History of Mental Health in the US

On December 27, 2016, actress Carrie Fisher passed away at the UCLA Medical Center in Los Angeles, CA, four days after falling unconscious on an LA-bound flight from London. Long candid about her challenges with mental health and substance abuse, toxicology reports after her death showed cocaine, heroin, MDMA, and other opiates in her system, in what likely contributed to her death.² Her remains were split between a plot in Forest Lawn Memorial Park, and a giant novelty Prozac pill urn, a final gag, and recognition of the ways that that giant pill had likely saved her life before.³ Fisher’s body of work talking about her mental health, and in the end her Prozac proclivity, shines a spotlight well known to comedians and their audiences: the link between comedians and mental health challenges.

In traveling back through the annals of American comedy of various types, be it the classic stand-up comedy, film, television, etc, two major developments stood out in focusing on how comedy approached mental health. Specifically, the approach of comedy toward mental health fundamentally changed during the deinstitutionalization movement and the accompanying development and rise of psychiatric medication from the 1960s to the 70s, and made the discussion of mental health far more prescient and acceptable than it had ever been before.

I hope then, to take you on an exploration of how American comedy has addressed mental health over time, and how its depictions have evolved from its earliest roots, to the newest Netflix specials you see today. This story is told over more than a century, and includes vastly different kinds of expression, styles of humor, and types of media. All of these, however disparate that they may be, speak to a greater awareness, sensitivity, and focus in the comedic landscape towards issues of mental health, a shift that came from comics and audiences alike.  

Humor and insanity frequently linked together in language and the popular imagination. One might laugh “like crazy” or “hysterically,” or someone with a peculiar personality might be described as “kooky,” “wacky,” or “bonkers,” words that have been used to refer to people who make you laugh, as well as people who are mentally ill. The “loony bin,” as one name the asylum came to be known by, is the start of this story, and the decline of this institution came to enable an era of openness around mental health and its struggles. 

From its earliest days of development in the mid to late nineteenth century, the asylum was the birthplace of psychiatry, and arguably the idea of mental health. From its outset, the institutionalists sought to create a treatment environment that was meant to “cure” the mentally ill.⁶ This “moral treatment,” based on principles of humane and social care dominated the early days of the asylum, but fell to the wayside in the twentieth century as institutions became overcrowded, underfunded, and neglected. High profile exposés of asylums, like Nellie Bly’s famous Ten Days in a Madhouse, began to sour public opinions of the asylum, and along with astronomical costs of institutions, and the introduction of new psychiatric medications, American psychiatric institutions began to shudder their doors in the 50s, 60s, and 70s.⁷

This movement came to be known as deinstitutionalization, which saw institutions began to lower their admissions and discharge early, point their newly released patients towards secondary psychiatric care, and after they had shifted enough people away, they closed for good. Much of the practical outcome that deinstitutionalization sought was the shift towards community support, and while a noble goal, there were simply too many people released too quickly, which shortly outpaced the establishment of adequate support services.⁸

For many patients, deinstitutionalization meant liberation from the often dehumanizing and overcrowded conditions of asylums of the time, but for others, the loss of structure and more constant care was a significant problem. Some successfully adapted to community living, benefiting from outpatient care and medications, while yet others faced homelessness, prison or other legal issues, or burdened their loved ones, who ultimately assumed the responsibility of their care. As the loony bin began to empty out, the new frontier of psychiatric treatment began its meteoric rise.

Meprobamate, famously known as Miltown, was one of the first tranquilizers to hit the US market in 1955, and immediately showed positive results in institutionalized patients and the general public. Valium, another anti-anxiety medication, came around in 1959, and joined a cast of psychotropic characters like Chlorpromazine, an antipsychotic widely used in institutions in the 1950s.¹⁰ The effect that these medications had on psychiatric care was immediate and immense, and these medications allowed those in inpatient care to move out of the asylum, as many patients now did not need constant supervision and attention. Deinstitutionalization was largely enabled by these new “miracle drugs,” and came to be used widely outside the institutional setting. 

The popularity of these psychiatric drugs grew immensely; as seen above, ads for drugs like Miltown touted that they “ relax both muscle and mind… without impairing physical or mental efficiency.” These drugs exploded in popularity among the general public, and were some of the most prescribed drugs in the 1950s and 60s. Tranquilizers took Hollywood by storm, and became popular with stars coping with their high stress lives. “Miltown” Berle, as he jokingly quipped, was a prominent proponent of the drug, and while by far the most notable example, many other celebrities were well on the bandwagon of the new era of medications. 

The rise of these medications was not seen as an unmitigated positive, however. Many critics correctly noted the danger that overuse of psychiatric meds posed. One of the most prominent stand-ups of American comedy, George Carlin, joked that “That’s why we have a drug problem, I really feel, you know, cause everybody has access to drugs … we’re just kinda dopey folks and we have all these drugs available to us … There’s all these drugstores every three or four blocks, you know, big sign: DRUGS.”¹¹ The proliferation and accessibility of addictive psychiatric drugs hit the comic world hard, and their expansion would have a massive effect on the comedic landscape, as many comedians came to deal with substance abuse problems, and then, did what comedians do best: work it into their tight five.

Stand-up comedy as an art form is relatively young. With its roots tracing back to the “stump speech” of minstrel shows in the mid nineteenth century, stand-up as a distinct comedic form came into focus around the 1920s at the tail end of the vaudeville era, where short, comedic monologues served as interstitial acts between the over-the-top sketches typical of vaudeville.¹³ Early stand-ups like Jack Benny and Bob Hope defined the form, with their rapid fire one-liners and quick distinct bits forming the foundation of stand-up.

The snappy style of older stand-up serves as an interesting frame through which to consider the advent of mental health in comedy. The classic quick quippy style dominant from the 1930s through the 1950s was meant to lampoon a subject on a surface level rather than to deeply examine it. As such, just like with anything else, mental health issues were a punchline, and only the most visible instances of mental illness were highlighted, like suicide, nervous breakdowns, and being plain “crazy.” Serious discussions of mental health were regarded as taboo by many, let alone the glib approach of comedy. 

During the 1960s, comedy began to take on a more narrative tone, with stand-ups increasingly eschewing the speedy one-liners of their predecessors, instead opting to tell stories. Such stories ranged from the flippant observational comedy like that of Phyllis Diller, the biting political satire of those like Tom Lehrer, and the irreverent counterculture comedy of stand-ups like Lenny Bruce and the aforementioned Carlin. Shifts toward narrative comedy allowed stand-ups to talk more about their own life in a more candid way, and tackle more complex and difficult topics like race, gender, politics,  and of course, mental health. Comedy increasingly became an outlet for malcontents from a variety of backgrounds with different axes to grind, many of whom had an ax to grind with their own mind.¹⁴ The rise of narrative styles, coupled with the greater societal visibility that deinstitutionalization created and the use of new psychotropic medications to help mitigate the most severe of mental health challenges, all made for a new freedom for comics to discuss mental health in their routines.

As the twentieth century came and went, the new millennium offered similarly new horizons for comedy. The explosive growth of the internet and subsequent meteoric rise of social media highlighted a critical aspect of comedy that would drive the approach of humor to mental health. Relatabilty became the bread-and-butter of comedy and mental health, audiences responding to honest, candid discussions of issues that so many people face. This era, beginning in the late 2000s and early 2010s is the golden age of mental health in comedy, and while the frequency and way it is discussed has certainly changed, many of the issues at hand are timeless.

While many of the issues that affected the growth and development of stand-up likewise affected film and television, the way these shifts manifested between the two was markedly different. Despite a handful notable exceptions, portrayals of mental health in media more broadly shied away from the comedic, and tended towards a sensationalized, usually melodramatic frame, and used a remarkably consistent thematic language in their approach.

For over a hundred years, the asylum was synonymous with mental health. Psychiatric institutions’ role as the backdrop for nearly all mental health care for such a long time made it a popular setting for various types of narratives, comic and dramatic. Very often in media, the asylum is portrayed as a severe, cruel landscape, and dramatic portrayal dominate the popular depictions of the asylum, with movies like One Flew Over the Cuckoo’s Nest typifying perceptions of the asylum. Comparatively few comedies take place in the asylum setting, which owes to the general historical trend of the highest profile depictions of mental health being dramas, a trend that has only begun to wane slightly in recent years. 

Comedic films about mental health have a smaller imprint on film and television culture. One of the aforementioned notable exceptions above is 1936’s Modern Times, a Charlie Chaplin film that sees his character suffer a nervous breakdown from the stress of his work, and bounce around various institutions to manage him (all while hilarity ensues, of course).¹⁶ Of the comedies that do take place in or feature asylums (1950’s Harvey and 1982’s The King of Comedy being good examples), they typically portray a more narrow set of mental health issues, notably delusions and hallucinations, and rarely more “invisible” mental issues like depression and anxiety.

Much like the trends seen in stand-up, depictions of mental health are far more frequent, honest, and in-depth in the modern day. Visual mediums in particular have made frequent and effective use of the “dramady,” “tragicomedy,” or “black comedy,” styles that mix tragic, heavy, or taboo issues with comic elements. Mixed comedic and dramatic styles became quite popular to use to depict mental health, and fit well tonally for many creators.¹⁷ Between these two major branches of comedy, a wide array of themes that they have considered come to light, but a few stand out as some of the most enduring.

As a microcosm of the human experience, nearly every disorder, illness, struggle, challenge, etc, has undoubtedly been covered by a comedian. While there are so many avenues, angles, and actual issues to cover, three general areas tend to stick out in depictions of mental health in comedy: substance use and abuse, stress and trauma, and depression, anxiety and suicide. Each comes with its own unique approach, and are worth dissecting a bit. As will become clear, the depictions of these issues became more realistic as mental health became more visible in society, and as less people were institutionalized and more were medicated, mental health issues were more frequently seen, experienced, and interpreted by comics.

Perhaps the single most commonly discussed mental health issue in comedy is almost not a mental health issue to begin with. Substance abuse, while not itself a mental health issue, is very often indicative of other underlying problems. The frequency at which substance abuse is discussed in a humorous context warrants a closer look at how substance abuse has been examined in comedy. As Carlin noted earlier, many of the problems with substance abuse stem from the expansion of psychiatric meds that came along with deinstitutionalization. Those medications were easily given to people who needed it, but many of those same people developed an addiction to those substances, overmedicating or self-medicating to cope with their mental illness.

Others used entirely illicit substances–some began with legal medications, and moved to illegal drugs when legal ones became unavailable or ineffective. Richard Pryor recounts his experience with crack cocaine and how he had used it to cope, and describes his experience hiding his crack problem from a friend, and the allure of the pipe that he uses and how it “talks” to him.

Outside of the world of stand-up, television has also tackled substance abuse to varying degrees of humor and authenticity, often opting for a hybrid “dramady” approach as mentioned earlier. These examples tend modern, as good comedic portrayals of substance abuse become more sparse further back. The medical drama House M.D. features a diagnostic savant in the titular Dr. House, who has a severe Vicodin addiction. While the show is predominantly a drama, its comedic elements frequently revolve around the sardonic wit of House, and the hijinks that his substance abuse often gets him into.²¹

Post traumatic stress is a curiously common depiction in comedy. The 1980 movie Airplane! sees its main character suffer flashbacks to “the war” and suffers a “drinking problem” as a result. At the time near its release, post traumatic stress was still stigmatized, and thought to only affect soldiers and others caught in war. This levity surrounding such trauma may well represent a disregarding of stress disorders as serious issues, but made possible by the greater visibility of the afflicted due to a lack of supporting psychiatric institutions.

George Carlin similarly speaks on the issue of post traumatic stress, and laments the euphemism creep of traumatic stress, reasoning that the “softening of language” that developed with stress disorders prevented adequate help for its sufferers.

Generational trauma, and the effect that it has on mental health has become an increasingly common topic in comedy in recent times. Bojack Horseman, an animated sitcom that has garnered critical acclaim for its depictions of mental health, follows the titular Bojack, an anthropomorphic horse who is a washed up sitcom star from the 90s, and deals with his personal relationships as he abuses substances in a self destructive pattern in an effort to self medicate severe depressive tendencies. Both Bojack himself and his close friend Diane in particular struggle with generational trauma, with Bojack suffering through an abusive childhood at the hands of his parents and turning to drugs and alcohol to cope, and Diane being relentlessly bullied by her family turns to writing as a way to make “something good” out of her trauma.

Perhaps the most common way that comedy talks about mental health is about suicide, and as an extension, major depression. Jokes about depression and suicide are some of the oldest ways mental health was confronted, as suicide in particular was a very visible issue of mental health and regarded with little complexity, making it comparatively easy to quip about.  

Like Hope, comedians like Bob Newhart confronted issues of suicide with a bit more tact, but were still rather glib with their depictions. In his 1960 “Ledge Psychology” routine, he employs his classic one-man dialogue style to recount a fictional encounter with a suicidal man on the edge of the building, with him variably encouraging the man to return from the ledge, or to go on and jump off.

Modern depictions of depression are far more in depth than the quips of the past, and focus on the everyday struggles of living with depression, a feat made possible in part by medications like Prozac and other antidepressants that many struggling comics may take.

All things considered, this is a narrow look at the constellation of depictions of mental health in comedy, and of course media in general. Not only is mental health depicted in comedy far more frequently than ever before, but it is also done more widely than ever before; increasingly popular comedic mediums like internet memes warrant an entire conversation of its own. Counting passing references, starting from the early days of stand up comedy and considering the menagerie of mental health issues included in the DSM-V, trying to cover that all here would be a fools errand.

It is because of the seismic shift in mental health care that deinstitutionalization and psychiatric medication created that there are nearly this many examples to choose from. Without their influence, it is not impossible to imagine a world most comics still only tell their one liners, and audiences are never treated to candid explorations of deeper struggles, not unlike other taboo subjects in comedy are treated nowadays.

Comedy is a fluid art form, one that is very sensitive to the temperature of society at large. Just as much as it is a product of societal attitudes, so too can it move the needle of acceptance and understanding. It is also a process of coping, and healing, and dealing with some of the most intractable issues one can face. Comedy is one of humanity’s most powerful tools for these things and more, and understanding its relationship with our mind and how that relationship has grown and changed is one of the best ways to keep on laughing and smiling our way through the day.

That’s all, folks.

1. Kimberly Senior, dir., Chris Gethard: Career Suicide. HBO, 2017.
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2. Anthony McCartney, “Coroner: Sleep Apnea Among Causes Of Carrie Fisher’s Death,” The Associated Press, June 16, 2017. https://tinyurl.com/yh9rpvn2 ︎
3. Daniel Kreps, “Carrie Fisher’s Ashes Placed in Giant Prozac Pill Urn,” Rolling Stone, January 7, 2017, https://tinyurl.com/4zdn9bzr ︎
4. Carrie Fisher, Wishful Drinking (New York: Simon & Schuster, 2008). ︎
5. Ibid. ︎
6. Gerald N. Grob, Mad Among Us: A History of the Care of America’s Mentally Ill (Cambridge, MA: Harvard University Press, 1994). ︎
7. Nellie Bly, Ten Days in a Mad House; Or, Nellie Bly’s Experience on Blackwell’s Island (New York: Norman L. Munroe, 1877). ︎
8. George W. Paulson, Closing the Asylums: Causes and Consequences of the Deinstitutionalization Movement (Jefferson, N.C: McFarland & Co., 2012). ︎
9. Spike Lee, dir., Katt Williams: Priceless: Afterlife, HBO, 2014. ︎
10. Andrea Tone, The Age of Anxiety: A History of America’s Turbulent Affair with Tranquilizers (New York: Basic Books, 2008). ︎
11. George Carlin, “Drugs, ” Side one, track four on FM & AM, 1972. Youtube. ︎
12. Bob Odenkirk. “Bob Odenkirk: ‘All People Are Sad Clowns. That’s The Key To Comedy,’” interview by Rebecca Nicholson, The Guardian, April 15, 2017. https://tinyurl.com/42tzryz8 ︎
13. Wayne Federman, The History of Stand-Up: From Mark Twain to Dave Chappelle. (Independently Published, 2021). ︎
14. Rebecca Kreifting, All Joking Aside: American Humor and its Discontents (Baltimore: John Hopkins University Press, 2014). ︎
15. Bojack Horseman, season 2, episode 1, “Brand New Couch,” directed by Amy Winfrey, written by Raphael Bob-Waksberg, aired July 17, 2015, https://www.netflix.com/80048076, 00:16:48.  ︎
16. Chaplin, Charlie, dir. Modern Times. 1936; Los Angeles, United Artists. ︎
17. Olga Khazan, “The Dark Psychology of Being a Good Comedian.” The Atlantic, February 27, 2014. https://tinyurl.com/5b33kyju. ︎
18. E. B. White and Katharine S. White. “The Preaching Humorist” in The Saturday Review of Literature (October 18, 1941): 16. ︎
19. Alex Timbers, dir., John Mulaney: Baby J, Netflix, 2023. https://www.netflix.com/title/81619082. ︎
20. Joe Layton, dir., Richard Pryor: Live on the Sunset Strip, Self produced, 1982. ︎
21. David Shore, House, M.D., Universal Televison, 2004. ︎
22. David Zucker and Jerry Zucker, dir. Airplane!. 1980; Los Angeles, CA: Paramount Pictures. ︎
23. Rocco Urbisci, George Carlin: Doin’ It Again, HBO, 1990. ︎
24. Bojack Horseman, season 6, episode 10, “Good Damage,” directed by James Bowman, written by Raphael Bob-Waksberg and Joanna Calo, aired January 30, 2020, https://www.netflix.com/81026968, 00:16:30. ︎