Andrew Scull
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Lex Fridman Podcast · #502 – Psychiatry, Insane Asylums, Mental Illness, ECT…
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Who Was Anna O in Psychoanalysis?
Andrew Scull says Anna O was the foundation patient of psychoanalysis, and she was Joseph Breuer's patient, not Sigmund Freud's. Her real name was Bertha von Pappenheim. It stayed hidden for a long time behind the pseudonym, the way many of these cases used false names because the stories exposed a patient's inner life. She had nursed her father through an illness until he died, then developed physical symptoms that troubled her and became somewhat depressed. Breuer and Freud treated that as repressed memories and trauma. Memories lurking in the subconscious, returning in distorted form, became central to psychoanalysis.
Freud and Breuer wrote Studies in Hysteria, with short cases of patien
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Why Did Freud and Jung Split?
Andrew Scull says Carl Jung was anointed the crown prince who was supposed to inherit psychoanalysis, then the two men had a serious falling out in 1913 and went their separate ways. A close collaborator called Sigmund Freud a great hater. Falling out with him meant excommunication. Jung was Swiss and worked in the major mental hospital in Zurich. He was the one who persuaded Freud to go to America.
Freud had a very low opinion of America. He said its only interest was the dollar, and he complained about the food and about American women. America still sent him fairly rich patients. The richest patients of all went to Jung, not to Freud, and that probably made the split worse.
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What Is Insulin Coma Therapy?
Andrew Scull says insulin coma therapy put people with schizophrenia into comas with extra insulin. A doctor at a German clinic for drug addicts had used mild comas to ease withdrawal. After he moved to Austria, he tried the same idea on schizophrenia, starting in 1933. People were put into comas that could last hours or days, then revived with glucose, usually given intravenously. Seizures during the coma were taken as a good sign. He claimed the treatment cured 80 percent of his patients, a percentage that keeps showing up in these cure stories.
The method spread after a demonstration at Harlem Valley Mental Hospital in New York. The American visit was in 1936. It never became a large-sca
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Why Was Malaria Used to Treat Syphilis?
Andrew Scull says doctors infected asylum patients with malaria because general paralysis of the insane, the tertiary stage of syphilis, was invariably fatal, and an Austrian doctor who had long thought fever could treat mental illness claimed the infection cured it. That doctor had tried another fever and a typhoid vaccine without success. Near the end of World War I he took blood from a captured Italian soldier with malaria and injected it into a series of patients. The cure claims were wildly exaggerated, and they were widely accepted anyway. The work won a Nobel Prize in 1927, one of only two Nobel Prizes awarded for psychiatric innovations. The other was lobotomy.
The treatment spread
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What Is Andrew Scull's Hope for Psychiatry?
Andrew Scull says a real hope for psychiatry is that it can actually help people who suffer. Many very well-meaning people in the profession see the suffering day to day and face to face, and he likes to think some of them will move care forward. Care has already moved forward: at times, highly motivated people have done very good things for people who suffer, and he thinks the future will show more of that.
The hope involves a shift in the mentality of the whole profession, toward a more caring direction, a less technocratic direction, and less reliance on something as simple as giving people pills. Pills can help, but they are clearly not the solution to the whole problem. The system need
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Have Drug Companies Quit Mental Illness Research?
Andrew Scull says major drug companies have abandoned research on serious mental illness. No research by the people with the most money to develop better treatments is depressing. He would be astonished if the major forms of mental illness did not have a biological component. Biology is never going to be the whole story, but it is an important part of the story. He hopes somebody has a breakthrough and produces a better drug.
Public policy is in a mess when it comes to serious mental illness. He is pessimistic about fixing it because it would cost bunches of money. A cure that turned people from tax eaters into taxpayers would create an incentive to spend. The honest answer is the field is
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Why Does England Recommend Therapy Before Antidepressants?
Andrew Scull says the picture with psychiatric drugs is mixed, which is why groups like NICE in England recommend CBT as the first treatment, not drugs. Patients often stay trapped on the drugs for a long time, and nobody knows what the long-term effects will be.
A recent Lancet study found the same split for both antipsychotics and antidepressants. One group responds pretty well, and the side effects are bearable or absent. With depressed patients, north of 40% are not responding, so the drugs do nothing for them while they still run a risk. A middle group gets some improvement and also gets side effects, and weighing the benefit against the harm is very difficult. Going in, the patient do
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How Did Prozac Arrive by Accident?
Andrew Scull says the second generation of antidepressants, Prozac, Zoloft, and Paxil, arrived by accident. In the 1950s, doctors treating advanced tuberculosis tried a new drug, iproniazid. Advanced tuberculosis was unpleasant enough to kill, and patients were coughing their lungs up and depressed as all get out.
Once they received iproniazid, the depressed tuberculosis patients started acting happy and dancing about, and their mood changed. The change looked like a way to treat depression. Circa 1960, drug companies still thought of depression as a small market, because they meant the melancholic, psychotic depression that leads people into the mental hospital. The group was not insignifi
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Were Newer Antipsychotic Drugs More Effective?
Andrew Scull says a 2005 National Institutes of Mental Health study, published in the New England Journal of Medicine, found that newer antipsychotic drugs were not more effective than an older one. The older first-generation drug was out of patent and cheap. The four newer drugs were still patented and, in some cases, 10 times as expensive.
Most patients did not stay on the drugs. Between 67% and 82% of patients dropped out of the trial, depending on which drug they were on, because the drug was not working or they could not stand the side effects. The newer drugs caused somewhat less tardive dyskinesia, but they brought a new set of side effects. In most cases, people who took the pills g
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How Was Chlorpromazine First Tested?
Andrew Scull says chlorpromazine was first tested by handing the drug to doctors with no controls and asking them to see whether it worked.
A French company came across chlorpromazine, an antihistamine synthesized in Germany in the 1880s, and went looking for a market. Other antihistamines had already been used in the war. One proposed use was an antiemetic for a child prone to car sickness. Another was eczema, to stop people scratching. Someone suggested an anesthetic potentiator: give some of the drug and a surgeon would need less anesthetic, because the drug made people sleepy. Dramamine leaflets carry the same caution about sleepiness and driving. The company gave the drug to surgeons.
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Why Weren't Drugs Used to Treat Mental Illness?
Andrew Scull says hardly anybody had conceived of using drugs to treat mental illness. In mental hospitals back in the 19th and 20th centuries, drugs were usually used to control patients and to calm them down.
Opiates and various hypnotics put people to sleep when they were extremely agitated. Marijuana was sometimes experimented with, as was alcohol in the 19th century, interesting given the revival of psychedelics. The idea that a drug would actually attack the underlying problem emerged by accident.
The drug industry had emerged mostly in Germany, where the most advanced medicine was being practiced in the late 19th century, from the chemical industry and from refining coal tar into di
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How Strong Is the Evidence for Cognitive Behavioral Therapy?
Andrew Scull says the evidence that cognitive behavioral therapy works in cases of schizophrenia is pretty poor. Cochrane reviews, which systematically judge how strong the evidence is for treatments, rate the evidence for cognitive behavioral therapy at best as low and medium confidence. Evidence for milder conditions is more ambiguous than advocates like to pretend.
For milder forms of depression, he thinks cognitive behavioral therapy works better than the drugs, without some of the side effects the drugs have. NICE, the British organization that decides which treatments the National Health Service will support when the evidence is strong enough, has come to the same conclusion. Some pat
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Did Screening Recruits Stop Shell Shock After Pearl Harbor?
Andrew Scull says psychiatric screening before America entered the war failed because the breakdowns came back after psychiatrists removed the recruits they called psychologically weak. He cannot speak from his own experience and is drawing on people who went through the fighting.
America's psychiatrists went to the military brass and the politicians before America entered the war. The European war was already going, and America did not enter until Pearl Harbor. They warned that a fight would repeat the First World War: soldiers would be trained, equipped, and put on the battlefield, and the psychologically vulnerable would break down and be shell-shocked again. The plan was to screen all r
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How Many Psychoanalysts Were in North America Around 1930?
Andrew Scull says North America had probably 300 psychoanalysts around 1930. Classical psychoanalysis took five hours a week, so a workforce that size could treat only a few thousand patients while hundreds of thousands were in hospitals.
Asylum psychiatrists who dealt with psychotic patients wanted nothing to do with Freud or talk therapy, and Freud's ideas were not popular in mainstream clinical psychotherapy either. The partial exception was St. Elizabeth's, the only federal mental hospital, in Washington, D.C., where superintendent William Alanson White was somewhat sympathetic and tried a bit. Thousands of patients still put talk therapy out of reach, and the patients were much more se
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When Did Neurology Emerge in America?
Andrew Scull says neurology emerged in America after the Civil War. The war gave specialists a run of naturalistic experiments in what happens to the human brain and the nervous system when bullets blow holes in the brain. A new group claimed expertise in the brain and the nervous system. Insanity was one side of that specialty, because insanity was also seen as a brain disease.
Religious groups were already treating many milder mental disorders. Christian Science gathered a considerable number of followers, disproportionately women, and began to treat people suffering from milder mental disorders. It drew both adherents and severe critics. Mark Twain was thoroughly dismissive of Mary Baker
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Did Andrew Scull Write Desperate Remedies Right Away?
Andrew Scull did not write Desperate Remedies right away. He worked on it piecemeal over the years and ended up with a much more comprehensive look at psychiatry, from its origins to now. He could not have written the book back then. An earlier version would have missed the developments from 1980 onward, which are very important to the overall picture. He finished it 40 years later, in 2022.
He has written a lot of books. He thinks keeping at least two projects going at once is part of how he stayed productive and interested. He cannot write two things at the same time. He works on one, and when he gets tired of it he picks up the other for a bit, then goes back. While one project is the ma
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Why Does Electroconvulsive Therapy Still Get Used?
Andrew Scull says electroconvulsive therapy still gets used because patients on the brink of suicide, with long-running depressions, have described it as life-saving, and recent controlled trials give enough evidence that it is hard to say the treatment never works.
The record in the 40s, 50s, and 60s is terrible. The CIA funded Ewan Cameron in Canada, and he gave multiple treatments a day until people could not walk, talk, or feed themselves and were incontinent. He claimed to rebuild them, but many were left permanently damaged. There is no clue why the treatment works. It is purely empirical, and Scull thinks the missing explanation tends to put people off. Removing a curable cancer rest
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Was Electroconvulsive Therapy Used as Discipline?
Andrew Scull says electroconvulsive therapy was used in the 1950s and 1960s as a tool of discipline in the hospitals. It was also used therapeutically, but overwhelmingly it was used as a tool of discipline and control.
One Flew Over the Cuckoo's Nest fairly successfully recreates the poverty of the rooms patients lived in. Staff very often put patients down, did not listen, poked fun at them, or were physically abusive, although the physical abuse stays off screen. The same features marked the hospitals. Boredom filled daily life, but putting boredom on screen turns an audience off rather fast.
An abusive element ran through a lot of mental hospitals and was almost inevitable. The people
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How Did World War Two Change American Psychiatry?
Andrew Scull says American psychiatric casualties among the troops in World War II were two to three times as high as in World War I. In the First World War, shell shock afflicted the troops. The military initially resisted recognizing shell shock and was ultimately forced to grasp it. Veterans hospitals were largely created after the Second World War, when psychiatric casualties among American troops were very many more than even in the First World War.
Ken Kesey wrote One Flew Over the Cuckoo's Nest about his own experience in a mental institution in Menlo Park. He was working in a hospital for veterans. Mental hospitals have had a very patchy and complicated history. After the war, the V
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Are Ketamine and Psychedelics a Miracle Cure for Depression?
Andrew Scull says ketamine and psychedelics are being put forward as a miracle cure for depression, and the evidence for that claim is enormously weak.
He has seen the same pattern before. An 80 percent cure was claimed for Cotton's work, an 80 percent cure for insulin coma therapy, and an 80 percent cure for the early asylums. The claims are overblown rhetoric. Progress usually comes in small steps, and sometimes it comes in big steps. Penicillin was a huge step. He grew up in the era when penicillin and other antibiotics became widely available. Antibiotics had already been overused, and a strep throat still cleared right away, without the heart valve damage that earlier patients risked.