Speaker unverified: evaluation

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…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. Is it fair to characterize your view on psychiatry and mental illness as that there’s a crisis in modern psychiatry? We have made some progress- … 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. 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. 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—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 nineteen fifties, was 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 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. ont 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 could see problems. With both antipsychotics and antidepressants, the two main classes of psychotropic drugs that we use, they’re at best partially effective and they don’t work for a significant fraction of patients who are given them. And 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 therapeutic effect, are finely balanced, and making those judgment calls about what to do 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 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-…

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