A Brief History of Psychiatry in the 100^th Anniversary of the Republic of Türkiye

ABSTRACT

In this review, we aimed to outline the scientific advances and service capacity in Turkish psychiatry within the century-long history of the Republic. We propose that the history of Turkish Psychiatry also sheds light on the history of our country. We have reviewed significant milestones in Turkish Psychiatry; the establishment of psychiatric hospitals, the development of formal psychiatry training, academic and scientific proceedings and the founding of professional organizations in the Republic era. We aimed to offer insights into the role of psychiatry in the modernization of our country, as well as to establish a foundation for future improvements by evaluating the progress made in the field of mental health services. The story that began with 20 neuropsychiatrists and 300 psychiatric beds in one mental hospital has now reached over 4000 psychiatrists and twenty-thousand psychiatric beds. Psychiatry in Türkiye continues its historical evolution with expansion in size and advancements in quality.

INTRODUCTION

The modernization that began in the 19th century in the Ottoman Empire extended over a significant period, touching nearly every domain. Among the areas where the process of modernization was notably observed, medicine stands out prominently. One of the areas where the evolution of modern medicine can be readily comprehended is undoubtedly psychiatry, a relatively young and dynamic medical discipline that emerged in the West.

The appointment of Luigi Mongeri, an Italian-born physician who sought refuge in the Ottoman Empire, as the chief physician of Süleymaniye Hospital in 1856, can be considered the starting point of modern psychiatry in our country (Erkoç and Artvinli 2011). Mongeri’s radical reforms aimed at improving the physical conditions of patients in the hospital, liberating them from chains, and his approach centered on medical understanding fundamentally paved the way for a new attitude towards psychiatric patients. This marked a completely new direction in the course of psychiatry. Later figures in the field of psychiatry, such as Avni Mahmud, Avram de Castro, and Derviş Paşa, received their psychiatric education alongside Luigi Mongeri. Another significant development of the period was the inclusion of psychiatry, under the names “tabâbet-i akliye” and “asabiye,” as a separate branch in the curriculum of the Mekteb-i Tıbbiye-i Mülkiye (Civil Medicine School). As far as is known, Lofçalı Derviş Paşa undertook the teaching of neurology and psychiatry courses (Unat and Samastı 1990). Raşit Tahsin Bey [Tuğsavul], specializing in neuropsychiatry in Germany, initiated the education in psychiatry and neurology as a separate branch at the Mekteb-i Tıbbiye-i Şahane (Military Medical School) in 1898, initially under the title of “emraz-ı asabiye” (neurology) due to censorship constraints (Reider 1904). Before this date, psychiatry and neurology were considered subfields of forensic medicine, leading to psychiatrists specializing in two separate fields: psychiatry and forensic psychiatry, until the early years of the Republic (Unat and Samastı 1990).

In the first quarter of the 20th century, the Ottoman Empire, after prolonged wars resulting in the loss of numerous trained individuals and facing difficulties in finding new talented individuals for employment, left a modest legacy to the young Turkish Republic. Of approximately nine hundred physicians inherited by the Republic, only about thirty were neuropsychiatrists, and of these, around ten were registered as forensic physicians (Unat and Samastı 1990). Alongside these trained physicians, the legacy inherited by the Republic included an asylum named Toptaşı Bîmarhanesi, a medical faculty named Mekteb-i Tıbbiye, and a military health institution known as Gülhane Askeri Tıp Okulu.

Attempting to encapsulate the century-long history of a medical discipline such as psychiatry, which influences numerous other scientific and cultural domains through its development, is not feasible within a single article. However, it is possible to identify the pivotal moments that shaped its trajectory and highlight important aspects. With limited resources, we have chosen to focus on specific areas such as psychiatric hospitals, psychiatric education and specialization, academic publications in psychiatry, established professional organizations, and organized scientific events to comprehend psychiatry, a field that carved out its unique space. Alongside this introductory and summarizing text about the history of psychiatry in our country, our aim is to shed light on the development of the field by exploring influential factors that have contributed to its evolution.

PSYCHIATRIC HOSPITALS

In the early years of the Republic, Toptaşı Mental Hospital in Üsküdar provided mental health services but remained insufficient due to its relatively limited capacity and deficiencies in its physical facilities (Uzman 1933). Consequently, in response to this inadequacy, the decision was made to convert the unfinished Reşadiye Barracks in Bakırköy, initiated before the Republic, into a mental hospital under the auspices of Mustafa Kemal Atatürk (Uzman 1941). Led by Mazhar Osman [Uzman], the Reşadiye Barracks was transformed into a hospital in 1924, and the transfer of patients from Toptaşı continued until 1927, leading to the closure of Toptaşı Bîmarhanesi. This institution, named Bakırköy Emraz-ı Akliye ve Asabiye Hospital, still operates at the same location under the name Bakırköy Prof. Dr. Mazhar Osman Mental Health and Nervous Diseases Training and Research Hospital. In 1925, two mental hospitals were established to serve as psychiatric branch hospitals in their regions: the Manisa Emraz-ı Akliye ve Asabiye Hospital, with Ali Muhlis Bey as its first chief physician, and the Elaziz Emrazı Akliye Hospital, with Ahmet Şükrü Emed as its first chief physician.

In the sole medical faculty inherited from the Ottoman era, Raşit Tahsin Tuğsavul and Fahrettin Kerim Gökay took charge of the psychiatry department. Fahrettin Kerim largely oversaw the administrative and educational services of the faculty’s psychiatry department between 1926 and 1933. This clinic, with significantly limited bed capacity compared to other mental hospitals, mainly catered to neurological patients. Additionally, the Gülhane Military Hospital admitted military psychiatric patients, where military doctors received their neuropsychiatric training during their specialization (Ataç 1996).

Despite some increase in the number of institutions and beds offering psychiatric health services in the early years of the Republic, this augmentation remained inadequate relative to the country’s population and needs. Before the establishment of mental hospitals, many mentally ill individuals resided in tekkes (Islamic hospices) and specialized villages (Bayat 1989). With the closure of tekkes, the burden on hospitals increased further.

By the Republic’s tenth year, the capacities of hospitals catering to mental patients increased, and new hospitals came into service to meet rising demands. According to Mazhar Osman’s “Sıhhat Almanakı” prepared for the Republic’s tenth year, Bakırköy Hospital, with nearly fifteen hundred patients, was the largest among these hospitals in 1933. Besides Bakırköy Hospital, the mentioned almanac listed institutions providing inpatient services to mental patients, including Darülâceze, Gülhane Seririyatı, Manisa Emraz-ı Asabiye ve Akliye Hospital, Elazığ Emraz-ı Asabiye ve Akliye Hospital, Rum Balıklı Hospital, Yedikule Armenian Hospital, Or-Ahayim Balat Jewish Hospital, and the French La Paix Hospital (Uzman 1933).

Following mental hospitals in Manisa and Elazığ, a psychiatric hospital started operating within Ankara University’s Faculty of Medicine in 1945, established under the guidance of Nazım Şakir and Rasim Adasal from Gülhane Military Academy (Sayıl 2015). It is worth noting that it was during Rasim Adasal’s tenure that an interest in cultural issues and psychoanalysis began in this hospital. Subsequently, psychiatry units, providing both outpatient and inpatient services, were established within Ege University in 1955, Hacettepe University in 1963, Atatürk University in 1965, and subsequently at newly founded universities. In the 1970s, in addition to the aforementioned institutions, hospitals such as Adana, Samsun, and Erenköy SSK Mental and Neurological Diseases Hospitals, similar to the Bakırköy prototype, started operating as specialized psychiatric hospitals. The Rahmi Duman Clinic, founded by Rahmi Duman and operational between 1951 and 1978, was the first example of private psychiatric specialty hospitals, providing both inpatient and outpatient services to psychiatric patients.

The discovery of antipsychotics in the mid-20th century facilitated significant changes in the treatment and management of severe psychiatric illnesses. While complete recovery was often not achieved due to the chronic nature of severe mental disorders, new treatment methods enhanced the possibilities for patients to participate in daily life. Consequently, globally and in Türkiye, the hospital-based approach shifted to a community-based healthcare model, maintaining outpatient treatment and follow-ups. Community mental health centers, similar in structure to mental health dispensaries that commenced in the 1960s but were not sustainable, began opening as of 2008. These centers, actively operational nationwide, continue to serve a large number of patients.

Over the years, the discovery of more effective psychiatric treatment methods and a broader understanding of mental health led to a reduction in stigmatization associated with psychiatric disorders. Consequently, there has been an increase in demand for psychiatric healthcare services across all sections of society. Legislative regulations implemented to meet this demand made it mandatory for every state hospital to establish a psychiatric clinic, and psychiatric clinics with 80-200 beds were established in major cities. Hospitals such as İstanbul Bakırköy, İstanbul Erenköy, Manisa, Bolu, Samsun, Adana, Elazığ, and Trabzon Ataköy Mental Health and Illness Hospitals were designated as regional hospitals. Additionally, Alcohol and Substance Treatment Centers (AMATEM) were established in many provinces (Ministry of Health 2011).

As of the last decade, it can be stated that in each province of our country, there is at least one psychiatrist working within state-affiliated healthcare institutions. With an increase in the number of specialists working in both state and private healthcare institutions, access to psychiatric health services has become considerably easier compared to the past.

PSYCHIATRY EDUCATION AND SPECIALIZATION

During the Ottoman era, physicians practicing in the field of psychiatry had not received specialization education. Figures like Luigi Mongeri and Avni Mahmud were practitioners who acquired their skills and knowledge through an apprentice-master relationship while working in mental hospitals. Raşit Tahsin was the first to receive formal psychiatric specialization in Germany under Kraepelin, contributing to the training of many psychiatrists, including Mazhar Osman. From the early years of the Republic until 1933, psychiatric education for medical faculty students was provided by Raşit Tahsin and his colleagues. Under the guidance of Mazhar Osman, specialization training was provided first at Toptaşı and later at Bakırköy and the Gülhane Military Academy. During these years, neurology and psychiatry were not considered separate disciplines, and specialists were trained as neuropsychiatrists. Until 1928, there was no defined structured framework for specialization training in medicine. It was deemed sufficient to spend approximately two years alongside the teaching professor and receive a document equivalent to a certificate from the professor to qualify as a specialist. However, in 1928, the Law on the Practice Style of Medicine and Its Branches stipulated a four-year duration for specialization training. In 1974, the training duration for the separate branches of neurology and psychiatry was set at three years, but in 1983, this duration was extended back to four years.

In 1933, the University Reform took place, leading to the renaming of Dârülfünûn to İstanbul University. As part of this reform, Mazhar Osman was appointed as the head of the Psychiatry Clinic at the Faculty of Medicine with the title of distinguished professor. Additionally, under Mazhar Osman’s leadership, the neurological and psychiatric education for students and specialists within the university’s Faculty of Medicine was provided in Bakırköy (Erkoç 2004). Mazhar Osman remained as the most prominent figure in Turkish psychiatry in terms of both medical practice and teaching until his death.

Upon Mazhar Osman’s departure from the chief physician position, a separation occurred in 1942 between the university clinic and the hospital departments under the Ministry of Health. As a result, two separate neuropsychiatry specialization training programs were conducted in Bakırköy under the auspices of the ministry and the university. In 1956, the section allocated to the university was relocated to the hundred-bed psychiatry clinic in Çapa. The establishment of a psychiatry hospital in the city center of Istanbul was met with opposition from local residents, who protested with slogans like “We don’t want the insane in our neighborhood.”

ACADEMIC WORKS PUBLISHED IN THE FIELD OF PSYCHIATRY

Although the emergence of modern psychiatry and the inclusion of neuropsychiatry as an independent branch in the medical curriculum occurred in the 19th century, it was not possible to publish in the field of psychiatry in the Ottoman Empire until the reign of Sultan Abdulhamid II, continuing until the Second Constitutional Period (II. Meşrutiyet). As far as we have been able to determine, the first independent printed Turkish psychiatry book in the Ottoman Empire was the work titled “Emraz-ı Akliye [Mental Illnesses]” translated by Lofçalı Derviş Paşa from Emanuel Regis in 1909. Subsequently, Avni Mahmud Bey, Mazhar Osman, Ali Muhlis, Raşit Tahsin, Nazım Şakir, Mustafa Hayrullah, and others authored various works in the field of psychiatry before the Republic. These figures and several others, such as Fahreddin Kerim, continued to produce works in psychiatry post-Republic until the alphabet reform.

Following the establishment of the Republic, notable works written in the old alphabet include Fahrettin Kerim’s “Akıl Hastalıkları [Mental Illnesses]” (1925), Mazhar Osman’s “Tababeti Ruhiye (I. Cilt) [Mental Medicine (Vol. I)]” (1927), and “Akıl Hastalıkları [Mental Illnesses]” (1928). The first psychiatry books written in Latin script were by Mazhar Osman and Fahreddin Kerim. Fahreddin Kerim’s “Ruh Hastalıkları [Mental Diseases]” (1931) and Mazhar Osman’s “Akıl Hastalıkları [Mental Illnesses],” which went through four editions during the period (1928, 1935, 1941, 1947), served as important reference sources for medical students and specialist physicians. Although Mazhar Osman planned “Tababet-i Ruhiye [Mental Medicine]” as a five-volume series, only three volumes were published in 1941, 1947, and 1947, respectively. İhsan Şükrü›s neuropathology book was published as the third volume. In subsequent years, Rasim Adasal authored a comprehensive three-volume series called “Psikonevrozlar [Psychoneuroses]” (1948), “Psikozlar [Psychoses]” (1949), and “Cinsel Bozukluklar [Sexual Disorders]” (1954), which served as a contemporary reference in the field of Mental Illnesses. Rasim Adasal’s bibliography also includes works related to psychology, such as “Medikal Psikoloji [Medical Psychology]” (1964), “Tabii ve Hasta Cepheleri ile Cinsiyet Aşk Evlilik [Natural and Sick Aspects with Gender Love Marriage]” (1963).

In addition to these mentioned names, authors such as Özcan Köknel, Ayhan Songar, Oğuz Arkonaç, Orhan Öztürk, whose works are still considered as important reference sources for psychiatric education, contributed significantly to the field. Starting in the 1980s, the American Psychiatric Association’s diagnostic and statistical manual (DSM) and the World Health Organization’s International Classification of Diseases (ICD) began to be widely used in Turkish psychiatry.

Regarding periodicals in the field of neuropsychiatry, their origin dates back to the pre-Republic era. The first Turkish journal, consisting of eleven issues, was published by Mazhar Osman between 1916-1918 under the title “Şişli Müessesesinde Emraz-ı Akliye ve Asabiye Müsamereleri.” The longest-running periodical in neuropsychiatry was “İstanbul Seririyatı,” by Mazhar Osman, which was published from 1919 until Mazhar Osman’s death in 1951. The first section of this journal comprised medical articles (fenni bölüm), while the second part included current social events, announcements, and obituaries (şu’un bölüm). The journal was published in the old script until the alphabet reform of 1928, after which it continued in Latin script. After Mazhar Osman’s death, another journal named “Acta Neuropsychiatrica” was published irregularly between 1952 and 1962. Fahreddin Kerim began another periodical, “Tıp Dünyası,” primarily focused on neuropsychiatry in 1928, which continued sporadically until 1983.

The “Nöropsikiyatri Arşivi,” initiated by the Turkish Neuropsychiatric Association in 1964, continues as an internationally peer-reviewed scientific journal, releasing four issues per year. Additionally, the “Düşünen Adam” journal, which commenced in 1983, could be considered one of the early journals in the field. The “Türk Psikiyatri Dergisi,” the scientific publication of the Turkish Neuropsychiatric Society since 1990, is currently indexed in numerous international databases, including the SSCI, and continues its publication activities.

PROFESSIONAL PSYCHIATRY ORGANIZATIONS

Osmanlı Tababet-i Akliye ve Asabiye Cemiyeti, a professional organization for neuropsychiatrists, began its establishment efforts in 1914 by Avni Mahmud, but due to the interruption caused by World War I, the association could only be founded in 1918. Mazhar Osman, who was elected as president when the society became active, continued in this position until his death. Later, this society transformed into the Turkish Neuropsychiatry Association and has continued its activities until the present day. However, during the founding of this society, Raşit Tahsin Bey, who had a disagreement with Mazhar Osman during the presidential election process, established a society named Tababet-i Ruhiye Cemiyeti in 1918, but this association could not continue its activities after 1926.

In the early years of the Republic, Fahreddin Kerim established the Turkish Mental Health Society in the 1930s. With the establishment of the Psychiatry Department within Ankara University’s Faculty of Medicine, organizational activities in the field of psychiatry also commenced in Ankara. Rasim Adasal founded an association called the Ankara Neuro-Psychiatry Society in 1945, which continued its activities for many years, organizing conferences and events for both neuropsychiatrists and the public. In 1962, its name was changed to the Turkish Society of Neurology and Psychiatry.

By the late 1980s, with an increasing number of psychiatry assistants and young specialists spreading across Türkiye, there was a search for a common ground where colleagues could communicate. This quest led to the establishment of the Psychiatry Assistants and Specialists Association (PAUD) aimed at evaluating psychiatric education and healthcare issues, facilitating access to current scientific knowledge, and strengthening professional activities. Following the initiatives and preparations by representatives of the Turkish Neuropsychiatry Association, PAUD, and the Turkish Society of Neurology and Psychiatry, a Psychiatry Association was formed in 1995. In 1999, with a decision by the Council of Ministers, the association adopted its current name, the Turkish Psychiatric Association, and has continued its activities since then.

In addition to these general neuropsychiatry-focused associations, several specialized associations in the fields of psychopharmacology and psychotherapy, some of which are still active today, have been established.

Apart from professional organizations, in the 2000s, several associations were established to bring together doctors, patients, and their families to increase awareness about specific diseases, create a communication network for patients and their families, gather people facing similar problems to expand and improve medical and social assistance. Notably, among these associations, the Schizophrenia Associations Federation and Autism Associations Federation have united various associations established in different provinces and centers under a single roof.

CONGRESSES, SYMPOSIUMS AND OTHER SCIENTIFIC EVENTS

In the first year after its establishment, the initiatives of the Ottoman Society for Mental and Nervous Diseases led to the convening of the first psychiatric congress in 1919 under the honorary chairmanship of Avni Mahmud and the presidency of Mazhar Osman. The congresses were continued to be held annually until 1925. As of 1925, National Medical Congress were initiated biennially. The neuropsychiatric community actively participated in these gatherings. In the years when National Medical Congresses had not organized, neuropsychiatric congresses continued under the auspices of the society until the passing of Mazhar Osman.

Following Mazhar Osman’s demise, these congresses were held irregularly. By the year 1964, the first National Neuropsychiatric Congress jointly organized by the Turkish Neuropsychiatric Society and the Turkey Mental Health and Neurology Society took place in the meeting hall of Ankara University’s Faculty of Language, History, and Geography. Initially encompassing neurology, neurosurgery, and psychology alongside psychiatry, separate congresses for neurology and psychiatry commenced after 1987. The Annual National Psychiatry Congresses, previously organized alternately by universities and specialized hospitals, have been under the responsibility of the Turkish Psychiatry Association since 1995. Moreover, the association has been arranging Spring Symposia, Autumn Schools, and Clinical Education Symposia annually, prioritizing assistant education since 1996. Additionally, separate congresses specialized in psychopharmacology, psychotherapy, and other fields continue at the national and international levels.

CONCLUSION

As a deficient aspect in the scientific and institutional domains, the legal dimension can be highlighted in the ongoing development of psychiatry. The legal regulations prepared by Luigi Mongeri in 1874, inspired by the French example, are currently insufficient to address the medicolegal issues in the field of mental health, thus necessitating a new mental health law that aligns with the present era.

This article outlines the history of psychiatry in Türkiye from the pre-Republic period to the present, delineating its main points and some significant intersections. Like any text that aims to encapsulate a specific issue or subject, this account of psychiatry history contains certain topics that remain beyond its scope. Some of these include the phases in the forensic aspect of psychiatry, the introduction of pharmacological and somatic treatments in Türkiye and their impact on psychiatric practice, the historical progression of psychotherapies and psychotherapy education in Türkiye, the discipline and practice of psychiatric nursing, and the establishment and activities of child and adolescent mental health departments. To better comprehend the history and evolution of psychiatry in Türkiye, it’s evident that these topics need separate and thorough examination within their historical contexts.

One of the most significant yet omitted subjects in this article, perhaps, is that of the patients. It might be seen as an irony of the discipline that the patients, the sole reason for the existence of psychiatric discipline, have almost always been, in the crudest sense, merely subjected to the historical changes within psychiatry. However, considering that the history of patients, especially those with schizophrenia, bipolar disorder, depression, etc., predates psychiatry itself and extends back to the dawn of humanity, it becomes apparent that a careful and meticulous examination of their history is essential to better understand and comprehend both the patients and their conditions.

In the early years of the Republic, around 20 neuropsychiatrists and the single psychiatric hospital, Toptaşı Bimarhanesi, inherited around 300 psychiatric beds and very few trained staff. Today, there are over 4000 psychiatrists in service, and with the number of psychiatric beds approaching twenty thousand, health ministry-affiliated training and research hospitals, as well as medical faculties, bring up around 250-300 new psychiatrists annually. Alongside the healthcare services offered by these physicians, the field of psychiatry continues to progress both medically and academically through organized scientific meetings, congresses, publications in national and international platforms, published journals, and books.