Psychiatric care for population deals mainly with the needs of and provisions for people aged 18-65. The organization of psychiatric services in any country inevitably depends on the organization of general medical services in that country.

The history of psychiatric services

Until the middle of the eighteenth century, there were hardly any special provisions for the mentally ill. In England , for example, the only hospital for these patients was the Bethlem Hospital , founded in 1247. In most of continental Europe , there was a similar lack of hospital provision; in the middle ages, hospitals in Spain were a notable exception (Chamberlain 1966). Nearly all mentally ill people lived in the community, often with help from Poor Law provisions, or else they were in prison. In England the Vagrancy Act of 1744 made the first legal distinction between paupers and lunatics, and made provision for the treatment of the latter. In response, private provisions for the mentally ill ('madhouses' - later to be called private asylums) were developed mainly for those who could pay for care, but also for some paupers supported by their parishes (Parry-Jones 1972). At about the same time, a few hospitals or wards were established through private benefaction and public subscription.

The Bethel Hospital in Norwich was founded in 1713. In London , the lunatic ward at Guy's Hospital was established in 1728, and in 1751, St Luke's Hospital was founded as an alternative to the overcrowded Bethlem Hospital . Then, as now, the value of psychiatric wards in general hospitals was debated (Allderidge 1979).

Moral management

At the end of the eighteenth century, public concern in many countries about the poor standards of private and public institutions led to renewed efforts to improve the care of the mentally ill. In Paris in 1793, Pinel gave an important lead by releasing patients from the chains that were used for restraint. Subsequently h~ introduced other changes to make the care of patients more humane. In England , similar reforming ideas were proposed by William Tuke, a Quaker philanthropist who founded the Retreat in York in 1792. The Retreat provided pleasant surroundings and adequate facilities for occupation and recreation.

Treatment was based on 'moral' (i.e. psychological) management and respect for patient wishes, in contrast with the physical treatments (usually bleeding and purging) and the authoritarian approach favored by most doctors at that time.

A description of the Retreat, published in 1813. These humane methods were adopted in other hospitals as it became clear that many mentally ill patients could exert self-control and did not require physical restraint and drastic medical treatment.

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