For much of history, the treatment of mental illness has varied widely depending on cultural and geographical context. In medieval Europe, for instance, it was commonly believed that mental illnesses were the result of demonic possession or witchcraft. Treatments often involved exorcism conducted by priests or trephining—a procedure where a hole was drilled into the skull to release spirits. These methods were often ineffective and led to high mortality rates.

However, other parts of the world had different approaches to mental health. In ancient China, mental illness was often attributed to an imbalance of Yin and Yang, and treatments included acupuncture and herbal remedies. Similarly, in Islamic Golden Age societies, mental health was considered a medical condition requiring diagnosis and treatment. Hospitals known as “Bimaristans” had special wards dedicated to the mentally ill, and treatments were more humane, involving medication, counseling, and even music therapy.

In African traditional societies, mental illness was often understood within the context of ancestral spirits and community well-being. Treatments could involve herbal medicine, ritualistic dances, or consultations with a spiritual leader to determine the cause of the illness.

In the Americas, Indigenous cultures had their own unique understanding of mental health, often linked to spiritual or communal harmony. Treatments could involve rituals, herbal medicines, or consultation with a shaman.

By the late 1400s to the late 1600s, particularly in Europe, the witch trials led to the execution of tens of thousands of people, many of whom were likely mentally ill. This was a dark period in the history of mental health treatment and was not reflective of attitudes worldwide.

The Rise of Asylums

By the 18th century, the concept of asylums began to take hold, especially in Europe. 

asylums

Asylums were the first institutions created for the specific purpose of housing people with psychological disorders, but the focus was on ostracizing them from society rather than treating their disorders. While asylums were a step away from the brutal treatments of earlier times, asylums were often overcrowded and poorly managed, leading to inhumane conditions. Often these people were kept in windowless rooms or dungeons, beaten, chained to their beds, and had little to no contact with caregivers.

Mental Health Care Reform

In the late 1700s, a French physician, Philippe Pinel, argued for more humane treatment of the mentally ill. He suggested that they be unchained and talked to, and that’s just what he did for patients at La Salpêtrière in Paris in 1795. Patients benefited from this more humane treatment, and many were able to leave the hospital.

 

In the 19th century, Dorothea Dix led reform efforts in the United States. After investigating the care of those who were mentally ill and living in poverty, she discovered an underfunded and unregulated system that perpetuated abuse (Tiffany, 1891). Her tireless lobbying of state legislatures and Congress led to the creation of the first mental asylums in the United States.

Conditions Persist

Despite reformers’ efforts, conditions in most asylums remained poor well into the 20th century. At Willard Psychiatric Center in New York, treatments included prolonged submersion in cold baths and electroshock therapy administered without anesthesia—a procedure that frequently caused broken bones. (Side note: electroshock is now called electroconvulsive treatment, and the therapy is still used, but with safeguards and under anesthesia. A brief application of electric stimulus is used to produce a generalized seizure. Controversy continues over its effectiveness versus the side effects.) Many wards were so cold that water would freeze overnight (Willard Psychiatric Center, 2009). Willard did not close until 1995.

Deinstitutionalization

The Movement Begins

Starting in the 1950s, two major developments transformed mental health care. First, the introduction of antipsychotic medications in 1954 proved effective in controlling symptoms of psychosis, including hallucinations and delusions. Second, in 1963, President Kennedy signed the Mental Retardation Facilities and Community Mental Health Centers Construction Act, providing federal funding for community-based mental health centers.

deinstitutionalization

Deinstitutionalization refers to the process of closing large psychiatric hospitals and transitioning to community-based treatment. In 1955, approximately 558,239 severely mentally ill patients were institutionalized in public hospitals. By 1994, this number had decreased by 92% (Torrey, 1997). The availability of psychiatric inpatient beds dropped from 237 per 100,000 people in 1970 to approximately 37 per 100,000 in 2020 (KFF, 2025).

Promises and Challenges

Deinstitutionalization was driven by legitimate concerns: the recognition that large institutions were often inhumane, hope that new medications offered better alternatives, and the civil rights principle that people should be treated in the least restrictive setting possible.

However, the community mental health centers promised to replace institutions were never adequately funded. Research indicates that only half of the projected centers received any funding, resulting in a fragmented system. Contemporary research presents a nuanced picture of outcomes—studies tracking discharged patients have found that most experienced favorable changes in social functioning, psychiatric symptoms, and quality of life when adequate community services were available (Winkler et al., 2016; Kunitoh, 2013). However, where community services were inadequate, significant problems emerged.

Contemporary Consequences

The incomplete implementation of community-based care has had serious consequences for vulnerable populations. According to 2024 data from the U.S. Department of Housing and Urban Development, approximately 26% of adults experiencing unsheltered homelessness have a serious mental illness—substantially higher than the 5-6% prevalence in the general population. Additionally, an estimated 16% of the incarcerated population has severe mental illness, leading some to observe that jails and prisons have become de facto psychiatric facilities.

It is important to note that research suggests the relationship between deinstitutionalization and these outcomes is not straightforward. Broader factors such as housing affordability, economic inequality, and gaps in the social safety net also contribute significantly to homelessness among those with mental illness (Winkler et al., 2016).

Health Equity Considerations

Marginalized communities have been disproportionately affected throughout this history. People with disabilities, people of color, and LGBTQ+ individuals were among the most institutionalized and mistreated populations historically (Chakraborty & McKenzie, 2018).

View this timeline showing the history of mental institutions in the United States.