Transcript [00:00] - The following is a conversation with Andrew Scull, a historian of [00:03] psychiatry and mental health. He has authored many books that I [00:07] highly recommend including Madness in Civilization: [00:11] A Cultural History of Insanity from the Bible to Freud, from [00:15] the Madhouse to Modern Medicine and Desperate Remedies: [00:20] Psychiatry's Turbulent Quest to Cure Mental Illness. [00:24] Andrew Scull has spent decades studying how societies have understood [00:28] madness, how psychiatry rose to authority, and how often [00:32] that authority was used with false confidence and catastrophic [00:35] consequences. In this conversation we'll trace the long arc from the [00:39] asylum era to eugenics, from lobotomy and insulin coma [00:43] therapy to electroconvulsive therapy, psychoanalysis, [00:47] antipsychotics, antidepressants and the modern crisis [00:51] of mental health. It is in part a story about the [00:55] terrifying history of bad ideas in medicine but it is [00:59] also about the fascinating mystery of the human mind and [01:03] about the difficult journey to understand it. [01:06] This is a Lex Fridman podcast. To support it please check out our sponsors in the [01:09] description where you can also find links to contact me, ask [01:13] questions, give feedback and so on. And now dear friends here's Andrew Scull. [01:20] Is it fair to characterize your view on psychiatry and mental illness [01:26] as that there's a crisis in modern psychiatry? We have made some progress- [01:30] - Yes [01:31] - ... over the past century but mostly we still are not good at treating [01:35] mental illness either via the drugs or talk therapy meaning psychopharmacology or [01:42] psychotherapy or as you put it the brain or the mind route. [01:48] So let's start at the end of our story. Let's start at where we [01:52] stand before we go into the rich history that you so eloquently write about. [01:56] - So psychiatry is a profession that tries to [02:00] deal with an enormously complicated thing. The [02:06] human mind, the human emotions, the human ability to attempt to understand the world [02:13] and in particular obviously it focuses on people where [02:19] our common sense approach to the world seems to break down. [02:24] People whose emotional life is filled with turmoil, [02:28] people whose ability to relate to others is badly [02:32] damaged, people who see things in the world that the rest of [02:36] us simply think aren't there. They're illusions, [02:40] they're hallucinations, they're delusions and this is a subject that has [02:47] occupied some very clever minds over the years [02:51] and there's no question that in the course of at least the last three quarters of a [02:58] century there has been some limited [03:01] progress in dealing with the problems that mental illness creates. Some of that is [03:09] confined to the milder forms of mental distress; [03:13] the more serious forms of psychosis and [03:16] breakdown of emotional control those are areas where I think [03:21] again there's been some progress but it's easy to overstate how much [03:25] of that there's been. As we'll see probably later in our conversation today the [03:31] advent of modern psychopharmacology which [03:35] occurred in the early nineteen fifties was a serendipitous [03:38] event. It wasn't planned for. It happened almost by accident [03:43] and it did mark in some ways an advance over some [03:47] of the things that psychiatry had engaged in before that [03:51] and no question for some people that revolution and a parallel revolution [03:59] in the psychotherapeutic realm have [04:02] created some advance for patients and we should not [04:06] minimize that. What we have available to us [04:10] are symptomatic treatments not cures. We don't have [04:14] a psychiatric penicillin for any of the conditions we're [04:18] gonna be talking about. That doesn't mean we can't do some things that [04:22] help but the help is quite limited and it's important to understand [04:28] both the ways in which we have progressed and the [04:32] limits of that progress and also to understand that when we treat something [04:40] sometimes we create new problems what we call [04:44] iatrogenic problems, things caused by the interventions that we use. [04:50] That's true of some psychotherapeutic interventions and [04:54] most certainly true of the drugs we use to treat mental illness these days. [04:58] So for example in treating PTSD we often get patients to confront [05:06] the episode -- the trauma which provoked their distress and that is [05:14] often a very, very fraught process and for many [05:17] patients it actually makes things worse. For some patients it makes them better. [05:23] So that's a situation where you could see problems [05:27] With both antipsychotics and antidepressants, the two [05:31] main classes of psychotropic drugs that we use, um, they're at best partially [05:39] effective and they don't work for a [05:43] significant fraction of patients who are given them and one of the big [05:46] problems psychiatry faces is that [05:51] psychiatrists don't know in advance who's going to respond well [05:55] to the drugs, who's going to respond badly, [05:59] for which group of patients in the middle the side effects and [06:03] the main effects, if that's what we want to call them, the therapeutic effect [06:07] are finely balanced and making those judgment calls about what to do [06:12] are very, very difficult. Now in terms of the [06:16] crisis psychiatry faces at the moment as I see it there are [06:23] a number of strands that point to this. Psychiatry's diagnostic system, [06:29] that is still used -- I mean, the fundamental basis of, [06:33] of psychiatric diagnosis today was really first formulated in 1980 with the third [06:40] edition of The Diagnostic and Statistical Manual of a profession -- [06:44] - DSM-III [06:45] - ... DSM-III and then there's been DSM-III-R, DSM-IV, DSM-IV-TR, and now DSM [06:53] 5. Finally not with a Roman numeral but with [06:57] with an Arabic numeral. So they thought with DSM [07:01] 5 when they needed to modify it it would be like a piece of [07:04] software. You have Windows 10, Windows 11, and [07:08] so on right? Now that diagnostic system [07:13] came into being because psychiatrists had a very hard time [07:16] agreeing with one another about what was wrong with somebody, and that [07:20] became embarrassingly clear in -- first in the professional [07:24] literature which outsiders didn't read and then via a [07:28] very famous study that's a scientific fraud by David [07:32] Rosenhan called On Being Sane in Insane Places where he [07:36] claimed to have sent in pseudo patients to the hospital [07:40] and they all were diagnosed as schizo. All but one of them diagnosed as [07:44] schizophrenic the other as somebody with bipolar disorder and they [07:47] were fake patients. So almost in a panic after [07:51] that study appeared in Science and because [07:55] there was an abundant professional literature from the [07:58] 1960s showing the same thing that diagnosis was a very erratic process. [08:05] The DSM-III task force led by Robert Spitzer who was then at Columbia [08:10] was explicitly set up to try to create a sort of tick the [08:14] boxes approach to deciding which box a [08:18] patient belonged in. Were you schizophrenic? Were you this type of [08:22] schizophrenic or that type of schizophrenic? Were you [08:25] manic depressive or bipolar? Did you have various forms of depression? [08:32] And to construct those boxes what they relied upon was a list of symptoms and if [08:39] you had more than a certain number If you had more than [08:43] six of ten Six or ten or more symptoms of a certain sort [08:49] you could be diagnosed with major depression for example. So that [08:53] system came into being. It was partially embedded [08:58] because it appealed to drug companies who were developing [09:02] drugs to treat these various disorders. [09:06] It appealed to insurance companies 'cause it gave them a stable base to look at. [09:11] It appealed to, as diagnosis always does to patients and their families who are [09:18] scrambling to deal with these enormous upsets in the mental life of either [09:25] themselves or a family member. [09:28] So provided some sense of certainty around diagnosis. [09:33] But that was always based simply on symptoms in the way an eighteenth [09:36] century doctor might diagnose dropsy or diagnose, [09:41] Some other kind of disor--- Fever for example well [09:46] fever and other diseases they talked about in the eighteenth [09:50] century are really a constellation of very different things under one label. [09:55] And I think that's what is turning out to be true of the [09:59] DSM labels. But that approach [10:03] was really all that psychiatry could come up with if it [10:07] wanted to make sure whether you were in Walla Walla or New York or [10:11] San Francisco or Atlanta you reached the same conclusion faced [10:15] by the same patient. That you had a reliable diagnostic system. [10:21] That didn't mean necessarily it was a valid diagnostic system if you [10:24] understand the distinction between validity and [10:28] reliability. Reliability means you and I faced with the [10:32] same sets of facts reach the same conclusion but [10:36] that conclusion may or may not reflect the [10:39] underlying reality of things right? So you had this [10:43] diagnostic system and it went through various [10:47] iterations each time it went through an iteration the number [10:51] of possible psychiatric disorders you could get grew and grew and grew and it [10:59] became difficult to believe in some of those categories shall [11:03] we say. That they were really illnesses rather [11:07] th-than some sorta social construct. But beyond that um, [11:13] psychiatrists wanted to be more like other medical doctors to root [11:20] their diagnoses in an understanding of the underlying [11:24] pathology of the disorder. What was it that caused [11:27] people to become schizophrenic? The sense was [11:31] if we could grasp that we'd have a better handle on how to attack it How [11:35] To treat it. And when uh, DSM-5 was mooted the fifth edition in the early 2000s [11:46] NIMH then under the leadership of Steven Hyman who's at [11:49] Harvard now and succeeded by Thomas Insel [11:54] who ruled NIMH for about thirteen years. The [11:58] two of them had pushed psychiatry and psychiatric [12:02] research in a very particular direction. [12:06] On the one hand, towards understanding the genetics of mental illness, [12:12] and on the other, to looking at what the new discipline of neuroscience could [12:18] contribute to understanding things. Both of them were heavily invested [12:22] in the idea that mental illness was brain disease. [12:28] And if it was brain disease, then the question was what was making the [12:32] mechanism here go awry? What was [12:35] causing people's emotions or their cognitive skills or [12:39] their sense of the world to become so disordered? [12:44] And they invested a lot of money in that approach. When Insel stepped [12:48] down, he gave an interview actually to somebody at MIT [12:52] and he's repeated it since in a book he wrote about his experiences [12:56] where he said, "Well, you know, as I look back on my 13 years, [13:01] I funded an enormous amount of scientific... really cool scientific research. [13:06] I funded geneticists and I funded neuroscientists and [13:10] we-- they did a lot of really interesting science." [13:14] And after spending 20 billion dollars, the lot of the [13:17] mentally ill has improved not one bit right?" [13:22] Which was a pretty devastating statement, I thought. [13:25] - And NIMH is National Institute of Mental Health. [13:27] - National Institute of Mental Health, yes. I shouldn't resort to jargon. [13:32] But the National Institute of Mental Health had been founded in the late [13:36] 1940s with the goal of improving, doing basic research training people in the field [13:43] advancing the care of the mentally ill and producing obviously [13:47] cures and advances. Uh, and its mission has varied widely [13:54] over the years since but starting in the [13:58] in the-- in the 1990s—the period when the first George Bush [14:02] declared the decade of the brain—uh, NIMH [14:06] increasingly focused on the idea that mental illness was purely a [14:10] brain disease and there's something to that and there's also some [14:13] mistake in thinking about it that way. [14:15] - This is, by the way, as we will talk about this distinction [14:19] between seeing mental health, the maladies of the human mind, [14:24] as a problem of the brain, like neurobiology, neuroscience, versus [14:28] the problem of the mind, which is more in the cognitive, psychotherapy, these more, [14:34] less amenable to scientific rigor. So I think what's [14:38] appealing about studying the brain and neurobiology, neurosciences, there's [14:42] data. Yes. It's more rigorous. You can do science. [14:45] - It’s the kind of thing that really appealed to medical school deans because [14:51] once NIH and the drug companies too were funding basic research on [14:57] neurobiology and basic research on genetics, the money flooded in. Um, and [15:05] psychiatry, which had been something of an orphan, became much more popular, [15:09] - and we should say that this is something you write a lot about. There are all these factors to [15:13] consider. So there's cultural elements, political, public policy elements. Then at [15:19] a certain point, drug companies, insurance companies come in, of course. [15:25] all human beings around somebody who's [15:29] suffering with a mental health issue, so family factors, that's connected, cultural stuff. [15:35] - it's a very complicated area and oversimplification is a real problem I think. [15:43] Uh, and I think even that dichotomy you just drew between, um, the [15:50] brain and the social or psychological, some mix of those things, [15:55] I think in some ways that's a category mistake, that's a mistaken way of looking at the [15:59] world, because the brain you have today, you're not born with. Human [16:07] brains are remarkably plastic things. They develop in response to the [16:11] environment. Social, psychological are embedded in our brains. [16:18] Rigid separation, saying one or the other—no. Abundant evidence from [16:26] epidemiology that social factors play an important role in the development of illness. [16:33] - Nevertheless, history of psychotherapy, for example, subfields... [16:39] human mind is complicated, all these factors. To say anything [16:46] helpful, you have to simplify. Freud famously simplified a lot towards a particular view of the human [16:53] mind. That simplification, actually, we'll talk about if it's correct [17:01] in a deeper sense, was productive. [17:04] - Yes. In fact, whenever you're trying to deal with a very complicated set of issues, [17:12] you have to simplify. You have to make heuristic [17:16] decisions about what you're going to neglect and what you're gonna [17:20] emphasize. But what I'm trying to say, well, you asked me about the crisis in psychiatry, [17:28] and the simplest way for me to encapsulate the issue and the [17:33] problem as I see it that's arisen—one of the problems—is a quote by Leon [17:40] Eisenberg, who had a very long career at Harvard, and Eisenberg [17:46] said towards the end of his career, he said, "When I entered [17:50] psychiatry, it was brainless psychiatry, leaving it mindless psychiatry." Yeah, [17:57] sums up the way the field to a large degree has moved. [18:04] In the process, insights are lost, though in other ways, things are being gained. Um, [18:13] Freudians tended to neglect the biological, to suggest the brain [18:18] as a biological organism was not something we needed to [18:22] worry about. We worried at the level of a [18:26] psychological model of how our minds work. And all too often, [18:34] not exclusively because some of the psychiatrists I'm friends with [18:38] are very sophisticated men and women and do grasp that you can't move in these [18:47] bipolar directions. You've got to meet somewhere in the middle. [18:51] But that sort of got lost, I think, in all the enthusiasm for [18:58] neuroscience. I mean, when antipsychotic drugs were discovered [19:02] in the early 1950s, we had no clue of how they worked. And one of the things [19:09] that they helped us spawn as people began to say, "Well, [19:13] why did these drugs work? What did they do?" [19:17] Was to begin to understand that the brain wasn't just a set of [19:20] electrical signals, as had been thought in the first half of the 20th [19:24] century and before. But rather there was this very [19:28] interesting chemical soup running around in our brains with [19:32] neurotransmitters that help the brain work the way it did [19:35] and perhaps explained why it went awry. [19:40] So it was one of the many factors that gave rise to neuroscience. The [19:43] first neuroscience conventions were in the 1970s, and they attracted a [19:47] few hundred people. Now it's tens of thousands of [19:51] neuroscientists. It's a huge enterprise. So [19:55] diagnosis has come under threat. The categories that [19:59] we have all become familiar with, that we're told are real [20:03] diseases like bipolar disorder, schizophrenia, major depression, [20:08] are beginning to falter, and we're beginning to [20:12] worry about whether those diagnoses are real [20:16] ways of thinking about the world and may in fact mislead us. [20:20] Because if we think there's something called schizophrenia or the [20:23] schizophrenias, as the inventor of that term put it, if we think [20:27] there's something like that and we try to research where it [20:31] comes from, but that's not really what's going on, obviously we're probably [20:37] gonna not make the progress we could be making if we had a better [20:41] diagnostic system. And that's what [20:43] DSM-V thought it was gonna be able to do and discovered [20:47] it couldn't. So it stayed basically with the symptomatic approach. [20:51] - If we can just really brief - [20:53] I would love to talk a little bit more about the DSM, but just to give a history [20:57] here, looking it up on Perplexity, DSM One in 1952 was a 32 page pamphlet- [21:04] with 106 diagnoses heavily influenced by psychodynamic concepts- [21:10] and etiology using broad, often vague categories like reactions. [21:14] DSM Two in 1968 expanded to 185 diagnoses still psychodynamically [21:21] flavored and reliability poor, but added more attention [21:25] to childhood disorders and later removed homosexuality as a disorder in [21:29] 1974 printing. Then to the revolution, as you [21:33] mentioned, the DSM Three in 1980 introduced explicit [21:37] symptom-based diagnostic criteria, a multi [21:40] axial assessment system, and an officially [21:44] atheoretical stance about causes aiming to improve reliability and research utility. [21:49] And then DSM Three R in 1987 revised criterion [21:53] expanded to around two 97 diagnoses. DSM Four in '94 and DSM Four TR in [22:01] 2000 focused on literature driven empirical revisions,- [22:06] added and deleted some disorders increased coordination with [22:10] ICD 10 and goes on. And then finally in 2013 DSM Five came [22:17] out which eliminated the multiaxial system [22:21] integrated most information into a single nonaxial [22:24] diagnostic list than separate notations for psychological and medical [22:28] factors. It reorganized chapters e.g. [22:32] Neurodevelopmental, obsessive-compulsive related, trauma and [22:36] stress related disorders introduce new and refined entities and so [22:40] on. But big picture trajectory conceptually the DSM moved from cause focused and [22:49] psychoanalytical to symptom-based, theoretical, and reliability driven [22:56] over time. There has been growth in the number of granularity of categories [23:00] closer alignment with ICD ongoing controversy [23:04] over medicalization, validity, and the balance between [23:07] categorical and dimensional approaches. Yes. It [23:11] feels like that description doesn't necessarily fully get to the [23:15] core of why the DSM five doesn't quite get the full scope of the problem [23:22] - You invest a ton of money. You invest- [23:26] ...$20 billion-- More than $20 billion in a particular approach. [23:30] And at the time you're constructing this, you say, "Finally, [23:34] because of all the work that's being done in genetics, we now have [23:38] decoded the human genome. [23:40] We have PCR so we can chop it up and we can look at bits of it. We have a lot more [23:48] understanding of the role of neurotransmission in the brain. [23:54] Surely we're going to be able to recast our diagnostic system [24:00] based on underlying pathology so that we won't be [24:04] worrying about symptoms anymore. We'll be looking at the actual [24:08] underlying pathological changes that have taken place. [24:12] But in the event, it turned out they couldn't do that. By about [24:16] 2008, they had thrown up their hands and said, "No, we're going [24:20] to have to continue to refine, [24:24] rely upon the same basic approach that we developed in 1980." And [24:31] when that document came out, and there'd been a lot of criticism, some of it from [24:38] Robert Spitzer, who had been largely in control of DSM-III and DSM-III-R, and then [24:45] his successor Allen Frances, who'd run DSM-IV, [24:50] they both were fiercely critical about what was going on and said it was [24:54] being done in the dark and it was done in secrecy and it wasn't scientific. [24:58] And when it was about to come out, [25:01] Thomas Insel and Steven Hyman, the two then existing and the [25:05] preceding director of the National Institute of Mental Health, denounced the [25:08] document as unscientific and useless. [25:12] So if you're talking about a crisis, that's a crisis for the field. If its [25:16] diagnostic system is being dissed by leading figures like that, [25:22] What else was a problem? The difficulties with the drug existing [25:28] therapies, particularly, had become more and more manifest. [25:33] To make matters worse, partly because Big Pharma had sometimes behaved, [25:42] shall we say, rather unethically sometimes with these drugs, it had hidden things [25:49] that undercut their claims. It had manufactured studies. It had manipulated data. [25:59] And it got caught out, and it paid billions of dollars in damages [26:02] for some of the tricks it had got up to. [26:06] Not just in psychiatry—I mean Vioxx, for example, the [26:10] painkiller, was another huge scandal, and it was a $5 billion [26:13] settlement. But the drug companies had [26:17] suffered some reputational damage. Beyond that, they didn't [26:21] have any real clues. Unfortunately, neuroscience hadn't thrown up new [26:25] targets for different forms of drug development [26:29] And they decided they could make more money with spending their money on [26:33] research on other diseases, not mental illness [26:37] A crisis was you were stuck with a set of drugs that Steve Hyman [26:41] says, "Aren't really any advance on the ones by [26:45] accident we found in the fifties. Mm-hmm. And [26:48] there isn't new research unless it's small startups going [26:52] on to develop new ones, so you have an increasing sense [26:57] Your diagnostic process is falling apart, your drug treatments' limitations are becoming [27:07] more manifest and, um, as well for people [27:14] with serious mental illness. Public policy has screwed things up badly. [27:19] So if you, a person with serious mental illness, you will [27:26] die on average fifteen to twenty-five years before the rest of us. That [27:32] gap has been growing rather than diminishing. So, that's not a good [27:36] thing. It's not something I want to [27:38] lay entirely at the door of psychiatry. So don't get me wrong, I think a [27:43] lot of this is public policy that has really abandoned treatment for the seriously [27:50] mentally ill. And you see it on the streets of our cities. You [27:54] see the sidewalk psychotics. You see people who are [27:57] cycling between brief periods of inpatient care, uh, the gutter, or the flop [28:04] house and the jail. You so the three [28:07] largest centers of inpatient psychiatric care, if you can call it [28:11] that in the United States today are the Los Angeles [28:15] County Jail, Cook County Jail in Chicago, and Rikers Island in New [28:20] York, that's shockingly, because by their very nature, of course, prisons aren't equipped to [28:26] deal with serious mental illness [28:29] - Some dark ways to return to the asylum era. [28:32] - Yeah, well, you know, the asylums had acquired a very bad reputation, and I've written about some [28:39] of the reasons why that happened, but when [28:42] asylums were founded, it was a period of enormous optimism that we were going to be able to cure these [28:49] people that we would rescue them from attics and from jail cells, and through providing a [28:56] therapeutic environment, coaxing them to [28:58] work, creating a system where they learn to control themselves, not necessarily to drive [29:06] their demons out, but to keep them under some sort of wraps. The expectation was when the [29:12] asylums came along is that they'd not [29:14] only rescue people from horrendous conditions in the prisons and [29:18] the jails, but they'd actively cure them and [29:22] the earliest alienists, as they called themselves then, thought that [29:28] they could cure 60, 70, 80 percent, maybe even more of patients, as long as they came in early. [29:35] And really, asylums were built out of that sense. [29:39] of optimism, that sense that we, you know, that so much was environmental and so much was [29:46] Not exacerbating the condition by treating people like animals or treating them, you know. [29:52] Beating them and in other ways horrifically maltreating them, that would create, um, a sense of [30:00] Cure and really that underlay the construction of the asylums and [30:06] Now having abandoned the asylums, which we did starting a little bit in the 1950s but really the late 1960s onwards, uh. [30:16] That was because there was going to be something miraculous called community care, but [30:21] Community care is a shell game without a pee. It's like one o' those. [30:25] confidence tricks. There were no substitute community facilities for dealing with [30:33] the really serious mentally ill. [30:35] - So now we're in this truly, in, in this crisis- [30:38] ... in this essentially dark ages. And in part [30:42] I think our conversation, our journey through the history of psychiatry- [30:47] ... is an exploration of some [30:51] gigantic mistakes but also an exploration of where lay some [30:55] hope for the future. So we'll talk quite a bit about this. I [30:59] was wondering if you can also just lay out [31:02] what are the big categories of mental illness that we're referring to. You've [31:06] already hinted at them, but like levels of seriousness- [31:11] ... and the categories of illness- [31:13] ... like with psychosis and depression and so on. [31:16] - So going back to the early 20th century was when the German psychiatrist Emil [31:23] Kraepelin working with thousands of records in German asylums [31:29] inductively developed a distinction between two very [31:32] broad categories of mental illness. [31:36] One he called dementia praecox or early dementia, [31:40] and the other he called manic depressive illness which was a more remitting [31:44] illness that sometimes went away entirely, [31:47] other times went back and forth whereas dementia praecox was a one way ticket down. [31:55] Now that label was transformed by a Swiss psychiatrist Bleuler [32:02] into the term we use today schizophrenia although [32:06] Bleuler talked about the schizophrenias because he thought [32:10] under that broad label there were a diverse group of things running around. [32:16] And I think that was an important insight that tends to get lost [32:20] sometimes. This was jamming together people [32:24] with very serious psychosis, that is people who'd lost touch [32:28] with we liked-- what we like to think of as reality, [32:32] whose emotional and cognitive lives were in total turmoil, [32:37] Who were -- who lost the ability to connect [32:41] with other human beings. So their social skills [32:45] atrophied, their-- Well, this is something contemporary [32:48] psychiatrists would refer to as the positive and negative symptoms of schizophrenia. [32:53] - But underlying the definition of schizophrenia here is a [32:57] detachment from reality. So you're hearing voices- ... you're seeing visions. [33:01] - You're thinking people are plotting against you. You think the [33:05] television is talking directly to you. [33:08] - And because of that it has these consequences of how you're [33:11] connected to the rest of the world and what your emotional life is like, all that kind of stuff. [33:15] - Yes. Your emotional life flattens out. Your language capacity [33:19] deteriorates. Your ability to relate to other people [33:24] either vanishes or becomes caught up in the web of [33:27] delusions where you think people around you are plotting [33:31] against you or doing terrible things to you. [33:33] - And is that a different world than the world of bipolar and the world of [33:37] depression? [33:38] - Yes. The Greeks recognized and the Romans, ancient Greece and [33:42] ancient Rome recognized different forms of insanity as they called it. [33:47] So melancholia [33:49] would have been the term the Greeks and the Romans would have used and it [33:53] survived and was very much around. And I think that is a form of [34:01] depression. What's happened now is major depression has become a catchall category. [34:07] So it embraces both what we might think of as milder forms of emotional distress [34:15] along with what melancholia referred to which was really [34:20] a kind of depression that had psychotic features. This loss of [34:24] contact as it were with everyday reality. [34:28] - Something you would talk about maybe like a clinical depression. And by the way, we [34:32] should mention that this field in the 21st century is like a minefield. [34:37] - Yes, very much so. So here's a very strange bit of historical record. The other [34:43] distinction and the distinction we're grappling with so we [34:47] have people who are-- whose depression is of such a scale they're [34:51] threatening to do away with themselves. They've retreated [34:55] into complete almost immobility. They're [34:59] overwhelmed by senses of sadness and loss and [35:02] they're-- If they're religious then they're damned to hell and all those [35:06] kinds of things. So we have this psychosis [35:11] that we've been talking about. We have something also that the [35:14] ancients recognize: dementia; the loss really the loss [35:18] of our mind as it were. But then we also have [35:24] other kinds of disturbance of our mental faculties that generally [35:31] we think of as more minor but I don't want to make light of them [35:35] because often people suffer from these things genuinely [35:38] suffer pretty badly. But those things-- we in [35:42] the 20th and 21st centuries tend to talk about as neuroses [35:47] neurotic diseases, psychotic diseases. In the 19th century neurosis was a [35:53] term that meant things rooted in the brain as you can [35:57] see from the root of the word and psychosis was stuff that [36:02] came from the mind, the psyche. [36:04] And yet sometime in the late 19th century those things crossed over [36:09] and so when we talk in the present we do tend to distinguish between the core, [36:17] really the most severe forms of mental disorder, [36:20] ...which would include things like Alzheimer's disease [36:24] and other forms of dementia, would include [36:28] very serious depression, would include bipolar [36:32] disorder where people oscillate either have extreme mania so they're [36:37] they're not getting any sleep. They're talking at an extraordinary rate [36:41] Their behavior is very hard to tolerate, and they're exhausting [36:44] themselves, and they may even die from exhaustion if it's not controlled. [36:48] And very often that alternates with periods of [36:52] depression. So that was a category that was captured initially as, [36:59] Manic depressive illness and later on evolved into [37:03] bipolar disorder and then separating out depression [37:07] and major depression separately. But then there are a whole bunch of [37:11] other things like, for example, phobias. [37:15] People can't go outside because they find it too frightening. [37:19] Milder phobias: "I can't get in an airplane because it's gonna crash," [37:24] "I can't go to school because it's overwhelming for me." So school phobia [37:28] emerges as a diagnosis. A disorder that at first attracted Freud, hysteria. [37:35] - And now we should say you wrote a book on hysteria. [37:38] - Oh, I did indeed, yes. [37:38] - You mentioned ... I mean, hysteria, every classification we're [37:42] talking about has been used and abused by every [37:46] layer of society including institutions- [37:49] - Yes [37:49] - ...including just culturally the word hysteria applied to different races [37:55] disproportionately, to different, um- [37:58] - Genders particularly, yes, yes [37:59] - ...genders disproportionate- [38:00] So we're in this crisis of trying to figure out what to do with this super [38:04] complicated human mind- [38:05] - Yes [38:05] - ...and everybody is dogmatically creating [38:09] narratives that hold, take hold, and in so doing can lead to some abuses- [38:15] - Yes, they do. Yes, they do [38:16] - ...as you document. [38:17] - If you look back at the asylum era born in this period of intense [38:21] optimism, and then the claims to be able to cure these vast [38:25] numbers of patients were overblown. [38:28] Uh, I do believe the early asylums actually did good work and that some [38:32] patients did very well and recovered as a result of their stays. But what happened, [38:39] they weren't discharging 80% of their patients. They were discharging [38:42] 35 or 40% of their patients, and what that meant is every year left behind [38:49] were a batch of chronic patients, and then the next year you repeated it. And over [38:53] time, what that means is the ratio of new [38:57] patients to chronic patients gets worse and worse. [39:02] And more and more the image of the asylum is defined by the [39:05] chronic patient who hasn't recovered and maybe spends years or [39:09] decades there and only leaves in a pine box. So the image of the asylum declined [39:18] drastically. As they became more and more overcrowded, [39:21] conditions in them deteriorated. Patients were often [39:25] abused. Psychiatrists didn't know what to do with them, and they [39:29] faced a problem in the late 19th century. You'd promised 70% or 80% cures, [39:36] but we're not seeing that. In fact, when we calculate cures and the numbers of [39:40] people in the asylum, it's more like 10% or 12%. That's [39:44] the way you could play with statistics 'cause that's all the old patients [39:48] mixed with the new. But still, it looks very bad. How do you explain this doctor? [39:56] You've promised us one thing, and you delivered something quite different. The [40:00] answer came in a way of blaming the victim, in a way [40:04] of saying, "Well, you know, what we didn't understand [40:07] was that mental illness is a fundamentally biological [40:11] condition. These people are evolutionary [40:15] throwbacks." Evolution was generally thought of as a [40:18] progressive onwards and upwards, but these people had fallen back [40:22] into a lesser form of [40:26] existence. They'd lost their essential humanity because their brains were defective. [40:32] So what emerged then was the idea of degeneration, the idea that [40:39] these patients were degenerates. They were people with an inferior [40:42] biology. You couldn't release them because they breed like rabbits. They didn't [40:46] have any self-control because of their diminished humanity. [40:50] - This is the narrative. [40:52] - This is the narrative. And so what it did was provide a [40:56] justification for locking up people in asylums that wasn't therapeutic [41:00] at all. It was just keeping them out of the way. [41:02] - And then it led to the justification of sterilization- [41:05] - Exactly. [41:06] - ...based on the same argument. [41:07] - So maybe we can release them if we make sure they can't breed. [41:10] - This is the beginning of the darkness. [41:12] - It is the beginning of the darkness. My own state was [41:16] one of the pioneers in this process, and it [41:20] continued to sterilize mental patients up until about 1960. [41:24] - By the 1960s, over 60,000 sterilizations have been performed in the US with [41:32] California performing a disproportionately high number. [41:36] - That's correct. But even more serious [41:39] consequences could flow from these set of issues. [41:44] When you start talking, one British psychiatrist said that if his patients that [41:51] were coming into the asylum had been puppies, [41:57] we'd have tied them up in a sack because they were some horrible mongrel, not [42:01] a purebred dog, tied them up in a sack with some lead weights, and thrown them in a [42:04] pond and drowned them. [42:05] - Man. [42:06] - That kind of language is very, very dangerous. [42:11] And what happened, California's law surrounding [42:14] sterilization was advocated for in the West. By that I [42:18] mean North America and Britain and much of Europe. [42:23] There were enough checks and balances in a democratic system that even [42:27] though there were enthusiasts, the eugenicists who said, [42:31] "Best get rid of these people, put them to death," [42:35] that never really, that never really acquired mass support. [42:41] But what happened in Germany once Nazi-- the Nazis came to [42:44] power is they seized on these notions and that the idea [42:48] that the mentally ill were, as they put it, useless eaters, [42:52] people consuming resources but never gonna get better, just a burden on [42:56] the state. Their lives weren't worth living because after all, they had this [43:00] serious mental illness. So first you [43:03] sterilize, and then you go, "But we're still supporting all these [43:07] people." And so Hitler starts something called the T4 program [43:11] after the street name of the house where this was concocted, Tiergartenstraße 4. [43:18] And the mentally ill were the first people to suffer from the Final Solution. [43:25] It was in the mass killing of the mentally ill, which may have been as many as a [43:29] quarter million people, that the technology of the gas chamber was developed, [43:35] and the technology of disguising the [43:39] gas chamber as showers was developed. And so patients were taken away [43:47] to a number of psychiatric centers and systematically [43:51] put to death, and they had the crematoriums and the black [43:55] smoke, and local people talked about the buses that were bringing them in as [43:59] killing crates. So they were aware of what was going on. [44:02] - Were they influenced by the narratives that were born in the United States? [44:05] - Yes, absolutely. They- [44:06] - About this kind of- [44:07] - About that sort of thing, and lacking the check, the checks and [44:11] balances that at least until recently this country had, um, [44:16] it was relatively easy for Hitler [44:19] to do that. And particularly with the war looming, the idea [44:23] that we're gonna support all these useless people, let's kill [44:27] them. And German psychiatry for the most part collaborated with that process. [44:34] - I wonder how many people throughout that whole journey in the psychiatry profession [44:39] sort of were brave enough to speak up like, "Hey, maybe the [44:43] sack of puppies kinda language-" [44:46] - Oh, yes. Oh, yes. [44:46] - ... is a problem?" [44:48] - That's the really nasty direction that that language could lead to. [44:53] And it was symptomatic of the kind of [44:57] stigma that tends to attach itself to mental illness and this [45:01] sense of hopelessness. So but if you're a healing profession, [45:05] if, if you enter psychiatry thinking, [45:09] "I'm gonna do this to help people, to cure people, to make their lives better," [45:15] to just become a glorified boarding housekeeper keeping them under lock and key [45:21] or in the alternative to collaborate in this, in the sorts of [45:25] awfulness that the Nazis perpetrated, that's [45:28] something from which decent human beings [45:32] tend to recoil and decent psychiatrists tended to recoil. And so [45:38] still thinking as they did by the end of the 19th [45:41] century that mental illness was predominantly a biological problem, [45:49] some of them began to say, "Well, maybe biology as well as being the [45:53] problem could provide the solution. Maybe we should look for [45:57] ways to intervene in the biological systems of these people and make them better." [46:04] The same logic that applies I would say in the present- [46:08] ... for, for many working in the field. [46:10] - But in a cruder form. [46:11] - But in a very different form, exactly. [46:14] - Yeah. If, if we can just speak about the Nazis a bit more, you [46:18] highlight that America financially supported the German psychiatric [46:21] researchers with deep Nazi ties like Ernst Rudin who was [46:25] the key architect of Hitler's mass sterilization and extermination [46:29] laws. So it seems like the Nazis borrowed [46:33] the American narratives of the psychiatrist that these are lesser [46:37] biological beings and then this financial support and the ties continued. [46:42] - Yeah. So one of the organizations that [46:46] recognized that mental illness was an acute social problem, very costly to the state [46:54] inflicting all kinds of suffering on people was The Rockefeller Foundation. [47:00] What we don't realize today is that the [47:04] involvement of the federal government in medical research [47:08] and indeed scientific research is a World War II [47:11] and post-war development partly the Cold War and Sputnik and [47:15] all of that. But that's when big science and big medicine got funded- [47:21] ... in extravagant ways. Before the war, [47:25] science was an orphan. It didn't get money from the government much and [47:29] medicine even more so. So to the extent medical training was reformed, that was the [47:38] product of investment by The Rockefeller Foundation enormously wealthy [47:42] by the standards of the time. And come about 1930, [47:48] The Rockefeller Foundation decided it needed [47:52] to concentrate its resources and pick priorities for the money it was investing. [48:00] And it may seem a rather strange thing within the [48:04] whole range of medical areas that it could choose, [48:08] it chose psychiatry as the one that it was going to invest in. And [48:12] I think it did so in part for [48:16] precisely because scientific research in psychiatry was so backward, [48:22] partly because it was such a pressing public problem. [48:26] And partly, and this was less public but nonetheless I [48:30] think played an important role, several of the trustees of The [48:34] Rockefeller Foundation had direct experience of mental [48:38] illness in their families. Wives who'd been [48:41] institutionalized as schizophrenic. In one case, a [48:45] wife who murdered the children and killed herself [48:48] leaving her husband as a major actor in The [48:52] Rockefeller Foundation bereft and of course inclined [48:55] then to support research in this area. And Rockefeller spread its money very widely, [49:02] Precisely 'cause it didn't know where to spend most of [49:06] its money. So it did some support of [49:10] Psychotherapeutics. It supported a number of the then [49:14] extant therapeutic experiments going on, [49:18] and it supported work in genetics. And one of the geneticists it [49:22] supported, Ernst Rüdin in Germany, who was the leading [49:26] German researcher in genetics and mental disorder. [49:30] And Rüdin, because he's absorbed the lessons from California [49:34] about sterilization, became a very enthusiastic proponent of that, [49:38] and then a supporter of murdering mental patients. [49:42] - And we should say, I mean, we'll probably talk about the complicated nature of science- [49:46] ...that it sometimes can be captured by certain ideologies and- [49:50] ...in so doing do a lot of damage to humanity. But [49:54] ultimately, the beacon of hope for the future of humanity lays in the [49:58] scientific method, as flawed as it is. So everything we're talking about, [50:02] we get to see how you F up- [50:09] In a major dark disturbing ways throughout the 20th century- [50:14] ...on the-- in the psychiatric profession. But that [50:17] should be instructive lessons of how we proceed forward to do [50:21] better and better and better. [50:24] - We can discuss a series of therapeutic experiments on people who were shut up in a [50:31] double sense. They were locked away, and their voices were not heeded [50:35] because it was the product of their madness. And so what we see in [50:39] the first five decades really of the 20th [50:42] century is people with a variety of motivations [50:46] including the desire to improve the lot of the mentally ill [50:50] engaging in uncontrolled experiments that had terrible results. [50:55] And the science behind it was shaky but nonetheless [50:59] it existed. It wasn't just plucked out of the sky. [51:04] And yes, it eventually those things break down. I mean, the clearest case [51:08] of that because it's the most extreme of these at least in the [51:12] public imagination is lobotomy. The [51:15] idea that you are going to solve psychotic breakdowns in people [51:20] by excising part of their brain [51:24] initially by drilling holes in the skull and injecting alcohol [51:28] or using what looks like a butter knife to break connections [51:32] between the brain. And then later when that process [51:36] seems to be too slow, the Henry Ford of lobotomy-- [51:40] his daughter said Walter Freeman aspired to be the Henry Ford of lobotomy, the [51:44] one who could mechanize the production of it and get it done [51:47] fast. He invented the ice pick lobotomy where you [51:51] used an ice pick in the orbit of the eye [51:55] having rendered somebody unconscious after two or three electric shocks [52:00] and you banged it through the bone and wiggled it about and [52:04] severed -- I mean, it's just hard to even describe. [52:08] - So this is from the 1930s to the 1970s? [52:12] - Yes. Freeman starts his work in 1936 [52:16] borrowing from the work of the preceding year of Portuguese [52:20] neurologist named Egas Moniz. And Moniz wins the Nobel [52:24] Prize in medicine in 1949 for lobotomy. [52:28] So it's important to see that. That was 14 years [52:32] of experience and yet that won a Nobel Prize. I'm [52:36] sure that's one they'd like to retract. [52:38] - So he popularized Walter Freeman, the ice pick. [52:42] - And his particular specialty after the war became this ice pick [52:46] lobotomy because there were over half million patients in [52:50] America's mental hospitals. Freeman was convinced this operation was [52:54] a cure all. And so he traveled around in a camper truck [53:01] which he called the Lobotomobile and he would descend in the [53:04] summer on state hospitals and he would teach them how to do this ice pick lobotomy. [53:11] - This is by the way an image of the tool. [53:15] - Yes, those are the tools he used. Originally, he used an actual ice pick and then [53:19] he developed this- [53:20] - This is what he developed. This is the state-of-the-art technology. [53:23] - This is the state of the art with a hammer or a mallet. [53:25] - Oh no! [53:26] - Yes, I'm sorry. It's very distressing. I, I don't know- [53:32] - You having to write about this by the way-- [53:34] - Well, it's really- [53:36] - Is a lot [53:36] - ...very, very, very, very difficult. I came across, for [53:39] example, picture of a woman, naked woman [53:43] being dragged away by attendants to be lobotomized and she's [53:46] resisting with all her might and to no avail. You have a picture there of [53:53] Walter Freeman lobotomizing a patient in Washington State. [53:58] Freeman was ambidextrous and when he taught neurology, he would draw simultaneously [54:06] with his left and right hand and he could do it perfectly. [54:09] When he was performing lobotomy, when his right hand got tired, he switched to [54:13] his left hand and he sometimes would do 20 or 30 lobotomies in an afternoon. [54:20] And he boasted, he said, "You know I could teach any damn [54:23] fool to perform a lobotomy in twenty minutes even a psychiatrist." [54:27] Because Freeman was a neurologist and he had a lot of contempt for psychiatrists. So [54:34] So this was a very ugly episode. How did it die away? It really took [54:41] generational change. Some of these lobotomists continued to operate into the [54:47] sixties even to the early seventies, [54:50] but the younger generation who became acquainted [54:53] with the really worst failures of that [54:57] regime; the people on the back wards who were incontinent, who were [55:03] basically zombies had lost all mental power. [55:07] They rebelled against this and by then they had [55:11] a different treatment in the form of antipsychotic drugs- [55:16] ... which looked much more like what regular medicine was doing, [55:20] And didn't have these horrible overtones. And of [55:22] course in the popular mind I think the, probably the most famous, [55:31] instance of telling the public about some of these interventions was the [55:37] film of Ken Kesey's novel One Flew Over the Cuckoo's Nest [55:41] where you see Jack Nicholson giving I think the performance of a [55:45] lifetime who is given ECT, electroconvulsive therapy, [55:52] at--in a very dramatic rendition of what that was not, not really [55:57] what was going on by, by the 1970s [56:01] with ECT but nonetheless certainly what had been going on back in the [56:05] past. And then finally when ECT doesn't smash him to bits [56:11] they lobotomize him and, and the film ends obviously with him being [56:15] smothered to death 'cause Chief can't bear to see him in, in the state that he's in. [56:22] So that fixed in the public mind [56:26] some of the images of these things. It is one of the things that gave [56:31] Electroconvulsive therapy such a bad name. [56:35] - So we will actually not to fast forward too quickly,- [56:38] -... let's talk about uh, the full journey [56:42] of everything we've been talking about. So we mentioned the asylum era that began in the [56:46] mid nineteenth century going into twentieth and we talked about the narratives- [56:51] - And we talked about sterilization [56:53] - Sterilization. And let's look at the insulin shock therapy of uh, nineteen [56:58] thirty three to the nineteen sixties where you were putting patients [57:02] in deep hypoglycemic comas using large doses of insulin. [57:07] - Yeah. So as I mentioned for psychiatrists who [57:10] went into the field and were ambitious but who also wanted to [57:14] think of themselves as therapeutic agents- [57:18] ....uh, to just sit there passively and contain the patients [57:22] was very unattractive. And so they looked around for ways in which perhaps [57:29] biological interventions could be used [57:32] to ameliorate this condition that they still saw in largely biological terms. [57:38] Now in some ways one of the crucial early ways in which this thinking went [57:47] and which affected a large number of patients was this: [57:52] one of the few diagnostic triumphs of psychiatry in the early nineteenth [57:55] century as the profession began to emerge [57:59] Was that it began to distinguish a group of patients who were deemed [58:03] to be suffering from something called general paralysis of the insane. [58:08] That encapsulates two things about what was going on. First of all, [58:14] paralysis; the gradual loss of motor control, [58:19] ability to walk, ability to swallow, ability to, to talk. [58:26] So those are primarily what we'd think of these days as neurological [58:30] issues. But those were accompanied by bizarre [58:35] psychiatric symptomatology. These were people who thought they were [58:38] Napoleon or Jesus Christ or the richest and sexiest man in the world- [58:44] ...or Mary the mother of God. They were primarily men [58:48] but there were also female victims. [58:51] At the turn of the twentieth century as many as twenty [58:55] five percent of the people being admitted to asylums [58:59] were suffering from General Paralysis of the Insane or GPI for short. [59:04] There have been a lot of suspicions about this being connected somehow to [59:08] sex and to moral dissolution and so forth [59:14] but what evolved in the early twentieth century was the [59:19] discovery of the actual origins of this [59:25] disorder. So I've said psychiatry has been looking for the [59:29] underlying pathology that lies behind mental [59:32] diseases. This was one that at Rockefeller Institute [59:37] they discovered that the organism that causes syphilis was residing in the brains of [59:45] the people who were suffering from GPI. This was in [59:49] fact tertiary stage of syphilis. Syphilis is a [59:53] still a real public health problem. It was like AIDS in the late nineteenth [59:57] century. It was everywhere. [59:59] And when you first contract syphilis in the primary phase you have pain [60:05] but then it goes underground and you think it's gone [60:09] and it lurks the way chicken pox virus lurks and can [60:14] surface years later right? It lurks, it lurks and it's insidiously damaging sometimes [60:21] it attacks the heart and people drop dead of a heart attack in their forties ohh [60:30] he died of a-- You know it's natural heart attack but in fact it was the syphilis [60:35] Or it attacks the central nervous system the spinal column in the brain [60:39] and then you get the paralysis - Mm-hmm ...and then you get also the [60:42] psychiatric symptomatology. So when that was discovered that sort of suggested [60:49] that mental illness might have an infectious origin. [60:52] Tertiary syphilis GPI went on to win for [60:56] somebody who developed a treatment for it a Nobel Prize one of only [61:00] two awarded for psychiatric innovations. One was a lobotomy [61:04] the other was giving people malaria to cure their syphilis. [61:08] - In case people didn't hear that- Giving people malaria- [61:15] .. In order to cure syphilis [61:18] - So there was an Austrian doctor, Wagner Jauregg, who had long thought that [61:26] fever could be used to cure mental illness. And he tried rat [61:30] bite fever. He tried giving people typhoid vaccine that creates a [61:33] fever to no avail. And towards the end of World War I, [61:38] the Italians were fighting in World War I on the side of the [61:41] British and the Americans and the French. [61:44] They captured an Italian soldier who had malaria. [61:48] Malaria was endemic in those years in Italy. [61:51] And they brought him to him, and he extracted the malarial blood and [61:55] injected it into a series of patients with GPI, with [61:59] general paralysis of the insane, and claimed it cured them. [62:03] We know from later on when he fessed up that [62:07] those claims were wildly exaggerated, but they were widely [62:11] accepted, and malarial treatment [62:14] spread to Britain, it spread to Germany, it spread to the United States. [62:21] Sometimes it was vials of malarial blood, but very often mental [62:26] hospitals had actual colonies of malarial mosquitoes. [62:30] So imagine you're a mental patient, and you're put in a straitjacket, and you're put [62:34] in a room, and you can't move, and mosquitoes are buzzing around, [62:38] and they bite you, and then you develop malaria. [62:40] - And he got a Nobel Prize for this? [62:42] - Yes, in 1937, he got a Nobel Prize. 'Cause this was a [62:46] condition that was invariably fatal. And the claim was that somehow [62:53] the malarial fever worked. Now, there are two possible [62:57] ways. Von Jauregg thought it stimulated the [63:01] immune system to attack whatever it was, was causing the insanity. [63:05] But the other possibility was the following: When [63:08] you have the malarial parasite in a test [63:12] tube and you heat the test tube to about 105, 106 degrees, it dies. So the idea [63:20] potentially was you were sort of burning the parasites out of the brain with [63:23] this agent. And because people were pretty unsophisticated about [63:29] statistics and because the idea of a controlled trial had not yet come to pass, [63:36] this treatment was used extensively for a couple of decades. What [63:42] caused it to stop, and you talk about the progress of science, [63:46] was the discovery of penicillin, which was a real magic bullet. [63:51] So once you had penicillin, you weren't gonna continue treating people [63:55] with malaria, so it died away. But it was the first [63:59] such treatment, and here's the other way this feeds into the [64:03] narrative of these desperate remedies that develop in this [64:07] period between the mid-'teens and, say, 1950. [64:12] The discovery of the syphilitic origins of general paralysis of the insane [64:18] occurred at a time when medicine had undergone a [64:21] undergone a profound transformation. In the late 19th [64:25] century, the work of Louis Pasteur, who was a chemist, not an MD, [64:31] and the work of Robert Koch in Germany had uncovered [64:36] the origins of a variety of diseases and suggested that bacteria were the reason why [64:45] people sickened. And that led, of course, to a whole series of public [64:51] health triumphs, because initially it didn't lead to antibiotics. But for a lot [64:57] of these diseases, even viral diseases like rabies, you could develop a vaccine. [65:05] And the vaccines were phenomenally effective. And so [65:11] that was one way in which the new germ theory of disease [65:16] transformed medicine and tied it into the laboratory and into science in a new way. [65:22] And the other was the adaptation of Pasteur's theories [65:26] by a British surgeon named Lister, who previously when pus developed [65:33] post-surgery, people had thought that was a good sign. [65:38] Lister said, "No, I don't think so. This is actually these [65:42] nasty germs causing this, and so we're gonna do [65:46] antiseptic surgery." So he sprayed carbolic acid [65:50] on the wounds to try to kill the microbes. [65:54] Most of his colleagues thought he was nuts. Thought he was just-- This [65:58] is ridiculous, these microorganisms. You couldn't even see them, you know? Well, you [66:02] could with a... But Lister prevailed. And eventually we moved from [66:07] antiseptic surgery to aseptic surgery, which is what we have now, [66:11] where you try to have a sterilized set of [66:15] instruments in a sterilized environment, so you don't infect things, right? [66:19] - By the way, these are definitive examples of progress in medicine. [66:23] - Absolutely. [66:24] - Penicillin-- [66:25] - Yes. [66:25] - ...uh, you know, making sure there's no germs in during surgery. [66:30] - Associated with wounds, yes. [66:30] - So these are all just refreshingly clear examples of progress. [66:35] The reason I say it's refreshingly clear that there's progress, there's not a [66:39] refreshingly clear progress in the history of psychiatry. Maybe, maybe a few hints. [66:44] - Some bits, yes. There haven't been [66:47] the dramatic breakthroughs that I think everybody in the field [66:51] would hope for. And there's some debate about [66:55] how powerful what we have done is, and I [66:59] think it's reasonable to debate that and to also acknowledge [67:03] that there is important progress, limited as it is. Now you have 25% of the admits [67:11] to a mental hospital actually suffering from an infectious [67:14] disease. Medicine in general has now tied its fortunes to the laboratory. [67:20] The idea that disease is caused by bacteria, we can't yet see viruses. [67:28] It is a very powerful one and that notion that disease is caused by bacterial [67:35] infection acquires great momentum but it [67:39] hasn't touched psychiatry so medicine now has interventions that work [67:46] And sometimes quite dramatically [67:50] um you know the first patient given diphtheria vaccine-- [67:54] Diphtheria causes a leather like membrane to grow over your [67:57] throat and you die choking to death And if you have a [68:01] child and you watch that child die like that You will never be over it [68:08] So when you had something that warded that off [68:13] That improved medicine's image dramatically and [68:17] improved its financial prospects dramatically particularly [68:21] as medical training became reformed and more involved with science [68:30] So that hasn't applied to psychiatry until [68:35] syphilis comes along Now we have the model that an [68:38] infectious agent can cause people's minds to go amok [68:46] So The very person who invents the basic distinction [68:50] between kinds of psychoses we still use today schizophrenia and bipolar disorder [68:57] Emil Kraepelin begins to think "You know there may be something infectious [69:02] about the mental illnesses we're treating." [69:05] And one of the people he trains is a young [69:08] psychiatrist from the United States named Henry Cotton Who's also [69:12] been trained by Adolf Meyer who is the leading [69:16] American psychiatrist of the first forty years of the twentieth century [69:21] And when he comes back from Germany having spent a year there [69:25] Meyer secures him a position as head of the New Jersey State Mental [69:28] Hospital at Trenton and Cotton is an ambitious reforming man [69:35] He wants to bring psychiatry back to medicine He also [69:39] wants to chuck out all the old stuff He doesn't want [69:43] chains in his hospital He doesn't want If he can help it straight jackets [69:47] So that goes away But nothing seems to change fundamentally He still isn't [69:54] curing patients And then he comes across this idea of [69:58] focal sepsis The idea that low grade [70:01] infections can lurk in the body and what they do is release [70:05] toxins into the bloodstream and the lymph And hey [70:09] imagine if those toxins get to the brain What's it going to do? [70:13] It's gonna poison the brain and the brain is then gonna act up [70:19] so We don't have antibiotics So what are we gonna do about this [70:24] Well we can perhaps locate the bacterial infection [70:29] and then we can Get rid of it We can engage in what he calls surgical bacteriology [70:35] So the first obvious target here is teeth [70:40] Your teeth look close to your brain They're often infected [70:44] That infection often goes untreated for a time... So we pull a lot of teeth [70:52] Patients don't get better Mm Maybe the theory's wrong No Um tonsils [70:58] well they're getting infected so we'll remove them Still don't get better [71:05] Well they're swallowing the bacteria so we remove stomachs and we move spleens [71:11] and we remove colons And we claim to be curing eighty percent [71:15] of our patients And rich patients come from all over America [71:19] to be treated with this novel treatment [71:21] - Crazy [71:22] - Cotton gives A series of lectures at Princeton There were not [71:26] some lectures which are given by Nobel Prize winners. There's a very [71:30] prestigious series. [71:32] Uh, it's published by Oxford University Press and Princeton University Press. [71:36] The New York Times hails it as a great breakthrough. And in reality, [71:41] 45% of the people who get the abdominal surgery die within a year. [71:46] - They're cutting out stomachs. [71:47] - Yep. He's cutting out stomachs. He says--there's this passage in one of his papers [71:51] where he says, "Stomachs are like cement mixers on a construction [71:55] site and could be dispensed with." When you think, oh my God, [72:00] if you were released from Trenton and you had no [72:04] teeth, people immediately knew you were an ex-patient because the word had spread. [72:10] And this goes on for--starting in 1916, Cotton drops dead of a [72:17] heart attack in 1933, but he's succeeded by three people he's trained. They [72:24] drop the abdominal surgery. They use colonic irrigation, but [72:29] but the teeth and the tonsils keep being pulled. I interviewed the dentist [72:34] who had come to the hospital in 1916 and must have pulled several [72:38] hundred thousand teeth. [72:41] In nine-- and he retired in 1960, which was when that finally stopped. [72:46] And he was convinced Cotton should have won the Nobel Prize for this. Oh, well. [72:51] - Can you just give some intuition, put ourselves in that [72:55] mind space? I mean, presumably these are smart [72:59] human beings. Why were they fraudulent in the reporting of how [73:02] effective it is? Why are all the people that are participating, [73:07] both the doctors and general culture-- [73:11] - It's extraordinary. So obviously, [73:15] many of the interventions I'm talking about are very powerful [73:19] interventions conducted by people in white coats and stethoscopes and scalpels. [73:24] - Powerful, by the way, by the amount of impact [73:28] they have on the human body, not powerful in terms of how effective they are. [73:31] - Yes, powerful as well in terms of placebo effect. [73:36] Look, what I am going to do to you, and yes, it's gonna hurt [73:40] and it's very intimate, but it's going to make you better. [73:44] So that's always-- this is a problem that persists in [73:47] contemporary psychiatry, trying to figure out [73:51] how much of the improvement we're seeing [73:54] is the placebo effect and how-- how much of it is the active effect of [73:58] whatever we're doing. [73:59] - But by the way, on that small tangent, let's return to that perhaps often. [74:04] - Yes. [74:04] - I for one can tell you that for me, for my mind, [74:10] the placebo effect even when you tell me it's placebo will work. [74:15] - Yes! [74:15] - But now if you have combined an actual gigantic [74:19] operation that is physically, mentally, in every way life changing - [74:25] ... everybody around you in lab coats, all of society's telling [74:29] you this is going to be life changing. I get it. That's like the most [74:32] pure kind of placebo effect. [74:34] - It's placebo effect that comes from both the patient who wants to be better- [74:39] ... and wants to believe this is gonna make them, and from the person [74:42] conducting. And it's easy to deceive yourself, [74:46] to see what you want to see. So anyway, that was one episode. Um, [74:53] we talk about triumphs of medicine so let me talk about one of [74:57] the real triumphs of 20th century medicine [75:03] which is interesting to refer to because it wasn't a cure, [75:09] just like psychiatric drugs aren't a cure for mental illness. [75:14] It was a symptomatic treatment but it transformed lives [75:18] and that was discovery of insulin in the 1920s. [75:23] Previously particularly what we now call type [75:26] one or juvenile diabetes was a death sentence. [75:30] You got it and whatever you did, you tried various quack [75:34] remedies, you tried diet, you tried all sorts of things. The [75:38] inevitable thing was it killed you. And then came insulin. [75:43] Now insulin doesn't mean you're cured of dia- your diabetes but what it means is [75:49] you can live a relatively normal life and your lifespan is [75:52] greatly expanded. So by any measure you have to say that's dramatic progress. [76:00] But insulin is something our bodies produce we hope [76:04] unless we're really seriously diabetic. Those of us with Type [76:08] Two diabetes, our bodies resist insulin and we have [76:12] to resort to other ways of trying to cope. But [76:16] if you get too much insulin, it makes you unconscious [76:21] and that's how another one of these desperate remedies came along. [76:28] A man named Sakel working in a German clinic [76:32] for drug addicts they were using putting [76:36] people under mild comas to help them through the [76:40] withdrawal symptoms once they got over their addiction. So he was [76:44] familiar with that. And when he moved to Austria, he [76:47] decided he'd try this as a treatment for schizophrenia. [76:52] And so he put people into comas sometimes comas that would [76:56] last hours days um they would be revived by giving them glucose [77:02] usually intravenously sometimes not. Um [77:06] during the time they were in comas they often seized had [77:10] seizures. He saw that as a therapeutic sign. [77:14] And he claimed that this Insulin Coma Treatment [77:18] cured eighty percent of his -- eighty percent tends to come up again and again [77:22] in these treatments as a sort of percentage that you cure. [77:26] And he was invited to New York [77:31] and demonstrated this at the Harlem Valley Mental Hospital. [77:35] It spread. This is in the thirties? This was starting in [77:39] nineteen thirty-three. The visit to America was I believe nineteen thirty- [77:43] six and Sakel ended up settling here. He had a very [77:46] lucrative private practice in New York and when he died he [77:50] left his partner I think an estate of about two million dollars which [77:54] in the early sixties was a very substantial amount [77:58] of money that he'd earned from practice, right? So [78:02] insulin coma therapy was widely adopted. What kept it [78:06] from being a large scale thing was it required an enormous [78:10] amount of nursing and medical attention 'cause people were literally [78:14] hovering on the brink of life and death. They could go into a permanent [78:17] coma, they could just die. Um, so they had [78:21] vital signs had to be monitored. They had to be brought around very [78:25] quickly if need be. And there's some evidence that the treatment killed [78:31] brain cells. And when Sakel was told that, he said, "Yes, that's probably [78:35] true. They're killing the schizophrenic brain cells." That's just [78:39] nonsense, of course. That's just nonsense, but that's [78:41] his rationale. Insulin comas weren't subjected to a [78:45] randomized controlled trial until the nineteen [78:48] fifties. And when they were subjected to a controlled [78:52] trial, they failed it, and so it died out. [78:56] And that's, I guess, scientific progress again in a way, but [79:00] took a long time. One of the people who [79:03] received insulin coma therapy—have you seen the film A Beautiful Mind? Mm-hmm, he did. [79:09] Receive insulin coma therapy. Ironically, actually at Trenton State Hospital where Cotton had been, so John Nash received [79:15] John Nash got insulin comas, and they were going to lobotomize him, [79:20] and they didn't, but he was at risk of that. We should say [79:25] that this treatment, patients would thrash, moan, and convulse before falling into a coma. The treatment required a course of up to sixty comas. It turned out to have a mortality rate of one to five percent and caused significant brain damage and obesity. Yeah, yet was hailed as a miracle cure for schizophrenia. [79:48] Yes, that's right. Performed on John Nash, one of the great [79:53] - minds of the 20th century. [79:55] - Yes, and Nash clearly did become delusional, [79:58] but that was one of the treatments he was subjected to, [80:03] and well represented, actually, in the film of A Beautiful Mind. [80:08] So I mentioned seizures. Also in Austria-Hungary in this period, [80:14] another psychiatrist decided that you couldn't be both [80:20] schizophrenic and epileptic. That there was somehow an antagonism between the two. [80:28] So if you had epilepsy, you didn't have schizophrenia. If you had [80:31] schizophrenia, you couldn't have epilepsy. [80:34] Uhh... I should say at the outset, that's not true, but that's what he believed. [80:39] So then, the logical next step was, "Well, if we could create [80:43] an artificial epileptic seizure, maybe we would drive out the schizophrenia." [80:50] So, what to do? He first tries injecting [80:54] camphor, a natural substance. Natural substances aren't necessarily [80:57] benign substances. That caused abscesses, and it [81:01] wasn't very effective. He sought an alternative, and he settled [81:05] on something that was, um, called Cardiazol [81:11] or Metrazol, depended which side of the Atlantic you were on. [81:15] And injecting that into a patient usually caused a [81:19] seizure, a big seizure like a grand mal seizure, where [81:22] your body arcs back, your legs contract dramatically. [81:27] - You can fracture spines and hips and bones. [81:30] - And you ended up, yes, with fractures of vertebrae, fractures [81:34] of the hip socket. Because when muscles in the [81:38] thigh contract that badly, what happens? The thigh bone [81:42] is driven into the socket at such a rate that it fractures, [81:46] right? So these were among the complications that Metrazol [81:50] produced. More than that, he himself conceded [81:55] that between the injection and the seizure, the [81:59] patient felt as though he were on-- or she was on the brink of death. [82:04] Now imagine, pretend you're a mental patient. You're brought in in a straitjacket, a [82:10] man in a white coat with a big hypodermic injects something into you, [82:16] You feel as though you're gonna die. [82:18] And maybe that lingers for two, three, ten minutes, and then [82:22] you seize, with those possible fractures following. [82:27] - Violent seizures. [82:28] - It's violent and hard to witness and is very unpredictable. [82:35] So it's used, but people are not very happy, and that's [82:39] how we get electroconvulsive therapy, electroshock, as it's first called. Two Italian [82:46] psychiatrists, Cerletti and Bini, experiment with electricity, and they [82:50] first experiment on dogs. [82:53] And they make a mistake initially. They have an electrode on the head, an electrode [82:57] on the anus. The electric current passes through the body, it stops the heart, the [83:01] dogs die. [83:03] So that seems a dead end. And then somebody says to them, "You know, you should go to [83:07] the Rome slaughterhouse and see the pigs being slaughtered, 'cause you'll learn [83:11] something very interesting." So they go, and the pigs are dangling by their [83:15] hind legs, and as they come by, two electrodes cross their head. [83:21] Electroshock, they convulse, they're unconscious, their [83:25] throats are slit and pork arrives. So, um, they try that on dogs, and current passing [83:35] through the brain, it turns out, doesn't kill them. [83:38] So they decide to try it out. They pick up a transient [83:41] homeless person at the Rome train station and they bring him in. [83:48] And they try it, and at first they don't use enough current. [83:52] And nothing very much happens. And they're very white- [83:56] faced, they're quite worried off in the corner. We have descriptions of this, and they're [83:59] talking, "What should we do?" "Well, we'll up the current." And the patient [84:03] hears that and says, "No, another one, that's deadly." They do it anyway, and he convulses. [84:10] Another grand mal seizure, with the same problems of spinal fractures [84:14] and hip fractures and so on. Not universally, obviously, but often enough. [84:21] And he stops breathing. You can imagine the scene. [84:27] And then he spontaneously starts breathing again, and when he comes around, [84:32] he's in contact with reality. They got this miracle cure, [84:36] and it's very easy to administer, cheap, [84:40] doesn't involve injecting things into people's bodies. So that quickly spreads [84:47] across the Atlantic and other parts of Europe. [84:52] And ECT becomes a very widely used intervention. [84:59] Couple of things to say about this. [85:02] It turns out it's not very useful for schizophrenia. [85:07] Remember the connection between seizures and [85:10] seizure and schizophrenia that was originally posited [85:15] posited, but it seems to work in cases of, um, [85:18] depression, suicidal depression particularly. [85:22] - Fast forwarding to the modern day. Mm-hmm. And this is something I [85:26] learned by reading a bunch recently. It seems to be one of the [85:32] few evidence-based, like scientifically backed methods that actually [85:36] worked for clinical depression, for serious depression. [85:40] - Um, yes, if we fast forward, we're looking at in some [85:43] respects a different animal for reasons I'll explain. Okay. [85:47] - This is unmodified ECT. [85:49] - Yeah, so we're talking about unmodified ECT, which rules the roost [85:54] really well into the 1950s, and some places even into the [85:58] 1960s. And so it is associated with all the problems of [86:02] fractures that we've talked about. It's also associated with memory [86:05] problems. People often lose memory. There's some [86:09] dispute about how serious that is, but it's pretty widely recognized [86:13] that's one of the prices you're going to pay for that treatment. [86:17] The thing is, for mental hospitals in the '40s and '50s, [86:23] ECT was much more used as a [86:26] device to control people's behavior, than as a therapeutic [86:30] intervention. It was quite punitive, seen as such. Patients didn't want to repeat, [86:39] and so they-- ...sort of controlled themselves a bit. But yes, [86:44] we don't know why it, quote, "works," but more recent work starting in [86:52] probably the 1990s -- and I'm going to get in trouble with some people for saying this [86:56] because you mentioned patients and [87:00] psychiatrists who swear by ECT. There are others who swear at it. [87:05] Um, partly because of the memory problems I alluded [87:09] to, and partly because of claims that it may cause [87:13] brain damage. Passing an electric current through the brain is possible. [87:18] What changed ECT a bit, quite a bit actually, was giving muscle relaxants [87:26] so that people didn't thrash about, and the fractures were largely a thing of [87:30] the past. When you introduce these muscle relaxers, originally they used curare, [87:36] but then they used other, more modern drugs [87:39] to paralyze the muscles temporarily. The problem is, that would also [87:43] paralyze your breathing muscles, so that's not too good. [87:47] So it became a more complicated procedure because you needed [87:51] anesthesiologists, breathing support, and so forth [87:55] during the procedure. But you did eliminate the [87:59] fractures. It still was a very widely [88:02] disdained practice, I think, particularly when they had drugs [88:06] available. The thinking was that, well, we'd sooner use those, but [88:10] the drugs turn out to be only partially effective, [88:14] and pretty ineffective very often for suicidal cases or in [88:17] cases of extreme melancholia. Now, a couple of [88:21] things to say: Very often, ECT has to be repeated at [88:25] intervals, as a kind of maintenance therapy. [88:28] So it hasn't cured things, but it temporarily [88:32] alleviates the symptoms, and the temporary may be fairly lengthy, but [88:36] nonetheless, very often things will recur. The memory problems can be quite severe. [88:43] The worries about brain damage are, I think, [88:47] certainly things we have to be very cautious about. [88:52] And when we talk about treatment-resistant depression, [88:56] that's an interesting concept to me. What it means is those are the [89:00] patients who don't respond to drugs. [89:03] They may not have a different disease, but the drugs [89:07] don't work for them, hence treatment resistant. [89:11] And the numbers of psychiatrists who are willing to give ECT are rather small, [89:19] and in many states it's hedged around with [89:23] lots of legal restrictions. In California, for example, um, [89:28] ECT now almost can't be given to [89:31] involuntarily confined patients 'cause you have to, you have to volunteer for it. [89:38] So as-- so it's unusual in that most medical procedures [89:42] aren't hedged about by legal constraints like that. And [89:46] there clearly is a very powerful group of people, [89:50] some of them psychiatrists, many of them ex-patients, [89:55] many of them other people who just are suspicious of modern medicine and [89:59] science, who form a group who are very powerfully opposed to ECT. So [90:06] although it's fair to say there are, Trials now that [90:13] seem to provide decent evidence that for some patients [90:16] this works and that those patients are deeply [90:19] distressed before the treatment it's also still [90:23] a controversial treatment, I think it's fair to say. [90:26] - Like basically every single topic, treatment, problem subfield of psychiatry today. [90:36] - Yes, yes. [90:37] - For everything, everything we say today, there will be at least [90:41] one person upset- ...and writing a letter. [90:43] - I think lots of people upset. So if we talk about drugs, [90:49] there'll be two kinds of people who will be upset, [90:53] those who think the drugs are more powerful than they [90:57] are or who have been successfully treated by the [91:01] drugs and go, "Well, it worked for me, so, you know, [91:05] stop criticizing it 'cause it really is an effective treatment." And then [91:09] on the other side of the coin, there are those who [91:13] either the drug treatment has been used and it's failed, or they're being [91:17] left with terrible side effects that don't go away, [91:21] or they're part of a general group of people that [91:24] unfortunately is of a growing number these days who are so suspicious [91:31] of medical science and of the drug companies [91:35] that no amount of evidence will sway them. They are convinced that [91:43] you know, the drug treatments are poisonous. [91:47] The Scientologists being a very extreme example of that, who they have a whole [91:54] museum in Los Angeles and the title is Psychiatry Industry of Death. [92:01] And then if you think about all the resistance, for example, that [92:05] has surfaced to vaccination in [92:09] contemporary US and how the trust in vaccination has been [92:12] destroyed for a substantial number of people, [92:16] it's very difficult to convince them that they're mistaken. [92:21] - And not just the trust in vaccination consequence of that is [92:25] a general distrust in science- [92:26] - A general distrust, exactly. [92:27] - ... and distrust in medicine and so on. [92:30] - That's one of my great worries about our contemporary situation, that we're [92:37] only-- we're less than a year in. [92:40] After four years of this, first of all, the degree of [92:43] mistrust will have grown exponentially, and once trust is lost, it's [92:47] very hard to recover. Secondly, the science itself is being [92:53] destroyed. Clinical trials that were midway through were [92:58] aborted, so that knowledge has been lost. You would have [93:02] to start from square one, and that's years of work. Scientists aren't being trained [93:11] because funding has been cut. Scientists [93:15] with successful careers no longer have the funding necessary to do their work, [93:21] and it takes at least six or seven years to train [93:27] a scientist at the beginning of their career. [93:30] And so if you have four years with nobody being trained, [93:34] you're talking about a decade being lost, and what's lost is invisible-- [93:41] ...because it's counterfactuals. We don't know what that science [93:45] will lead to or what that medical treatment might [93:49] lead to, and very many times they fail. That's [93:53] the nature of science. It's the nature of [93:57] medicine and medical research that not every bright [94:00] idea we have is going to eventuate in a breakthrough. [94:05] It would be really simple and wonderful if that opposite were the case. [94:09] But the reality is we have to go down lots of blind alleys, we [94:13] have to try lots of different things, and we have to take [94:17] years to move from the laboratory to practical application. And when we eliminate [94:26] a whole segment of that, and when on top of that we diminish people's trust-- [94:35] ...in science, that's a really, I think, a profoundly [94:42] devastating thing that probably given my advanced [94:45] age, I won't live to see the consequences of, but [94:49] my children and grandchildren will. It really [94:53] is something cultural that you've got to build up trust. [95:00] And it can be destroyed very easily. So one of the things, to go back to the [95:03] very first question you asked me about, is psychiatry in crisis? Well, genetics was [95:10] supposed to provide a clear picture of the origins [95:14] of various mental diseases 'cause they do seem to run in [95:17] families. So the expectation was once we decoded the [95:21] human genome and we could examine bits and pieces of it, that we would very [95:25] quickly find a Mendelian gene or set of [95:28] genes for schizophrenia, let us say. Hasn't happened. [95:33] We now use genome-wide association studies, that is throwing [95:37] everything in the kitchen soup into, into the picture, and then [95:41] without any preconditions and seeing what relates to what. And if we [95:44] use three hundred small variations in [95:48] the genome, we can account for about ten percent of schizophrenia. [95:53] That's not very powerful. Beyond that, what psychiatric genetics has [96:00] tended to throw up is something that undermines the [96:04] distinctions that we've made based on symptomatology. So if you look, [96:10] there is a great deal of overlap in the kinds of genetic [96:14] abnormalities that heighten the susceptibility [96:18] to bipolar disorder or schizophrenia or autism. There's a lot of overlap there. [96:24] What that suggests is these aren't distinctive entities in the way [96:28] that, you know... Schizophrenia, as my friend Robin Murray, [96:33] a British psychiatrist, has to say, "It really seems to be the [96:36] extreme end of psychosis, the most serious." But it's sort [96:40] of on a continuum, you know. And so if psychiatry has to say in ten years, [96:47] as some leading psychiatrists are speculating, [96:50] that there's no such thing as schizophrenia, there's no such thing as [96:54] bipolar disorder, that will tend, I [96:57] suspect, to have pretty bad effects on people's trust- [97:02] ...in psychiatry, and yet that's where the science may lead them. [97:06] So it's a complicated picture, but this issue of, of trust and its absence [97:15] and is, is vital, I think, in looking at not just what [97:20] we're talking about today, but across a whole spectrum of things, [97:25] even outside the medical realm altogether. If you lose trust in institutions, [97:32] trust in science, trust in history. So [97:36] I think more humility and less arrogance, more [97:40] willingness to confess the limits of what we can do, more awareness of the dangers [97:48] of enthusiasm, more skepticism when we're told something is a breakthrough. [97:59] One of the things I worry about is the tendency of science journalism and medical [98:06] journalism to hype things and then [98:11] When the hype turns out to be just that, that undermines trust. [98:16] You know? So be cautious when things come along- ... don't be [98:21] so sure that it represents a breakthrough. I'm very worried at the moment. I see, [98:29] Ketamine and psychedelics being propounded as a miracle cure for depression, [98:36] and the evidence for that is enormously weak is the best [98:39] way to put it. And I've seen this movie before too many [98:43] times. You know? I mentioned that 80% cure for Cotton's work, 80% cure [98:51] for insulin coma therapy, 80% cure for the early asylums. [98:56] This is overblown rhetoric, and the reality is [99:00] usually progress comes in small steps. [99:03] Sometimes it comes in big steps. Penicillin, I think [99:08] was a huge step. Uh, I was lucky enough to grow up [99:13] in the era when penicillin and other antibiotics [99:17] became widely available. They hadn't been overused by then. [99:21] And so if I had a strep throat, I had something that got rid of [99:25] it right away. I didn't run the risk of heart valve damage, which [99:29] in previous times would've been the case. So you know, [99:33] once in a while you do have these dramatic shifts, [99:37] and maybe AI will help us in that regard, but [99:41] maybe it won't. It's another potential double-edged sword. [99:46] - I should mention that psychedelics, psilocybin in [99:50] particular, has been demonized for a long time. And so there's studies now out of John [99:54] Johns Hopkins- ... that are doing serious studies on cases [99:59] where it is effective. I think it's nice to give a
[100:02] chance to the different treatments with the rigor of science, but with caution -
[100:08] ... and basically ignoring like you're saying, science journalists
[100:12] who are basically hyping every new thing 'cause they have to get clicks and all-
[100:16] ... this kind of stuff and-
[100:17] ... Look at the actual science in the modern day. So the-
[100:21] ... in the past, the rigor was not there. In the modern day, there's more.
[100:25] - Yes. We can add beyond the realm of science journalists. I think Science and Nature
[100:33] make choices about what they're gonna foreground, and they too
[100:37] have this tendency to look for things that make a big splash.
[100:42] - Oh, you mean the, the editors and the- ... the major journals.
[100:44] - I think the editors, the major journals, that's what they're looking for. As,
[100:48] you know, I mean
[100:50] negative findings are very important in science. They're, they're the things that
[100:55] help us avoid mistakes, but they're not the
[100:59] things that are going to get you published in the journal.
[101:01] - Right. So it's not just the surface level science journalism.
[101:05] It is also the extra journals and the conferences and the publication process.
[101:10] - Having lots of scientists working on
[101:14] these problems in different sites and different places
[101:19] turns out to be very important, I think, as a check on
[101:22] enthusiasm, as a check on premature claims that turn out to be unfounded.
[101:29] And also because you're often partially right but you're not
[101:33] fully right and someone else following the same idea-
[101:37] ... is, is perhaps gonna be a little closer to the truth than you were. And so
[101:43] it's, it's very helpful to have multi-centered things and not
[101:47] everything under one all-knowing- ... uh,
[101:51] thing. And that's a problem with funding agencies. The
[101:54] maverick scientist has a hard time- ... very often-
[101:59] ... getting a hearing. And we know of lots
[102:02] of examples of that in history where after the
[102:06] fact we go "oh well yes," we should have supported that line of
[102:10] research, but we didn't."
[102:12] - Uh, very well put. Let us return to,
[102:15] the origins of ECT and how it was applied. But first, if it's okay,
[102:19] a quick bathroom break.
[102:21] Quick ten second thank you to our sponsors. Check them out in the description. It
[102:25] really is the best way to support this podcast. Go to
[102:28] lexfridman.com/sponsors. And now dear
[102:32] friends back to my conversation with Andrew Scull. Now we're back
[102:39] just to talk a little bit more about ECT and One Flew Over the Cuckoo's
[102:42] Nest. So what can we say about that, that little cultural
[102:46] moment, one of the most famous moments about psychiatry?
[102:50] First of all, Ken Kesey wrote this book about his own experience
[102:54] in a mental institution.
[102:55] - Yeah, Menlo Park. Yes.
[102:57] - How representative is it of the system at the time?
[103:01] - Mental hospitals have had a very patchy and complicated history.
[103:09] He was working actually in a hospital for veterans.
[103:12] Those were largely created after the Second World War
[103:16] when there were very many more psychiatric casualties among
[103:20] American troops than even the First World War. The interesting thing is we all by
[103:27] osmosis know that in the First World War there was something called
[103:31] shell shock that afflicted the troops and that the
[103:34] military initially resisted recognizing and ultimately were forced to grasp.
[103:41] But in World War II, American psychiatric
[103:45] casualties among the troops were two to three times as high as in World War I,
[103:50] and that's an important part of the history of psychiatry. But the
[103:54] upshot of that was that post-war the VA
[103:58] was heavily involved in, first of all, paying to train
[104:02] psychiatrists and even psychologists, and then had in its mental hospital
[104:08] system a considerable involvement with psychiatric disorders.
[104:15] Kesey-- Well, the book is different than the film is the first thing to say.
[104:21] Obviously, the film is heavily indebted to the book, but it changes various things.
[104:26] - Uh, if I may just go into Perplexity, "The book and the
[104:29] 1975 film tell the same basic story of McMurphy
[104:33] challenging an oppressive psychiatric ward, but they differ sharply in
[104:37] point of view, tone, and what the story is about. The novel is
[104:41] weirder, more political, and more about Chief Bromden's
[104:45] inner world and the combine while the
[104:49] film is more naturalistic, character-driven, and turns McMurphy into the
[104:53] central hero."
[104:54] - Yes, I think that's right.
[104:56] - McMurphy is the person that received ECT played by Jack Nicholson.
[105:00] - Yes. And you have a nurse figure in Nurse Ratched.
[105:03] - Yeah. Yeah.
[105:03] - Louise Fletcher, uh, I think is an equally powerful performance.
[105:08] - It's one of the greatest films of all time who happens to be--
[105:12] which is unfortunate for, you know, maybe psychiatry.
[105:14] - Psychiatry, yes. It's very interesting. I used to teach, um, a
[105:18] class called Madness In The Movies, and, um, I didn't just use... In fact,
[105:25] I used relatively few contemporary films and all among all the films from back
[105:33] then, the one almost everybody in the class had
[105:36] seen was One Flew Over the Cuckoo's Nest. So 18, 19, and 20-year-olds,
[105:44] In two thousand and fifteen If I
[105:48] showed them Alfred Hitchcock's Spellbound, no chance they'd ever
[105:52] seen that, maybe one,
[105:54] because they were a class of people interested in film. But everybody had
[105:58] seen One Flew Over the Cuckoo's Nest.
[106:01] - On that tangent really quick, what is the greatest film on madness in your view?
[106:06] - Oh, well...
[106:06] - Would that be One Flew Over the Cuckoo's Nest?
[106:08] - I think One Flew Over the Cuckoo's Nest, I think
[106:12] oddly a very different film appeared at about the same
[106:16] time was I Never Promised You a Rose Garden,
[106:20] which is a much more sympathetic portrait of a different
[106:24] kind of psychiatry, a very Freudian psychiatrist,
[106:28] really about Frieda Fromm-Reichmann who worked
[106:32] at Chestnut Lodge in Maryland and treated
[106:35] schizophrenia with psychotherapy rather than with drugs
[106:39] or other forms of physical intervention. And that was a bestselling novel by a young
[106:47] girl who had been her patient with some fairly serious delusions
[106:55] and a very complicated family background, and again the film
[107:01] changed a lot of things in the novel. That's what films do. My book
[107:07] Madhouse at one point interested Hollywood, and one of the
[107:11] two principals said to me, "I really like this story. It's got a great
[107:15] first act and a great second act, but where's the third act?" Meaning,
[107:18] "Where's the happy ending?" And I had to say there wasn't any happy
[107:22] ending to that story. It was just rather grim.
[107:26] - Madhouse: A Tragic Tale of Megalomania and Modern Medicine
[107:31] is the book you're referring to. Yes, that's right. Now that reminds me of Flowers for Algernon. That
[107:35] doesn't have a happy ending, and it's not about mental health
[107:38] necessarily, but it's about the journey of institution in relation to
[107:42] the health of a patient.
[107:44] - Yes, Pat Barker's trilogy of novels about World War
[107:48] I was turned into a film. I think it was called
[107:51] Regeneration, and that was quite powerful.
[107:55] It was about World War I and the treatment of shell shock. Mm-hmm.
[107:59] And I thought was quite well done. And my friend Patrick McGrath, who's a novelist,
[108:07] wrote a book called Asylum. Patrick grew up
[108:11] in the grounds of Broadmoor. Broadmoor is England's
[108:15] premier hospital for the criminally insane,
[108:18] and he was babysat by some of the patients. And when you read his novels, you
[108:22] can see how that upbringing affected his rather macabre imagination. But anyway,
[108:31] so One Flew Over the Cuckoo's Nest, the poverty of the environment,
[108:36] room that the patients were in, I think fairly successfully recreates that
[108:44] way in which staff very often put patients down, didn't listen to them, or poked fun at
[108:52] them, or even were physically abusive, although you don't see that.
[108:58] Those were all features of mental hospitals. The general boredom of life,
[109:04] sort of there, but yeah, hard to reprea--
[109:09] putting boredom on the screen will turn an audience off rather fast.
[109:14] - What about nurses and this kind of abusive element, you know?
[109:18] - Yeah, I think there was an abusive element in a lot of mental
[109:22] hospitals, and it was almost inevitable. Look at who had the
[109:30] most contact with the patients: it was the lowest paid,
[109:35] least respected ward attendants, very few even RNs, and you know,
[109:43] ratio of doctor to patient in the large state mental hospitals meant that patients
[109:51] hardly ever saw a physician, you know.
[109:54] Remarkable about the film, there are many remarkable
[109:57] things about the film as well as its polemical edge,
[110:02] think is that chief psychiatrist that you see
[110:06] in the film is the real head of Oregon State Mental Hospital. He really was
[110:12] introduction to acting, and I thought he was pretty remarkable, actually.
[110:17] Obviously, there's a lot of exaggeration there, but
[110:20] ECT was used in the fifties and sixties
[110:24] as a tool of discipline in the hospitals. It was also
[110:28] used therapeutically, but overwhelmingly it was used
[110:33] a tool of discipline and control. And that's true to life. Lobotomy...
[110:40] One of the interesting things we haven't talked about with all these treatments we've been
[110:44] discussing is that almost invariably,
[110:49] except for the case of the syphilitic patients, for obvious reasons, men
[110:53] were more troubled by that condition than women,
... [transcript truncated due to length]
