inflammation, improves mitochondrial health, and it also shakes up the thermoregulatory system. In depression, the body stays at a relatively constant and slightly elevated temperature, and this jolt of heat might reset that. Similar therapies have been used in sleep clinics since the 1990’s, where a 20 minute hot bath 2 hours before bed deepens sleep quality. The idea is to accentuate the normal circadian shifts in body temperature that we are missing in the controlled climate modern world of HVACs. When you heat the body up in the early evening and then sleep in a cold room – the fall in body temperature sets the stage for sleep.

Dr. Raison’s work was followed by two controlled trials using hyperthermic baths. Here the body temperature was brought to a similar elevation, but by sitting in a spa pool, covered in very warm water from the neck down for 20-30 minutes in the late afternoon. The exact temperature was 40 °C, or 104 degrees Fahrenheit, and after the bath they laid down in warm blankets. The control group got a fake version of light therapy (Naumann J et al, BMC Complement Altern Med 2017, 17(1):172).

The baths were repeated weekly, and after 4 weeks there was a significant decrease in depression, although the improvements were much smaller than those found with the infrared passive heating in the original study.

I’ve tried this hot bath at home and can say it is not comfortable. It caused my heart to race in a way that felt a bit like aerobic exercise, but I slept better than ever and felt great the next few days. I don’t recommend it for patients because the evidence is not solid yet – the studies are small – and there is a risk of skin burns if the temperature is too hot and a risk of falling – blood pressure tends to drop when you get out of a hot bath.

CHRIS AIKEN: Okay, so if we’re tracing the life of the generalized anxiety-depressive patient it goes from spas to psychoanalysis and then what happens? 

EDWARD SHORTER: Then psychopharmacology happens.

CHRIS AIKEN: Oh and by the way, the psychoanalysts called it would they call it “neurosis” or what words would they use for these patients?

EDWARD SHORTER:“Psychoneurosis” was the psychoanalytic phrase for what we would call “nonpsychotic illness” was known more or less specifically as “psychoneurosis.” The term has gone out of style because it’s associated with psychoanalysis, and among the main psychoneuroses were hysteria and neurasthenia neither of which exists in psychiatry today. We’ve removed hysteria from psychiatry although we haven’t removed it from neurology.

CHRIS AIKEN: What about hysteria – would you say that’s almost identical to conversion disorder?

EDWARD SHORTER: Well, that was Freud’s term for conversion disorder for what other people were calling hysteria. By conversion disorder, Freud meant relatively specific loss of the ability to speak, loss of vision, loss of audition. Hysteria was actually a separate concept for the analysts and the whole idea of hysteria which you would see basically in women was that these are symptoms that occur in people who are sexually very repressed.

CHRIS AIKEN: Can you describe the symptoms of hysteria?

EDWARD SHORTER: Yeah, they were mainly psychosomatic symptoms: paralysis in those days was very common. Women in particular would become paralyzed, would have to take to their beds because they wouldn’t be able to walk anymore. Or the upper limb would dangle uselessly. This still happens to some extent, but it doesn’t happen very often.

CHRIS AIKEN: What did neurasthenia look like?

EDWARD SHORTER: Neurasthenia starts out as fatigue. The term means tired nerves literally but then the term has expanded from fatigue to include just about everything else like mood disorders, phobias, obsessive-compulsive disorder; all of that becomes caught up in the whole neurasthenia umbrella basically.

CHRIS AIKEN: And regardless, they are trying to treat it by relieving unconscious conflict I take it as kind of the same etiology?

EDWARD SHORTER: Well, that’s the idea that psychoanalytic therapy helps you resolve unconscious conflict. This is, I think, largely fanciful, but it was what people believed in those days.

CHRIS AIKEN: And it worked.

EDWARD SHORTER: Psychotherapy works like a charm. People respond to it, but it was very expensive and it was very often long and drawn out and a quick course of ECT would work wonders in place of years of psychotherapy.

CHRIS AIKEN: Okay and I imagine spas were very expensive too.

EDWARD SHORTER: Yeah, if you were poor you wouldn’t be able to afford a spa, and outside of central Europe there weren’t any government programs to send you to spas. So this is for people, who were middle class or frankly wealthy, but there were a lot of those people and they afforded spas for themselves.

KELLIE NEWSOME: We interrupt this podcast for a preview of the CME questions. Earn CME through the link in the show notes. 

1. Which disorder was not recognized in Emil Kraepelin’s diagnostic system?

A. Schizophrenia

B. Manic Depression

C. Anxiety Disorders

D. Mixed States

Answer: C

CHRIS AIKEN: And does anything start to change in the 1940s in how these patients are treated for nonpsychotic distress?

EDWARD SHORTER: Well what happens in the 1940s is the advent of therapies that really work, and the main therapy that works is ECT. ECT is introduced in 1938. But the early ‘40s and late ‘30s also saw a number of treatments that really work such as amphetamines. Amphetamines are introduced in 1936 in psychiatry. Barbiturates introduced in 1903; they are very effective sedatives, and when we talk about anxiolytics today what we are really talking about is sedation; sedating anxious patients. Barbiturates do that very well. 

CHRIS AIKEN: Right because they have similar actions but I believe that the barbiturates are stronger on the antianxiety and insomnia side.

EDWARD SHORTER: Yeah, they are excellent treatments for insomnia for sure, but for what was called then “agitation” in the day they tended to prefer the term agitation to anxiety. Anxiety wasn’t such a big diagnosis. In Kraepelin’s (Emil Kraepelin who was the German psychiatrist who really is the founder of modern diagnosis), but for Kraepelin anxiety didn’t even exist as a diagnosis in his manual of illness which was basically the nosological guide right up until DSM. There is no chapter on anxiety and there isn’t an entry in the index for anxiety either.

CHRIS AIKEN: I think Kraepelin mentions anxiety but he sees it as a symptom of like mixed states, is that right?

EDWARD SHORTER: Well he admits there is a thing called mixed depression-anxiety that’s a disease entity of its own, but free-standing anxiety for Kraepelin didn’t exist. He saw all illnesses were accompanied with anxiousness.

CHRIS AIKEN: Right, it’s just a symptom of other illnesses; that makes sense. Well keep telling us the story of how we’ve changed, how we’ve treated these folks. So we introduced barbiturates and amphetamines but we were still using psychoanalysis in the 1940s.

EDWARD SHORTER: Yeah, this were referred to contemptuously by psychoanalysts as “pills” because they had a deadly fear of pills because they saw that pills were superior to psychoanalysis because pills could make people reliably better quickly in a way that the couch couldn’t. And so psychoanalysis, Freud’s doctrines, ruled the roost in psychiatry right up until the 1960s. 

And what happens in the 1960s is the generalization of psychopharmacology which begins in the 1950s. And conventionally we see psychopharmacology as being kicked off with the introduction of chlorpromazine (Largactil, Thorazine) in 1952. And that wasn’t the first psychoactive drug by any means, but for the first time psychiatrists and neurologists saw that you can take people who are very sick and make them better with a drug. And you can’t do that with amphetamine or barbiturates really; if you have psychotic patients they don’t respond to either of those drug classes, but they respond to chlorpromazine.

CHRIS AIKEN: I believe they first used it in mania and psychosis is that right?

EDWARD SHORTER: Yeah, it was first used for mania for sure, and then very quickly it became used for what was called then schizophrenia. And then the success of the antipsychotics meant that it was like opening a cornucopia; a whole bunch of them came onto the market. And they became coprescribed with antidepressants, for depression, for example. And so antipsychotics became widely prescribed outside of the dominion of psychosis within psychiatry for all kinds of disease conditions. They are just specific treatments for psychosis at all. They are a very effective drug class.

CHRIS AIKEN: What you’re describing is the antipsychotics perhaps became overused for every condition in the 1960s and then something happened and they shrunk back and then something happened and they rose again, can you tell us that history?

EDWARD SHORTER: Well, antipsychotics they weren’t the first effective drug class in psychiatry, but they were the first effective treatment for serious illness both melancholia and psychotic illness. And so they had a big run and their popularity tended to be reduced a lot with the discovery in the late 1950s that they had all kinds of side effects, particularly motoric side effects: you know various symptoms involving the motoric side of the CNS were exacerbated or created with antipsychotics and so people tended to lay off them to some extent using them only when they had nothing else in the armamentarium. 

And then antipsychotics in our own time have enjoyed something of a rebirth with the discovery of hey, they can be used in the elderly and they can be used in kids and they can be used in depressed women and coprescribed with antidepressants and so they are very useful adjuncts.

CHRIS AIKEN: Is it fair to say for now awareness of tardive dyskinesia and these motoric side effects caused antipsychotics to be restricted to more psychosis more severely ill psychosis in the late ‘60s and ‘70s is that right?

EDWARD SHORTER: Yeah, we dialed back on the use of antipsychotics.

CHRIS AIKEN: Then they rose again as we found that our antidepressants were not so effective as we’d like them to be and they started FDA approving them which opens up a whole – I mean once you approve something for anxiety and depression, I mean heck, I could take it; I have anxiety and depression – like anybody has those things, so it really widens the market so we see a rise again of antipsychotics.

EDWARD SHORTER: Well, you have to also bear in mind that one of the other things that also happened in the 1990s was the growing popularity of ECT for depression, but a lot of clinicians were very uneasy about ECT and yet they wanted something that would work for their seriously depressed patients without having to send them to the ECT suite and so the idea of using antipsychotics in connection with Prozac gained a lot of popularity just as an alternative to ECT.

KELLIE NEWSOME: Edward Shorter is Professor and Hannah Chair in the History of Medicine at the University of Toronto. His 1997 book A History of Psychiatry from the Era of the Asylum to the Age of Prozac is a classic that traces the history of psychiatry up to the SSRIs. In 2021 Dr. Shorter followed that up with a history of the post-SSRI years: The Rise and Fall of the Age Psychopharmacology. He will join us again next week for a discussion of controversies in psychiatry.

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