Psychiatry, Insane Asylums, Mental Illness, ECT, Lobotomies, Freud & Jung | Lex Fridman Podcast #502

1. 0:00 – 1:20

   Introduction

   1. LFLex Fridman0:00

      The following is a conversation with Andrew Scull, a historian of psychiatry and mental health. He has authored many books that I highly recommend, including Madness in Civilization: A Cultural History of Insanity from the Bible to Freud, from the Madhouse to Modern Medicine and Desperate Remedies: Psychiatry's Turbulent Quest to Cure Mental Illness. Andrew Scull has spent decades studying how societies have understood madness, how psychiatry rose to authority, and how often that authority was used with false confidence and catastrophic consequences. In this conversation, we'll trace the long arc from the asylum era to eugenics, from lobotomy and insulin coma therapy to electroconvulsive therapy, psychoanalysis, antipsychotics, antidepressants, and the modern crisis of mental health. It is in part a story about the terrifying history of bad ideas in medicine, but it is also about the fascinating mystery of the human mind and about the difficult journey to understand it. This is a Lex Fridman podcast. To support it, please check out our sponsors in the description where you can also find links to contact me, ask questions, give feedback, and so on. And now, dear friends, here's Andrew Scull.

2. 1:20 – 30:58

   Crisis in Psychiatry

   1. LFLex Fridman1:20

      Is it fair to characterize your view on psychiatry and, uh, mental illness is that there's a crisis in modern psychiatry? We have made some progress-

   2. ASAndrew Scull1:30

      Yes

   3. LFLex Fridman1:31

      ... over the past century, but mostly we still are not good at treating mental illness either via the drugs or talk therapy, meaning psychopharmacology or psychotherapy or as you put it, the brain or the mind route.

   4. ASAndrew Scull1:47

      Yeah.

   5. LFLex Fridman1:48

      So let's start at the end of our story. Let's start at where we stand before we go into the rich history that you so eloquently write about.

   6. ASAndrew Scull1:56

      So psychiatry is a profession that tries to deal with an enormously complicated thing, the human mind, the human emotions, the human ability to attempt to understand the world. And in particular, obviously, it focuses on people where our common sense approach to the world seems to break down, uh, people whose emotional life is filled with turmoil, people whose ability to relate to others is badly damaged, people who see things in the world that the rest of us simply think aren't there. They're illusions. They're hallucinations. They're delusions. And this is a subject that has occupied some very clever minds over the years, and there's no question that in the course of at least the last three-quarters of a century, there has been some limited progress in dealing with the problems that mental illness creates. Some of that is confined to the milder forms of mental distress, the more serious forms of psychosis and breakdown of emotional control. Those are areas where I think, again, there's been some progress, but it's easy to overstate how much of that there's been. As we'll see probably later in our conversation today, the advent of modern psychopharmacology, which occurred in the early 1950s, was a, a serendipitous event. It wasn't planned for. It happened almost by accident, and it did mark in some ways an advance over some of the things that psychiatry had engaged in before that. And no question for some people that revolution and a parallel revolution in the psychotherapeutic realm have created some advance for patients, and we should not minimize that. What we have available to us are symptomatic treatments, not cures. We don't have a psychiatric penicillin for any of the conditions we're gonna be talking about. That doesn't mean we can't do some things that help, but the help is quite limited, and it's important to understand both the ways in which we have progressed and the limits of that progress and also to understand that when we treat something, sometimes we create new problems, what we call iatrogenic problems, things caused by the interventions that we use. That's true of some psychotherapeutic interventions, and it's most certainly true of the drugs we use to treat mental illness these days. So for example, in treating PTSD, we often get patients to confront the episode, the trauma which provoked their distress, and that is often a very, very fraught process. And for many patients, it actually makes things worse. For some patients, it makes them better. So that's a situation where you can see problems. With both antipsychotics and antidepressants, the two main classes of psychotropic drugs that we use, um, they're, they're at best partially effective, and they don't work for a significant fraction of patients who are given them. And the-- one of the big problems psychiatry faces is that psychiatrists don't know in advance who's gonna respond well to the drugs, who's gonna respond badly. For which group of patients in the middle, the side effects and the main effects, if that's what we wanna call them, the, the therapeutic effects, are finally balanced and making that-- those judgment calls about what to do. are, uh, uh, is very, very difficult. Now, in terms of the crisis psychiatry faces at the moment as I see it, there are a number of strands that point to this. Psychiatry's diagnostic system, uh, that is still used, I mean, the fundamental basis of, of psychiatric diagnosis today was really first formulated in, in 1980 with the third edition of the Diagnostic and Statistical Manual of a Profession.

   7. LFLex Fridman6:44

      DSM-III.

   8. ASAndrew Scull6:46

      DSM-III, and then there's been DSM-III-R, DSM-IV, DSM-IV-TR, and now DSM-5.

   9. LFLex Fridman6:54

      Mm-hmm.

   10. ASAndrew Scull6:54

       Finally, not with a Roman numeral, but with a, with an Arabic numeral. [chuckles] So they thought, uh, with DSM-5, when they needed to modify it, it would be like a piece of software. You have Windows 10, Windows 11, and so on, right? Now, that diagnostic system came into being because psychiatrists had a very hard time agreeing with one another about what was wrong with somebody. And that became embarrassingly clear in, first in the professional literature, which outsiders didn't read, and then via a very famous study that's a scientific fraud by David Rosenhan called "On Being Sane in Insane Places," where he claimed to have sent in pseudo-patients to the hospital, and they all were diagnosed as schizo-- all but one of them diagnosed as schizophrenic, the other as somebody with bipolar disorder, and they were fake patients. So almost in a panic after that study appeared in Science, and because there was an abundant professional literature from the 1960s showing the same thing, that diagnosis was a very erratic process. The DSM-III task force, led by Robert Spitzer, who was then at Columbia, was explicitly set up to try to create a sort of tick the boxes approach to deciding which box a patient belonged in.

   11. LFLex Fridman8:19

       Mm-hmm.

   12. ASAndrew Scull8:19

       Were you schizophrenic? Were you this type of schizophrenic or that type of schizophrenic? Were you, uh, manic depressive or bipolar? Uh, did you have various forms of depression? And to construct those boxes, what they relied upon was, uh, a list of symptoms, and if you had more than a certain number, if you had more than six of 10, six or 10 or more symptoms of, of a certain sort, you could be diagnosed with major depression, for example. So that system came into being. It was partially embedded because it appealed to drug companies who were developing drugs to treat these various disorders. It appealed to insurance companies 'cause it gave them a stable base to look at. Uh, it appealed, as diagnosis always does, to patients and their families who are scrambling to deal with these enormous upsets in the mental life of either themselves or, or a family member. Uh, so it provided some sense of certainty around diagnosis. But that was always based simply on symptoms in the way an 18th century doctor might diagnose dropsy or diagnose, uh, some other kind of dis-- or fever, for example. Well, fever and other diseases they talked about in the 18th century are really a constellation of very different things under one label. And I think that's what is turning out to be true of the DSM labels. But that approach was really all that psychiatry could come up with if it wanted to make sure whether you were in Walla Walla or New York or San Francisco or Atlanta, you reached the same conclusion faced by the same patient, that you, you had a reliable diagnostic system. That didn't mean necessarily it was a valid diagnostic system, if you understand the distinction be-between validity and reliability. Reliability means you and I, faced with the same sets of facts, reach the same conclusion, but that conclusion may or may not ref-re-reflect the underlying reality of things, right? So you had this diagnostic system, and it went through various iterations. Each time it went through an iteration, the number of possible psychiatric disorders you could get grew and grew and grew. And it became difficult to believe in some of those categories, shall we say, that they were really illnesses rather than some sort of social construct. But beyond that, um, psychiatrists wanted to be more like other medical doctors to root their diagnoses in an understanding of the underlying pathology of the disorder. What was it that caused people to become schizophrenic? Uh, the sen- the sense was if we could grasp that, we'd have a better handle on how to attack it, how to treat it. Uh, and when, uh, DSM-5 was mooted, the fifth edition in the early 2000s, NIMH, then under the leadership of Steven Hyman, who's at Harvard now, and succeeded by Thomas Insel, who ruled NIMH for about 13 years, the two of them had pushed psychiatry and psychiatric research in a, a very particular direction. On the one hand, towards understanding the genetics of mental illness, and on the other, to looking at what the new discipline of neuroscience could contribute to understanding things. Both of them were heavily invested in the idea that mental illness was brain disease.

   13. LFLex Fridman12:27

       Hmm.

   14. ASAndrew Scull12:28

       And if it was brain disease, then the question was, what was making the mechanism here go awry? What was, uh, causing people's emotions or their cognitive skills or their sense of the world to become so disordered? And they invested a lot of money in that approach. Uh, when Insel stepped down, he gave an interview actually to somebody at MIT, and he's repeated it since in a, in a book he wrote about his experiences, where he said, "Well, you know, as I look back on my 13 years, I funded an enormous amount of scientific-- really cool scientific research. I funded geneticists, and I funded neuroscientists, and we-- they did a lot of really interesting science. And after spending $20 billion, the lot of the mentally ill has improved not one bit." Right?

   15. LFLex Fridman13:21

       Wow.

   16. ASAndrew Scull13:22

       Which was a pretty devastating statement, I thought.

   17. LFLex Fridman13:25

       And, and NIMH is National Institute of Mental Health.

   18. ASAndrew Scull13:27

       National Institute of Mental Health. Yes, I shouldn't resort to jargon. [laughs]

   19. LFLex Fridman13:31

       [laughs]

   20. ASAndrew Scull13:32

       But the National Institute of Mental Health had been founded in the late 1940s with the goal of improving, doing basic research, training people in the field, advancing the care of the mentally ill, and producing obviously, uh, um, cures and advances. Uh, and it, it is-- its mission has varied widely over the years since. But starting in the l- in the 1990s, the period when the first George Bush declared the decade of the brain, uh, NIMH increasingly focused on the idea that mental illness was purely a brain disease. And there's something to that, and there's also some mistake in thinking about it that way.

   21. LFLex Fridman14:15

       This is by the way, as we'll talk about, this distinction between seeing mental health, the maladies of the human mind-

   22. ASAndrew Scull14:24

       Right

   23. LFLex Fridman14:24

       ... as a problem of the brain, like neurobiology, neuroscience-

   24. ASAndrew Scull14:27

       Right

   25. LFLex Fridman14:27

       ... versus the problem of the mind, which is more in the cognitive science, psychotherapy. These more less amenable to scientific rigor. So I think what's-

   26. ASAndrew Scull14:38

       Yeah

   27. LFLex Fridman14:38

       ... appealing about the studying the brain and neurobiology, neuroscience is there's data.

   28. ASAndrew Scull14:42

       Yes.

   29. LFLex Fridman14:43

       It's more rigorous. You could do science.

   30. ASAndrew Scull14:45

       It's the kind of thing that really appealed to medical school deans.
3. 30:58 – 38:17

   Categories of Mental Illness

   1. LFLex Fridman30:58

      about this. I was wondering if you can also just lay out what are the big categories of mental illness that we're referring to. You've already hinted at them, but like levels of seriousness-

   2. ASAndrew Scull31:10

      Yes

   3. LFLex Fridman31:11

      ... and the categories of illness-

   4. ASAndrew Scull31:13

      Mm-hmm. Mm-hmm

   5. LFLex Fridman31:13

      ... like with, with, with psychosis and depression and so on.

   6. ASAndrew Scull31:16

      So going back to the early 20th century was when, um, the German psychiatrist Emil Kraepelin, working with thousands of records in German asylums, inductively developed a distinction between two very broad categories of mental illness. One he called dementia praecox, or early dementia, and the other he called manic depressive illness, which was a more remitting illness that sometimes went away entirely, other times went back and forth. Whereas dementia praecox was a one-way ticket down. Now, that label was transformed by a Swiss psychiatrist, Bleuler, into the term we use today, schizophrenia, although Bleuler talked about the schizophrenias because he thought under that broad label there were a diverse group of things running around.

   7. LFLex Fridman32:15

      Mm-hmm.

   8. ASAndrew Scull32:16

      And I think that was an important insight that tends to get lost sometimes. This was jamming together people with very serious psychosis, that is, people who'd lost touch with we like to-- what we like to think of as reality, uh, whose emotional and cognitive lives were in total turmoil, uh, who were-- who lost the ability to connect with other human beings. So their social skills atrophied. Their-- Well, this is something contemporary psychiatrists would refer to as the positive and negative symptoms of schizophrenia.

   9. LFLex Fridman32:53

      But underlying the definition of schizophrenia here is a detachment from reality. So you're-

   10. ASAndrew Scull32:59

       Yes

   11. LFLex Fridman32:59

       ... hearing voices, you're seeing visions.

   12. ASAndrew Scull33:01

       You're thinking people are plotting against you. Uh, you think the television is talking directly to you.

   13. LFLex Fridman33:08

       And because of that, it has these consequences of how you're connected to the rest of the world and how-- what your emotional life is like-

   14. ASAndrew Scull33:15

       Right

   15. LFLex Fridman33:15

       ... and all that kind of stuff.

   16. ASAndrew Scull33:15

       Yes. Your emotional life flattens out. Your language capacity deteriorates. Your ability to relate to other people either vanishes or becomes caught up in the web of delusions where you think people around you are, are plotting against you or doing terrible things to you.

   17. LFLex Fridman33:33

       And is that a different world than the world of bipolar and, and the world of depression?

   18. ASAndrew Scull33:38

       Yes. The Greeks recognized, and the Romans, uh, ancient Greece and ancient Rome recognized different forms of insanity, as they called it. Um, so melancholia would have been the term the Greeks and the Romans would have used, and it survived and, and was very much around. And I think that is a form of depression. What's happened now is major depression has become a catch-all category.

   19. LFLex Fridman34:07

       Mm-hmm.

   20. ASAndrew Scull34:07

       So it embraces both what we might think of as milder forms of emotional distress, along with what melancholia referred to, which was really a kind of depression that had psychotic features. This loss of contact, as it were, with, with everyday reality.

   21. LFLex Fridman34:28

       So something you would talk about maybe like a clinical depression. And by the way, we should mention that this field in the 21st century is like a minefield.

   22. ASAndrew Scull34:37

       Yes. Very much so. So here's a very strange bit of historical record. The other distinction, and the distinction we're, we're grappling with, so we have people who are-- whose depression is of such a scale they're threatening to do away with themselves. They've retreated into complete almost immobility. They're overwhelmed by senses of sadness and loss, and that they're-- if they're religious, that they're damned to hell, and all those kinds of things. So we have this psychosis that we've been talking about. We have something also that the ancients recognized, dementia, the loss, really the loss of, of our mind, as it were. Um, but then we also have other kinds of disturbance of our mental faculties that generally we think of as more minor, but I don't want to m-make light of them because often people that suffer from these things-

   23. LFLex Fridman35:37

       Mm-hmm

   24. ASAndrew Scull35:37

       ... genuinely suffer pretty badly. But those things we in the 20th and 21st centuries tend to talk about as neuroses, neurotic diseases, psychotic diseases. In the 19th century, neurosis was a term that meant things rooted in the brain, as you can see from the root of the word, and psychosis was stuff that came from the mind, the psyche.

   25. LFLex Fridman36:03

       Mm-hmm.

   26. ASAndrew Scull36:04

       Uh, and yet sometime in the late 19th century, those things crossed over. And so when we talk in the present, we do tend to distinguish between the core, really the most severe forms of mental disorder-

   27. LFLex Fridman36:20

       Mm-hmm

   28. ASAndrew Scull36:20

       ... which would include things like Alzheimer's disease and other forms of dementia, would include, um, very serious depression, would include, um, bipolar disorder where people oscillate, either have extreme mania, so they're, they're not getting any sleep, they're talking at an extraordinary rate.

   29. LFLex Fridman36:40

       Mm-hmm.

   30. ASAndrew Scull36:41

       Their behavior is very hard to tolerate, and they're exhausting themselves, and they may even die from exhaustion if it's not controlled. And Very often that alternates with periods of depression. So that's, that was a category that, um, was captured initially as, uh, manic depressive illness and later on evolved into bipolar disorder and then separating out depression a- and major depression separately. But then there are a whole bunch of other things like, for example, phobias.
4. 38:17 – 50:23

   Asylums, Eugenics, and the Nazis

   1. ASAndrew Scull38:17

      If you look back at the asylum era born in this period of intense optimism, and then the claims to be able to cure these vast numbers of patients were overblown. Uh, I do believe the early asylums actually did good work and that some patients did very well and recovered as a result of their stays. But what happened, they weren't discharging 80% of their patients. They were discharging 35 or 40% of their patients, and what that meant is every year left behind w- were a batch of chronic patients, and then the next year you repeated it. And over time, what that means is the ratio of new patients to chronic patients gets worse and worse.

   2. LFLex Fridman39:01

      Mm-hmm.

   3. ASAndrew Scull39:02

      Um, and more and more the image of the asylum is defined by the chronic patient who hasn't recovered and maybe spends years or decades there and only leaves in a pine box. So the, the image of the asylum de- declined drastically. As they became more and more overcrowded, conditions in them deteriorated. Patients were often abused. Uh, psychiatrists didn't know what to do with them, and they faced a problem in the late 19th century. You'd promised 70 or 80% cures, but we're not seeing that. In fact, when we calculate cures on the numbers of people in the asylum, it's more like 10 or 12%. That's the way you can play with statistics-

   4. LFLex Fridman39:45

      [laughs]

   5. ASAndrew Scull39:46

      ... 'cause that's all the old patients mixed with the new, but still it looks very bad. Uh, how do you explain this, doctor?

   6. LFLex Fridman39:55

      Mm.

   7. ASAndrew Scull39:56

      You've promised us one thing, and you've delivered something quite different. The answer came in a way of, uh, blaming the victim, in a way of saying, "Well, you know, what we didn't understand was that mental illness is a fundamentally biological condition. These people are evolutionary throwbacks." Evolution was generally thought of as a progressive onwards and upwards, but these people had fallen back into a, into a, a, a lesser form of existence.

   8. LFLex Fridman40:27

      Mm.

   9. ASAndrew Scull40:27

      They'd lost their essential humanity because their brains were defective. So what emerged then was the i- idea of degeneration, the idea that these patients were degenerates. They were people with an inferior biology. You couldn't release them because they'd breed like rabbits. They didn't have any self-control because of their diminished humanity.

   10. LFLex Fridman40:51

       This is the narrative.

   11. ASAndrew Scull40:52

       This is the narrative. And so what it did was provide a justification for locking up people in asylums that wasn't therapeutic at all. It was just keeping them out of the way.

   12. LFLex Fridman41:02

       And then it led to the justification of sterilization-

   13. ASAndrew Scull41:05

       Exactly

   14. LFLex Fridman41:06

       ... based on the same argument.

   15. ASAndrew Scull41:07

       So if maybe we can release them if we make sure they can't breed.

   16. LFLex Fridman41:10

       This is the beginning of the darkness.

   17. ASAndrew Scull41:12

       It is the beginning of the darkness. Um, my own state was one of the pioneers in this process, and it continued to sterilize mental patients up until about 1960.

   18. LFLex Fridman41:24

       By the 1960s, over 60,000 sterilizations have been performed in the US, with California performing a disproportionately high number.

   19. ASAndrew Scull41:36

       That's correct. But even more serious consequences could flow from these set of issues. When you start talking, one, one British psychiatrist said that if his patients that were coming into the asylum had been puppies, we'd have tied them up in a sack because they were some horrible mongrel, not a purebred dog. Tied them up in a sack with some lead weights and thrown them in the pond and drowned them.

   20. LFLex Fridman42:06

       Yeah.

   21. ASAndrew Scull42:06

       That kind of language is very, very dangerous. And what happened, California's law surrounding sterilization was advocated for in the West. By that I mean North America and, and Britain and much of w- Europe. There were enough checks and balances in a democratic system that even though there were enthusiasts, the eugenicists who said, "Best get rid of these people, put them to death," uh, that never really, that never really acquired mass support. But what happened in Germany once Nazi, the Nazis came to power is they seized on these notions and that the idea that the mentally ill were, as they put it, useless eaters, people consuming resources but never gonna get better, just a burden on the state. Their lives weren't worth living because after all, they had this serious mental illness. So First you sterilize, and then you go, "But we're still supporting all these people." And so Hitler starts something called the T4 program after the street name of the house where this was concocted, Tierstraße 4. And the mentally ill were the first people to suffer from the Final Solution. It was in the mass killing of the mentally ill, which may have been as many as a quarter million people, that the technology of the gas chamber was developed, and the technology of dis- of disguising the gas chamber as showers was developed. And so the patients were taken away to a number of psychiatric centers and systematically put to death, and they had, they had the crematoriums and the black smoke, and the local people talked about the buses that were bringing them in as killing crates. So they were aware of what was going on.

   22. LFLex Fridman44:02

       Were they influenced by the narratives that were born in the United States-

   23. ASAndrew Scull44:05

       Yes, absolutely

   24. LFLex Fridman44:06

       ... about this kind of-

   25. ASAndrew Scull44:07

       About that sort of thing. And lacking the check, the checks and balances that, at least until recently, this country had, um, it, it was relatively easy for Hitler to, to do that. And particularly with the war looming, the idea that we're gonna support all these useless people, let's kill them. Uh, and German psychiatry, for the most part, collaborated with that process.

   26. LFLex Fridman44:34

       I wonder how many people throughout that whole journey in the psychiatry profession sort of were brave enough to speak up like, "Hey, maybe the sack of puppies kind of language-

   27. ASAndrew Scull44:46

       Oh, yes

   28. LFLex Fridman44:46

       ... is a problem."

   29. ASAndrew Scull44:47

       Oh, yes. That's the really nasty direction that that language could lead to. Uh, and it was symptomatic of the kind of stigma that tends to attach itself to mental illness and this sense of hopelessness. So, but if you're a healing profession, you're-- if, if you enter psychiatry thinking, "I'm gonna do this to help people, to cure people, to make their lives better," to just become a glorified boarding house keeper, keeping them under lock and key, or in the alternative, to collaborate in this, in the sorts of awfulness that the Nazis perpetrated, that's something from which decent human beings tend to recoil, and decent psychiatrists tended to recoil. And so still thinking, as they did by the end of the 19th century, that mental illness was predominantly a biological problem, some of them began to say, "Well, maybe biology as well as being the problem could provide the solution. Maybe we should look for ways to intervene in the biological systems of these people and make them better." Uh, the same logic that applies, I would say, in the present-

   30. LFLex Fridman46:08

       Mm-hmm
5. 50:23 – 56:36

   The Ice Pick Lobotomy

   1. ASAndrew Scull50:24

      We can discuss a series of therapeutic experiments on people who were shut up in a double sense. They were locked away, and their voices were not heeded because it was the product of their madness. And so what we see in the first five decades, really, of the 20th century is people with a, a variety of motivations, including the desire to improve the lot of the mentally ill, engaging in uncontrolled experiments that had terrible results. And the science behind it was shaky, but nonetheless, it existed. It wasn't just plucked out of the sky. And yes, it eventually, those things break down. I mean, the clearest case of that, because it's the most extreme of these, at least in the public imagination, is lobotomy, the idea that you're going to solve psychotic breakdowns in people by excising part of their brain, um, initially by drilling holes in the skull and injecting alcohol or using what looks like a butter knife to break connections between the brain. Uh, and then later, when that process seems to be too slow, the Henry Ford of lobotomy, the-- his daughter said Walter Freeman aspired to be the Henry Ford of lobotomy, the one who could mechanize the production of it and get it done fast. He invented the ice pick lobotomy, where you used, uh, an ice pick in the orbit of the eye, having rendered somebody unconscious after two or three electric shocks, and you banged it through the bone and wiggled it about and severed-- I mean, it's, i-it's just hard to even describe.

   2. LFLex Fridman52:08

      So this is from the 1930s to the 1970s.

   3. ASAndrew Scull52:12

      Yes. Uh, Freeman starts his work in 1936, borrowing from the work of the preceding year of a Portuguese neurologist named Egas Moniz. And Moniz wins the Nobel Prize in medicine in 1949 for lobotomy. So it's important to see that. That was 14 years of experience, and yet that won a Nobel Prize. I'm sure that's one they'd like to retract.

   4. LFLex Fridman52:38

      So he popularized Walter Freeman, the ice pick.

   5. ASAndrew Scull52:42

      And his particular specialty after the war became this ice pick lobotomy because there, there were over half a million patients in America's mental hospitals. Freeman was convinced this operation was a cure-all. And so he traveled around in a camper truck, which he called the lobotomobile, and he would descend in the summer on state hospitals, and he would teach them how to do this ice pick lobotomy.

   6. LFLex Fridman53:11

      This is, by the way, image of the tool.

   7. ASAndrew Scull53:15

      Yes, those are the tools he used. Originally, he used an actual ice pick, and then he developed this.

   8. LFLex Fridman53:20

      This is what he developed.

   9. ASAndrew Scull53:21

      Yes.

   10. LFLex Fridman53:21

       This is the state-of-the-art technology.

   11. ASAndrew Scull53:23

       This is the state of the art with a hammer or a mallet.

   12. LFLex Fridman53:25

       Oh, no.

   13. ASAndrew Scull53:26

       Yes. I'm sorry. It's, uh, it's very distressing. I, I don't know.

   14. LFLex Fridman53:32

       You having to write about this, by the way-

   15. ASAndrew Scull53:34

       Well, it's really-

   16. LFLex Fridman53:35

       ... is a lot

   17. ASAndrew Scull53:35

       ... very, very, very, very difficult. I came across, for example, a picture of a woman, a naked woman being dragged away by attendants to be lobotomized, and she's resisting with all her might, and to no avail. Y-y-you have a picture there of Walter Freeman lobotomizing a patient in Washington State. Freeman was ambidextrous, and when he taught neurology, he would draw simultaneously with his left and right hand, and he could do it perfectly. When he was performing lobotomy, when his right hand got tired, he switched to his left hand, and he sometimes would do 20 or 30 lobotomies in an afternoon. And he boasted, he said, "You know, I could teach any damn fool to perform a lobotomy in 20 minutes, even a psychiatrist," 'cause Freeman was a neurologist, and he had a lot of contempt for psychiatrists. So, um, so this was a very ugly episode. How did it die away? It really took generational change. Uh, some of these lobotomists continued to operate into the '60s, even to the early '70s. But the younger generation who became acquainted with the really w-worst failures of that regime, the people on the back wards who were incontinent, who were, um, basically zombies, had lost all mental power, uh, they rebelled against this. And by then, they had a different treatment in the form of antipsychotic drugs-

   18. LFLex Fridman55:16

       Mm-hmm

   19. ASAndrew Scull55:16

       ... which looked much more like what regular medicine was doing, uh, and didn't have these horrible overtones. And of course In the popular mind, I think the, the probably the most famous, uh, instance of telling the public about some of these interventions was the film of Ken Kesey's novel, "One Flew Over the Cuckoo's Nest," where you see Jack Nicholson giving, I think, the performance of a lifetime, who is given ECT, electroconvulsive therapy, uh, in a very dramatic rendition of what that was. Not, not really, um, what was going on by, by the 1970s with ECT, but nonetheless, certainly what had been going on back in the past. And then finally, when ECT doesn't smash him to bits, they lobotomize him, and, and the film ends obviously with him being smothered to death 'cause Chief can't bear to see him in, in the state that he's in. Um, so that fixed in the public mind some of the images of these things. It was one of the re- things that gave, uh, electroconvulsive therapy such a, a, a bad name.

   20. LFLex Fridman56:35

       So we'll actually,

6. 56:36 – 1:14:52

   Malaria "Cure" for Syphilis

   1. LFLex Fridman56:36

      uh, not to fast-forward too quickly-

   2. ASAndrew Scull56:38

      Yes

   3. LFLex Fridman56:38

      ... let's talk about, uh, the full journey of everything we've been talking about. So we mentioned the asylum era that began in the mid-19th century, going to the 20th, and we talked about the narratives-

   4. ASAndrew Scull56:51

      And we talked about sterilization

   5. LFLex Fridman56:53

      ... sterilization.

   6. ASAndrew Scull56:54

      Yes.

   7. LFLex Fridman56:54

      And let's look at the insulin shock therapy of, uh, 1933 to the 1960s, where you were putting patients in deep hypoglycemic comas using large doses of insulin.

   8. ASAndrew Scull57:07

      Yeah. So as I mentioned, for psychiatrists who went into the field and were ambitious, but who also wanted to think of themselves as therapeutic agents-

   9. LFLex Fridman57:19

      Mm-hmm

   10. ASAndrew Scull57:19

       ... uh, to just sit there passively and contain the patients was very unattractive. And so they looked around for ways in which perhaps biological interventions could be used to ameliorate this condition that they still saw in largely biological terms. Now, in some ways, one of the crucial early ways in which this thinking went and which affected a large number of patients was this. One of the few diagnostic triumphs of psychiatry in the early 19th century as the profession began to emerge was that it began to distinguish a group of patients who were deemed to be suffering from something called general paralysis of the insane. Uh, that encapsulates two things about what was going on. First of all, paralysis, the gradual loss of motor control, ability to walk, ability to swallow, ability to c- to, to talk. So those are primarily what we think of these days as neurological issues, but those were accompanied by bizarre psychiatric symptomatology. These were people who thought they were Napoleon or Jesus Christ or the richest and sexiest man in the world-

   11. LFLex Fridman58:44

       Mm-hmm

   12. ASAndrew Scull58:44

       ... or Mary, the mother of God. They were primarily men, but there were also female victims. At the turn of the 20th century, as many as 25% of the people being admitted to asylums were suffering from general paralysis of the insane, or GPI for short. There have been a lot of suspicions about this being connected somehow to sex and to moral dissolution and so forth. But what evolved in the early 20th century was the discovery of the actual origins of this disorder. So I've said psychiatry's been looking for the underlying pathology that lies behind mental diseases. This was one that at the Rockefeller Institute, they discovered that the organism that causes syphilis was residing in the brains of the people who were suffering from GPI. This was, in fact, tertiary stage of syphilis. Syphilis is a, still a real public health problem. It was like AIDS in the late 19th century. It was everywhere. And when you, you first contract syphilis in the primary phase, you have pain, but then it goes underground, and you think it's gone. And it lurks the way chickenpox virus lurks and can surface years later, right? It lurks, it lurks, and it's insidiously damaging. Sometimes it attacks the, um, heart, and people drop dead of a heart attack in their 40s. "Oh, he died of a, you know, it's a natural heart attack," but in fact, it was the syphilis. Or it attacks the central nervous system, the spinal column in the brain, and then you get the paralysis.

   13. LFLex Fridman1:00:40

       Mm-hmm.

   14. ASAndrew Scull1:00:41

       And then you get also the psychiatric symptomatology. So when that was discovered, that sort of suggested that mental illness might have an infectious origin. Tertiary syphilis, GPI, went on to win for somebody who developed a treatment for it a Nobel Prize, one of only two awarded for psychiatric innovations. One was the lobotomy. The other was giving people-

   15. LFLex Fridman1:01:05

       Oh, wow

   16. ASAndrew Scull1:01:06

       ... malaria to cure their syphilis.

   17. LFLex Fridman1:01:08

       In case people didn't hear that.

   18. ASAndrew Scull1:01:11

       Hmm.

   19. LFLex Fridman1:01:12

       Giving people malaria-

   20. ASAndrew Scull1:01:14

       Yes

   21. LFLex Fridman1:01:15

       ... in order to cure syphilis.

   22. ASAndrew Scull1:01:18

       So there was an Austrian doctor, Wagner Jauregg, who had long thought that fever could be used to cure mental illness, and he tried rat bite fever. He tried giving people typhoid vaccine that creates a fever to no avail. And towards the end of World War I, the Italians were fighting in World War I on the side of the, the British and the Americans and the French. They captured a- an Italian soldier who had malaria. Malaria was endemic in those years in Italy. And they brought him to him, and he extracted the malarial blood and injected it into a series of patients with GPI, with pr- general paralysis of the insane, and claimed it cured them. We know from later on when he fessed up that those claims were wildly exaggerated, but they were widely accepted, and malarial treatment spread to Britain, it spread to Germany, it spread to the United States. Some, uh, sometimes it was vials of malarial blood, but very often mental hospitals had actual colonies of malarial mosquitoes. So imagine you're a mental patient, and you're put in a straitjacket, and you're put in a room, and you can't move, and mosquitoes are buzzing around, and they bite you, and then you develop malaria.

   23. LFLex Fridman1:02:40

       And he got a Nobel Prize for this.

   24. ASAndrew Scull1:02:42

       Yes, in 1937, he got a Nobel Prize. 'Cause this was a condition that was invariably fatal, uh, and the claim was that somehow the, the malarial fever worked. Now, there are two possible ways. Um, von Jauregg thought it stimulated the immune system to attack whatever it was, was causing the insanity. But the other possibility was the following. When you, um, have the malarial parasite in a test tube and you heat the test tube to about 105, 106 degrees, it dies. So the idea potentially was you were sort of burning the parasites out of the brain with this agent. And because peop- people were pretty unsophisticated about statistics and because the idea of a controlled trial had not yet come to pass, uh, this treatment was used extensively, uh, for a couple of decades. What caused it to stop, and you talk about the progress of science, was the discovery of penicillin, which was a real magic bullet.

   25. LFLex Fridman1:03:51

       Mm-hmm.

   26. ASAndrew Scull1:03:51

       So once you had penicillin, you weren't gonna continue treating people with malaria, so it died away. But it was the first such treatment, and here's the other way this feeds into the narrative of these desperate remedies that develop in this period between the mid-teens and, say, 1950. The discovery of the syphilitic origins of general paralysis of the insane occurred at a time when medicine had undergone a pro- undergone a profound transformation. In the late 19th century, the work of Louis Pasteur, who was a chemist, not an MD, and the work of Robert Koch in Germany had uncovered the origins of a variety of diseases and suggested that bacteria were the reason why people sickened. And that led, of course, to a whole series of public health triumphs, because initially it didn't lead to antibiotics. But for a lot of these diseases, even viral diseases like rabies, you could develop a vaccine.

   27. LFLex Fridman1:05:04

       Mm-hmm.

   28. ASAndrew Scull1:05:05

       And the vaccines were phenomenally effective. And so, um, that was one way in which the new germ theory of disease transformed medicine and tied it into the laboratory and into science in a new way. And the other was the adaptation of Pasteur's theories, um, by a British surgeon named Lister, who previously when pus developed post-surgery, people had thought that was a good sign. Um, Lister said, "No, I don't think so. This is actually these nasty germs causing this, and so we're gonna do antiseptic surgery." So he sprayed carbolic acid on the wounds to try to kill the microbes. Most of his colleagues thought he was nuts, thought he was just-- This is ridiculous, these microorganisms. You couldn't even see them, you know, [chuckles] well, you could with a... But Lister prevailed. Uh, and eventually we moved from antiseptic surgery to aseptic surgery, which is what we have now, where you try to have a sterilized, uh, set of instruments and a sterilized environment so you don't infect things, right?

   29. LFLex Fridman1:06:19

       By the way, these are definitive examples of progress in medicine.

   30. ASAndrew Scull1:06:23

       Absolutely.
7. 1:14:52 – 1:22:44

   Insulin Coma Therapy

   1. ASAndrew Scull1:14:52

      Um, we talk about triumphs of medicine, so let me talk one of the real triumphs of 20th century medicine, which is interesting to refer to because it wasn't a cure, uh, just like psychiatric drugs aren't a cure for mental illness. It was a symptomatic treatment, but it transformed lives, and that was the discovery of insulin in the 1920s. Previously, particularly what we now call type 1 or juvenile diabetes, was a death sentence. You got it, and whatever you did, you tried various quack remedies, you tried diet, you tried all sorts of things. The inevitable thing was it killed you. And then came insulin. Now, insulin doesn't mean you're cured of di- your diabetes, but what it means is you can live a relatively normal life, and your lifespan is greatly expanded. So by any measure, you have to say that's dramatic progress. But insulin is something our bodies produce, we hope, unless we're really seriously diabetic. Those of us with type 2 diabetes, our bodies resist insulin, and we have to resort to other ways of trying to cope. But if you get too much insulin, it makes you unconscious. And that's how another one of these desperate remedies came along. A man named Sackel, working in a German clinic for drug addicts, they were using putting people under mild comas to help them through the withdrawal symptoms as they got over their addiction. So he was familiar with that. And when he moved to Austria, he decided he'd try this as a treatment for schizophrenia. And so he put people into comas, sometimes comas that would last hours, days. Um, they would be revived by giving them glucose, usually intravenously, sometimes not. Um, during the time they were in comas, they often seized, had seizures. He saw that as a therapeutic sign. And he claimed that this insulin coma treatment, uh, cured 80% of his-- 80% tends to come up again and again in these treatments as a sort of percentage that you cure. And, uh, he was invited to, um, New York and demonstrated this at the Harlem Valley Mental Hospital. It spread.

   2. LFLex Fridman1:17:36

      This is in the '30s.

   3. ASAndrew Scull1:17:37

      This was starting in 1933. The visit to America was, I believe, 1936. And Sackel ended up settling here. He had a very lucrative private practice in New York. And when he died, he left his partner, I think, in a state of about two million dollars, which in the early '60s was a very substantial amount of money that he'd earned from, from practice, right? So insulin coma therapy was widely adopted. What kept it from being a large-scale thing was it required an enormous amount of nursing and medical attention 'cause people were literally hovering on the brink of life and death. They could go into a permanent coma. They could just die. Um, so they had-- Their m- vital signs had to be monitored. They had to be brought around very quickly if need be. And, um, there's some evidence that the treatment killed brain cells, and when Sackel was told that, he said, "Yes, that's probably true. They're killing the schizophrenic brain cells." That's just nonsense.

   4. LFLex Fridman1:18:39

      Of course.

   5. ASAndrew Scull1:18:39

      That's just nonsense, but that's rational. Insulin comas weren't subjected to a randomized controlled trial until the 1950s. And when they were subjected to a controlled trial, they failed it, and so it, it died out. And that's, I guess, scientific progress again, in a way, but took a long time. One of the people who received insulin coma therapy-- Have you seen the film "A Beautiful Mind"?

   6. LFLex Fridman1:19:07

      Mm-hmm.

   7. ASAndrew Scull1:19:08

      He did receive insulin coma therapy, ironically, actually, at Trenton State Hospital, where Cotton had been.

   8. LFLex Fridman1:19:14

      So John Nash received-

   9. ASAndrew Scull1:19:15

      John Nash got insulin comas, and they were going to lobotomize him, and they didn't. But he was at risk of that.

   10. LFLex Fridman1:19:24

       We should say that this treatment, patients would thrash, moan, and convulse before falling into a coma. The treatment required a course of up to 60 comas. It, uh, turned out to have a mortality rate of 1% to 5% and caused significant brain damage and obesity.

   11. ASAndrew Scull1:19:43

       Yeah.

   12. LFLex Fridman1:19:44

       Yet was hailed as a miracle cure for schizophrenia.

   13. ASAndrew Scull1:19:48

       Yes, that's right.

   14. LFLex Fridman1:19:49

       And it's performed on John Nash, one of the great minds of the 20th century.

   15. ASAndrew Scull1:19:55

       Yes. And Nash clearly did become delusional But that was one of the treatments he was subjected to, and well-represented actually in the film of, um, A Beautiful Mind. So I mentioned seizures. Also in the Austro-Hungary in this period, another psychiatrist decided that you couldn't be both schizophrenic and epileptic.

   16. LFLex Fridman1:20:23

       Mm-hmm.

   17. ASAndrew Scull1:20:24

       That there was somehow an antagonism between the two. So if you had epilepsy, you didn't have schizophrenia, and if you had schizophrenia, you couldn't have epilepsy. Uh, I should say at the outset, that's not true, but that's what he believed. So then the logical next step was, well, if we could create an artificial epileptic seizure, maybe we would drive out the schizophrenia. So what to do? He first tries injecting camphor, a natural substance. Natural substances aren't necessarily benign substances. That caused abscesses, and it wasn't very effective. He sought an alternative, and he s-settled on something that was, um, called cardiazol or metrazol, depended which side of the Atlantic you were on. And injecting that into a patient usually caused a seizure, a big seizure, like a grand mal seizure, where your body arcs back, your legs contract dramatically.

   18. LFLex Fridman1:21:27

       You can fracture spines and hips and bones.

   19. ASAndrew Scull1:21:31

       And you ended up, yes, with fractures of the vertebrae, fractures of the hip socket, because when the muscles in the thigh contract that badly, what happens? The thigh bone is driven into the socket-

   20. LFLex Fridman1:21:44

       Mm-hmm

   21. ASAndrew Scull1:21:44

       ... at such a rate that it fractures, right? So these were among the complications that metrazol produced. More than that, he himself conceded that between the injection and the seizure, the patient felt as though he were on or she was on the brink of death. Now imagine, pretend you're a mental patient. You're brought in in a straitjacket. A man in a white coat with a big hypodermic injects something into you. You feel as though you're gonna die, and maybe that lingers for two, three, ten minutes, and then you seize with those possible fractures following.

   22. LFLex Fridman1:22:27

       Violent seizures.

   23. ASAndrew Scull1:22:28

       It's violent and hard to witness and is very unpredictable. So it's used, but people are not very happy, and that's how we get electroconvulsive therapy, electroshock as it's first called.

8. 1:22:44 – 1:42:13

   Electroconvulsive Therapy (ECT)

   1. ASAndrew Scull1:22:44

      Two Italian psychiatrists, Ugo Cerletti and Frederico Bini, experiment with electricity, and they first experiment on dogs, and they make a mistake initially. They have an electrode on the head, an electrode on the anus. The electric current passes through the body. It stops the heart. The dogs die. So that seems a dead end. And then somebody says to them, "You know, you should go to the Rome slaughterhouse and see the pigs being slaughtered 'cause you'll learn something very interesting." So they go, and the pigs are dangling by their hind legs, and as they come by, two electrodes cross their head. Electroshock, it convulses. They're unconscious. Their throats are slit, and pork arrives. So, um, they try that on dogs, and current passing through the brain, it turns out, doesn't kill them. So they decide to try it out. They pick up a transient, a homeless person at the Rome train station, and they bring him in, and they, they try it, and at first they don't use enough current, and nothing very much happens. And they, they're very white-faced. They're quite worried. They're off in the corner. We, we have descriptions of this, and they're talking, "What should we do?" "Well, we'll up the current." And the patient hears that and says, "Not another one. That's deadly." They do it anyway, and he convulses, another grand mal seizure with the same problems of spinal fractures and hip fractures and so on. Uh, not universally, obviously, but often enough. And, uh, he stops breathing. You can imagine the scene. And then he spontaneously starts breathing again. And when he comes around, he's in contact with reality. They go, "Oh, we got this miracle cure, and it's very easy to administer, cheap, doesn't involve injecting things into people's bodies." So that quickly spreads across the Atlantic and to other parts of Europe, um, and ECT becomes a very widely used intervention. Couple of things to say about this. Um, it turns out it's not very useful for schizophrenia. Remember the connection between seizures and seizure, uh, and schizophrenia that was originally positive, posited. But it seems to work in cases of, um, depression, suicidal depression particularly.

   2. LFLex Fridman1:25:22

      Fast-forwarding to the modern day-

   3. ASAndrew Scull1:25:23

      Mm-hmm

   4. LFLex Fridman1:25:23

      ... and this is something I learned by r-reading a bunch recently.

   5. ASAndrew Scull1:25:29

      Mm-hmm.

   6. LFLex Fridman1:25:29

      It seems to be one of the, uh, few evidence-based, like scientifically backed method that actually work for clinical depression, for, for serious depression.

   7. ASAndrew Scull1:25:40

      Um, yes, if we fast-forward, we're looking at, in some respects, a different animal and for reasons I'll explain, okay?

   8. LFLex Fridman1:25:47

      This is unmodified-

   9. ASAndrew Scull1:25:48

      This is-- Yeah

   10. LFLex Fridman1:25:49

       ... ECT.

   11. ASAndrew Scull1:25:49

       So we're talking about unmodified ECT, which rules the roost really well into the 1950s, in some places even into the 1960s, and so it is associated with all the problems of fractures that we've talked about. It's also associated with memory problems People often lose memory. There's some dispute about how serious that is, but it's pretty widely recognized that's one of the prices you're gonna pay for that treatment. Um, the thing is, for mental hospitals in the '40s and '50s, ECT was much more used as a, um, device to control people's behavior than as a therapeutic intervention. Um, it was quite punitive, um, seen as such. Uh, patients didn't wanna repeat, and so they-

   12. LFLex Fridman1:26:39

       Yeah

   13. ASAndrew Scull1:26:39

       ... sort of controlled themselves a bit. Um, but yes, it-- we don't know why, why, why it, quote, "works," but, um, more recent work starting in probably the 1990s-- And I'm gonna get in trouble with some people for saying this because you mentioned patients and psychiatrists who swear by ECT. There are others who swear at it.

   14. LFLex Fridman1:27:05

       Hmm.

   15. ASAndrew Scull1:27:05

       Um, partly because of the memory problems I alluded to, and partly because of claims that it may cause brain damage. Passing an electric current through the brain is possible. What changed ECT a bit, quite a bit actually, was giving muscle relaxants so that people didn't thrash about and the, and the fractures were largely a thing of the past. When you introduce these muscle relaxants, originally they used curare, but then they, they used other more modern drugs to paralyze the muscles temporarily. Problem is, that would also paralyze your breathing muscles, so that's not too good. So it became a more complicated procedure because you needed an anesthesiologist, breathing support, and so forth during the, during the procedure. But you did eliminate the fractures. It still was a very widely disdained practice, I think, particularly when they had drugs available. The thinking was that, well, we'd sooner use those, but the drugs turn out to be only partially effective and pretty ineffective very often for suicidal cases and cases of extreme melancholia. Now, a couple of things to say. Very often, ECT has to be repeated at intervals. It's a kind of maintenance therapy. So it hasn't cured things, but it temporarily alleviates the symptoms, and the temporary may be fairly lengthy, but nonetheless, very often things will recur. The memory problems can be quite severe. The worries about brain damage are, I think, certainly things we have to be very cautious about. And when we talk about treatment-resistant depression, that's an interesting concept to me. What it means is those are the patients who don't respond to drugs. They may not have a different disease, but the drugs don't work for them, hence treatment-resistant. And the numbers of psychiatrists who are willing to give ECT are rather small, and in many states, it's hedged around with lots of legal restrictions. In California, for example, um, ECT now almost can't be given to involuntarily confined patients 'cause you have to, you have to volunteer for it.

   16. LFLex Fridman1:29:38

       Mm-hmm.

   17. ASAndrew Scull1:29:38

       So as-- So it's unusual in that most medical procedures aren't hedged about by legal constraints like that.

   18. LFLex Fridman1:29:46

       Mm-hmm.

   19. ASAndrew Scull1:29:46

       And there clearly is a very powerful group of people, some of them psychiatrists, many of them ex-patients, m-many of them other people who just are suspicious of modern medicine and science, who, um, form a group who are very powerfully opposed to ECT. So although i-it's fair to say there are, um, trials now that seem to provide decent evidence that for some patients this, this works and that those patients are deeply distressed before the treatment, uh, it's also still a controversial treatment, I think it's fair to say.

   20. LFLex Fridman1:30:26

       Like basically every single topic, treatment, problem, subfield of psychiatry today.

   21. ASAndrew Scull1:30:36

       Yes, yes.

   22. LFLex Fridman1:30:37

       So everything, everything we say today, there will be at least one person upset-

   23. ASAndrew Scull1:30:42

       [laughs]

   24. LFLex Fridman1:30:43

       ... and writing a letter.

   25. ASAndrew Scull1:30:43

       I think lots of people upset. So if we talk about drugs, there'll be two kinds of people who'll be upset, uh, those who think the drugs are more powerful than they are or who have been successfully treated by the drugs and go, "Well, it worked for me, so, you know, stop criticizing it 'cause it, it really is an effective treatment." And then on the other side of the coin, there are those who either the drug treatment has been used and it's failed or they're being left with terrible side effects that don't go away, or, uh, they're part of a general group of people that unfortunately is of a growing number these days who are so suspicious of medical science and of the drug companies that no amount of evidence will sway them. They are convinced that, um, y-you know, the, the drug treatments are poisonous. Um, the Scientologists being a very extreme example of that, uh, who they have a whole museum in Los Angeles and the title is Psychiatry: Industry of Death. And then if you think about all the resistance, for example, that has surfaced to vaccination in contemporary US and how the trust in vaccination has been destroyed for a substantial number of people, it's very difficult to convince them that they're mistaken.

   26. LFLex Fridman1:32:21

       And not just the trust in vaccination, uh, consequence of that is a, a general distrust in science and-

   27. ASAndrew Scull1:32:26

       A general distrust, exactly

   28. LFLex Fridman1:32:27

       ... and distrust in medicine and so on.

   29. ASAndrew Scull1:32:30

       That's one of my great worries about our contemporary situation, that we're only-- we're less than a year in. Uh, after four years of this, first of all, the degree of mistrust will have grown exponentially, and once trust is lost, it's very hard to recover.

   30. LFLex Fridman1:32:49

       Mm-hmm.
9. 1:42:13 – 1:59:45

   One Flew Over the Cuckoo's Nest

   1. LFLex Fridman1:42:13

      Uh, l-let us return to, uh, the origins of ECT and how it was applied. But first, if it's okay, a quick bathroom break. Quick 10-second thank you to our sponsors. Check them out in the description. It really is the best way to support this podcast. Go to lexfridman.com/sponsors. And now, dear friends, back to my conversation with Andrew Scull. Now we're back just to talk a little bit more about ECT and "One Flew Over the Cuckoo's Nest." So what can we say about that, that little cultural moment, one of the m-most famous moments about psychiatry? First of all, Ken Kesey wrote this book about his own experience in a mental institution.

   2. ASAndrew Scull1:42:55

      Yeah, Menlo Park, yes.

   3. LFLex Fridman1:42:57

      How representative is it of the system at the time?

   4. ASAndrew Scull1:43:01

      Mental hospitals have had a very patchy and complicated history. He was working actually in a hospital for veterans. Those were largely created after the Second World War when there were very many more psychiatric casualties among the American troops than even the First World War. You know, the interesting thing is we, we all, by osmosis, know that in the First World War there was something called shell shock that afflicted the troops and that the military initially resisted recognizing and ultimately were forced to grasp. But in World War II, American psychiatric casualties among the troops were two to three times as high as in World War I, and that's an important part of the history of psychiatry. But the upshot of that was that post-war, the VA was heavily involved in, first of all, paying to train psychiatrists and even psychologists, and, uh, then had in its mental hospital system a considerable involvement with, um, psychiatric disorders. Kesey-- Well, the book is different than the film is the first thing to say Obviously, the film is heavily indebted to the book, but it changes various things.

   5. LFLex Fridman1:44:26

      Uh, if I may just go into Perplexity, the book and the 1975 film tell the same basic story of McMurphy challenging an oppressive psychiatric ward, but they differ sharply in point of view, tone, and what the story is about. The novel is weirder, more political, and more about Chief Bromden's inner world and the Combine, while the film is more naturalistic, character-driven, and turns McMurphy into the central hero.

   6. ASAndrew Scull1:44:54

      Yes, I think that's right.

   7. LFLex Fridman1:44:56

      Murphy is the person that received DCT played by Jack Nicholson.

   8. ASAndrew Scull1:45:00

      Yes. And you have a nurse figure in Nurse Ratched.

   9. LFLex Fridman1:45:03

      Yeah.

   10. ASAndrew Scull1:45:03

       Louise Fletcher, I think is an equally powerful performance.

   11. LFLex Fridman1:45:08

       It's just one of the greatest films of all time, who happens to be, which is unfortunate for, you know, maybe psychiatry. Yeah.

   12. ASAndrew Scull1:45:15

       Psychiatry. Yes. It's very interesting. I used to teach, uh, a class called Madness in the Movies. And, um, I didn't just use... In fact, I used relatively few contemporary films. And all-- among all the films from back then, the one almost everybody in the class had seen was One Flew Over the Cuckoo's Nest. So eight, uh, 19 and 20-year-olds, uh, in 2015, if I showed them Al-Alfred Hitchcock's Bell Bound, no chance they'd ever seen that, maybe one, uh, 'cause they were a class of people interested in film. But everybody had seen One Flew Over the Cuckoo's Nest.

   13. LFLex Fridman1:46:01

       On that tangent, really quick, what, what is the greatest film of madness in your view?

   14. ASAndrew Scull1:46:06

       Oh, well.

   15. LFLex Fridman1:46:06

       Would that be the One F-Flew Over the Cuckoo's Nest?

   16. ASAndrew Scull1:46:08

       I think One Flew Over the Cuckoo's Nest, I, I think. Uh, oddly, a, a very different film, uh, appeared at about the same time was I Never Promised You a Rose Garden, which is a much more sympathetic portrait of a different kind of psychiatry, a very Freudian psychiatry. It's really about Frieda Fromm-Reichmann, who worked, uh, at Chestnut Lodge in Maryland and treated schizophrenia with psychotherapy rather than with drugs or, um, other forms of physical intervention. And that was a bestselling novel by a young girl who had been her patient, uh, with some fairly serious delusions and a very complicated family background. Um, and again, the film changed a lot of things in the novel. That's, that's what films do. My book, Madhouse, at one point interested Hollywood, and one of the two principals said to me, "I, I really like this story. It's got a, a great first act and a great second act, but where's the third s- act?" Meaning, where's the happy ending? [chuckles]

   17. LFLex Fridman1:47:20

       Mm-hmm.

   18. ASAndrew Scull1:47:20

       And I had to say there wasn't any happy ending to that story. It was just rather grim.

   19. LFLex Fridman1:47:26

       Madhouse: A Tragic Tale of, uh, Megalomania and Modern Medicine-

   20. ASAndrew Scull1:47:30

       Yeah

   21. LFLex Fridman1:47:31

       ... is the book you're referring to.

   22. ASAndrew Scull1:47:32

       Yes, that's right.

   23. LFLex Fridman1:47:32

       And that, that, that reminds me of Flowers of Argonon. That doesn't have a happy ending, and that's not about mental health necessarily, but it's, it's about the journey of the institution in relation to the health of a patient.

   24. ASAndrew Scull1:47:44

       Yes. Pat Barker's trilogy of novels about World War I was turned into a film, I think it was called Regeneration, and that was quite powerful. It, it was about World War I and the treatment of shell shock.

   25. LFLex Fridman1:47:58

       Mm-hmm.

   26. ASAndrew Scull1:47:59

       Uh, and I, and I thought was, was quite well done. Uh, and my friend Patrick McGrath, who's a novelist, uh, wrote a book called Asylum.

   27. LFLex Fridman1:48:09

       Mm-hmm.

   28. ASAndrew Scull1:48:10

       Patrick grew up in, uh, the grounds of Broadmoor. Broadmoor is England's premier hospital for the criminally insane, and he was babysat by some of the patients. And when you read his novels, you can see how that upbringing affected his, uh, uh, rather macabre, uh, imagination. But, uh, anyway. So One Flew Over the Cuckoo's Nest, the poverty of the environment, the room that the patients were in, I think fairly successfully recreates that. The, um, way in which staff very often, uh, put patients down, didn't listen to them or poke fun at them or, or even were physically abusive, although you don't see that. Um, those were all features of mental hospitals. The general boredom of life is sort of there, but yeah, it's hard to rep- You don't-- Putting boredom on the screen will turn an audience off rather fast, so. [chuckles]

   29. LFLex Fridman1:49:14

       What about nurse and, uh, this kind of abusive element, you know?

   30. ASAndrew Scull1:49:19

       Yeah, I think there, there was an abusive element in a lot of mental hospitals, and, um, it, it, it was almost inevitable. If you look at who had the most contact with the patients, it was the lowest paid, least respected ward attendants, very few even RNs. And, you know, the ratio of doctor to patient in the large state mental hospitals meant that patients hardly ever saw a physician, you know? Um, what's remarkable about the film, uh, there are many remarkable things about the film as, as well as its polemical edge, uh, I think is that the chief psychiatrist that you see in the film is the real head of Oregon State Mental Hospital. He really was. That was his introduction to acting, and I thought he was pretty remarkable actually. But obviously, there's a lot of exaggeration there. But ECT was used in the '50s and '60s as a tool of discipline in the hospitals. It was also used therapeutically, but overwhelmingly it was used as a A tool of, of discipline and control, and that's true to life. Um, lobotomy, one of the interesting things we haven't talked about with all these treatments we've been discussing is that almost invariably, except for the case of the syphilitic patients, for obvious reasons, men were more troubled by that condition than, than women. It was women that got the brunt of these experiments. So Henry Cotton, about 70% of his patients who were treated were female. Lobotomy patients, it's hard to get overall numbers, but those of us who've looked at the records of a number of different hospitals again and again discover, again, 60 or 70% of the patients are female. ECT tends to be heavily female. That's complicated by the fact that it's used primarily as, as we were discussing, in serious cases of depression and so-called treatment-resistant depression, and depression is a diagnosis that is m- more to be found among women than men. Not that there aren't very many men with depression, but again, the ratio is such. Men tend to get a different-- they get different diagnoses. Personality disorders, for example, are very, very common and, and more a male diagnosis. Um, ADHD-
10. 1:59:45 – 2:29:40

    Freud and Psychoanalysis

    1. LFLex Fridman1:59:45

       one.

    2. ASAndrew Scull1:59:45

       Yeah.

    3. LFLex Fridman1:59:46

       I have to, if it's okay-

    4. ASAndrew Scull1:59:47

       Yes, of course

    5. LFLex Fridman1:59:48

       ... so that we- we've been carrying multiple threads together. One of the threads that I think, uh, is really exciting to me and really important to the history of psychiatry is the psychotherapy side.

    6. ASAndrew Scull2:00:01

       Okay.

    7. LFLex Fridman2:00:01

       We have mentioned the psychopharmacology that we'll also-- it would be nice to discuss when the two clash and there's a revolution where ph- uh, psychopharmacology-

    8. ASAndrew Scull2:00:13

       Yes

    9. LFLex Fridman2:00:13

       ... kinda wins over, over psychoanalysis for a time.

    10. ASAndrew Scull2:00:18

        Okay.

    11. LFLex Fridman2:00:18

        But let us start at, at the, uh, somewhat beginning, the 19th century-

    12. ASAndrew Scull2:00:23

        Yes

    13. LFLex Fridman2:00:23

        ... when, uh, talk therapy starts coming to life, maybe in the religious context with the Christian Science and then psychoanalysis context.

    14. ASAndrew Scull2:00:32

        Yes. So I'd mentioned late 19th century psychiatry, confined as it was to the mental hospital and to people in, uh, incarcerated in those places, had become very biological. But there were people experiencing mental troubles of various kinds, s-- uh, sadness, um, confusion, loss of, um, social relationships that were troubling them, grief, all sorts of things like that, that didn't involve time in a mental hospital, but nonetheless in- involved a good deal of distress as they continue to do. And one of the things that was interesting about 19th century America is it spawned a number of new religions, sort of variants of Christianity. So you had Seventh Day Adventists group that still exists, who actually spawned a sanitarium for their depressed congregants that was later taken over by two prominent members of the Adventist Church, the Kellogg family. Everybody knows them through cereal, but they ran a huge sanitarium to which Abraham Lincoln's widow went, Tarzan went, Henry Ford went, lots of very prominent industrialists and politicians and, you know, it, it was kind of a, a, a farm to go and recover your mental stability and health, and it was all bound up also with, um, beliefs about diet and, um, uh, defecation and all sorts of things. So there were the Mormons or Church of Jesus Christ of Latter-day Saints. Many Christians don't believe they're really Christian, but they think they are and call themselves such. So you have a number of these, and one of them was Christian Science, which was the invention of a woman named Mary Baker Eddy. And it wasn't just about mental troubles. Mary Baker Eddy developed the idea, and there are still Christian Science churches and Christian Science reading rooms all across America, that there wasn't such a thing as disease, that it could be prayed away, that it was just a lack of sufficient faith. So faith healing, uh, tended to work, I think, better if it worked at all for psychiatric problems than it did if you had, say, cancer. Um, but, uh, Christian Science achieved a considerable number of followers, disproportionately women, but not only women. Uh, and it began to treat many of the people suffering from what we would think of as the milder mental disorders. And it attracted both, uh, adherents and severe critics. Uh, Mark Twain, for example, uh, was thoroughly dismissive of, of Mary Baker Eddy. But it was very successful for a time, and there were other religiously based attempts to join in, the most important of which in New England was something called the Emmanuel Movement, centered around the Church of the Emmanuel in Boston, which was an attempt actually initially to bring medical and religious approaches to helping the mentally troubled. But rather quickly, the doctors involved decided this was veering too much in the direction of medically based therapeutics, and they kind of withdrew from, from that enterprise. And it dispensed-- I mean, there were, there were talk therapies, um, obviously with a strong religious component around them. Um, and this was also at a time when some, I guess we can call them psychiatrists, they were often neurologists, were beginning to get lots of patients with these kinds of, um, difficult to treat disorders. Neurology had emerged in America after the Civil War. Civil War provided a lot of naturalistic experiments on what happens to the human brain and the human nervous system when trauma affect-- I don't mean psychological trauma, I mean bullets blowing holes in your brain. And so a group of new specialists emerged after the Civil War who claimed expertise in the brain and the nervous system. Well, one of the other side parts of that is insanity, because insanity is also seen as a brain disease. So there is a conflict that erupts in the seven- 1870s and '80s between neurologists and psychiatrists. But the neurologists can't, for the most part, get into the asylum where the most seriously ill patients are. And so gradually, what comes to their waiting room, along with people like multiple scro- suffering from things like multiple sclerosis, are people with functional m-mental disorders. And so there's the beginning of an outpatient practice, um, which initially involves, um, some, some drugs, some, the, the use of electricity, not ECT, but the use, for example, of static electricity, 'cause it produces obvious physiological responses, and electricity is seen as dominating the workings of the body. Um, and sometimes tonics of one sort and another, and most notoriously of all, something called the rest cure, which Silas Weir Mitchell, one of the leading lights of American neurology, develops, which is complete bed rest, lots of calories, lots of food, complete lack of intellectual stimulation, and supposedly this is gonna cure you, mainly aimed at, at women.

    15. LFLex Fridman2:06:55

        I feel like that's another, uh, evidence-backed, uh-

    16. ASAndrew Scull2:06:58

        [laughs] Yes

    17. LFLex Fridman2:06:58

        ... technique that works well.

    18. ASAndrew Scull2:07:01

        Well, you know-

    19. LFLex Fridman2:07:02

        I've, uh, I've partaken in this, and I know it has helped me.

    20. ASAndrew Scull2:07:05

        So, uh, [laughs] uh-

    21. LFLex Fridman2:07:08

        Laying in bed doing nothing, eating snacks

    22. ASAndrew Scull2:07:10

        ... Virginia Woolf was one of the people subjected to this, and she's claimed it practically drove her mad and made her worse, you know?

    23. LFLex Fridman2:07:17

        Just to clarify, we're talking about laying in bed eating snacks.

    24. ASAndrew Scull2:07:20

        Eating lots of snacks, a very high calorie. So-

    25. LFLex Fridman2:07:23

        Okay

    26. ASAndrew Scull2:07:23

        ... Weir Mitchell wrote two popular bestsellers, self-help books I suppose you'd call them in the modern genre. One was called Wear and Tear. So the pace of modern life, the telegraph, the railway was all too much, and your nervous system was overstressed. Either your batteries ran down, that was one analogy, or you overtaxed your system and went, you know, bankrupt. So Wear and Tear, that was the problem, and the solution was Fat and Blood. That was the title of the other book. So y- you got scrawny and all nervous and twitchy, and what you really needed was to build back up your strength, including your nervous strength.

    27. LFLex Fridman2:08:08

        Isn't it fascinating to look at that 120 years plus ago, they're talking about how anxiety-inducing society is, how much is going on, and we in the modern day talk in the exact same way about, you know, social media, the internet, all that kind of stuff.

    28. ASAndrew Scull2:08:23

        Yeah. Yeah. It is. You know, we look back on the 19th century and think of it in idyllic terms of, you know, as much slower pace of life and people. They thought it was stressful in exactly the ways we do. So there was a c- so there was a class of potential patients. Some of them were seeking help in the neurologists and, and a few psychiatrists who moved out of the asylum. But there were also these mental healing Groups that were religious, and they're all around at the beginning of the 20th century. And in 1909, a Viennese gentleman and two of his close colleagues travel across the Atlantic on a German steamer and arrive in New York and then transport themselves up to Worcester, Massachusetts, where Clark University is celebrating its 20th anniversary. Clark University was then set up, it still exists, but it was set up to copy the German research university. The only comparable example at the time was Johns Hopkins in Baltimore, and Hopkins developed the leading medical school of the time, borrowing from that German concept of mixing research and teaching and patient care.

    29. LFLex Fridman2:09:46

        I like how you're telling this in a cinematic way, the, the story of Sigmund Freud and Carl Jung-

    30. ASAndrew Scull2:09:52

        Yes
11. 2:29:40 – 2:50:14

    WWII and Cognitive behavioral therapy (CBT)

    1. ASAndrew Scull2:29:40

       to know circa 1930, there are probably 300 a- psychoanalysts in North America. Um, if they each-- if classical psychoanalysis involving five hours a week, um, they can't treat that many patients, a few thousand, when there are hundreds of thousands in the hospitals, right?

    2. LFLex Fridman2:30:03

       Mm-hmm.

    3. ASAndrew Scull2:30:03

       So what changes that?

    4. LFLex Fridman2:30:06

       The war, Second World War.

    5. ASAndrew Scull2:30:08

       Hitler starts killing off Jews and killing off psychoanalysts. The ones who can escape, some of them go to England and some come to America. Uh, the most famous escapee is Freud himself and his daughter Anna, who-- Princess Bonaparte, who's one of Freud's great supporters, bribes the Nazis to get him out, and he travels by train to London, very sick with, uh, cancer of the jaw, as he has been since the mid-'20s. So he sets up shop in London, and Anna succeeds him really as one of the central figures in British psychoanalysis. But other analysts come here to America. So the numbers of analysts probably by 1940, America's not yet in the war, have a bit more than doubled. And more importantly, psychoanalytic training has become much more organized here. The institutes outside the universities control psychoa-- And universities are not yet the knowledge factories they become after the war.

    6. LFLex Fridman2:31:14

       Mm-hmm.

    7. ASAndrew Scull2:31:15

       And that's a crucial mistake that psychoanalysis makes. It's great because it controls its training completely. The bad thing is when the center of gravity moves to the university, it, it's not there, and it, it either resists being incorporated or is-- the university resists incorporating it. So I think that's a structural weakness for that. But what really transforms things is World War II.

    8. LFLex Fridman2:31:42

       To backtrack, what's officially the process for psychoanalysis as Freud and Carl Jung saw it? You said five hours a week. So it's this long, deep dive-

    9. ASAndrew Scull2:31:51

       Five 50-minute hours famously. They-

    10. LFLex Fridman2:31:54

        Yeah

    11. ASAndrew Scull2:31:54

        ... they last 50 minutes 'cause then there's 10, 10 minutes for the poor analysts to recover before the next patient arrives.

    12. LFLex Fridman2:32:00

        And literally, I mean, you think it's not important, but I guess they were pretty, uh, strict about this, is you're, you're lying on the couch.

    13. ASAndrew Scull2:32:08

        Yes, you are free associating on the couch and gradually being coaxed to see as the material emerges what you're hiding from yourself.

    14. LFLex Fridman2:32:20

        I mean, initially they tried-- this is in the early, early days, they tried hypnosis.

    15. ASAndrew Scull2:32:24

        Yes.

    16. LFLex Fridman2:32:25

        But they've-- you know, this is where Freud took the big leap and expanded to free association.

    17. ASAndrew Scull2:32:30

        Right. So I mentioned Freud training under Charcot. Charcot hypnotized his hysterical patients.

    18. LFLex Fridman2:32:37

        Mm-hmm.

    19. ASAndrew Scull2:32:38

        We now know a lot of that was fakery. Um, not-- I don't think he was conscious of the fakery, but the patients were on display over and over again, and they worked their routines up very well, and they deceived him, and they deceived the audience. But Freud came back from Paris bringing with him the idea that hypnosis was the way forward. But after the break with Breuer, Breuer had a general medical practice and lost interest in hysteria and didn't want anything to do with the revisions of Freud's work on hysteria. After that happened, Freud, who was a very clumsy hypnotist by his own account, um- Began to develop this alternative of free association and getting people to speak whatever came into their head without a censor. That was the important thing, that the half-murdered memories were being hidden from you and your, uh, the constellation of psychological forces in your unconscious was squashing them down, but they, they were reemerging as, as other kinds of symptoms.

    20. LFLex Fridman2:33:49

        So how well does psychoanalysis work? How much do we understand? We've talked about all these approaches that didn't work.

    21. ASAndrew Scull2:33:57

        Hmm.

    22. LFLex Fridman2:33:59

        How well did it work at that time?

    23. ASAndrew Scull2:34:01

        You know, one of the things after World War II when psychoanalysis was making great strides in America and the Rockefeller Foundation was still heavily involved in promoting psychiatry and developing what it hoped would be new tools in it, the then heads of the institute, of the funding program, Alan Gregg and Robert Morrison, especially Morrison, kept pressing the analysts, "Provide us proof that what you do works."

    24. LFLex Fridman2:34:31

        Mm-hmm.

    25. ASAndrew Scull2:34:31

        And the analysts kept resisting and resisting and resisting, saying it's much more complicated than that and there's no easy measure because what we're doing is reconstructing entire personalities, entire ways of being and the sense-- people sense of themselves, their ways of being in the world, and we don't have easy ways to measure that.

    26. LFLex Fridman2:34:52

        To contrast that with the 80% promises-

    27. ASAndrew Scull2:34:55

        Yes

    28. LFLex Fridman2:34:55

        ... over and over and over and over.

    29. ASAndrew Scull2:34:57

        Yes, yes. And it's a long and complicated pro-- That was very important because another kind of psychotherapeutics is emerging in, in the aftermath-- during and in the aftermath of the war as a rival for both psychiatry and for psychoanalysis. Initially not terribly successful, but as time goes on, a more and more important part of the story. So to focus on the war for a minute, um, America's psychiatrists went to the military brass and to the politicians before America entered the war, and it had some advance warning because America didn't enter till Pearl Harbor, but the European war had been going on. And they said, "Look, if we have to fight, we're gonna have the same problem we had in the Wor- First World War. We're gonna train these soldiers, we're gonna equip them, we're gonna put them in the battlefield, and the psychologically vulnerable among them are gonna break down."

    30. LFLex Fridman2:35:59

        Mm-hmm.
12. 2:50:14 – 3:13:35

    Antipsychotics

    1. LFLex Fridman2:50:14

       So this, this is the lay of the land. We talked about some of the darkness.

    2. ASAndrew Scull2:50:18

       Yes.

    3. LFLex Fridman2:50:20

       Lobotomies and so on. There is some talk therapy ideas of psychoanalysis, and then there is, from the clinical psychology side, cognitive behavioral therapy. Then starts to emerge the psychopharmacology-

    4. ASAndrew Scull2:50:36

       Yes

    5. LFLex Fridman2:50:36

       ... that challenges this whole shebang of talk therapy, period. And can you talk about the accidental origins of psychopharmacology-

    6. ASAndrew Scull2:50:46

       Yes

    7. LFLex Fridman2:50:47

       ... that challenges this whole thing?

    8. ASAndrew Scull2:50:49

       Hardly anybody had conceived of the idea that drugs could be used to treat mental illness. Drugs had been used in the mental hospitals back in the 19th and 20th centuries, but they were usually things that were used to control patients, to calm them down. Opiates, for example, um, various hypnotics that would put people to sleep, uh, when they were extremely agitated, um, and so forth. Uh, sometimes marijuana was experimented with, as was alcohol in the 19th century, interestingly enough-

    9. LFLex Fridman2:51:22

       Mm-hmm [chuckles]

    10. ASAndrew Scull2:51:22

        ... given the revival of psychedelics. But the idea that a drug might be used to actually attack the underlying problem, it emerged by accident in the following kind of way. The drug industry in general had emerged mostly in Germany, where I'd mentioned the most advanced medicine was being practiced in the late 19th century, from the chemical industry, from, for example, refining coal tar into different substances. That's where we got aspirin. That's where we got a whole bunch of drugs. And gradually, the drug companies become more organized. They differentiate themselves from all the quack remedies that are around. And the war, I think, greatly accelerates. Again, World War II, uh, greatly accelerates things, not least because we discover a real magic bullet called penicillin and then the other antibiotics that we subsequently c-come across. Penicillin had been observed by Alexander Fleming in his, famously in his lab in some Petri tube, uh, Petri dishes where bacteria had been killed. Later was one of the co-winners of the Nobel Prize and made a lot of capital out of that discovery. It was really Howard Florey and his team at Oxford who developed the therapeutic potential of penicillin. And actually, Florey flew some of it in his jacket across the Atlantic to America, and it was Americans that solved the critical thing. Um, it took Florey and his team weeks to develop enough penicillin to treat a single mouse. What America learned how to do was mass produce penicillin. Ma- and that was critical because it was vital to the war effort-

    11. LFLex Fridman2:53:27

        Mm-hmm

    12. ASAndrew Scull2:53:27

        ... obviously. Uh, and after the war, it was vital to the civilian population because it was such an, an important breakthrough. So, um, drugs, drug companies grew fatter on that. They embarked on research to try to find new substances they could use to treat things. Um, and a French company named Rhône-Poulenc came across a chemical that had actually been synthesized back in the 1880s in Germany. It was an antihistamine, chlorpromazine. They didn't know what to do with it, but other kinds of antihistamines in the war had been used effectively, and they thought, "Well, let's look and see if we can find a market for this drug." And so they, uh, the interesting thing to remember in those days is that investigating the property of new drugs was a Wild Wild West phenomenon. There were no controls. You could do whatever you wanted, and you handed stuff out and said, "Why don't you try this and see if it works?" Right? Uh, so Rhône-Poulenc did that. They thought this might work as an antiemetic. If you have a child who's prone to car sickness, you give them an antiemetic drug. So that was one possibility. Another possibility, it might work for eczema so that people didn't scratch themselves. Well, there were a number of possibilities, and somebody said, "Well, maybe it'll work as an anesthetic potentiator." Meaning if you gave some of this, you'd need to lo- use less anesthetic. It would act like a catalyst, um, because it tended to make you sleepy. If you read the leaflets on Dramamine, one of the cautions is it'll make you sleepy. Don't drive, right? So why don't we give it to some surgeons and see if they can find a use for it?

    13. LFLex Fridman2:55:22

        Yeah.

    14. ASAndrew Scull2:55:22

        Literally, it's like that. And one of the people who gets that drug is a lieutenant in the French Navy, Henri Laborit, and he tries it as an anesthetic potentiator, and he also gives it to some of the patients who are awaiting surgery. Normally, when you're awaiting surgery, you're a little bit anxious. These patients stop being anxious.

    15. LFLex Fridman2:55:47

        Mm-hmm.

    16. ASAndrew Scull2:55:48

        Um, this was the era of lobotomies, and he wrote to one of his relatives who worked in one of the Paris mental hospitals. He said, "This like-- this works like a chemical lobo- lobotomy. These people don't care anymore about their surgery."

    17. LFLex Fridman2:56:01

        And that's supposed to be a good thing, right?

    18. ASAndrew Scull2:56:02

        Well, lobotomy hadn't become the nasty word it, it would become in a few years. So one of his colleagues contacts Delay and Deniker, who work at Sainte-Anne's, which is the biggest mental hospital in Paris, and says, "Hey, guys, th-this might work on your psychiatric patients. You should give it a try." And they do, and they give-- When it doesn't work, they give a larger dose, and when it doesn't work, they give a larger dose. And sure enough, um, patients stop acting out. They stop smashing furniture. They, they become-- They're still sort of conscious, but they're less mobile, and they're much calmer. And this is why in the early stages, chlorpromazine, which becomes known as Largactil or Mighty Drug in Europe and Thorazine here, it becomes known as a major tranquilizer because it has this tranquilizing effect.

    19. LFLex Fridman2:57:01

        Mm-hmm.

    20. ASAndrew Scull2:57:01

        The hospitals see it as a boon because it'll help control the patients. They're not yet thinking of it as more than that. So that's the accidental when it, where it's discovered. It comes to North America via Quebec-

    21. LFLex Fridman2:57:15

        Mm-hmm

    22. ASAndrew Scull2:57:15

        ... where there's a psychiatrist up there, Hans Lehmann, who actually works in the Protestant hospital. Quebec in those days is dominated by its Anglo-speaking elite, who oppressed the [chuckles] the French Canadians pretty mightily. But because of the French Connection, he gets co- amounts of the drug.

    23. LFLex Fridman2:57:37

        Mm-hmm.

    24. ASAndrew Scull2:57:37

        He's the one that does the early trials here. The early-- I shouldn't say they're really trials. I gave it to 15 patients-

    25. LFLex Fridman2:57:45

        Yeah

    26. ASAndrew Scull2:57:45

        ... and they were like that. It's completely uncontrolled. But, um, Rhône-Poulenc has had to sell the rights to an American company. Um, in those days, American physicians don't trust European science or European medicine-

    27. LFLex Fridman2:58:02

        Mm-hmm

    28. ASAndrew Scull2:58:03

        ... especially European medicine. So, Rumpole sells the rights. The first two drug companies it approaches say, "No, thank you. This doesn't look very interesting to us. I don't think there's much of a market." And then Smith, Kline & French buys it up, and within two years, two million people are taking this drug. It's a bonanza for them, right? Not an accident, 'cause they put their best salesman on the job of selling this, and they realize the hospital psychiatrists mostly aren't interested. They don't yet-- They haven't yet cottoned to this idea of a chemical cure or a chemical treatment.

    29. LFLex Fridman2:58:43

        So it's the companies that wake up to this.

    30. ASAndrew Scull2:58:44

        The companies wake up. They sell it to the politicians. They go to the state legislatures. They have moving pictures of an agitated patient who turns calm, you know?
13. 3:13:35 – 3:26:29

    Antidepressants

    1. LFLex Fridman3:13:35

       So there's that, that picture, the SSRIs, there also came to be Prozac, Zoloft, Paxil-

    2. ASAndrew Scull3:13:40

       Yes

    3. LFLex Fridman3:13:40

       ... during that time

    4. ASAndrew Scull3:13:41

       All of that. Well, again, they're the second generation of antidepressants.

    5. LFLex Fridman3:13:45

       Mm-hmm.

    6. ASAndrew Scull3:13:46

       So that's a complicated story. Again, it's an accident. They're treating patients with advanced tuberculosis in the 1950s. Now, that's a very unpleasant thing that's also gonna kill you. So tuberculosis, very advanced cases. You're coughing your lungs up. You're depressed as all get out. And here we have two new drugs, iproniazid, that we can use that maybe will treat the condition. Well, you give it to the patients, and these depressed tuberculosis patients start acting happy, dancing about. Their mood changes. Bingo. We've got something that maybe we can use over here to treat depression. However, the drug companies in circa 1960 think of depression as a small market because what they're talking about is the kind of melancholic, psychotic depression that leads people into the mental hospital, and that's not an insignificant group, but it's not a huge group. So it's really much later on that things begin to change. Right now, it's fair to say depression is the common cold of psychiatry. It's, you know, it's, it's abundant. The, the depressive diagnosis is probably the most commonly given one, uh, among psychiatrists.

    7. LFLex Fridman3:15:11

       So part of that is a deeper understanding of the human mind, and a big part of that is probably the drug companies convincing the world.

    8. ASAndrew Scull3:15:19

       Well, it's transforming, yes. So there were big disputes, for example, when DSM-5 was being contemplated about whether grief, be- bereavement would count as a mental disorder, as-- count as a form of, of depression. If you lose a parent, if you lose, even worse, a child, um, it's a deep-- how can I put it? Deeply upsetting.

    9. LFLex Fridman3:15:49

       Yeah. It's one of the most horrible things that can happen to you. Yeah.

    10. ASAndrew Scull3:15:52

        Yes, exactly.

    11. LFLex Fridman3:15:53

        In this life.

    12. ASAndrew Scull3:15:53

        As I unfortunately know from personal experience. So, um, if you're feeling emotionally pretty wrought in the aftermath of an event like that, does that mean you're mentally ill? Does it mean you need an antidepressant? Well, some psychiatrists say yes, and some no. But it's an example of what happens In psychiatry repeatedly, what I would call diagnostic creep, which is a term actually a, an Australian named Nick Haslam came up with, but it's a phenomenon I described before that. You start with a core of unambiguous deviations from the norm that are so serious that any competent member of the culture knows that's that. But then it-- you begin to say, "Well, there's this penumbra," you see, and just outside that core, there are people who are also disturbed, not perhaps as sufficiently disturbed that you actually recognize it, but it's happening. And so that has tended to happen over and over again. Parents with an autistic child won't necessarily agree with what I'm about to say, but the chief editor of DSM-IV, Allen Frances, is convinced the huge increase in the number of diagnoses of autism is more driven by the fact he loosened the criteria for the diagnosis than it is because there are more actual cases. Autism used to be a fairly rare phenomenon, and now sadly, it's a, a very broad one. And I understand why parents react very negatively to that because the diagnosis is the key to all sorts of social supports and educational supports and all the rest, and they're dealing with a child who is extremely difficult. But there is a real difference between the most severe forms of autism where people lose the capacity to speak and very often any, uh, ability to interact with other people and so forth, and the other cases that are of a still serious but milder sort. Diagnostic creep is not driven just by psychi- psychiatric imperialism, the desire for more territory, more patients. It, it's driven as well by, by patients and people and, and they resist it being pushed back very often. So families have formed organizations like NAMI, but those aren't the mentally ill. Those are the family members of the mentally ill, and there are differences in the perspectives and the interests of the family members and the patients-

    13. LFLex Fridman3:18:37

        Mm-hmm

    14. ASAndrew Scull3:18:37

        ... um, and that's easy to forget.

    15. LFLex Fridman3:18:40

        I think one of the things you talk about is, uh, I mean, the quote you had was, used the word madness.

    16. ASAndrew Scull3:18:47

        Hmm.

    17. LFLex Fridman3:18:48

        But that, um, madness or mental health maladies, if you're suffering from them, it's a deeply lonely experience. And then if you're around somebody suffering from it, it's a very social experience.

    18. ASAndrew Scull3:19:04

        Yeah. Yeah, this is actually, um, that's a paraphrase of-- I was quoting one of my friends and fellow historians of psychiatry, Michael McDonald. The most solitary of afflictions for the sufferer and the most social of maladies for those around them. And there's lots of ways in which you can see that very powerfully, and that's why I think there are a ton of people who suffer in various ways from, from mental disturbances of one sort and another. But the effects aren't confined to them. They extend out to everybody else around them, and that's really powerful. So we had this first generation, uh, there were actually two different kinds of antidepressants, MAOIs, as they're called in the trade, and tricyclics, which were called tricyclics because they had a third ring of a certain element in their molecule. Those had, uh, as I say, a limited market, but also there were complications associated with them that it was easy to overdose and die. And so depressed-- giving a depressed patient a bunch of pills that if they o-took too many of them would kill them was tricky. Um, they also could kill you another way because, um, for example, you couldn't, uh, certain dietary items, cheese, cured meats, in combination with them were, were very, very health-threatening, maybe even fatal. Now, in the late '80s, the drug companies came a- came across a new class of antidepressants that didn't have those side effects. As we'll see, they had other side effects, but not those. And the most famous of those was Prozac. They were a class of drugs called SSRIs, and again, forgive the acronyms, but what it means is selective serotonin reuptake inhibitors. Serotonin is something manufactured in our bodies, actually in our digestive system, and it performs a variety of functions in the body, but it's also one of the neurotransmitters in our brains. And the way these drugs worked was by, um, slowing the reuptake of serotonin in the brain, which was m- marketed by the drug companies as the solution to depression. That when you got depressed, it was because you didn't have enough serotonin in your brain, and these pills solved that problem. It was like, uh, well, um, Tipper Gore, Al Gore's ex-wife, was like many politicians' wives, depressed for reasons I fully understand, or at least partially understand. And she went to her psychiatrist, and that was one of the things she was given, and she became one of the big public advocates for SSRIs, uh, which still are the most prescribed antidepressants.

    19. LFLex Fridman3:22:15

        Do they work, and what are the side effects?

    20. ASAndrew Scull3:22:18

        Yeah. So here's where we get into slippery territory. Every time you do a controlled study of these antidepressants, they beat placebo In a statistically significant margin, but not necessarily in a clinically significant margin. And this is when you see drug ads, be very careful. This one significantly improves X or Y. Does that mean clinically or does it mean statistically? Because the fact-- if you-- when we measure improvement with depression, we tend to use rating scales of various sorts. Um, and if you improve on one of the major scales that's used by one or two points, uh, on a 60-point scale, it may be enough to show statistical significance. This drug's a little, it's a little better than placebo, but doesn't really affect your quality of life much. And for most patients, um, antidepressants are marginally better than placebo, but a lot of the effect is the placebo effect.

    21. LFLex Fridman3:23:32

        Mm-hmm.

    22. ASAndrew Scull3:23:32

        And they come with very difficult side effects. A lot of people describe them as numbing drugs. They flatten everything out. Um, so you can't experience the highs and lows of-- that normally we ta-take as part of human experience. And then, um, the numbing extends elsewhere in your body. In particular, lots of patients find, um, the-- a complete loss of li-libido. They, they ha-- They're-- They can't get an erection. They can't c-climax if they're a woman. Their sex life just goes away. And sometimes it doesn't come back after you stop the drugs. Next layer of problems, getting off the drugs for some people turns out to be hell on, hell on wheels. Uh, they get worse depression than they had before. They get a feel-- terrible feelings. Their brain is sparking something's wrong. Um, and so many patients find themselves trapped on those drugs for a long time, and we don't know what the effects of that are gonna be. So it's a very mixed picture, you know. Uh, that's why I think groups like NICE in England are saying, "Use CBT as the first line, not drugs." Um, but again, it's also fair to say, I think what we find, and there was a recent La-Lancet study that I think was revealing on this point. It's like this with both antipsychotics and antidepressants. You have a group of people who respond pretty well, and, and the side effects for them are bearable, or even they don't experience them. That's great. You have a group of people, and it's significant. With depressed patients, we're talking 40 or north of forty percent who aren't responding. Okay? So drugs aren't doing a-anything for them, and they're running a risk. And then in the middle, you have a group of people who get some positive improvement, but they also get side effects. And that's where, you know, this cost-benefit analysis, if we can call it that, comes into play, and it's very difficult. And the problem is going in, you don't know which group you're gonna fall in.

    23. LFLex Fridman3:25:57

        Mm-hmm.

    24. ASAndrew Scull3:25:57

        And your, and your doctor doesn't know which group you're gonna fall in. And m-more importantly, one of the things the drugs revolution did was it moved the diagnosis and the prescribing of things away from psychiatry alone. So many of these things, particularly antidepressants, are dispensed by primary care docs, not, not psychiatrists.

    25. LFLex Fridman3:26:23

        Let's zoom out. Uh, we did say that there's a real crisis.

14. 3:26:29 – 3:35:08

    Future of Psychiatry

    1. LFLex Fridman3:26:30

       From an individual perspective, suffering from psychosis or suffering from depression-

    2. ASAndrew Scull3:26:34

       Mm-hmm. Mm-hmm

    3. LFLex Fridman3:26:35

       ... uh, what are you supposed to do? What works, and what is the hope for the future in the next ten, 20 out?

    4. ASAndrew Scull3:26:43

       So you probably need to try the drugs because the suffering is very intense. But you need to be aware of things, and you need a clinician who's monitoring very carefully. More generally, psychiatric research needs to broaden. We have spent all our monies on drugs, on neuroscience, and on genetics. But there are other things we could do that would improve the lives of families and patients more immediately. So we need to spend some time on the psychosocial dimensions of mental illness and to allow psychiatrists to build careers in those fields. One of the problems if you're an academic psychiatrist, your whole future is dependent on you bringing in grant monies. And there aren't grant monies available to study, are there better ways we could cope with the problem of homelessness? Are there better ways we could make-- ease the problem for families who are having to cope with somebody in their midst who's hallucinating? That sort of thing, I think, would help.

    5. LFLex Fridman3:28:03

       What about talk therapy on both the CBT, cognitive behavioral therapy, and psychoanalysis? We left psychoanalysis in this place where society left it behind.

    6. ASAndrew Scull3:28:14

       I think it's become a niche product now. Only, only the very wealthy can afford to do it, and some of them indeed do make use of it, and some of them claim that it helps them.

    7. LFLex Fridman3:28:27

       Oh, do you think there's future in it? I, I will add an extra-- I would a-add an extra bit to that-

    8. ASAndrew Scull3:28:33

       Yes

    9. LFLex Fridman3:28:34

       ... carefully Is with the advent and the rapid improvement of artificial intelligence systems-

    10. ASAndrew Scull3:28:41

        Mm-hmm

    11. LFLex Fridman3:28:41

        ... that are able to communicate with individual humans and learn a lot about them and have a conversation about the deepest secrets that you sometimes actually would even be uncomfortable telling even a therapist. That starts to go, uh, into the realm of Freud and Jung and psychoanalysis.

    12. ASAndrew Scull3:29:05

        Well, yes, and we did see, um, actually COVID, with the isolation that it produced and the fact people couldn't go to their therapist directly, we did see the rise of some of this distant learning of this, and some of it may indeed be mechanizable in the way you described. It's very important that psychiatrists broaden their perspective on these things, and some already have. I think public policy is in a mess when it comes to serious mental illness, but I'm pessimistic about fixing that 'cause it would cost bunches of money. If we were talking about something where we could cure people, transform them from, as they used to say, tax eaters to taxpayers, there'd be incentive to do it. But the honest answer is right now that's not where we are. And so we face dilemmas. I think helping people as much as we can with social supports, and, you know, social interaction is tremendously important to people's mental health. If they lack it, if they're lonely, if they're isolated, it does bad things to people. So somehow providing that kind of support, providing some sense of agency to people who often lack it, uh, would, would be very helpful. I hope somebody has a breakthrough and produces a better drug because unlike some people, I would be astonished if the major forms of mental illness didn't have a biological component to them. I don't think that's ever gonna be the whole story, but it's gonna be an important part of the story, and therefore, you know, the fact that major drug companies have abandoned research in this area, they've been bad actors in many ways. But the drugs have had some positive effects, and the fact that there's no research being done by the people with the most money to develop better treatments i- is, uh, well, one word for it would be depressing. [chuckles] You know? That's not what we wanna see.

    13. LFLex Fridman3:31:20

        So the path forward is a mix-

    14. ASAndrew Scull3:31:23

        Yes

    15. LFLex Fridman3:31:23

        ... of, uh, continued research on drugs, but from a patient perspective, extreme caution in use of those drugs.

    16. ASAndrew Scull3:31:30

        Yes.

    17. LFLex Fridman3:31:31

        Uh, talk therapy, whether it's CBT or psychoanalysis, further investigation research on that front. Then the psychosocial component of social family-

    18. ASAndrew Scull3:31:41

        Yes

    19. LFLex Fridman3:31:42

        ... people around you, less loneliness, investigating how fro- from a cultural, social perspective and from a public policy perspective, can we increase the amount of social connections that people who suffer have and all of that together?

    20. ASAndrew Scull3:31:58

        Yes, and breakthrough with people who have very hard time making those connections or who've lost the ability to make them.

    21. LFLex Fridman3:32:07

        If we can zoom out, looking back at this rich history of human beings, and we did look at the darkness, but I think there's a very large number of people that want to help those who suffer. So looking at the history of people trying to figure out-

    22. ASAndrew Scull3:32:27

        Yes

    23. LFLex Fridman3:32:27

        ... how to help those who suffer, what gives you hope about our future? A real hope for the future of psychiatry that we can actually help people who suffer.

    24. ASAndrew Scull3:32:39

        Well, I think we have a profession with many very well-meaning people who see the suffering on a day-to-day, face-to-face basis. And I like to think that among them will be people who will move this thing forward. And the fact is, we have moved things forward. We have tended to dwell a lot on some of the very unsavory p- aspects of the past, uh, and even some of the drawbacks of what we have available to us in the present. Um, but it is important to see at times, highly motivated people have been able to do very good things to help people with these conditions. And there is, I think, hope in the future that we will see more of that, uh, than, than has been the case. And that involves, in some senses, a, uh, a shift in the mentality of a whole profession in, in a more caring kind of direction or less technocratic kind of direction, a less s-- um, reliance on, um, something as simple as giving people pills, because that can help, but it's clearly not gonna be the solution to the whole thing. W- we need a system that is aware of and catering to the, the suffering that, that people experience and finds ways, if they can't eliminate it entirely, to ameliorate it in, in ways that people will sense is, uh, actually of, of help to them. It's a, it's a very difficult area, this one. It's one that, uh, tou- touches some of the most profound aspects of our selves as human beings. And, uh, I think as difficult as this problem is, uh, it's very important not to be cynical, not to give up hope, not to deny the possibility of progress, because that's always there and, and has happened, and I hope will happen with increasing pace in the years ahead of us.

Episode duration: 3:36:55