Year : 2018 | Volume
: 27 | Issue : 1 | Page : 21--26
History of psychiatry: An Indian perspective
Anand Mishra, Thomas Mathai, Daya Ram
Department of Psychiatry, Central Institute of Psychiatry, Ranchi, Jharkhand, India
Dr. Anand Mishra
Department of Psychiatry, Central Institute of Psychiatry, Kanke, Ranchi - 834 006, Jharkhand
A knowledge of history becomes important in learning the way concepts have evolved and how they are understood in different and conflicting traditions in psychiatry. Modern psychiatry and its history has always been observed through the prism of western science which has its own evolutionary line in which the eastern sciences can't fit and are always at a disadvantage. Especially the colonial bid to prove its legitimacy as a civilizing mission led to representation of European medicine as morally superior to the eastern practices resulting in a biased history. Though in reality, the history of psychiatry is heterogeneous and consists of many different scientific and cultural traditions which vary between populations. hence the Indian concept of “unmada” can't be compared or conformed to “schizophrenia” without addressing its cultural and historical contexts. Many suggest that in case of Indian patients, an understanding of illness through a Vedantic model of psych seems more appealing in comparison to the western constructs, as such an attitude has been transferred over generations. Therefore, a knowledge of history of psychiatry, especially from an Indian perspective becomes important.
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Mishra A, Mathai T, Ram D. History of psychiatry: An Indian perspective.Ind Psychiatry J 2018;27:21-26
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Mishra A, Mathai T, Ram D. History of psychiatry: An Indian perspective. Ind Psychiatry J [serial online] 2018 [cited 2019 Mar 20 ];27:21-26
Available from: http://www.industrialpsychiatry.org/text.asp?2018/27/1/21/243321
History of psychiatry might be interesting but most psychiatrist still do not consider it as a core topic and many consider it at best, nonrelevant. But owing to the close analogy between the neurobiological paradigms and the concepts of old authors like Kraepelin  and Bleuler, that has come up with advanced researches of the past few decades, interest in the history of psychiatry has renewed from the academic point of view.
A knowledge of history becomes important in learning the way concepts have evolved and how they are understood in different and conflicting traditions in psychiatry. It helps in detecting and preventing different understandings of mental illness (biological, psychological, cultural, etc.) from becoming dogmas or myths. Psychiatry might be the only specialty in which admission can be a legal issue which calls for the perspective of personal autonomy, and hence, precedence becomes important. Several other factors also bring psychiatry into a close and complex relationship with jurisprudence which makes the historical perspective important.
Overall the study in history of psychiatry can broadly be divided into three main domains – conceptual history (how core concepts developed), institutional history (asylums, societies, etc.), and biographical history (important figures).
Why an Indian History of Psychiatry?
In early part of 19th century, Dr. James Esdaile, a surgeon working in Kolkata under the East India Company, with the help of his native assistant, experimented with mesmerism. He utilized it as a pain relieving technique during the surgeries he performed and also in some cases of mental problems. Due to favorable reviews of his peers, he also received official support for the establishment of an experimental mesmeric hospital near Kolkata (Report of the Committee Appointed by Government to Observe and Report upon Surgical Operations by Dr. J. Esdaile…., 1846). Instead of being recognized as one of the first Europeans who performed painless surgeries, he invited much controversy  and was compared to tricksters and performers by the scientific communities in France and England, who were sceptic about mesmeric practices.
Dr. Esdaile was undoubtedly one of the myriads of casualty which the rich history of “nonwestern psychiatry” suffered at the hands of the positivistic and reductionism approach of Western science in an age influenced by the law-governed paradigms of enlightenment.
Modern psychiatry and its history have always been observed through the prism of Western science which has its own evolutionary line in which the eastern sciences cannot fit and are always at a disadvantage. Especially, the colonial bid to prove its legitimacy as a civilizing mission , led to representation of European medicine as morally superior to the eastern practices  resulting in a biased history. Although in reality, the history of psychiatry is heterogeneous and consists of many different scientific and cultural traditions  which vary between populations. For example, in stark contrast to the reliance of western history of psychiatry on the history of institutions in general, Sharma pointed out the fact that there were no institutions for insane before the arrival of the East India Company as family used to support the mentally ill. In addition, a universal conceptualization of psychiatry is difficult, and hence, the Indian concept of “unmada” cannot be compared or conformed to “schizophrenia” without addressing its cultural and historical contexts. Thus, knowing the history of psychiatry with an Indian perspective becomes pertinent in conceptualizing major issues in phenomenology and management specific to the Indian context.
Conceptualizing Mental Illness-An Indian Way
Chronology is the hard problem of history when it comes to ancient India. The controversy surrounding the precise age of Vedas and other related scriptures which has been estimated from a few million years to a few thousand years by various Eastern and Western researchers, makes precise historicizing a difficult task.
Vedanta philosophy conceptualizes Atman as the core of personality which is the prime control of the mind, body, and intellect, but “Vasanas” (inherent tendencies) determine nature and activities originating from them. This difference between the mind and Atman has always confused the Western philosophers, till the researches of Freud, Jung, and Adler recognized the reality of unconscious. Cartesian dualism differentiating mind from matter is very recent to the Western thought while the Indian philosophy, particularly the Upanishads understood the mind “more from within than from without.”
Vedas mention mantras for prayers to bring noble thoughts to mind and purify it. Rigveda describes sattva, raja, and tama as personality traits and also identifies mental illness independent of physical illness. Yajurveda conceptualized mind as the inner flame of knowledge.
Atharvaveda describes “Manas” as an instrument of hypnotism and talks in details about will power, emotion, inspiration, and consciousness. “Unmad” (psychosis) has been mentioned as a deluded state of mind in Vedas with etiology suggestive of both organic (worms/microorganisms, fever, etc.) and functional (sins toward Gods) origin. Vedas also mention treatment for mental disorders ranging from psychosis, epilepsy, sleep disorder, and aggression in the form of “Bheshaj” (medicine) and prayers to God (psychotherapy), along with preventive methods such as “Yam” and “Niyam” (behavioral control) and “Asan” and “Pranayam” (physical activities).
Upanishads describe the various states of mind (Jagrat, Svapana, Sushupti, and Samadhi), theories of perception, thought, and memory. Ichchha Shakti (will) Kriya Shakti (Action) and Jnana-Shakti (Knowledge) were described by them as the three mental potencies, and the psychopathology was understood by Trigunas and Tridosas.
Considering the difficulty in understanding the teachings of Vedas and Upanishads, it became necessary to simplify them for the nonscholars. Bhagavad Gita is considered to be the simplified and condensed form of the Vedas and Upanishads. It has one of the earliest written descriptions of anxiety and depression as seen in Arjuna and also describes the several aspects of psychotherapy.
Contrary to popular notion, Ayurveda, our traditional medicine system is not confined to physical health alone. Mira Roy in her commentary on Ayurveda for the voluminous cultural heritage of India series published by Ramakrishna mission, clearly mentions its holistic role in promoting physical, mental, and spiritual health in context to a man's environment. In contrast to modern psychiatry where diagnosis is based on phenomenology in Ayurveda, it is based on etiology (the Tridoshas).
Charak Samhita and Sushrut Samhita, the two classics of Ayurveda describe mental disorders according to trigunas (sattva, raja, and tam) and tridoshas (three humors in the body vat, pitta, kapha). They also describe 14 causative factors which include immoral behavior, weak mind, stress, anxiety, and substance to name a few. They also classify mental disorders as “Nijmanas rog” (endogenous) and “Agantujmanas rog” (exogenous) with further subdivision of “Nijmanas rog” into “manas dosh” (psychological) and “Sharir Doshanubandh” (physical) causation types. In Ayurveda, over 200 herbal medicines have been described and categorized into various categories such as memory enhancer, intoxicating, antipsychotics, and anticonvulsants.
Earliest evidence of attribution of mental illness to demons and treatment by magic and occult practices was note in the Indus valley period (around 1500 BCE). This conceptualization was possibly imported from the contemporary civilizations in Mesopotamia, Egypt, and Crete during those times.
Buddhism and Jainism (around 6th century AD) brought in the philosophical systems (Nyaya, Vaiseshika, Samkhya, Yoga, and Vedanta) following which medicine separated from the magicoreligious tradition and entered into an alliance with these philosophical systems. Buddhist conceptualization of psychosis as the “breakdown of one's worldview with insufficient emotional support from within” and severe mental illness as a result of pursuing a lifestyle that is different from inherent disposition and spiritual destiny, appears to be the bridging gap between the religious certainties and rationality during those times. Supernatural gave way to rationalism and psychiatry benefited a lot from Vaiseshika, Nyaya, Samkhya and Yoga systems. Buddhism stressed on specific meditational practices which aimed at direct restructuring of the consciousness in contrast to the Western psychotherapy which tends to be indirect and aims at removing blockages in the way of awareness.
With the advent of the Delhi sultanate and the Mughal dynasty which followed it, Unani medicine gained prominence. Najabuddin Unhammad (1222 AD), a prominent Unani practitioner of his time, described seven types of mental disorders; Sauda-a-Tabee (Schizophrenia); Muree-Sauda (depression); Ishk (delusion of love); Nisyan (Organic mental disorder); Haziyan (paranoid state), and Malikholia-a-maraki (delirium).
Overall, after the classical era (maybe till 2nd century AD), there has not been much development in the conceptualization and management of mental illnesses from an Indian perspective  and following the arrival of the British empire, we became a part of the modern psychiatry, and as we will discuss in the following sections, our contribution has mostly been about institutions and increasing their accommodation.
A History of Institutions and Institutionalization in India:
As mentioned before, mental asylums were mostly a British concept. Except for a few institutions (or “collection of curious humanity” as referred to by a few authors) scattered in time across various parts of India, the institutions and institutionalization were introduced to India in the colonial era. It seems that the institutions were initially started for European soldiers only but later went on to treat the local population too.
Sharma in his book on the development of mental hospitals in India, went on to describe the five phases of development which were influenced by the dominant geopolitical predicaments of their times.
First phase (18th-mid 19th century)
Some of the first mental asylums (Calcutta (1787), Kilpauk(1794) and Monghyr (1795)) were established during this period with the sole guiding principle of separating the mentally ill patients from the society.
Second phase (Mid 19thlate 19th century)
The first Lunacy Act (1858) was promulgated which mentioned guidelines for establishment of asylums and their admission procedures. Several new asylums were built in places such as Patna, Dacca, Calcutta, poona, Agra, etc. These institutions were overloaded which led to deterioration in services along with the health and hygiene of these places.
Third phase (First quarter of 20th century)
A major change to counter the deteriorating conditions of the institutions as noticed during the 2nd phase, was shifting the charge of asylums from Inspector general of Police to the Civil Surgeons. In addition, psychiatrists were appointed in these hospitals. The introduction of Indian Lunacy Act in 1912 further refined and systemized the admission, treatment, and discharge procedures of the mentally ill with the introduction of the provisions for voluntary boarder admissions.
Fourth phase (1920 – independence)
In a bid to promote the illness model and to reduce stigma, the “asylums” were renamed as “mental hospitals” in 1920. Occupational therapy and rehabilitation were stressed on as a core issue with respect to mentally ill. The Bhore committee  health survey for the first time surveyed and made recommendations for mental hospitals. A committee headed by Col Moore Taylor  suggested for focused training in psychiatry, promotion of occupational therapy, and separate child psychiatry units. It also recommended for the establishment of friendly relationship with the community by countering the ignorance, superstition, and suspicion associated with mental illness.
Fifth phase (postindependence)
Keeping the international trend toward deinstitutionalization and persisting poor conditions in mental hospitals, Government of India concentrated on creation of psychiatric units in general hospitals rather than building new mental hospitals. Improving the conditions of existing mental hospitals has also been stressed upon. A series of conferences were held in Agra (1960), Ranchi (1986), Bangalore (1988), Delhi (1995), and Bangalore (1999), in which the state of existing mental hospitals were reviewed and recommendation for their improvement were made. Considering the experience of the Indian Lunacy Act, 1912 as outdated, The Mental Health Act, 1987 came into force from 1993. It stressed on the role of treatment and necessity to safeguard the interests of the mentally ill. It also has guidelines for establishing and maintaining of psychiatric hospitals and nursing homes.
With the trends toward deinstitutionalization and outpatient care, the focus on the institutions are largely decreasing, but considering the fact that the severely ill patients or patients with poor social support systems, who require chronic institutionalization are still present in a significant number in the society, the mental hospitals are here to stay and contribute to the history for a longer period.
Some Important Figures in Indian Psychiatry
Considering the predominance of the scriptures over individuals from ancient India and the prevailing tone of Western philosophy and education, the prominent figures from the history of Indian psychiatry are of those who contributed to the progress and modernization of mental health care in India. Nevertheless, there also have been a few names who tried to address the phenomenological and treatment aspects of mental illnesses.
With the emergence of Indian doctors trained in western medicine by mid-19th century, the prevailing conditions started getting incorporated into the Western paradigms. Pandurang et al. gave one of the earliest descriptions of hysteria and unlike Briquet, did not see it as a disorder of brain. Indian doctors in 19th century were reporting on biomarkers and debating on genetic causes of mental illnesses. W. B. O'Shaughnessy from Kolkata in 1839 reported on the use of cannabis indica in treating illnesses such as rheumatism, cholera, and delirium tremens. Dr. Fraser a psychiatrist posted in British Army during World War II wrote an article in the British Medical Journal on ganja psychosis.
Owen Berkeley-Hill as medical superintendent of European Mental Hospital, Ranchi, was instrumental in changing the word asylum to mental hospital by a government notification in 1920. He also founded that the Indian Association for Mental Hygiene, which was affiliated to National Council for Mental Hygiene in Great Britain., Girindra Shekhar Bose, pioneer of psychoanalysis in the country, founded that the Indian Psychoanalytical Association in 1922 in Calcutta and got it affiliated with International Psychoanalytic Association. He also set up the first psychiatric outpatient service at the Carmichael Medical College (now R. G. Kar Medical College), Calcutta in 1933. J. E. Dhunjibhoy, inspired by Western researchers, pioneered many a first in the country such as Sulfosin therapy, Cardiazol-induced seizure treatment for schizophrenia, subshock nitrogen gas inhalation in excited patients, glandular therapy, Soneryl as a hypnotic in excitement and insomnia, and benzedrine as a stimulant in depression, way back in the 1930s–1940s. R. B. Davis as medical superintendent of European Mental Hospital, Ranchi (now Central Institute of Psychiatry), introduced electroencephalography (leukotomy, modified electroconvulsive therapy, and insulin coma therapy in India.
Gananath Sen and Karthick Chander Bose were the first to report on the use of alkaloid extracts from the Rauvolfia serpentina plant in reducing psychosis. Initially overlooked, but when rediscovered, reserpine became one of the first agents to be used in the treatment of schizophrenia.
Postindependence, there is not much of the biographical history to be mentioned. Probably because most of it is still contemporary with several distinguished figures still busy contributing to all aspects of mental illness research. In near future, as new paradigms develop, undoubtedly, they are deemed to become part of the illustrious history of modern Indian psychiatry.
The Future – Where from Here?
Way back in the 1950s, Bhagwat had observed that for a bright future, psychiatry needs to establish itself as an independent discipline with specific stress on postgraduate training and research. Needless to say, Indian psychiatry has come far ahead and in the right direction since then.
The District Mental Health Program started in 1996–1997 reflected a major shift in policies from the concept of custodial care to emphasis on treatment and care at the primary healthcare level. Still, a lot needs to be done proactively regarding financial allocation, training programs, etc., for the fulfillment of roles envisioned for mental hospitals in the national mental health program.
The skills and capacity for research can be raised further through research-oriented training, providing resources, possible collaboration with ongoing projects and with help from international agencies such as WHO, which can be influential in the further progress of Indian Psychiatry.
The acceptability of the alternative system of medicine in the masses and the cropping up of evidence-based research in their support cannot be denied. Recently, the National Rural Health Mission has recommended mainstreaming of AYUSH, the various forms of alternative medicines practiced legally in India. By mainstreaming, they intend to integrate AYUSH with the existing healthcare system of the country at all levels to combat the existing workforce shortage. A similar bid to integrate the alternative system of medicine in psychiatric research can be contemplated upon. Especially, considering their better agreeability with the ancient and precolonial concepts, a more holistic understanding of mental illness and its management can be developed from the Indian perspective.
In the light of the mental healthcare bill, 2013, which is still in process of becoming an act and an issue of both positive and negative criticism among the mental health professionals in the country, the future holds many exciting prospects. The effects of concepts such as judicial review and advance directives in an Indian context are difficult to be predicted in the present but for sure will have indelible impressions on the pages of history.
So far, the focus remains on a model of care which not only treats the illness but also addresses issues of self-respect and dignity, the progress will be in the right direction with a better comprehension of the complicacies of mental illness.
Based on studies , of his time, which supported the fact that a significant proportion of patients with mental illness improved irrespective of the treatment type, Rao questioned if it was correct to ridicule ancient concepts on the ground of rationality. Considering the fact that most of the outcome studies for an illness like schizophrenia  over the years have provided conflicting results, and major textbooks in psychiatry  also refrain from giving a strong opinion regarding this, Rao's question is still pertinent.
The difficulty in finding established causation and heterogeneity in presentation and prognosis were explained on the construct of “primitive”, “gullible,” and “superstitious” native mind during the 19th century India as reported by Radhika et al. in their review of psychological symptom profile in colonial India. In the same review, they go on to report how rarity of general paresis in Indian population was explained on the basis of it being a disease of civilized society and men who do brain work.
Such instances from history open not one but several questions. Who holds the authority to reject something as magic or superstition and accept other things as science and rational? What draws the line between fact and fiction? And what becomes history and what becomes story? Voltaire once rightly said that “History is a trick the living play on the dead”, and the vetting which our precolonial history of psychiatry received from the zeitgeist of the colonial era, seems to prove him correct.
Colonialism brought in a dominant British flavor to Indian psychiatry when at best we could prove ourselves to be good followers. One would hardly disagree with Varma's  comment that “the history of Psychiatry in this country is the history of establishment of mental hospitals and then increasing its accommodation from time to time as the exigencies of the time demanded”.
One of the greatest achievement of modern psychiatry has been its openness to inputs from other disciplines. The zeal to grow in the right direction allows us to entertain all sorts of ideas, For example–an anthropological perspective of mental illnesses, which calls for considering International Classification of Diseases and Diagnostic and Statistical Manual of Mental Disorders phenotypes as culture-bound syndromes. In appreciation of the same argument, imposition of a particular diagnostic system on a different cultural setting has been questioned by many. Similarly, many suggest that in case of Indian patients, an understanding of illness through a Vedantic model of psych seems more appealing in comparison to the Western constructs, as such an attitude has been transferred over generations. Therefore, a knowledge of the history of psychiatry, especially from an Indian perspective becomes important and not just interesting, for who knows what truth the future might prove or end up agreeing upon.
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