Thomas A. Ban
Neuropsychopharmacology in Historical Perspective
Education in the Field in the Post-Neuropsychopharmacology Era
Background to An Oral History of the First Fifty Years
Special Areas (Volume Seven): 2. Geriatric Psychiatry
While individual life span has remained unchanged, average life expectancy has increased at least four-fold over the course of recorded history (Dublin, Lotka and Spiegelman 1969). There was an unprecedented rapid increase in life-expectancy during the first half of the 20th century; from 1900 to 1960 the percentage of old people tripled, reaching 13% of the total population of Europe and 10% of North America (Encyclopedia Britannica 1979).The increase in individuals aged 65 years or older has directed attention to gerontology, a term introduced in 1907 by the Russian medical scientist Eli Metschnikoff for the scientific study of the aging process, and to geriatrics, a term introduced in 1914 by the American pediatrician, Ignatz Nascher, for the medical specialty concerned with the study, prevention and treatment of pathologic conditions in the aged (Metchnikoff 1907; Nascher 1914). Gerontology deals with primary aging or senescence, which is a biologic process rooted in heredity; geriatrics deals with secondary aging or senility, i.e., defects and disabilities resulting from trauma, including disease (Butler 1975).
Psychiatric morbidity is high in the aged. The three-fold increase in the number of people 65 or older in the United States was associated with a nine-fold increase in admissions to mental hospitals from this age group (Kramer, Taub and Starr 1968). A study in Baltimore from the 1960s showed that 12% of the non-institutionalized geriatric population suffered from mental illness (Pasamanick 1967). In San Francisco, the figure was 15% (Simon 1968). It was the high prevalence of psychiatric morbidity in old people that created the need for the geropsychiatry, or psychogeriatrics (Ban 1980).
Developments which led to psychogeriatrics began in the 1870s with Krafft-Ebing’s introduction of the term “dementia senilis” and with his separation of senile dementia from the other organic dementias (Kraft-Ebing 1872). It continued in the 1880s with the description of what was to become known as the Wernicke-Korsakoff amnestic syndromeand the separation of the dysmnesias from the dementias (Korsakoff 1887; Wernicke 1881). In 1892 the disease that was to bear his name was described by Pickand separated from senile dementia (Pick 1892). In 1899 Binswanger coined the term “pre-senile dementia”that was to include Pick’s disease; Alzheimer’s disease, described in 1907; Jacob-Creutzfeld’s disease,described in 1920 and ’21; and several other conditions (Alzheimer 1907; Binswanger1898; Creutzfeld1920; Jacob 1921; Mayer-Gross, Slater and Roth 1980)
In the mid-1930s, a possible relationship between Alzheimer’s disease and senile conditions was raised by Rothschild and Kasanin; and in the mid-1940s Jervis suggested that atrophy of nerve cells and fibers with some glial reaction is the common basic process of the senile and presenile dementias (Jervis 1945; Rotschild and Kasanin 1936). Yet, it was also in the mid-1940s that Rothschild described the differential clinical features of senile and arteriosclerotic (today referred to as multi-infarct) “psychoses” (Hachinski, Lassen and Marshall 1974; Rotschild 1947).
By the 1950s it was recognized that psychiatric diseases in the aged are not restricted to the dementias and dysmnesias.A survey in the UK indicated that the in 30 to 50% of patients admitted to mental hospitals over 60 years of age, the clinical picture was dominated by depressive clinical features (Roth and Morissey 1957). Martin Roth and his associates found little overlap in symptomatology between these patients and patients with organic degenerative diseases. They also demonstrated that only about 3% of them developed dementia in two to three years (Roth 1952).
In Kraepelin’s estimation about 6-7% of the first episode of manic-depressive psychosis occurs at age 60 or later (Kraepelin 1921).A similar figure was reported in 1952 by Stenstedt (Stenstedt 1952).
“Late paraphrenia,” another distinct diagnosticpopulation in the aged, was identified in 1957 by Roth (Roth 1957).It differs from “late schizophrenia” by firmly systematized delusions.
Late schizophrenia was first recognized in 1911 by Eugen Bleuler (Bleuler 1911).In 1943, Manfred Bleuler found that in 15-17% of patients, schizophrenia, starts at age 40 or later. He referred to this population as “late onset schizophrenia.” In Bleuler’s estimation, for the 4% of patients with late schizophrenia the onset of the disease starts at age 60 or later (1943).Frank Fish, in the early 1960, found that in 1% of patients with schizophrenia the disease starts at age 69 or later (Fish 1962).
In the late 1940s De Werdenerand Lennox found that Vitamin B1 insufficiency induced loss of memory for recent events, disorientation and confabulations, a clinical picture similar to that seen in the Wernicke-Korsakoff syndrome. They also demonstrated that thiamine administration reversed the memory disturbance (De Werdener and Lennox1947).
In the 1950s, V. A. Kral separated “benign senescent forgetfulness” from “malignant senescent forgetfulness” (Kral 195, 19591, 1959b, 1962).He also reported on favorable effects with fluoxymesterone in “benign senescent forgetfulness” (Kral and Wigdor 1959, 1961).
Stimulated by Holger Hyden’s discovery of the role of ribonucleic acid (RNA) in learning, Ewen Cameron administered yeast RNA to patients with senile and arteriosclerotic dementia in the late 1950s (Cameron 1958; Cameron and Solyom 1958; Hyden 1955).In spite of his initial favorable impression and of the supportive findings of Leonard Cook in animal pharmacological research,later studies by Cameron and his associates with labeled RNA revealed that RNA molecules don’t enter the cerebral neurons (Cook, Davidson, Davis, Green and Fellows 1963). They could only be found in the cells of the ependyma and plexus choroideus (Cameron, Sved, Solyom and Wainrib 1964).
During the 1950s a wide variety of drugs - including gonadal hormones, i.e., estrogen and testosterone alone and in various combinations;psychostimulants, such as pentylenetetrazol,pipradroland methylphenidate; vasodilators, e.g., isoxsuprine;and drugs with an effect on cerebral metabolism, e.g., Hydergine, a hydrogenated alkaloid of ergot,were employed in the treatment of psychiatric diseases in the aged (Bachrach 1959; Begg and Reid1956; Benjamin 1949; Billiottet and Ferrand 1958; Birkmayer and Mentasti 1958; Caldwell and Watson 1957; Chesrow, Giacobe and Wosika 1951; Darwill 1959; Gould and Strosberg 1953; Foster, Schultz and Henderson 1955; Hollister 1955; Jacobson 1958; Kleemeier, Rich and Justin 1956; Levy 1953; Martin, Overly and Krone 1957; Pauker, Kheirn, Mensh and Koun 1958; Pomeranze and Ladek 1957; Popklin 1956; Zahn 1965).Prescription practices in elderly patients began to shift in the middle of the decade with the introduction of psychotropic drugs. The first reports on the effects of chlorpromazine in geropsychiatric patients were published in 1955 by Kurland,Seager and Terman; on reserpine alone and in combination with psychostimulants and/or vitamins in 1956and ’58;on prochlorperazine in 1957;on meprobamate in 1957and ’58; on imipramine in 1958and ’59; and on perphenazine,thioridazineand trifluoperazine in 1959 (Blackman, Glenn and Olinger 1958; Blanc 1958; Cameron 1959; Ferguson 1956; Jensen, Kristjansen and Paerregaard1957; Judah, Murphree and Seager1959; Kropach1959; Kurland1955; Lehmann, Cahn and deVerteuil 1958; Cruzand Sarro-Martin 1959; Seager 1955; Settel 1957; Silverman, Parker and Busse 1959; Terman 1955; Tschudin 1958).
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March 7, 2019