Mental Illness History – Health And Social Care Essay

This article covers a sample Mental Illness History Health And Social Care Essay. Mental illnesses are medical conditions that disrupt a person’s thinking, feeling, mood, ability to relate to others and daily functioning…


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Any opinions, findings, conclusions, or recommendations expressed in this essay are those of the author and do not necessarily reflect the views of This essay should not be treated as an authoritative source of information when forming medical opinions as information may be inaccurate or out-of-date.

Mental Illness History

Mental illness is a general term for a group of illnesses. Mental disorders result from biological, developmental and/or psychosocial factors. A mental illness can be mild or severe, temporary or prolonged.

Mental illness can come and go throughout a person’s life. Some people experience their illness only once and fully recover. For others, it is prolonged and recurs over time. Mental illness can make it difficult for someone to cope with work, relationships and other aspects of their life.

Definition of mental illness

Mental illnesses are medical conditions that disrupt a person’s thinking, feeling, mood, ability to relate to others and daily functioning. Just as diabetes is a disorder of the pancreas, mental illnesses are medical conditions that often result in a diminished capacity for coping with the ordinary demands of life.

Serious mental illnesses include major depression, schizophrenia, bipolar disorder, obsessive compulsive disorder (OCD), panic disorder, post traumatic stress disorder (PTSD) and borderline personality disorder. The good news about mental illness is that recovery is possible.

Mental illnesses can affect persons of any age, race, religion, or income. Mental illnesses are not the result of personal weakness, lack of character or poor upbringing. Mental illnesses are treatable. Most people diagnosed with a serious mental illness can experience relief from their symptoms by actively participating in an individual treatment plan.

In addition to medication treatment, psychosocial treatment such as cognitive behavioral therapy, interpersonal therapy, peer support groups and other community services can also be components of a treatment plan and that assist with recovery. The availability of transportation, diet, exercise, sleep, friends and meaningful paid or volunteer activities contribute to overall health and wellness, including mental illness recovery.

History of Mental illness


1247: Bethlehem Hospital (more frequently known as ‘Bedlam’) opens in London to house ‘distraught and lunatik people.

1566: The New World’s first mental hospital is established in Mexico City.

1774: The Act for Regulating Madhouses, Licensing, and Inspection is passed in England. The law forbade a person’s commitment to a madhouse without a physician’s certification of that individual’s insanity.

1790’s: A Quaker called William Turke opens the York Retreat near York, England, an asylum for the mentally ill. The Retreat favored humane treatment; physical restraints were not used and patients were comfortably housed.

1790’s: French physician Phillipe Pinel begins working at the Bicentre and Salpetriere asylums where he develops ‘traitement morale,’ a form of treatment that focused on the mental origins of madness. His kind treatment of his patients brought about recovery for many

1817: Quakers in Philadelphia open the first asylum in America based on the principles of moral treatment.

1841: Dorothea Dix, a schoolteacher from Cambridge Massachusetts, becomes inspired to take up the cause of the mentally ill. She travels to several states where she lobbies state legislatures to better their treatment of the mentally ill. Over thirty state mental hospitals were opened as a result of her efforts.

1867: The Packard Law passes in Illinois. Named for Eliza Packard, a woman committed against her will by her husband after a property dispute, the law required that a patient’s insanity be determined by a jury before he or she could be sent to an institution.

1927: The US Supreme Court rules in Buck v. Bell that the forced sterilization of ‘defectives,’ including the mentally ill, is constitutional.

1954: The Durham Rule is established by the US Court of Appeals for the District of Columbia. It states that a person accused of a crime is not responsible if the criminal act “was the product of a mental disease or a mental defect.” It was later rejected due to problems defining ‘mental disease’ and ‘product.’

1963: Congress passes the Community Mental Health Centers Act. This leads to the closure of many large state psychiatric hospitals.

1966: Lake v. Cameron, a case of the US Court of Appeals for the District of Columbia Circuit , declares that patients in psychiatric hospitals have the right to receive treatment in the setting that is least restrictive.

1975: US Senate holds hearings about the use of neuroleptics (antipsychotic drugs such as Thorazine) in juvenile jails and homes for the developmentally disabled.

1979: NAMI is founded.

1988: The Fair Housing Amendments Act prohibits housing discrimination against people with disabilities, including mental disabilities.

1990: The Americans with Disabilities Act is passed. It prohibits discrimination against people with physical or mental disabilities.

2004: DuPage County begins the Mental Illness Court Alternative Program (MICAP.)

2008: Congress passes the Mental Health Parity and Addictions Equity Act. It requires that any limits to insurance coverage for mental illness be no more restrictive than those for physical health issues.

2010: Williams v. Quinn, a case heard by U.S. District Court for the Northern District of Illinois, rules that Illinois residents with mental illnesses living in nursing homes and other ‘institutions for mental diseases’ (IMDs) have the right to live in integrated settings in the community

Types of Mental Illness

There are many different conditions that are recognized as mental illnesses. The more common types include:

Anxiety disorders: People with anxiety disorders respond to certain objects or situations with fear and dread, as well as with physical signs of anxiety or nervousness, such as a rapid heartbeat and sweating.

An anxiety disorder is diagnosed if the person’s response is not appropriate for the situation, if the person cannot control the response, or if the anxiety interferes with normal functioning. Anxiety disorders include generalized anxiety disorder, post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), panic disorder, social anxiety disorder, and specific phobias.

Mood disorders: These disorders, also called affective disorders, involve persistent feelings of sadness or periods of feeling overly happy, or fluctuations from extreme happiness to extreme sadness. The most common mood disorders are depression, mania, and bipolar disorder.

Psychotic disorders: Psychotic disorders involve distorted awareness and thinking. Two of the most common symptoms of psychotic disorders are hallucinations — the experience of images or sounds that are not real, such as hearing voices — and delusions, which are false beliefs that the ill person accepts as true, despite evidence to the contrary. Schizophrenia is an example of a psychotic disorder.

Eating disorders: Eating disorders involve extreme emotions, attitudes, and behaviors involving weight and food. Anorexia nervosa, bulimia nervosa and binge eating disorder are the most common eating disorders.

Impulse control and addiction disorders: People with impulse control disorders are unable to resist urges, or impulses, to perform acts that could be harmful to themselves or others. Pyromania (starting fires), kleptomania (stealing), and compulsive gambling are examples of impulse control disorders. Alcohol and drugs are common objects of addictions.

Often, people with these disorders become so involved with the objects of their addiction that they begin to ignore responsibilities and relationships.

Personality disorders: People with personality disorders have extreme and inflexible personality traits that are distressing to the person and/or cause problems in work, school, or social relationships.

In addition, the person’s patterns of thinking and behavior significantly differ from the expectations of society and are so rigid that they interfere with the person’s normal functioning. Examples include antisocial personality disorder, obsessive-compulsive personality disorder, and paranoid personality disorder.

Other, less common types of mental illnesses include:

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Adjustment disorder: Adjustment disorder occurs when a person develops emotional or behavioral symptoms in response to a stressful event or situation. The stressors may include natural disasters, such as an earthquake or tornado; events or crises, such as a car accident or the diagnosis of a major illness; or interpersonal problems, such as a divorce, death of a loved one, loss of a job, or a problem with substance abuse. Adjustment disorder usually begins within three months of the event or situation and ends within six months after the stressor stops or is eliminated.

Dissociative disorders: People with these disorders suffer severe disturbances or changes in memory, consciousness, identity, and general awareness of themselves and their surroundings. These disorders usually are associated with overwhelming stress, which may be the result of traumatic events, accidents, or disasters that may be experienced or witnessed by the individual. Dissociative identity disorder, formerly called multiple personality disorder, or “split personality,” and depersonalization disorder are examples of dissociative disorders.

Factitious disorders: Factitious disorders are conditions in which physical and/or emotional symptoms are created in order to place the individual in the role of a patient or a person in need of help.

Sexual and gender disorders: These include disorders that affect sexual desire, performance, and behavior. Sexual dysfunction, gender identity disorder, and the paraphilias are examples of sexual and gender disorders.

Somatoform disorders: A person with a somatoform disorder, formerly known as psychosomatic disorder, experiences physical symptoms of an illness, even though a doctor can find no medical cause for the symptoms.

Tic disorders: People with tic disorders make sounds or display body movements that are repeated, quick, sudden, and/or uncontrollable. (Sounds that are made involuntarily are called vocal tics.) Tourette’s syndrome is an example of a tic disorder.

Other diseases or conditions, including various sleep-related problems and many forms of dementia, including Alzheimer’s disease, are sometimes classified as mental illnesses, because they involve the brain.

Causes of Mental Illness

We’re aware of several different forms of mental illnesses, right from bipolar disorder to schizophrenia to compulsive disorders. How often we come across murders carried out by mentally unstable people! In fact, there are scores of famous people with bipolar disorders.

Mental illnesses are especially common in the United States. Approximately 26.2 % Americans above 18 years of age are believed to suffer from mental disorders every year, thereby conducing to one of the leading causes of disabilities in the US and Canada. But what causes mental illness?

Mental illness is a condition affecting the brain, that influences the way a person thinks, feels, behaves and relates to others around him or her. The symptoms of mental illness may range from mild depressive symptoms to severe behavioral problems.

Genetic Factors

Depression and mental illnesses are often passed on from one generation to another through the genes. This means, a person with a family history of mental illness is more vulnerable to develop a mental illness. It is believed that mental illness is associated to various abnormalities in not just one, but several genes.

This is the reason why the person inherits the vulnerability to develop this illness, but does not inherit the illness itself. When such people go through horrendous situations the balance of their mind tips and they get engulfed by mental illnesses.

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Mental illness history
Mental Illness History

Physical Factors

People who have landed up injuring their head several times in accidents, are seen to damage certain areas of their brain and central nervous system, that lead to mental illnesses. Trauma occurring at the time of birth can also cause damage to the brain.

Moreover, disruption of early fetal brain development can also lead to conditions like autism, etc. Some biological factors such as chemical imbalance in the brain, are also associated to mental illnesses. The chemicals called neurotransmitters help nerve cells in the brain to transfer impulses, thereby facilitating communication.

However, when this balance tips, messages are not transferred correctly, leading to mental illness. Diseases affecting the brain such as Huntington’s chorea, multiple sclerosis and infections like Tuberculous meningitis, Encephalitis lethargica, etc. also result in mental illnesses.

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Psychological Factors

People who have gone through harrowing experiences in their lives like emotional, physical, sexual abuse, domestic violence or bullying are often unable to cope with their traumatic past. Sometimes, the death of a loved one, betrayal or neglect during childhood years, also mars the person’s emotional state of mind. This sometimes can be the reason of mental illness of a person.

Social and Environmental Factors

Poverty, living in a difficult and unsafe environment like in war zones, residing in earthquake prone and other natural disaster-prone areas, living in neighborhoods plagued by gangsters, etc. can lead to mental illnesses. These people develop a constant fear that conduces to mental illness.

Moreover, unhealthy environment factors at home, such as growing up in a dysfunctional family, with narcissistic parents or neglecting parents can cause the balance of the child’s brain to tip. The person’s appearance regarding height and weight also causes depression in certain people.

Mental illnesses should be not confused with mental retardation. People with mental illnesses do not exhibit limitations in mental, cognitive and social functions. Thus, causes of mental retardation and causes of mental illnesses are obviously different. The above mentioned causes cannot be viewed in isolation. It’s when two or three different factors come together, such as past abuse and present horrendous situation come together, that it often causes the mental illness.

It is important to not look upon people with mental illnesses with disdain and ostracize them. What they need is unconditional love. Espouse them and help them out of their pits of depression.

The symptoms of mental illness

A person with a mental illness can experience problems with their thinking, emotions and/or behaviour. These changes may happen quickly, or they may be gradual and subtle. It may take time to understand and identify what is happening.

Psychotic symptoms

These symptoms can include:

  • Thoughts and feelings that are out of the ordinary or difficult to understand, such as thought of being persecuted or under surveillance for which there is no proof
  • Experiencing sensations (seeing, hearing, smelling, tasting something when there is nothing there that others can identify)
  • Odd behaviour.
  • Schizophrenia is a psychotic illness.

Mood symptoms

Some of the symptoms of a changed mood may include:

  • Persistent and pervasive feelings of sadness, elation, anxiety, fear or irritability
  • Changes in sleep patterns
  • Changes in appetite
  • Loss of interest in things that were previously enjoyable
  • Periods of increased or decreased activity, where things may be started and not finished
  • Difficulty thinking and concentrating
  • Excessive worries
  • Changes in use of alcohol and other drugs.

Exact causes are unknown

Many mental illnesses are thought to have a biological cause. What are the exact causes , its unknown.

The relationship between stress and mental illness is complex, but it is known that stress can worsen an episode of mental illness.


Extraordinary advances have been made in the treatment of mental illness. Understanding what causes some mental health disorders helps doctors tailor treatment to those disorders. As a result, many mental health disorders can now be treated nearly as successfully as physical disorders.

Psychological treatment

Psychological treatments are based on the idea that some problems relating to mental illness occur because of the way people react to, think about and perceive things. They are particularly relevant to many people with anxiety disorders and depression. Psychological treatments can reduce the distress associated with symptoms and can even help reduce the symptoms themselves. These therapies may take several weeks or months to show benefits.

Different psychological therapies used in the treatment of mental illness include:

Cognitive behaviour therapy (CBT) – examines how a person’s thoughts, feelings and behaviour can get stuck in unhelpful patterns. The person and therapist work together to develop new ways of thinking and acting. Therapy usually includes tasks to perform outside the therapy sessions. CBT may be useful in the treatment of depression, anxiety disorders and psychotic disorders such as bipolar and schizophrenia.

Interpersonal psychotherapy – examines how a person’s relationships and interactions with others affect their own thoughts and behaviours. Difficult relationships may cause stress for a person with a mental illness and improving these relationships may improve a person’s quality of life. This therapy may be useful in the treatment of depression.

Dialectical behaviour therapy – is a treatment for people with borderline personality disorder (BPD). A key problem for people with BPD is handling emotions. This therapy helps people to better manage their emotions and responses.

Treatment with medication

Medications are mainly helpful for people who are more seriously affected by mental illness. Different types of medication treat different types of mental illness:

Antidepressant medications – about 60 to 70 per cent of people with depression respond to initial antidepressant treatment. These medications are now also used (in combination with psychological therapies) to treat phobias, panic disorder, obsessive compulsive disorder and eating disorders.

Antipsychotic medications – are used to treat psychotic illnesses, for example schizophrenia and bipolar disorder. Newer antipsychotic medications may have some side effects, but tend to have fewer of the effects that were associated with the older medications, for example stiffening and weakening of the muscles and muscle spasms.

Mood stabilising medications – are helpful for people who have bipolar disorder (previously known as manic depression). These medications, such as lithium carbonate, can help reduce the recurrence of major depression and can help reduce the manic or ‘high’ episodes.

Other forms of treatment

Effective treatment involves more than medications. Treatment may also involve:

Community support – including information, accommodation, help with finding suitable work, training and education, psychosocial rehabilitation and mutual support groups. Understanding and acceptance by the community is very important.

Electroconvulsive therapy (ECT) – this treatment can be a highly effective treatment for severe depression and, sometimes, for other diagnoses when other treatments have not been effective. After the person is given a general anaesthetic and muscle relaxant, an electrical current is passed through their brain.

Hospitalisation – this only occurs when a person is acutely ill and needs intensive treatment for a short time. It is considered better for a person’s mental health to treat them in the community, in their familiar surroundings.

Involuntary treatment – this can occur when the psychiatrist recommends someone needs treatment but the person doesn’t agree. In general, people receive involuntary treatment to ensure their own safety or that of others.

Mental illness in Pakistan:

Mental health in Pakistan has remained a subject of debate since the last few years. The incidence and prevalence have both increased tremendously in the background of growing insecurity, terrorism, economical problems, political uncertainty, unemployment and disruption of the social fabric. 1 Sinking below poverty line by almost 39% of the individuals is an alarming factor worth noting.

Many people are now presenting to psychiatrists probably because of the growing awareness through the good work of media. Though there are many things which can be done to improve the mental health of the people in the areas of social environment, economic improvement and political harmony etc. but the important subject for debate is that, how far we are in the areas of education, service and research related to mental health having direct impact on the patient population.

From 1947 to 2005, almost 58 years have passed since the independence of the country and many countries with this age have done wonders in overall upkeep of health care and specially the mental health. The scenario though is improving, but is it at the required pace? If we first take the area of education by virtue of which we train our future doctors who in turn can become navigators helping us in sailing smoothly through the heavy storm of up surging mental illnesses, we find lacunas which are evident when it comes to ultimate care of patients.

With the exception of very few institutions, the subject of behavioral sciences which has been introduced by the PMDC in the early years of medical teaching is not being taken serious enough, low number of behavioral scientists cannot alone be blamed for this, there are no structured rotation programmes for senior medical students which means a calendar indicating topics, patient sessions, log book and evaluation strategy with weightage in the final year marking system.

Low interest by students in the subject of psychiatry despite few institutions’ model teaching/training programme is understandable in view of no separate paper in psychiatry and very low representation in the paper and clinico-orals of the subject of General Medicine. Regarding the departments, are we fulfilling the international requirements of a good department of psychiatry with full-fledged faculty in all hierarchies?

The answer is simply ‘no’. Regarding the postgraduate education, how many recognized centers follow structured programmes emphasizing adequate patient exposure, ongoing continuing medical education programmes, research, exposure to subspecialties like, child, geriatric, forensic and rehabilitation psychiatry etc., is there a rural exposure, is there training in cultural issues, is there emphasis on liaison service and multidisciplinary team approach, is there a standard methodology for continuous monitoring and evaluation with resultant weightage in postgraduate exit examinations, is there training in audit and psychiatric administration, the answers to most of these questions will remain unanswered nationally.

It is precautionary not to say a word about the selection criteria of evaluators and examiners lest it is not politically biased and motivated. It is also worth noting that during postgraduate training how many of the prospective specialists are monitored and assessed for culturally relevant mental state examination, adequate case note management, observation of prescribing practices and its justification, communication skills etc.

Once certified, there is no provision of higher specialist training for a period of at least three years on the pattern of UK with evaluation of practice-based efficiency, infact, the UK model is worth adopting. 2 There is no trend for CME credit maintenance and hence no programme specifically designed for psychiatrists though there are many such programmes for the general practitioners of course with no condition of maintaining credit certification, this is mostly prompted by the pharmaceutical companies with a view of improving sale as evidence has shown that the knowledge of even most common disorder depression was not adequate among general practitioners.

When we come to service, though the major teaching hospitals have established separate departments of psychiatry but in most of the cases they are not well equipped specially in terms of psychiatric manpower both skill and number wise. Still Pakistan has very low number of psychiatrists and these too are continuously being drained by the developed countries especially by the western world where they are being offered an attractive package and lifestyle that the question remains as to who comes back and serves the nation.

It is not surprising that there are a large number of Pakistani psychiatrists in United Kingdom, United States, Canada, Australia and New Zealand apart from those in Middle East, Africa and South East Asia. It seems that soon we shall become a psychiatrists exporting region like our neighbour India thus causing further deepening of the problem related to the already existing scarcity of psychiatrists.

Also, at the same time it is vitally important to abolish the feudal psychiatry which fortunately is being eroded by young generation of psychiatrists. There is also acute shortage of allied mental health professionals. In view of poverty, low health budget, high cost of medicines there is huge economic burden on the patients.

The hospitals also don’t follow the intake/admission criteria, no separate unit for subspecialties, no appropriate long stay units, no exit/discharge criteria, no rehabilitation services, no exchange of information between psychiatrists and family practitioners, no proper advertisement of available services, no concept of day centers, day hospitals, ill developed community services, no central registry of patients and set policy for management systems in the psychiatric set ups and finally no internal referral system.

As far as research is conc erned, there is still low representation in local accredited journals and very low in international journals. 7 Though there has been an increase in lay and scientific write-ups recently but it is still far from satisfactory state. Papers are produced for promotions and that too are for the sake of papers, matter of keeping up standards are ignored. The Journal of Clinical Psychiatry published regularly from Lahore once upon a time disappeared eventually. The first journal of Pakistan Psychiatric Society called JPPS was published in the year 2003, which was blocked politically and was not reproduced again. .

It appears that still we are far behind in achieving the standards and in order to improve the existing scenario some steps are essential. In order to bring improvement in psychiatric education, it is important to pay emphasis on the subject of behavioral sciences, design an appropriate undergraduate training program in line with one of the international modules, inculcation of research interest among medical students, either introduction of a separate paper of psychiatry or at least 25% of weightage in the paper of medicine, at postgraduate level more structured training program with exposure to subspecialties, designing a postgraduate curriculum and module, introduction of audit of training and performance, provision of higher specialist training at the level of specialist registrar, private-public partnership in provision of services, mobilization of more resources for mental health and maintaining of records.

There is a need for development of research culture especially in the areas of need assessment is also necessary. Along with these efforts the medical fraternity can force the government to allocate a higher budget, reduce poverty, bring social justice and harmony, improving political scenario.

It is also advisable to create better incentives for the mental health professionals in order to avert brain drain. Efforts for providing a conducive environment to the public to help in promoting sound mental as well as physical health are imperative.

Literature Review

Anxiety and depressive disorders are common in all regions of the world.

1 They constitute a substantial proportion of the global burden of disease, and are projected to form the second most common cause of disability by 2020.2 This increased importance of non-communicable diseases such as anxiety and depressive disorders presents a particular challenge for low income countries, where infectious diseases and malnutrition are still rife and where only a low percentage of gross domestic product is allocated to health services.3 These disorders are also important because of their economic consequences.

With an estimated population of 152 million, Pakistan is the sixth most populous country in the world. It is projected that, by 2050, the population will have increased to make it the fourth most populous country.5 There is a need to develop an evidence base to aid policy development on tackling anxiety and depressive disorders. We therefore conducted a systematic review as no such work existed to our knowledge.

Our main questions were (a) what the estimated prevalence of anxiety and depressive disorders is in Pakistan and how this compares with estimates from other low income countries; (b) what the associated social, psychological, and biological factors are; and (c) what evidence exists for effectiveness of treatment or prevention in this population.

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Prevalence of anxiety and depressive disorders

the prevalence of anxiety and depressive disorders estimated in the studies. The overall mean prevalence in men and women in the six studies of random community samples (n = 2658) was 33.62%, with the point prevalence varying from 28.8% to 66% for women (overall mean 45.5%) and from 10% to 33% for men (overall mean 21.7%).

Women aged 15-49 were studied in a paper with 28.8% prevalence, while young men with a mean age of 18 participated in a study reporting 33% prevalence. Only one study reported adjusted prevalence with 95% confidence intervals.

For those presenting to traditional or faith healers (n = 511), the prevalence of anxiety and depressive disorders among men varied from 2.65% to 27%, and among women from 11.5 % to 52%.

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Mental illness history
Mental Illness History

Three studies looked at total psychiatric morbidity in primary care (n = 774). One described women in a rural area, with a prevalence of 50%, while another described 18% prevalence for men and 42.2% for women in an urban area. The third study, with a prevalence of 38.4%, did not specify participants’ sex.

Of those presenting to psychiatric outpatients (n = 2430), the prevalence varied between 32% and 66.3%. There were two studies on psychiatric inpatients, one reported a prevalence of depressive illness of 37% (n = 2620), while the other reported 19.1% (n = 177).

Comparison with other low income countries

Using stringent criteria, Harding et al reported an overall frequency of anxiety and depression of 13.9% in four developing countries.9 Community studies from Africa have reported prevalences of 24% in rural Uganda and 20%-24% in rural South Africa. Among patients attending primary care, the prevalence varied from 8% to 29%. Patients attending primary care in India showed prevalences between 21% and 57%.

In relation to risk factors, Abas and Broadhead found a significant association with formal employment, below average income, overcrowding, and certificate of secondary education in urban Zimbabwe.

Related FAQs

1. What is mental health essay?

Mental Health Essay: Mental Health includes one’s psychological, emotional and social well-being – one’s mental health affects how they think, feel and act. It also helps in determining how one handles stress, makes choices and relates to others.

2. What is the history of mental health in America?

Mental Health America began in the early 1900’s by Clifford W. Beers, a former psychiatric patient who experienced mental/physical abuse during his stay in public and private institutions. It wasn’t until short after a reform group emerged, to stand against the abuse and ill-treatment at these institutions.

3. How does family history affect mental health?

This means, a person with a family history of mental illness is more vulnerable to develop a mental illness. It is believed that mental illness is associated to various abnormalities in not just one, but several genes. This is the reason why the person inherits the vulnerability to develop this illness, but does not inherit the illness itself.

4. What is mental illness?

This essay may contain factual inaccuracies or out of date material. Please refer to an authoritative source if you require up-to-date information on any health or medical issue. Mental illness is a general term for a group of illnesses. Mental disorders result from biological, developmental and/or psychosocial factors.

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