The Invisible Plague: The Rise of Mental Illness from 1750 to the Present

E. Fuller Torrey Judy Miller Rutgers University Press: 2001. 400 pp. $28

That the 'strain of modern life' causes more mental illness is a refrain that goes back several centuries at least. There is certainly evidence for some increase in the prevalence of depression in recent decades, at least in industrialized countries. But for the most serious of mental disorders — schizophrenia — trends are, if anything, now in the other direction. In the view of Fuller Torrey and his colleague Judy Miller, the 'modern life' that may have provoked the rise in mental illness was in fact some two centuries ago.

Torrey is a distinguished US researcher in psychiatry, a prolific writer for both scientists and the public, and director of the Stanley Foundation. His extensive work on schizophrenia — notably using twins — has led him to be increasingly critical of conventional views that the frequency of the illness does not vary much worldwide and has not varied over time. Its presence in practically every known human society does seem to have been confirmed, but identifying it as a relatively 'new' disease is more controversial.

The first scientific suggestion of this kind was by the British psychiatrist Edward Hare in the early 1980s, but acknowledgement here of this work is rather sparse and only one of his two important papers is referenced. The crux of his argument is that there was a massive but steady rise in the number of patients with 'lunacy' in mental hospitals from the early nineteenth century to the mid-twentieth. Of course, for there to be in-patients, there have to be hospitals, so the story is also one of building a huge system of asylums in every country that could afford it. In The Invisible Plague, Torrey and Miller draw evidence from England, Ireland, the Maritime provinces of Canada and the United States; Scotland is also included but has a rather marginal position.

Useful information about this question first appears in English in the late sixteenth century, when madness was clearly recognized. There are 20 references to it by Shakespeare alone, but Torrey and Miller believe that it remained relatively rare for the next 200 years. Insanity seems to have been regarded then mostly as a temporary state, secondary to some medical condition, rather than as a disorder in its own right. In the late eighteenth century there was increasing public concern in England about ill-treatment of the insane, as part of a wider humanitarian movement. Its most important expression was the foundation by the Quakers in 1792 of the York Retreat, where 'moral treatment' replaced chains and brutality. The authors say that the first clear description of schizophrenia appeared four years later.

Head count: the number of institutionalized insane increased rapidly in the nineteenth century.

As the nineteenth century began, the first public asylums were established in Britain, and then it was uphill all the way, both in the number of hospitals and of patients. That the number of the institutionalized insane increased far more rapidly than the general population is clearly documented: in all four of the countries concerned, from the mid-eighteenth to the mid-twentieth century the number of institutionalized insane as a proportion of the general population increased sevenfold. The highest figure ever in England or Wales — almost 4 per thousand population — was reached in 1915. Why this was the peak is not entirely clear, but in some other countries the growth in numbers continued with the building of new hospitals, a process that had practically finished in Britain.

In these calculations, 'insanity' has been taken as roughly equivalent to schizophrenia, although the Victorian asylums contained many patients with tertiary syphilis, alcoholism and senile dementia. In 1870 there were also 12,000 'lunatics' among the poor in English workhouses, and it was not until the 1950s that provision for the poor was clearly separated from that for the sick. The argument put forward in the book, though, is that such considerations make little difference to the concept of a huge increase then in the number of institutionalized insane in all the countries concerned.

This view of schizophrenia as a new and epidemic disease has not gone unchallenged. Historians following the philosopher Michel Foucault see the rise of asylums as the removal of troublesome people from general society, although examination of how the early institutions were set up shows that humanitarian concern was the strongest motive. Alternative views to the epidemic theory have emphasized the effects of migration, better medical care (so that asylum patients lived longer), urbanization (which made the insane more visible) and diminished tolerance by larger communities. But Torrey and Miller believe that no such factors can account for the increase in the identified insane.

If there was an epidemic, though, it must have had a cause. The authors argue that “novel approaches” are needed to investigate what this was, but mention only diet, alcohol, toxins and infections as candidates — none with much conviction. This epidemic, they say, has been “so insidious that after 200 years, it has barely been noticed. It affects over four million Americans, but is not recognised as a major public health problem.”

This highly informative and stimulating work has certainly raised some neglected questions that demand more serious scientific attention. For one thing, the burgeoning cities of developing countries might be a fertile soil for schizophrenia, although there is no evidence yet that this is happening.