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Chlorpromazine: The introduction of this "major tranquilliser" in 1952, described by David Healy (University of Wales College of Medicine) as "the single most important breakthrough in psychiatric treatment", had a dramatic impact on the management of schizophrenia: for the first time some patients became non-psychotic, and the acute management of schizophrenia improved markedly.

Improving the practice of ECT: Electroconvulsive therapy is still psychiatry's most powerful treatment for depression. Despite major advances -- the introduction of anaesthetics and muscle relaxants, stimulus dosing and electroencephalographic monitoring -- the antipathy of patients (and the community) to ECT has regrettably only slightly lessened.

Lessons from military psychiatry and refugee groups: Principles developed between World War II and the Vietnam War (ie, making psychiatric care immediately available "on the spot", and communicating an expectation that recovery would occur) were intrinsically important and diffused into other practice domains, such as community psychiatry, and the management of post-traumatic stress disorder.

Deinstitutionalisation: This misnomer was used to describe the moving of patients in the 1960s from maxi-institutional lives in large psychiatric hospitals to mini-institutional existences in boarding houses and nursing homes, often to be even more forgotten and neglected. Yet, we progressively recognised an old principle -- that while risking "dying with one's rights on", people value personal freedom above institutional existence. Forced community assimilation also modified images of the "insane" to softer, disability images.

Mainstreaming: Moving the care of psychiatric patients from the Dickensian, isolated psychiatric institutions to general hospitals helped bring Australian clinical psychiatry into general medicine, reducing stigma and resulting in superior lines of responsibility.

Malfeasance responses: Disturbing revelations of the Royal Commission into Deep Sleep Therapy at the Chelmsford Private Hospital, and the Queensland Commission of Inquiry into assault and maltreatment of patients in the psychiatric ward of the Townsville General Hospital, reports of sexual misconduct and other boundary violations surfaced in the past 20 years. Grave community concerns resulted in impressively non-defensive responses by the profession and the monitoring authorities to redress such issues, including increased legal involvement (and procedures) now intertwined with public mental health services.

Formalised professional markers: The establishment in 1964 of a Royal College (the RANZCP) linking Australian and New Zealand psychiatrists, and, in 1967, of a professional journal (The Australian and New Zealand Journal of Psychiatry), together with the development of an innovative membership examination, were markers of a move from a small network of individual psychiatrists to a formalised grouping -- now one of the largest professional medical specialties in the region.

Growth in Australian academic psychiatry: Once a "home alone" model (eg, David Maddison, Professor of Psychiatry, Sydney University, and Foundation Dean of the Newcastle University Medical School being one of a small set of identifiable local produce) or "run away from home" expatriate model (eg, local Adelaide lad, Aubrey Lewis, dominating British academic psychiatry), now "home grown" dominance is evident, with a disproportionately successful Australian impact on international research publications, but also a decrease in "critical attitude" by academics and an overvaluation of quantitative research.

Clozapine: This "atypical" neuroleptic drug was produced in 1962, but only taken up in Australia in the past decade (because of its side effect of agranulocytosis). Despite its monitoring requirements and its expense, its wide prescribing by Australian public mental health services is noteworthy. Its use gradually causes a considerable number of patients with schizophrenia to "normalise", and its capacity to restore suggested cognitive limitations has changed our understanding of a disorder once called "dementia praecox".

Growth of biological psychiatry and psychiatry as a neuroscience: This movement has delivered striking results in understanding the determinants of many major psychiatric disorders, in establishing a dominant and successful research paradigm, and in integrating psychiatry with medical research. Caveats emerge from overly zealous or inappropriate application of the model -- "the sin of biologism". At risk is rejection of psychiatry's distinctive contribution to the practice of medicine -- a pluralistic model, respecting and integrating (in formulation and management) the multiple paradigms of sentient human beings.

Detumescence of psychotherapy: Psychotherapy has been shrunk less by failure to produce an evidence base, ad hominem attacks and growth of alternative contenders (eg, cognitive behavioural therapy) than by a loss of significance and relevance as biological psychiatry has "Pac-Manned" the old Zeitgeist. Psychotherapy requires revisionism, repositioning and more pragmatic advocacy.

Introduction of "new" antidepressants and "atypical" antipsychotic drugs: The selective serotonin reuptake inhibitors (SSRIs) are not merely antidepressants, but non-addictive "anti-worry" agents, with the potential to modify "neurosis", a feat once thought impossible. The "atypical" antipsychotic drugs may only be slightly more effective for treating schizophrenia, but their more benign side-effect profile improves quality of life and medication compliance.

Formulation of clinical depression as an economic problem: The number of people with depression is not growing substantially, despite historical formulations of depression as a response, a disorder, an illness and a disease. Its recent reformulation as a major economic cost due to its disabling effects, endorsed by the World Bank, Harvard University and the World Health Organization, provided the spin, attracting public, media, health department and political attention.

Consumerism: At last year's RANZCP Conference, psychiatrists danced in a congo line to music played by a band of consumers. As the Convenor, Bob Barrett, observed: "It was a delicious sight indeed to see psychiatrists dancing, for the first time, to the tune of the patients." Consumers and their advocates have had a more difficult row to hoe in psychiatry than in most other medical specialties, with their contribution and impact on professional attitudes humbling.

On doctors and nurses: Once non-psychiatrist doctors married their hospitals and, on the rebound, the ward sister, who was ever able to undertake ward rounds at home ("Are all the children in bed, sister?"). Once psychiatrists were strange schizoid creatures (to wit, "alienists"). Now doctors no longer marry nurses (most are professors now) and psychiatrists are rugby-following, tie-wearing, non-intellectual conservatives. As biological psychiatry has reached its zenith, psychiatry is no longer as attractive or distinctive to those seeking "different" medical careers. The "magic" in the therapeutic process has gone -- magic that could lead to foolishness and invite ridicule or, alternatively, which imbued psychiatrists with a luminous sense of understanding. Recruitment is down and there is a lack of plurality in the air. Has psychiatry been mainstreamed away from its ineffable status? Has it not become stale to medical student and graduates seeking a specialty? How will it reconstitute itself above and beyond its procrustean biological bed? The January 2051 issue of The Medical Journal of Australia will detail the rollback.

Gordon B Parker
Professor and Head
School of Psychiatry University of New South Wales
Prince of Wales Hospital, Sydney, NSW

John H Ellard
Psychiatrist
Bead Lane Specialist Centre, Sydney, NSW

Above photograph. Ambulatory psychiatric patients, who have been put to bed in broad day-light, Callan Park Mental Hospital, Sydney, circa 1960. From the Report of the Royal Commission into Callan Park Mental Hospital, 1961. Crown copyright.

©MJA 2001
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