Factually! with Adam Conover - Psychiatry’s Desperate Remedies with Andrew Scull

Episode Date: June 15, 2022

Despite our efforts, we seem to be no better at treating mental illness than we were hundreds of years ago. Desperate Remedies author Andrew Scull joins Adam to explain why, on the way touching on the history of lobotomization, the collapse of psychoanalysis, and why our current regime of pharmaceutical intervention might not be all it’s cracked up to be. You can purchase Andrew's book here: https://factuallypod.com/books Learn more about your ad choices. Visit megaphone.fm/adchoices See Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

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So if all of that sounds good, if you want a big box of delicious snacks like this for yourself, use the code factually for $15 off your first order at Bokksu.com. That's code factually for $15 off your first order on Bokksu.com. I don't know the way. I don't know what to think. I don't know what to say. Yeah, but that's alright. Yeah, that's okay. I don't know anything. Hello there. Welcome to Factually. I'm Adam Conover. Thank you for joining me on the show once again. As I talk to, you know the deal, I talk to an amazing expert from around the world of human knowledge about all the amazing shit they know that I don't know, that you might not know. All of our minds are going to get blown together. We're going to have an incredible time. Now, before we get going, I just want to remind you that I am going on tour this summer. If you live in or near Phoenix, Arizona,

Boston, Massachusetts, Arlington, Virginia, Nashville, Tennessee, Spokane, Washington, Tacoma, Washington, or New York City, head to adamconover.net slash tour dates. You can see me do a brand new hour of standup. I'm so excited for you to see it. If you come out, I'll shake your hand. I'll take a selfie with you. It's going to be wonderful. Please come out. And just to remind you, if you want to support the show, the best way you can do that is by signing up for our Patreon at patreon.com slash Adam Conover. You'll get bonus podcast episodes, exclusive standup I don't post anywhere else. And you can join our live community book club where we read a nonfiction book together and discuss it with the author. We just had our book club session for Judith Krizell's Never Enough, The Experience and

Neuroscience of Addiction. And our next book, which we'll be meeting about in August, is T. Nguyen's Games, Agency as Art. We had such a blast talking to him on this very podcast that now we are all reading his book together and chatting with him about it live. If you want to sign up and get all those awesome perks, head to patreon.com slash adamcounover and a thank you for doing so. Now, on to today's episode. Today, we're talking about mental illness. You know, mental illness is something that humans have been struggling with for literally as long as there have been humans. Schizophrenia, mania, depression, all of these issues have bedeviled humans throughout our entire history, and we have tried to cure them for just

as long. But the sad truth is, after millennia, we still have really no effective treatments for them. For real, practically none. And it's not as though we haven't tried. Going back to the dawn of history, when people weren't acting right, they would literally do surgery on each other's skulls. This was called trepanation, and it involved cutting out a chunk of a person's skull to change their behavior. And, you know, it probably did change your behavior, but not for the better. In the Middle Ages, mental illness, like other illnesses, was attributed to an imbalance of the different fluids flowing through a person, the humors. And this meant the cure for a serious mental illness might be bloodletting or inducement to vomit. Not a pretty picture and also not very helpful in curing

bipolar disorder. But as silly as those remedies seem, they are not much worse than what came next. In the modern period, the idea arose that you could just push all the mentally ill people into a filthy asylum. And then there they might be, well, if not cured, just sort of kept away from everybody else. They treated it more as a storage problem than a human one. After that, we got Freudian analysis, which is very interesting in a literary sense, but, you know, not really super scientific psychology per se. And then, finally, we entered the era of modern psychology and a whole new suite of bonkers treatments. From removing teeth, to putting the mentally ill into comas, to electroshock therapy, and of course that iconic modern update of trepanation, the lobotomy.

Now today, as I speak to you in 2022, our most recent approach is mass pharmaceutical intervention. We drug people who are mentally ill. And all you really need to do is look around to see that it's not really working. I mean, everyone is screaming from the rooftops that we have a mental health crisis, rates are as high as ever, and we are not making a dent in them. The sad truth is that mental illness is just one of the most complex, difficult, intractable problems facing human medicine. There are no easy fixes, and unfortunately, we're also pretty hazy on what the complex, difficult fixes might be. Which is why I get so frustrated when people blame social problems like homelessness or gun violence on mental illness and say we need to solve mental illness before we can solve those

problems. Oh yeah, just solve one of the most intractable problems in human history, we'll get right on that. Do we need to cure cancer too before we can treat people's toothaches? Like what the fuck? Now look, I may be overstating the case a little bit. We do understand more about the human brain and the human mind than we did centuries ago. But we still have to grapple with how little we actually know if we're ever going to get closer to solving this problem. So to walk us through the unsparing history of mental health treatment on the show today, we have a world-renowned expert. On the show today, we have a world-renowned expert. Andrew Skull is a professor of sociology at UC San Diego, and he is one of the foremost historians of medicine and madness.

His most recent book is Desperate Remedies, Psychiatry's Turbulent Quest to Cure Mental Illness. It is beyond an honor to have him on the show today. Please welcome Andrew Skull. Andrew, thank you so much for being on the show. Thank you for having me. So you've written a book about the history of psychiatry and our attempt as a society to treat mental illness generally. I have to say that I don't always feel that we as a society are treating mental illness particularly well, especially here in the United States. You may feel differently in England, but I'd just like to ask, does psychiatry work? Are we helping people? Are things better than they were in the past? Well, let me say this. I'm not somebody who's

written a book that's a narrative of straightforward progress from early darkness to modern scientific enlightenment. But I'm also not somebody who's a technological lud. I don't think there's been zero progress, but I think it's easy to exaggerate how much progress we've made. One of the things that fascinates me about the problem of serious mental disturbance is how difficult it is, how many smart minds have tried to come to terms about where these terrible kinds of suffering come from. And while we still don't know, if you ask, what's the cause of schizophrenia? Presuming we can take these labels at face value for the moment, what's the cause of schizophrenia? What's the cause of bipolar disorder? Why do people become depressed? The answer is we don't really know. And because of that absence, we have some clues, we have some speculations, we have a profession in psychiatry that over the last 40 or 45 years has placed all its bets on biology

as the sole answer to these problems, which I think is a mistake. But the answer is all the work we've done in neuroscience, in genetics, other attempts to understand the neurobiology of the brain, understand the neurobiology of the brain, as yet have led to very little progress. And that's obviously hampered our ability to treat diseases. It's not unknown for medicine in general to not know the causes of a disease and yet be able to come up with effective treatments. The history of psychiatry, as I show in my book, is that in the desperation of patients, families, and the physicians themselves, we've often resorted to some pretty extraordinary

measures which often have harmed rather than helped the patient. We live at the moment, of course, in the era of psychopharmacology. The era of drugs is the primary way we treat serious forms of mental illness. And unfortunately, those drugs arrived on the scene, whether you look at antipsychotics or antidepressants, they arrived on the scene, whether you look at antipsychotics or antidepressants, they arrived on the scene in the 1950s. And we haven't got better drugs now than we did then. And the drugs do help some people quite a bit. They help relieve symptoms. They're not penicillin. They don't cure, but they do make it easier for some patients to live with their mental illness. They damp down, for example, with schizophrenics. They help to relieve to some degree the hallucinations and the delusions which plague them, but they don't really deal with the more

negative symptoms of schizophrenia, the loss of pleasure, the kind of confusion of thought and language, the social isolation, those kinds of things, the drugs we have simply don't touch. And then there's another problem, whether you look to the antidepressants or the antipsychotics, they come with a lot of side effects. And you have some patients for whom the side effects are manageable, and the drugs help, if not cure. And those are the lucky ones. And we need to recognize that that's the case then there are a group of people in the middle for whom the side effects are so bad that on balance it's hard to recommend the drugs yeah and finally at the other end there are a group of people who simply don't

respond at all and what they get are the side, which can be life-threatening. So with current antipsychotic medications, so-called second-generation or atypical antipsychotics, people tend to experience massive weight gain, as much as 30, 40, 50 pounds within a year. They develop diabetes. they develop heart problems. So the trade-off, I mean, with all medications for psychiatric illness or for regular illness, you know, there isn't a free lunch. Drugs of all sorts come with potential side effects, but the ones we've got to deal with psychiatric illness, they're the best thing we have, but they only work for some, and they come often at very, very heavy price. So that side of things is difficult. And in the present, the major drug companies who have made billions of dollars off these drugs have decided that they don't have an obvious way forward. This isn't an area where they want to invest research dollars. And basically, they've

disbanded research. So that's a real problem. In the pills for those conditions like schizophrenia? Yes. So if you look at a company like Pfizer, for example, they've essentially disbanded their research on treatments for mental illness. Wow. So we're stuck with things that offer some relief to some people and where the next improvements, assuming that you can rely simply on drugs, which I think is an oversimplification. But even if you assume that drugs are going to be the answer, the real problem in 2022 is that the places with the most research funding have given up. They've said

we've suffered reputational damage because we mess with the research around these drugs. In some cases, companies have been fined billions of dollars for mismarketing, for suppressing research that didn't meet their needs. And they've just moved on. And they found other areas that are much more lucrative, much more promising from their commercial point of view. But that leaves them at the heel in this very unsatisfactory situation. Yeah. I mean, just reading, your book is just out. And so I've only had a chance to read the introduction, but you talk about how our treatment of mental illness has really transformed over the past, you know, it's gone through

different phases in the past few centuries. And when I look at that, I think that, okay, there's some similarities to the rest of the medical world. For instance, we used to believe in the four humors and balancing the humors, right? And, oh, well, they were able to cure some things that way, but obviously it was ultimately pseudoscientific and our understanding of the body has improved. And now diseases like cancer, for instance, even though we don't have a quote cure for cancer, our treatments are so much better that, you know, survivability rates have skyrocketed. We've, we've improved in all these specific ways in psychiatry or our treatment of mental illness.

We've gone through these stages, like, I mean, just starting from Freud and, you know, the talking cure, oh, you can cure everything just by sitting someone on a couch, talking to them. Maybe occasionally they snort some Coke or something as, as Freud liked to do, I guess. But, you know, and then through, you know, there's like behavioral psychology and, you know, being Skinner and all those folks. And then today we've got, you know, the exact opposite of Freud, which is give people pills and never talk to them again. And the question for me is have, you, you know, the rest of medical science has clearly progressed. We have not cured everything, but we have figured out how to cure so many or treat so many diseases. Have we actually made progress in psychiatry?

You know, it's very, very difficult. This brings up the question of how we diagnose illness. up the question of how we diagnose illness. And in the case of most physical illnesses, we have tests, we have visual confirmation via scans, we have blood assays and so on that allow us to uncover a pretty good sense of what causes these illnesses and our definitions of illness are tied very much into our understanding of the underlying pathology. But in the case of psychiatry, we don't have that understanding. And so what psychiatry relies on to make its judgments about what's wrong with somebody are the symptoms that the patient reports of the era of the four humors and blood and bile and so forth being the operative factors. Back in the 18th century when doctors looked at patients,

they said, do they have a fever? Are their eyes yellow? Is their pulse quick? They looked at those things, and they didn't really have an underlying understanding. They thought they did, but they didn't. And so they would classify things. For example, they talk about somebody having a fever. Well, a fever is a symptom that could be caused by a whole variety of things.

a symptom that could be caused by a whole variety of things. And so lumping things together like that, or talking about dropsy, which very often was caused by heart problems, your heart wasn't pumping, but it could be caused by a multitude of other things. So the way they categorized disease back there then was very much based on symptoms. And that's what American psychiatry, indeed psychiatry everywhere, has been forced back on. And it's not clear that judging by symptoms, you're really cutting nature at the joints. You're actually identifying real diseases. What you may be doing is lumping in many different things under a single label. Yeah. So when the term schizophrenia was invented back in 1910,

the person who invented it, a Swiss psychiatrist named Bleuler, didn't refer to schizophrenia. He called it the schizophrenia plural because it seemed such a protean disorder with so many manifestations. Lots of psychiatrists now are beginning to ask themselves and have been for the last 20 years whether schizophrenia really exists. One of the striking things when the American Psychiatric Association published the fifth edition of its Diagnostic and Statistical Manual, a lot of words, we usually say DSM, in 2013, the then head of NIMH, the National Institute of Mental Health, Thomas Insull, said this is a scientific waste of time. There's no such thing as schizophrenia. There's no such thing as depression. There's no such thing as a bipolar disorder. Well, the Scientologists will have loved that statement. If I know what he was getting at, the suffering is real. The ways we've categorized it may not fit. And when you're chasing the cause of schizophrenia, may not fit. And when you're chasing the cause of schizophrenia, and maybe schizophrenia doesn't exist, you're not going to find it. You're chasing after something that's elusive and not likely to

be found. So Insult's solution was to say, well, we need a new diagnostic system based on biology. And that's exactly what the American Psychiatric Association had hoped they could do when they issued this manual in 2013. But the reality was the science wasn't there and it isn't there. And so they're forced back on using symptomatic diagnoses, and diagnoses play a variety of roles for the scientists and for the patients. For the scientists, it may send them down the rabbit hole, down in the wrong direction, but for patients, getting a diagnosis, this was true in the 18th century when patients got diagnosed and then bled and purged, at least gave them a sense, oh, somebody knows what this is. I have a label for these terrible things I'm experiencing.

And maybe they know something about how to deal with it. And that's not entirely false. But unfortunately, what we know is extremely limited. And looking back at the past, extremely limited. And looking back at the past, what we have to say in the 20th century is that desperation, that sense of we've got to have something to treat these conditions with, coupled with the fact that mental patients tend to lose agency. They're treated as things, not people. Their wishes, their beliefs are dismissed as pathological. And so, they're a very vulnerable group. And what we see before the Second World War is a whole string of what the title of my book refers to as desperate remedies, attempts, because psychiatry at the time, as today, thought things were rooted in the body, they looked to try to attack where they thought the pathology lay. An extreme example, Henry Cotton and his followers, Henry Cotton was a superintendent of Trenton State

Hospital in New Jersey, thought that mad people's brains were being poisoned. And that's why they behaved and thought and felt as they did. Where was the poison coming from? It was coming from low-grade infections in the body that were releasing toxins into the bloodstream and poisoning the brain. Pre-antibiotics, what do you do about that? You resort to what Cotton called surgical bacteriology. When I translate that for you, that meant pulling the patient's teeth, taking out their tonsils, and when they didn't get better, arguing that they'd swallowed the germs down into their gut. So you took out stomachs and spleens and cervixes in the case

of women and colons. There was this program of surgical evisceration, which killed, I know from my research is killed about 45% of the patients who underwent the most serious treatments. And Cotton was proclaiming he was curing 85% of his patients. But actually, he was maiming and killing them. And that went on. Well, in New Jersey, the pulling of teeth and tonsils and so forth forth went on until 1960. So all the way to almost the present. You know, I'm reminded of, and I think I'm going to talk about this in the intro to this episode and my

introductory monologue, but I grew up on Long Island and near me there was an abandoned mental hospital on Long Island. I'm blanking on the name of it, but it was a large- Pilgrim, perhaps, or Central Islet. Say the name again? Central Islet or Pilgrim State Hospital might have been. That sounds right.

They were one of the largest in the world. I remember going there because I knew an older girl who would do urban exploration, and she took me into it once we snuck onto the premises and we walked around this abandoned asylum and she told me uh you know this was once the lobotomy capital of the country that they did more lobotomies here than than anywhere else that you know hundreds thousands of lobotomies were done um and that's you know that always stuck with me as you you know, this was a extremely common treatment for certain mental disorders, but also certain things that were not disorders at all.

There's the famous case of, is it Rosemary Kennedy, the Kennedy sister, who received an unnecessary or what we'd now probably consider an unnecessary lobotomy. I think every lobotomy was unnecessary. Okay. Yes. It won, of course, the Nobel Prize in Medicine in 1949. Really? I didn't know that. Yes. And it had been invented, it had been first tried by a Portuguese neurologist

who had arthritis, and he used a surgeon to inflict the first lobotomies in Portugal in 1935. But it was brought to America by a man named Walter Freeman, who practiced medicine in Washington, D.C. And his partner, who was a neurosurgeon, who were a relatively rare breed at that time. neurosurgeon, who were a relatively rare breed at that time. And initially, Jim Watts, who was the neurosurgeon, did the surgery. Freeman was a very impatient man, and he wanted lobotomy to become, he thought it was the cure for all sorts of mental disorder. And he became very impatient with an operation that took two or three hours and required lots of operating theater and attending staff to perform. And he developed something called the transorbital lobotomy, which is one of the more awful experiments on the mentally ill that I can recall.

That involved using literally the first time he did it, an ice pick from his home and a hammer. And he zapped the patients twice with electroshock, which rendered them unconscious, peeled back their eyelid, inserted the ice pick into the bone, banged with a hammer to break through the bone. The bone is quite thin there. Wiggled the instrument around and then did it to the other eye.

Wow. So this was a lobotomy. Sometimes he did 20 or 30 of these in a day. Wow. He said he could teach any damn fool to do this in 20 minutes, including psychiatrists for whom he didn't have much regard. So, there were large numbers of lobotomies done. They were disproportionately done on women, and that's a feature of many of these extreme treatments that I talk about in the book,

that women, for some reason, are the ones, they were a minority, a small minority, you know, it's almost 50-50 in the state hospitals, men and women, but women got almost two-thirds of the lobotomies. Wow. When Henry Cotton did his operations, again, about 60% of his patients were female. operations, again, about 60% of his patients were female. So that's itself a very interesting feature of this, how over and over again, you see that pattern emerging. And a lot of us have tried to grasp why that would be. And obviously, to some degree, it was because women who acted out were seen as more troublesome. And also, with respect to lobotomy, the sense was that, well, you could return a woman to be

a housewife, and that didn't require much initiative. That was a pretty low-grade job. Whereas these men, they had to go back to work in the real world. And so that, I mean, Friedman recognized that lobotomy caused defects, but he argued that the defects were better than being psychotic. And he persuaded large numbers of people in all the major medical schools, Harvard, Yale, Columbia, Pennsylvania, they all had very active lobotomy programs in the 1940s and into the 1950s. What was the theory behind this procedure? What was it meant to treat and why did they think it worked? Very empirical, but the notion was, at least among Egas Moniz, the Portuguese who invented this awful thing, that the frontal lobes were kind of the area where the executive functions of the brain lay. And mental patients, the connections

between those frontal lobes and the rest of the brain had got tangled and were working in a bad feedback loop. And you could interrupt it by severing the connections in the brain. So that was one theory. After the war, some, many psychoanalysts, I should say, bitterly opposed lobotomy. They thought it was a category mistake. You couldn't cure a psychological illness by damaging the brain. In fact, damaging the brain was, they argued, quite criminal. But others of them actually provided a psychoanalytic explanation for why the bottoming worked. The frontal lobes were the superego. The ego and the id resided further back in the brain.

And the superego got out of control. And so you had to cut it off, literally. And there was a diagram published in Life magazine, which was a big circulating magazine in the 40s, showing exactly that. It was sort of a brain. They had captions coming out of it. Here's the superego. Here's the ego.

Boom, we cut off this thing that's ruining this patient's life. So that's wild to me because you've got what you know, what is essentially a pseudoscience. I mean, Freudian psychoanalysis has many things to recommend it. But I think the idea that, you know, the superego lodges somewhere in it. Now, it's nice to understand the superego as a literary device or a way of understanding oneself. Certainly not a physical place in the brain. And then that is interacting with a, I don't know if you want to call it pseudoscience,

but certainly bad science of the physical lobotomy. And then it's being spread in the largest circulated magazine in the United States within living memory. You know, like some of the people who committed these, these, you know, atrocities are still alive today. Right. William Scoville at Yale was still performing lobotomies in 1970. Wow. And then he was killed in a car crash. He drove very fast cars on this occasion.

He was by then in his 70s, and he was killed, which maybe spared some patients from his attention. But yeah, these are almost within that. I've interviewed survivors. There was a late case of Walter Freeman's. I did a program. I was part of a program on PBS called Lobotomous, which was about Walter Freeman,

based on a book by a journalist named Jack Elhage. And on it, Freeman's children appeared, one of whom's professor of neurology at Berkeley, and a patient, a young boy who was 11. His parents divorced. The new stepmother found him a pain in the ass. He acted out, as 11-year-olds sometimes will, when their parents' marriage breaks up. He decided he should have a lobotomy. And Howard Dully, as he was called, was taken at age 11 and given a lobotomy, which damaged him for the rest of his life. He's written an account of it with the co-author.

And it was an enormously sad case. I mean, you looked at this and you thought, my God. Freeman operated on children as young as four. Wow. And it just said, well, you know, children's brains are still developing, so we can do more damage to them, and they seem to recover. And they've been a pest and a nuisance. Maybe they're autistic in modern-day terminology.

And once we do this, they become placid and sort of like a pet. It's really extraordinary because all this stuff was appearing in the medical literature. Freeman even made movies of him in action, and one of them was broadcast on television in the late 1940s. Now, very few people had TVs, but you couldn't broadcast that today. When the documentary was made about Freeman, they had that footage. And I talked with the directors whether they'd use it. And they said, well, maybe we'll put it on a monitor in the background so people aren't focusing on it. And I think in the end, they just thought it was too disturbing. But this stuff wasn't hidden away.

You know, it was widely publicized. When Henry Cotton was ripping teeth and tonsils and stomachs and colons, the New York Times was publishing a review, lauding him as a great medical benefactor, pioneer. He went off to England and the great good of British medicine compared him to Lord Lister, who'd introduced antisepsis into surgery and allowed surgeons to develop. Cotton was seen as the psychiatric equivalent. And in fact, what he was doing was maiming and killing everybody he set his hands on. And it went on and on and on. There was an investigation undertaken by Phyllis Greenacre, who later became a leading psychoanalyst, but at that time was working at Johns Hopkins, the best medical school in the country under the best known psychiatrist for the first 40 years of the 20th century, Amanda Adolph Meyer. And she reported exactly what was going on,

and Meyer suppressed the report. And not only suppressed the report, but when Henry Cotton died of a heart attack, Meyer wrote an obituary in the American Journal of Psychiatry saying what a tragedy it was that this experiment had been cut short. So, really an extraordinary history. And, you know, you'll see it. One of the most gruesome passages in the book, and I apologize to readers, but you need to understand quite how dreadful this was. Freeman and Watts used to form lobotomies very often under local anesthetic. The brain doesn't have pain thresholds. So, they drill through the person's skull and insert the knife and do their damage. And while they were doing that, they were talking

to the patients because empirically they had decided that when a patient started to get confused, it was time to stop severing brain tissue. It was that proof. And so Freeman recorded these things. And there's an operation on a railroad brake man named Frank. And in the operation, he's saying, stop, stop. And they just keep going. Wow. And then another one, they're in the midst of the operation, and they say, tell me, Mr. Jones, what's passing through your mind right now?

And there's a pause. You're a comedian. You wait to deliver the punchline. Yeah. Mr. Jones says, a knife. Okay. Yeah. Exactly.

One way we cope with the horror, and again, as a comedian, you'll know that, difficult subjects, we deal with humor because the reality is so painful that we just recoil and go, how could this happen? But this wasn't even a way. It really wasn't. And after 14 years of this, the Nobel Prize Committee in Stockholm decided, oh, this is the major medical innovation of the year here. Unbelievable. We have to take a really quick break. But when we come back, I want to talk about how that incredible story bears on our current understanding of psychiatry and of mental illness. And how, how much more advanced than that are we really, but we have to take a really quick break. We'll be right back with more Andrew Skull.

Okay. We're back with Andrew Skull. And we just got done talking in very gruesome detail about the horrors of mid-century lobotomies and that kind of psychiatric practice. And what really strikes me is, this was a pseudoscientific practice based on a misunderstanding of how the brain and the mind worked. And we like to think that we're more advanced than that. Again, even though, you know,

the, the, this is again, still in living memory. This was only in, you know, this was happening as late as the seventies. We like to think we're more advanced than that. But when I think about, you know, how little we understand about brain disorders, about mental illnesses, about learning disabilities, about all of the different, you know, ills and differences of the mind. Our understanding of neuroscience is advancing, but it's still very, you know, we're describing the pine needles and we're not able to see how they add up to the forest in many ways when it comes to neuroscience. pine needles and we're not able to see how they add up to the forest in many ways when it comes to neuroscience we've got cognitive psychology which is very interesting and promising but is often you know often ends up mixing metaphors with you know your brain is like a computer and that

sort of thing and you know sort of another misunderstanding of the mind you've got psychopharmacology which says well okay this drug seems to work. We don't know why. And it has side effects. You've got the DSM-4, which is, or sorry, the DSM-5, excuse me, which describes symptom after symptom after symptom, including, you know, we talked on the previous episode of the show, I have attention deficit disorder or what's now called ADHD.

And that's a condition where it's a bundle of symptoms. They don't know a cause, right? They have various treatments. They know, they seem to work for some people. They're not really sure why. And so it makes me have to ask, like, are there procedures comparable to the lobotomy that we're performing today?

Are there drugs that we are giving people where in 50 years, we're going to say, what a horror that we did that, or at least what a mistake that we gave people these drugs for these conditions. Do we really understand the mind as well as many think we do? Well, this is obviously a fascinating area. I guess the first thing I'd say is that the advent of the drug era was an accident. Nobody expected, thought about drugs as a treatment for mental illness.

They used opiates to calm patients down. They used sleeping draughts to put them, you know, when they're agitated. But the idea that drugs might actually treat mental illness, it was pure serendipity. A French company, Roncolac, was messing around with antihistamines, looking for something that might work.

Initially, they thought as a potentiator for anesthesia, if you've ever had general anesthetic, you'll know it's a poison. You're glad to take the poison as opposed to lying awake and sentient, feeling everything while they're cutting you. But after you come around, until your body gets rid of the residuals, you often feel pretty groggy and nasty from the after effect. So the idea was that maybe if they use a chemical which had first been identified in the 1880s in Germany and nobody had a use for it, but if they use this, which was an antihistamine, they might be able to get away with lower doses of anesthesia and that that would help the patient. It was a reasonable hypothesis. They also thought it might be useful for a variety of other things. For example, for itching, you know,

people have skin disorders. Anyway, in those days, there were no formal procedures around clinical trials. Drugs sort of just migrated out of the drug companies, laboratories. People said, here, try this, try that. And it just so happened that a French naval surgeon tried this drug on some disturbed patients and they calmed down. He said, well, it's like a chemical lobotomy because lobotomy wasn't a bad word at that point. And he passed it along to a relative whootomy because lobotomy wasn't a bad word at that point. And he passed it along to a relative who worked in the major mental hospital in Paris. And it seemed as though it did calm the patients down.

In fact, calm them down to such an extent that the term chemical lobotomy wasn't completely misplaced. And it was from there that drug, that antipsychotic drugs emerged. Similarly with antidepressants, they were trying a drug to treat tuberculosis, which is still a serious problem in those days as it's becoming again with drug resistant versions. And they gave this drug, which they're hoping to use to cure the tuberculosis, to a bunch of patients with advanced TB who started acting happy. How are these patients who are facing this grim future suddenly in this much better mood? And that was where the first antidepressants came on the scene. So these were accidents. After the fact, they started to say, well, why do these things work?

And that's when modern neuroscience began to emerge. So you're looking at things after the fact saying, well, why is it that Thorazine, the earliest of these antipsychotics, why does it work? And so there was, at that point, the brain was largely seen as an electrical thing. Electrical signals between the cells were what drove the brain. Instead, now there was this emphasis on discovering neurotransmitters. I wish it turns out there are quite a few. And so we got, after the fact, attempts to construct explanations of the disease because the drugs worked in particular ways on particular neurotransmitters. The most famous example occurred at the beginning of the 90s,

where serotonin was alleged to be the thing that caused depression. You didn't have enough happy serotonin in your brain, and that's fine. Well, it turns out that's scientific nonsense. in your brain and that's fine. Well, it turns out that's scientific nonsense. The drugs do indeed, well, some of them affect serotonin and increase it, some of them decrease it. They both work equally well or equally badly. And there are lots of reasons not to believe that story. But as a marketing thing for the drug companies, that story was tremendously powerful. It also was embraced by patients and their families because it was somewhat destigmatizing. Yes. I remember in high school and in the nineties, I had friends who were on antidepressants and they would tell me, oh yeah, it's because I don't have enough serotonin in my brain. And

this floods my brain again with serotonin. And the thing is like, first of all, I now know that that's a very simplistic way of looking at the brain and is not, you know, there's only a couple of neurotransmitters and like, you know, these things can't just, it's like the four humors all over again. It's like, you have too much bile, you have not enough, you know, black bile or whatever it is. But I still hear people say that. And in fact, I hear people say that about modern drugs that, oh, you don't have enough dopamine or this floods your brain with dopamine or it's similar sort of- Yes, with schizophrenia, dopamine, many, but not all of the drugs act on the dopamine receptors in the brain. And for a long time, there was that narrative, and people chased it.

And Carlson won a Nobel Prize for his work on neurotransmitters. It became a very hot thing. And we've learned a lot more about how those work in the brain, but those stories have been embraced by lots of people and they're a story still told by the drug companies, but scientifically they're nonsense. But they are, as I was saying, there's so much stigma attached to mental illness.

And when people are depressed, for example, the common reaction is, oh, just pull yourself together, you know, this is ridiculous. Well, that's completely, I mean, it's not that simple, let's put it that way for people who are badly depressed. And that suspicion of them that since they might be malingering, this isn't real, it's all in between your ears. To have a story that says, no, no, no, there's something physically wrong with my brain and a drug can fix it. That's a very powerful story. It's one for the patient that says, your illness is very real. It's not your fault. It's

not your parents' fault, which is something that mattered a lot to parents of depressed children, who otherwise being told by the Freudians, it was, you know, because they were refrigerator mothers or whatever. No, you actually have this deficiency in your brain and we can fix that with a pill. Yeah. Lovely story. Wish it were true. Wish those drugs worked without nasty side effects. But all of that is just marketing copy. It's bad science, but it's great marketing copy. It reminds me of when you watch a commercial for, you know, say a stomach

medicine and it says, oh, it goes down and coats the walls of your stomach. And they show you a little diagram of this cool blue liquid entering your stomach and sort of coating the edges and the angry redness goes away. And you now have a mental picture of when I take this, this is what's happening. And that's very comforting. And it helps you understand, Oh, next time I feel that feeling, Oh, there's an angry redness down there. I need to get the cool blue stuff. And, and this provides the same thing to people and it's very comforting, but it is sounds very similar in many ways to, Oh,

the lobes of your brain have gotten snarled up and we need to separate them with an ice pick, right? Yeah, it's, you know, narratives are very powerful things. Telling stories about mental illness and where it comes from are, I mean, they're things that, one of the problems for mental illness that all of us, when we see it confront, it's so baffling.

It's so alien. It's so distressing. It's so, it disturbs the normal texture of being. It looks like people don't share the same common sense universe as the rest of us. And to have a narrative that explains why that is, is very powerful. That's why I think psychoanalysis, which enjoyed a heyday in America from the end of World War II until sometime in the 1970s before it collapsed, it told stories. I mean, Freud himself said, because he was rather annoyed about this, he said, look, what I wrote right about when I discussed these patient case histories sounds like a short story or a novel. Well, that's not my fault. That's because that's the nature of the disease we're talking about. So he was explaining and telling a story

in terms of psychodynamics. These guys are telling a story in terms of brain biochemistry, but the brain biochemistry, it just doesn't work. Again, when Insel stepped down, he'd run the National Institutes of Mental Health for about a dozen or 13 years, stepped down in 2015. And he gave an interview. And I thought it was a striking example. He's out peddling a book now about how we should move forward in the treatment of mental illness. Well, he was in charge for that long. He said, well, you know, I spent a lot of money while I was the head of NIH. Oh, he said roughly $20 billion or maybe a bit more.

And I funded a lot of very cool science, a lot of cool genetics, a lot of cool neuroscience. And so far as the mental illness was concerned, none of this did any good whatsoever. We learned nothing that was clinically useful. The head of NIMH said that. Suicide rates went up, life expectancy went down, and we kept plugging away, pouring money down these holes. And his successor, Joshua Gordon, is doing exactly the same thing. And it's extraordinary. You know, it's the old doing the same thing over and over again and expecting a different result is sort of insanity. Not to say we shouldn't be doing some basic research along these lines, because it would astonish me with the really

serious kinds of mental illness if there weren't some biological component. But it's wrong to put all your eggs in that one basket. Leon Eisenberg at Harvard once said something very witty, but also very profound. He said, we've gone from a brainless psychiatry to a mindless psychiatry. Meaning, when Freud was dominant, everybody ignored the body. It was all a matter of psychology. It was all a matter of psychology. When we swung back to biology, we ignored the social and the psychological elements of mental illness and just thought the whole thing was explainable in terms of damaged brains. You wrote in your introduction that since the collapse of psychoanalysis,

that now something like a very small percentage of mental illness patients or psychiatric patients go through any kind of talk therapy at all. The ones who do predominantly pay for it themselves rather than have it be covered by insurance. Insurance covers it less. And many more people now are being prescribed drugs without any talk therapy, without any psycho, what we would formally call psychoanalysis. without any talk therapy, without any psycho, what we would informally call psychoanalysis? So we know that back in the 60s, the average encounter between a psychiatrist and patient lasted between 45 and 60 minutes, the classic analytic hour. Nowadays, we're talking five to 10 minutes under the impact of managed care. Now, it's not quite true that patients aren't

getting psychotherapy, but they're not getting it increasingly from physicians, from psychiatrists. One of the other stories that I tell in the book is the rise after World War II of clinical psychology and the development of techniques like cognitive behavioral therapy and related attempts, which were quite different than psychoanalysis. Psychoanalysis treated the symptoms of the disease as just the things that brought people to their attention and were the underlying causes weren't the symptoms. They were something much deeper about somebody's personality. Cognitive behavioral therapy and the kinds of techniques that clinical psychologists

use treat the symptoms. What they want to do is make the symptom go away. And for certain things, we can see that and it actually seems to work. For example, a lot of people are frightened stiff about getting on an airplane. Right. They have fear of flying.

Right. And they can be desensitized. Not everybody, but significant fractions. And it's not just being frightened as the partner of someone who who has faced this it's it's anxiety it's panic it's discomfort it's you're you're you need to fly but you're in a total panic the entire time you feel your body starts reacting you know yes you can you're you're tense you're you're sometimes even vomiting out of fear.

Yes. And, yeah, so, you know, analysts were scornful. They said, you know, when you treat symptoms, you're playing whack-a-mole. You'll get rid of this symptom and another one will pop over here because you have, you know, this is reflective of your underlying personality disorder. The insurance companies didn't like psychoanalysis. Woody Allen notoriously has been in psychoanalysis for most of his adult or semi-adult life. It goes on and on and on. CBT and its analogs, by contrast, have some basis in the laboratory. They seem to have some findings behind them.

They're relatively short term. They work on the symptoms. And if you're lucky, the symptoms abate. And there you go. There you go. The second thing that attracts insurance companies to this is that MDs require a certain level of compensation that PhDs aren't used to getting or are willing to settle for less. So clinical psychologists are less expensive. It tends to be a profession that's heavily female. And one of the things my sociological colleagues have demonstrated over and over again is when an occupation becomes

heavily feminized, its pay and working conditions suffer. So you can get away with paying a clinical psychologist 100 bucks for an hour session. You can't get away with paying a clinical psychologist 100 bucks for an hour session. You can't get away with paying an MD for that. So those MDs who still practice psychotherapy of various forms are a vanishing breed. But the ones that do it tend to not take insurance. And so it's patients with resources who go to them and are willing to pay out of pocket. So, you know, that's another complicated aspect of the story.

And again, as with the drug treatments, CBT and other kinds of psychotherapy, well, one of the findings is it almost doesn't matter which flavor you get. Results tend to be very similar. You can get a watered down version of psychoanalysis. You can get interpersonal therapy. You can get cognitive behavioral therapy. They all work about the same, even though they're quite different. And they all work only a bit. They work for some people and they work for some conditions, but not for others. And there are so many things that remain, you know, besides we've talked about bipolar and schizophrenia and depression, but autism is a major source of suffering and an exploding condition if you look at the statistics, whatever that means.

tremendously uh children now being diagnosed with pediatric bipolar disorder and a disease invented at harvard by a dreadful man uh named biederman who was taking money under the table from the drug companies and publishing work that really was non-scientific and uh basically marketing copy for the drug companies for which he's being paid quite handsomely. Yeah, I've heard about that case. So, you know, you'll see that story in the book. Marketing has become a vital part of not just psychiatry, of course, but medicine in America. We all, if you sit and watch television for very long, you'll be bombarded with advertisements directed at you, the consumer, about a remedy for some disease. You talk about stomach things, erectile dysfunction, you name it.

Look, it's on social media, you know, my friends are constantly talking about it. The media is, those patients go to the doctors and ask for the drug. Yeah. And so it's a very effective technique, even though those ads are usually lies. Interestingly, that whole line of disguising what really is marketing as science has its origins with Arthur Sackler of the Sackler family, who, as you know, were heavily involved in creating the opioid epidemic. Yes. Bill Sweets, the country. And Sackler was a master. He ran advertising agencies, and he created a journal which looked like a scientific journal, but actually was paid copy

for the drug companies. There's a lot of bad stuff that happens out there. So look, so we've talked a lot about all of this bad stuff. And by the way, the ads are not just on television. They're on social media. I have so many friends who everyone is, you know, you go on Tik TOK and you you're bombarded with videos telling you that you have ADD. If you happen to lose your keys every so often or have trouble focusing during a meeting, you need to take medication like it's true. And we've adopted it into our own practice as well.

Like I have, you know, friends, even myself, I'll find myself parroting these, you know, these sort of media claims. But, you know, we've talked a lot about the negative parts of it, of how, you know, how bad our understanding is, how, you know, little basis there is for many of these treatments. But I do want to talk about, you know, there are millions of people making a good faith effort to understand the brain better and to understand their patients. And there's millions and millions of patients who are simply trying to understand themselves better and to understand their patients. And there's millions and millions of patients who are simply trying to understand themselves better and who, you know, I'm sure there's plenty of people listening who, you know, take one of these medications, who work with a psychiatrist,

who feel that it helps them. Maybe it doesn't help them perfectly, but they're trying to weigh, my God, are the side effects worth the benefits that I feel? And, you know, they need relief. Yes, absolutely. Absolutely. So how do we make our way through this system when we, you know, desperately need these treatments? And some of them claim to work and maybe do, but how do we tell the difference? Right, right. Well, a couple of observations, and of course, you know, living with a COVID world and all the social isolation that's come with that, reported levels of, you know, mental pathology have been trending upward considerably, which shouldn't be a complete surprise. One of the real problems, I spoke earlier of these sort of three different groups of patients, a group of patients who benefit unambiguously, some for whom the trade-offs are very close and difficult to manage, and another group for whom these treatments just don't work at all.

work at all. Part of the problem is we don't have at the moment any way to tell in advance which group of people a given patient is going to fall into. So one of the things that might be nice and some of the defenders of genetic research have been, well, maybe we'll find something that allows us to predict before we administer the pills, which ones will work with which patient. Maybe. It's a promissory note. If you're suffering very badly, I'm not a clinician and I'm not giving people clinical advice, but I would look at it and say, for many patients, it's worth the gamble. And for some of them, that gamble

will pay off, and they'll be improved, they'll feel better. And besides that, you've got to have psychiatrists who are watching those patients very carefully, trying to figure out whether this is actually going to work in those cases, and if they need to taper off the drugs rather than stop them abruptly, you know, how to manage that. Beyond that, I'd say a lot of the problems of people with serious mental illness extend beyond the individual pathology. This has very profound effects on families, on communities, and on the patient. And we should be looking for ways to alleviate some of those problems, which are more social and psychological in nature, not so much physical. And by neglecting those kinds of things, we are making, that seems

to me, a big mistake. We're leaving people with more suffering than need be because the remedies we have are at best a band-aid, a partial fix. Again, you can look to, you know, I remember where I was. I'm not a big basketball fan, but I remember when Magic Johnson was announced to have AIDS. And AIDS at that point was a death sentence. It's not a death sentence anymore. We can't absolutely cure it, but we can make it a manageable chronic disease. Years ago in the 1920s, when we discovered insulin, diabetes among children went from being a killer, imagine watching your child die slowly,

to being something that's manageable. The problem is the symptomatic treatments we have in psychiatry aren't nearly as powerful as the drugs we have for AIDS or as insulin is, for example. It would be nice if we were working towards better treatments. But as I stressed earlier in the broadcast, unfortunately, that seems to have reached a dead end for the moment. The incentives for big pharma are not to continue down that pathway. And so one worries about that. But as well, I'd like to see NIMH, which is the entity that sponsors much of the research in universities, spreading its money more broadly, not emphasizing solely and simply biology, but looking to some other ways we might alleviate mental illness in the moment.

I mean, the social dimension is so important. You know, like I think about, just to, lives in an institutional setting, but a pretty relaxed institutional setting and is well cared for because, you know, his family has the resources to make sure that he is. And so he's relatively stable. And, you know, when I when I see him on occasion, it's, you know, he's doing OK. Generally, you know, he has a he has a relatively good quality of life. I also work with, you know, I volunteer with a with a group that does street engagement with folks who are unhoused or experiencing homelessness here in L.A. And I'm very close with a woman who I've been visiting on the street for the past three years and she has schizophrenia and her situation is almost hopeless because she is she's tormented by uh tormented by delusions that she's being persecuted that

are very real to her every so often she's you know picked up by the police they take her to some sort of you know uh psychiatric hold where she's given medication she improves for a little bit and then she's put back on the street because she has nowhere else to go. And the county and state provide no other services. And when I see her after that, I say, Hey, how are you doing? Are you, are you taking your medication? And last time she, I asked her that she said, well,

I can't take the medication because someone keeps switching my pills with, with, you know, and, and now she might, I believe is having side effects from the pills but also her delusions are interfering with her ability to take the medication and you know when people say there's this thing that people like to say in the united states about homelessness that oh it's a it's mental illness it's not you know it's not it really has to do with housing like well the difference in these two cases both these people are receiving medication but one of them has absolutely no social support from anybody has no family has no support from

the state um i as someone who visit her once a week to bring her water and food is is the get giving her the most care that that anybody is anybody is yeah and so that's the social dimension is what's making the difference in her care when when we shut the mental hospitals yeah we provided nothing in to replace them the community community care is an orwellian euphemism for ignoring and neglect and what we see so the largest single sites of inpatient care for psychiatric patients today are the Los Angeles County Jail, the Cook County Jail, and Rikers Island Jail in New York. Asylums were built in the 19th century to rescue the mentally ill from jails and prisons. That's where we put them. And what we see, you had a cycle of short-term psychiatric intervention back to the gutter in the street.

The third wheel in that is people being sent to jail or to prison for extended periods and then being cycled back out. And, of course, once they have a criminal record, chances that they'll get a job, which already are low. So, yes, there's no social support for these folks. Public psychiatry was killed off back in the 70s and 80s. The profession has moved. I mean, the bulk of the profession now treats other kinds of disorders. And the most that psychotic patients get is occasional prescriptions of pills. And pills may help some, they're not universal. But on top of that, these people have so many other needs. They have a need for human contact. They have a need for some sense that somebody's listening to them. They need a roof over their heads. They need that sense of security. And without having those things, it deepens whatever mental problems you may be having,

to not have shelter, to not have human contact. And it's so striking to me that, you know, if you watch a movie set in the 19th century, you know, the asylum is depicted as, you know, a hellhole that was better left in the past. And maybe with some justification, I'm sure. I mean, we talked about institutionalized lobotomy and all these horrible things. But the fact that now we have no, you know, no centralized care whatsoever and people are just dying on the street or being left to fend for themselves or or receiving a drug after a five-minute consultation with a psychiatrist, and then, you know, no follow-up is no better, it seems to me. Well, let me cite a statistic that I think sums up how difficult the contemporary scene is. Please.

People with serious mental illness live, on average, 15 to 25 years less than the rest of us. Wow. And that gap is growing. It's not diminishing, it's growing. If we were effectively coping with mental illness, that's not what we would be seeing. And it's really a terrible commentary on contemporary society that that's where we are. a terrible commentary on contemporary society, then that's where we are. So this has been a very stark and upsetting conversation. I'd love you to find a little bit of positivity for us, either in, are there any signs of hope that you see where maybe things are turning in a better direction? Or what would you prescribe? You said earlier what you'd love

to see NIMH do. What else would you love to see to start to solve some of these problems? You know, it's interesting. I think among some of the psychiatrists I know and respect, there is a growing recognition that this monistic approach, this biology above all, is not the way to go. And the younger people entering the field, I think, sense how badly things have developed and would like to see things change. You hope that that will have an effect. hope that that will have an effect. But the problem that I would see precisely because mental illness is not something we generally want to talk about, it's very upsetting, the realities are very grim. The chances people are actually going to recover from the really serious kinds of mental illness are not great, although some people do, and I need to emphasize that for

reasons we don't entirely understand. So that's good. But it's very, very hard to, in the political environment we're in, to argue for resources to go to this population. We've moved, I hate the kind of jargon when people talk about neoliberalism, but the idea that the market rules everything and that people should compete in the marketplace and it's their own fault if they fail.

All of that language is an intellectual environment where arguing for actually helping people out of a sense of our common humanity is a hard conversation to have. I almost despair when I look at the political landscape. It seems to be tilting in directions that are deeply troubling. When we look to Hungary, for example, obviously the awful situation in the Ukraine, the election that's happening right now in France with the possibility of an extreme right-wing nationalist winning the election. These are really deeply disturbing. The whole populist response to difficult times seems to me to reside around simplistic solutions. And the idea that you're going to encourage people to be more humane, more caring about one another, We have to hope for that. That's what we will work towards while recognizing that in the contemporary world, things look a bit bleak and we have to hope they'll turn around. I love that as a, I asked you for a positive note to end on and you were like, well, we have to keep hoping for positive things, even as things look bleak. I guess that says a lot about you. Are you depressed, Andrew? You're a realist, I think. Very often, people go into fields for deeply personal reasons. And that really wasn't the case for me when I started in this area 50 years ago now.

I didn't have a particular motive to get in it. My earliest academic appointment at the University of Pennsylvania, the head of my department, Renee Fox, was one of the last victims of polio and had been left crippled by it. Wow. And she studied medical sociology, I think in part because illness had played such a central part in her own life. With me, that really wasn't the case. It was more, I think, two things. Intellectually, I think this is a profound puzzle. It really is. It's, you know, trying to grasp mental illness and how to deal with it. I've studied it now across over 2000 years. My book before this one was called Madness in

Civilization. And it traced everything from the ancient Greeks and ancient Palestine and ancient China all the way to now looking at art and music and religion and politics, all sorts of things. So, it's a very rich subject intellectually. The other side of the coin is there's an immense amount of suffering here and we've been discussing that. And our efforts, many of which have been very well-meaning, not all have been well-meaning, but many have been, our efforts often seem to be counterproductive. And that's a puzzle for me as a historian, trying to understand that and trying to, because I do think the past conditions everything we do. It's really, history is our deep memory. If we lose it, we're like people who don't have anything but a recent memory,

and we're very disabled by that. So it's important to understand the past, and the past can tell us some things, some constants, some worries, where things came from, how is it that we reached a situation that the mentally ill lie in the gutter or in the jail, or kept in a psychiatric facility for five days and discharged again to repeat the process. We can learn about that. And maybe if we learn to get back to your optimistic thing, my hope is that being realistic, not being too pessimistic, but not disguising from ourselves the limitations of what we can do.

I think the first step towards moving in a more positive direction. It's also, if we can understand those limitations, we can really get an appreciation for, in terms of our understanding in the mind and the brain, how much more there is to study and research that it's still one of the most fruitful. If you want to be of benefit to humanity with your scientific efforts, it's a wonderful field to to try to research more about it's one of the most popular majors that we have um at least in the united states and um hopefully if we take that clear-eyed view that you propose we can you know learn more about what is actually causing these illnesses and not, not keep making the same mistakes.

Andrew Scull, thank you so much for coming on the show. This has been a really fascinating, bracing conversation. I can't thank you enough for being here. Well, thank you very much. It's been a pleasure talking with you and I hope listeners find it of interest. I'm sure they will. Thank you so much. Thank you. Bye-bye.

Well, thank you again to Andrew Skull for coming on the show. If you want to pick up his book, the URL once again is factuallypod.com slash books. That's factuallypod.com slash books. I want to thank our producer, Sam Roudman, our engineer, Ryan Connor, and all the fine folks who are backing this show at the $15 a month level on Patreon. That's WhiskeyNerd88, Tyler Darach, Susan E. Fisher, Spencer Campbell, Sam Ogden, Samantha Schultz, Robin Madison, Richard Watkins, Rachel Nieto, Paul Mauck, Nuyagik Ippoluk, Nikki Battelli, Nicholas Morris, Mom Named Gwen, Miles Gillingsrood, Michael Warnicke, Mark Long, Lacey Tyganoff, Kelly Lucas, Kelly Casey, Julia Russell, Jim Shelton, Hillary Wolkin, M, Drill Bill, David Conover, that's my dad,

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