Across the world, we’re seeing unprecedented levels of mental illness at all ages, from children to the very old – with huge costs to families, communities, and economies. In this series, we investigate what’s causing this crisis and report on the latest research to improve people’s mental health at all stages of life.

Society’s increasing awareness of mental health issues and demand for mental health support has been driven, in part, by social media and easier access to information online. While this is no bad thing in many ways, the related increase in self-diagnosis (including among children and adolescents ) is clearly open to abuse by some organizations offering costly diagnoses and treatments.

But there is another reason for this rapid growth in private mental healthcare. In England alone, the NHS spends around PS2 billion per year on personal hospital care for mental health patients – equating to 13.5% of its total mental health spend. Due to the reduction in NHS bed provision, nine out of ten privately run mental health beds are now filled by NHS patients.

While the UK government says it is committed to spending more money on mental health, private investment companies are reportedly queuing up to “seize the opportunities offered up to them by the NHS crisis”. Private providers say they can do more to help avert a mental health emergency exacerbated by the COVID pandemic. Yet, a dozen of the 80-odd privately-run mental health hospitals in England were rated as “inadequate” in the Care Quality Commission’s latest report, which has warned of possible closures.

As a health historian, I find our worsening mental health crisis sadly predictable. Governments around the world have been involved in tackling mental illness since at least the early 19th century. While not all of their attempts were successful, many important lessons remain unlearned.

At the heart of them is this: amid aging populations and the spiraling costs of mental illness to national economies, investing in people’s future mental health, based on what the key socioeconomic factors that we know are underlying it, is the only effective, long-term way to reduce this burden. As a major coalition of UK mental health organizations recently reported:

The risks to mental health and the poor outcomes that follow do not fall evenly across the population. People living in poverty, those with physical disabilities and illnesses, people with neurodevelopmental conditions, children in care, people from racialized communities, and LGBTQ+ people all experience much poorer mental health outcomes because of intersecting disadvantage and discrimination.

This all adds up to the life expectancy of a person with a severe mental illness being about 20 years shorter than someone without a diagnosis – and that gap is getting bigger. We understand the reasons why – so why do we seem unable to do anything about it?

Learning from history: the emergence of asylums

The first asylum in Britain was Bethlehem Hospital near London’s Bishopsgate, which began to specialize in insanity by the 15th century. Commonly referred to as “Bedlam,” what is now Bethlem Royal Hospital was often depicted negatively – including in A Rake’s Progress, a series of eight paintings by the 18th-century English artist William Hogarth.

‘In The Madhouse’ (1732-1735) by William Hogarth, from his series A Rake’s Progress. Wikimedia

Across the Atlantic, the treatment of patients in American asylums also proved very controversial. When Ebenezer Haskell escaped the Pennsylvania Hospital for the Insane in 1868, he immediately sued the hospital for unjust confinement and published an account of his ordeal, writing in the foreword:

The object of these pages is … to speak a few plain unvarnished truths [on] behalf of the poor, helpless, and suffering patients put in these [institutions], and to show why a strong and positive legislative action should be taken for their protection.

The pamphlet included depictions of Haskell being punished and tortured, sometimes in the guise of treatment. In one, he is shown naked and lying on his back on the floor, restrained by four men, while another performs “hydrotherapy” – dumping a bucket of water on Haskell’s face as a second man stands ready with another bucket.

Public perceptions of the brutal forms of care provided in mental asylums – and private “madhouses” – continue to be heavily influenced by films such as Shutter Island (2010), Girl, Interrupted (1999), and, perhaps most notably, One Flew Over the Cuckoo’s Nest (1975). Such films and the novels that inspired them portray asylums as harsh, unforgiving places run by mostly callous or sadistic staff. While this is justified in some cases, such portrayals mask the impressive ambition, care, and expense that went into the building of many asylums by governments around the world during the 19th century.

Trailer for One Flew Over the Cuckoo’s Nest (1975)

The provision of care for the mentally ill has long been considered a public responsibility. In Britain, the 1774 Madhouses Act was a response to concerns about abuse in private psychiatric hospitals. Soon after, the County Asylum Act of 1808 and the Lunacy Act of 1845 were passed in England and Wales to create dedicated public facilities for the mentally ill so that they wouldn’t languish in workhouses. Dozens of asylums began popping up all over Britain, regulated by the newly established Lunacy Commission.

Encouraged by the Age of Enlightenment, which spurred the idea that science could solve most of the world’s problems, Britain was among the pioneers embracing the concept of public health, with governments investing in public infrastructure to prevent infectious diseases. In the case of asylums, little expense was spared, even for so-called “pauper lunatics”.

At this time, asylums would have been among the most impressive buildings people would have seen – overshadowed only by cathedrals. However controversial, they were the first concerted, state-led effort to deal with mental illness. And while few mental health experts would recommend a return to the asylum era today, they might well envy the commitment that governments in Britain and elsewhere demonstrated in the facilities they provided for their mentally ill.