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>> are you thinking this is just a committee center? it's way more than that. >> con casters parting with 1000 commuters to create wi-fi enabled lift zones so students from low-income families can get the tools they need to be ready for anything. >> comcast, along with these television companies, supports c-span2 as a public service. >> good evening, everyone and welcome to warwick's. thank you all very much for coming. on behalf of warwick's i want to thank you for your support. just as an aside, last year warwick's celebrate 125 years as the oldest continuously family owned bookstore in the united states. so thank you very much. hopefully next year we will have our 126 year period this evening warwick's is pleased to welcome andrew scull who will discuss his newest book "desperate

remedies: psychiatry's turbulent quest to cure mental illness." and he will be an conversation with dr. david lehman. andrew scull received his ba from oxford university and his phd from princeton university, and is currently distinguished professor of sociology americus at the university of california san diego. in 2015 he received the roy porter metal for lifetime contribution to the history of medicine. and in 2016, the eric carlson award for lifetime contributions through the history, to the history of psychiatry. his previous books include madness and civilization, hysteria, the disturbing history, and madhouse, a tragic tale of megalomania and modern

medicine. he has contributed to many documentaries including the pbs series of mysteries of mental illness, and also the lobotomized. andrew scull blogs for psychology today and mad in america. and he has written for the atlantic, "scientific american," paris review, the "wall street journal," and the nation, among many others. dr. david lehman received his medical degree from washington university st. louis medical school, and completed his psychiatry residency at university of california san diego. he is currently chief of cognitive disorders clinic at the v.a. medical center in san diego, as well as the medical director of the inpatient unit.

dr. lehman is also heavily involved in education at the university of california san diego medical school, and the residency training program. and he is the recipient of teaching awards in both departments. in addition, he is the associate director for the third year medical student psychiatry clerkship, and the coordinator of the fourth-year medical student psychiatry sub internships. so please give a very warm welcome to andrew scull with david lehman. [applause] >> thank you very much for that introduction. it's a real pleasure to be here. i hadn't realized that warwick's was quite the ancient, that's quite a remarkable accomplishment, and i'm so pleased that we have a bookstore of this quality in our community. very few places these days i'm

sad to say have the advantage of a place like this. so i'm very pleased to be with you tonight. the book that i have just completed i actually first envisioned if you can believe it in the early 1980s. it would've been a very different book cat i published it back then. i have spent my very early part of my career first of all looking at the rise of psychiatry, the emergence of psychiatry and the rights of the asylum in victorian england. and before i published that book because i was tired of it as was my doctoral thesis, when i went around interviewed people, what people said what do you think about the shedding of silence? i don't know. i thought that's a big surprise. i knew how much money and

intellectual capital had been invested in the idea that the mental hospital was a solution to mental illness. so anyway i thought that would be an interesting topic and one more congenial to my social colleagues who regarded people who wandered about victorian england as a bit strange. so i wrote a book on the institutionalization very early, i mean in the mid-70s, widow still being hailed as grand reform. my book suggested that perhaps all was not quite what it seemed and in many ways i like to think it was a pressing book. it was a book that anticipated what we live with today, the abandonment really of people with serious mental illness and the problems that has resulted in. so later on i moved into the 18th century, then i did some books that spans vast regions of

history and the student to work on the 20th century, and that, the period i was initially working on was the 1920s d '30s which was a period of extraordinary therapeutic experimentation in psychiatry. mental patients were set up in a double sense. they were locked away and the voices were stifled. and in any event anything bad to say was seen as a product of their mental illness. so that meant, given the desperation at the times, that they were very vulnerable and the upshot was a series of interventions, some of which i discuss in this book. so at the beginning united states is the title occurred to me in about 1981 1981 winde institute in london. but as time went on i wrote many of the books and went back and forth. iowa's at this project and

madness and civilization which is a true exercise of chutzpah in the back of my head. and finally i said to myself i have to write these things but i wanted to put american psychiatry in a very long historical context, where did it come from, how did he come to be, how did it evolve in the 19 century as the initial utopian hopes that we could cure mental illness began to subside into a climate of hopelessness, i period and towards the end of 19 century where we come psychiatrists in the culture at last dismissed mentally ill people as degenerates, as people who would suffer devolution running reverse, were no longer fully human and need to be locked away lest they become produce more of their kind. and that was a state at the endd

of the 19th century, very heavily biological account of mental illness but one that was imbued with a sense of hopelessness that what would you do? one of the things we did and i say we, california was the leader in the united states, is we started involuntarily sterilizing the mentally ill. and california didn't stop doing that until about 1960. a very long history. and that legislation was the model for the nazis in germany. and they produced a compulsory sterilization, lacking the restraints of our kind of political system, they exterminated en masse and then they decided that these people were as they call them useless eaters, and so they killed them. the final solution was first started on mental patients. it was there that the technologies of the gas chamber

was developed, about a quarter million patients were killed with active participation that leading german psychiatrists and that was one possible response to this awfulness. but in other respects, psychiatrist though were not satisfied with jews being boardinghouse keepers running an asylum and keeping the population under wraps, there was, they wanted to be healers, and so they looked for various ways to intervene. and, unfortunately, that produce some pretty terrible results, and i think at this point i will show up for a few minutes and let david who i know has read the book talk about those middle chapters where i talk about that experimentation -- orgy of experimentation, as i call it. >> well, first of all let me

thank you for inviting me. you have been training me since i was a resident in psychiatry, and probably more than anyone else, introduced me to the unpalatable nature of history of psychiatry. and that unpalatable history really has had a traumatic and in the end i think a very positive effect on my psychiatric career. and i would think it's sad and perhaps horribly amiss if a resident were to graduate from a psychiatry program and really not be familiar with these warnings that you do so well and in such really a devastated fine ash and devastating and horrifying matter reporting on the history of psychiatry.

>> yes. i think one of the things that's very important to understand is there was a strain in my discipline and among some renegades psychiatrists in the 1960s to dismiss mental illness, to claim it was a myth or to claim it was a matter of social labels, and that's never been my point of view. i understand how deeply distressing and disturbing and disruptive mental illness is in people's lives. i've seen a close up with close friends, one of whom committed suicide after a postpartum depression. so i am not in any sense at the psychiatry but i am very much somebody who thinks we need to face up straightforwardly to the truth of what we can and can't do, what we understand, what we don't understand, the limitations of our knowledge, the kinds of things that in the present we really ought to be doing and are not.

and so while the book is heavily critical in many ways of psychiatry, it's not meant to be, and i'm glad to say that critics have responded to it so far have not seen it as, an attack on the field but more an attempt to analyze ways in which it's gone wrong, ways in which it has made some limited progress in the last 50, 70 years, but the limits of that at the moment, and the ways in which i think the national institute of mental health has been captured by a very monochromatic view of mental illness that it is all brain disease, that's all that needs to be said, so we concentrate on genetics, we concentrate on neuroscience. and the upshot of that for patients were actually sick has basically been nothing.

you think that's me speaking as an outsider so i will just say, thomas o-ran nimh from 2002-2015 more or less, when you step down said no, you know, over the last period i spent a lot of money, about $20 billion, and he said we find it some really cool cool neuroscience and some really cool genetics, and the payoff for patients has been zero. and actually he was being too kind. if you look to people with serious mental illness, some in the audience will know, the life expectancy of those people is 15-25 years less than the rest of us, and that gap is growing not diminishing. that's not purely psychiatry speak. it's a result of public policy. but it is a sobering reminder that we've got a very long way to go.

>> i thought a lot about thomases comments. and the way i think about it is this way. psychiatry is concerned with the mind, the mine is an abstraction of the brain, and the brain is by far the most complex organ in the body. the questions psychiatry asks are vastly orders of magnitude more difficult than other branches of medicine. i mean, what is consciousness is among the most difficult question that science has ever proposed. and so i don't think it should be a surprise that psychiatry has that come up with many answers very quickly. it will take time. as you point out in the book, in the 1990s there was some

irrational exuberance, the decade of the brain, when we made all kinds of promises that have not yet been delivered. but from my perspective what i would say to thomas insel is i see no reason why science, given the time, cannot address these very, very difficult questions in psychiatry the same way that its address it in other branches of medicine. it's not going to happen in the next decade. i don't see why it cannot happe happen. >> i guess what i would add there, david, is that it seems to me that the distinction that's often made between the biological and social is a false dichotomy. our brains are very plastic organs. for years and take its it ae are born they are very much the joint product of the brain we are born with and the brain that develops over those years, and the patents that develop within the brain are very much a

product of the social and cultural the cultural environment in which that brain matures, and that person matures. one of the problems i have, i'm not trying to say they should not be neuroscientific research and there should not be research into genetics, although so far that is proved to be something of a dead end. what i would like to see is research as well that deals with the other dimensions of mental illness. as a clinician you are only too aware of that, right? we have, we need research on how best to give families some relief. we need research on how we provide suitable housing and social support for people with serious mental illness. nimh has largely neglected that for two decades now. >> yeah, but i think that it seemed that biological

psychiatry was a way to go, and you mentioned in your book of the rockefeller institute really struggled with this question, what should they find, given all this money to research and who should they trust in terms of recommendations? there were so many advances that were happening so quickly with medical technology at the time that it seemed reasonable to place a bet on the sexy, exciting stuff rather than the quotidian less fun and exciting questions of how you house people, how you address loneliness, and how you minimize the suffering associated with the human condition. >> i would agree. what many people may not realize and it's why it's important i think to have a historical perspective is that before the second world war there was essentially no federal involvement in mental illness,

other than running one mental hospital saint elizabeth in d.c. with no federal funding of medical research that of psychiatric research. and the major actor in filling that gap was, in fact, the rockefeller foundation which made the rather brave and unorthodox decision in the early 1930s that is going to fund psychiatry as the least developed part of medicine and the one where it thought they could make the most difference. and it did spread its net quite widely. some of the directions in which it spent money seemed reasonable, others in the light of later developments seemed rather problematic. for example, rockefeller founded, funded the german nazi psychiatrists and continue to do so right up to the outbreak of world war ii.

and was heavily involved. on the other hand, rockefeller also provided funds to try to rescue many psychoanalysts who were jewish from the nazis and bring to america, and that proved to be a very difficult exercise but it about doubled the number of psychoanalysts here and it was one of the preconditions for something that happened in america after the war, which had really no counterpart anywhere else that i'm aware of other than buenos aires, , and that was the emergence and the dominance for period of about a quarter century of psychoanalysis in american psychiatry. now, understand that in 1950 there were a half million people america's mental hospitals, , ad i continue to grow for another four or five years, that population. those psychiatrists obviously couldn't practice psychoanalysis and indeed it was in that environment, that the drugs

revolution emerged sort of behind the backs of the psychoanalysts. but if you looked to academic psychiatry, if you looked to the high status growth the psychiatry on an outpatient basis and office space practice, that was heavily psychoanalytic. and that wasn't just a matter of the profession. the whole of american culture, especially high culture, but also popular culture, was actually would cycle analytic ideas. freud was seen the equivalent, as being the equivalent of darwin or copernicus. we sort of raise a smile these days but intellectuals in all disciplines, the humanities and the social sciences particularly flocked to forget ideas. hollywood flocked to 40 9d is. look, look at the movie spellbound, one of alfred hitchcock films and i think 1948 and you will see its propaganda

for psychiatry. it begins that, so there's that where people sought meaning in madness, tried to understand on a psychological level, tried to treat it, and some american analysts went so far as to say they could treat schizophrenia with psychoanalysis which freud himself had not thought possible. so it was really, i can't stress it, other than washington dash in st. louis, david's alma mater -- [laughing] other than that, virtually every other department was headed by somebody who's either a psychoanalysts or sympathetic to psychoanalysis, and the best recruits to the profession went that way. that's where the rewards were. that is where the best patients were, the patients who had money and who also were more interesting, not stuck on a

backboard of the state hospital. so it's curious in a way that the thing that marked a real revolution in psychiatry emerged not there and not in the university, but in the mental hospitals which is where the drugs, the antipsychotics in particular, thorazine and its copycat drugs, first emerged. and what happened for many years is, like a building that is being destroyed by termites. the structure looks solid. the psychoanalysts thought we are in the saddle, then with remarkable rapidity, that shifted. a week and date it almost precisely in 1980 fueled by problems that had emerged about psychiatric diagnosis, the fact that psychiatrists could agree in in a given case what was wrong. there was a sustained effort to

create a diagnostic system that at least was reliable, which meant a doctor here and doctor heer looked at the same patient, they would produce the same diagnosis. and it was an approach that was a theoretical by its nature but fact underneath that was fueled by hostility to psychoanalysis and it helped to serve as the death knell for that branch of the profession, for good or for ill and i think that's a complicated question. so psychiatrist of the generation who trained in the '60s will have all encountered cycles than the goal ideas now a day. i don't know if they've can speak to that. >> if i do anything to do about they do. i have lots to criticize about psychoanalytic psychiatry, but it's important to recognize that

whatever the flaws in their doctrine and the ideas, whatever their flaws in the rigidity that have produced so many practitioners which you bring out, that in many ways they sowed the seeds of their own demise through their rigidity and esoterica. but they were and are the humanists in this story. and rather than sort of re-correcting or redirecting some of the rigidity in psychodynamic thought, that ended up throwing out the baby with the bathwater, wholesale replacement of psychodynamic psychiatry with biological psychiatry. and as carl gasper would've pointed out decades previously, that would be a dead end. and so far biological psychiatry

is only part of the answer and that needs to be recognized and is and always recognized. >> that something i absolutely concur with. i have own quarrels with the rigidity of freudianism, but it did entail listening to patients and giving patients voice and that was very important. and that's really lost now when it's very interesting there was a study done in the '60s of what patents of psychiatric practice were like at that point and outside the institution the average length of time somebody spent when it went to consult a psychiatrist of between 45 minutes and an hour. almost the typical 55 minute to an an hour. that meant there was a lot of exploration of the patient whereas now partly because of managed care, partly because of the pressures of the insurance

companies, partly the need, psychiatry is not the best paid medical specialty, that it sort of has become a pill mill, you know? you see the psychiatrist for ten minutes and us barely time to really penetrate. now, and may be different in your clinic, david, but a lot of research has suggested that, and there's a real decline in the, on the professions part, delivering psychotherapy as well as the psychopharmacology that the profession has come to turn on. and indeed one of the stories in the book is the emergence of other professions in the psychiatric, in the psychological realms, so very many particularly patients with other kinds of disorders end up with clinical psychologists and with psychiatric social workers

getting some of the psychotherapy they don't get when they go and see their m.d.s. >> yeah, this is an unpleasant topic. [laughing] these are economic forces that are driving this rather than theoretical forces, rather than ideas about what is possibly the best way to treat mental illness. and so in my mind, i separate out the mistakes made for theoretical scientific or ideological reasons from just the sheer market forces that every industry is going to respond to, producing either favorable or unfavorable results because of those incentives. >> i mean, one of the things that happened when the mental hospitals emptied out is that there had been, and it was mixed as my history shows, but there

had been a long tradition of mental illness, unlike physical illness in this country, being a state responsibility, being something that was funded publicly and it was a very strong public psychiatric wing to the profession. it was obliterated, really, and it wasn't, the profession didn't protest, i would say, some did but not enough people protested about what was happening. but what was going on was not the product of the psychiatrists deciding this was a way forward. it really was those other forces that you were talking about, conscious public policy choices, pressures from the insurance industry, the availability of technology in the form of the drugs that look like conventional medicine and could be dispensed pretty quickly, and the insurance companies were not

willing to pay decently for the other kinds of care, and they still are not. >> yeah, , unfortunately, that s the place that we find ourselves in right now. and i think that one has to recognize if you are going to promote improved treatment for the severely mentally ill, you're going to have to recognize its phenomenally expensive. i think your book comments that when the asylums were open it was a single biggest line item on the budgets of most states. that is jaw-dropping. and that was crappy care. that was snakepit care. so you can imagine the cost that would be involved in providing beautiful state-of-the-art care

for the severely mentally ill. and it brings up the very difficult question that most people do not want to look interface, which is, should people with severe mental illness who are marginalized and do not vote get the majority of the resources that otherwise are going to people with mental illness but not assignment level mental illness? >> i think that's right. i think one of the other things that i would say that's not confined to the history i review here of the last 200 euros or so, but extends much, through all of recorded history that i'm aware of, mental illness is something that it constantly is associated with stigma and with fear and rejection.

and so this is a population, as david said, they don't vote, so in that sense the politicians are not going to be responsive to them, but much of the problems are kind of hidden away. i think one of the things i saw in the years of the institutionalization, a lot of the burden originally fell on families where there are still intact, particularly on women who are often pulled out of the workforce to care full-time for the patient, eventually families crumbled under that strain very often. it's just too much. you know, those families who are very reluctant to make a lot of noise, and the reason for that is obvious. they didn't want people to know that in their domestic bliss there actually was something else happening.

and it's amazing how when you become aware of this problem, people sometimes open up and you realize what they have been going through. and when that breaks down and, in fact, so-called welfare reform has worsened the situation i think for many patients. harder for them to get social support. states haven't replaced the monies they used to for the most part spend on the mental hospitals. in new york state in 1950 it was 30% of state budget was the mental hospitals. extraordinary number. and so what we see as a result, we see the worst of it, i mean living here in california whether you in downtown san francisco, l.a., san diego, the problem of homelessness, which is not only a problem with mental illness but a subset, and for the subset of it, is, in

fact, people with serious psychiatric problems who just cycle from the flophouse to the jail with an occasional stop off in a psychiatrist office to get a prescription, and then back into the cycle all over again. and it's a dismal part of life in in a country as rich as ours, that that's what we face. >> i would suspect that you and i differ politically on this issue. when i read the book one of the things that jumped out at me is how many of the devastatingly bad ideas were promoted by progressive ideas. so much of psychiatry involved unscrupulous people, but more of it was well-meaning people who did hugely unscrupulous things,

jaw-dropping, in the name of the inns justify the means. they were so enamored with their do good in some ideas that they lost the boundaries of western civilizations ideas. and i think eugenics of course it is example of that and the institutionalization is an example of that -- de-institutionalization. i do worry quite a bit that the idea that if we just sit down and come up with yet another program to help the severely mentally ill and spend a lot of money on it, , that that will tn be the panacea. i have my doubts, and i see these patients in the emergency room on a regular basis and i know that the solution is going to be much more difficult and subtle and challenging than

convincing the state of california to spend more money. >> i don't disagree at all, david, actually. i mean, one of the great messages i think of the book is psychiatry would take to heart the hippocratic injunction come first do no harm. that jumping into enthusiasm and refusing to see the evidence that runs contrary to one's enthusiasm and thinking that you have a magic wand that will solve the problem, that's repeatedly happened over the last 200 years and the results have almost been uniformly disastrous. and indeed some of these people were perhaps venal, many of them were absolutely sincere in their belief that they had discovered the royal road to intervening. one of the figures in this book

also appears in my book madhouse as a gentleman named henry cotton who ran the new jersey state asylum from about 1908 198 until he died suddenly in 1933 and cotton decided it was an idea he may well picked up from crap and, arguably the major figure of the times, that mental illness was a result of infections, lurking in the body that reporting the brain and pre-antibiotic era, the only solution to that was to surgically eliminate them. and so you started and his first targets were teeth. a lot of people had rotten teeth. although you hope they get better. consult with another thick -- tonsils were another thing, tonsillectomy. but when people don't get better instead of thinking perhaps i'm on the wrong track here, you

start saying there has to be other areas of infection in the body and he starts eliminating stomachs and spleens and collins and uteruses and another patent the recurs again and again with these treatments, women are disproportionately targeted for some reason. now, we can talk but what i think some of the reasons were, but trust become 65, 70% of the patients were female who were operated on. when i say cotton was sincere, he decided any teeth were a potential menace, and so he had his wife's teeth and is two children's teeth prophylactically removed. and in one of his sons seem to be masturbating. he renewed part of his colon. when he felt mentally l under the pressures of an investigation into him, he took off the hot spring arkansas and has own teeth pulled. so he believed what he was

doing, but what he was doing was an absolute scientific travesty. and it was, it wasn't unique to him. he was praise when he went to london in 1927 as psychiatrist lister, the equivalent for psychiatry lister hill interviewed antiseptic to surgery and that of the most prominent figures in british medicine. so yeah, they were sincere. walter freeman was sincere. he was a moral monster, in my eyes, absolutely. he lobotomized kids as young as four and boasted that their brains could tolerate more damage than adults. and i actually, when i did, took part in the pbs documentary, i think you can still see it online called the lobotomized, which is about his career, too sympathetic in my view to freeman, but nonetheless, two of his children took part but so

did one of his last lobotomy patients, a man named howard dolly was lobotomized at 11 after his parents marriage broke up and his new stepmother decided he was acting out too much and he needed to have his brain operated on. so yeah, there's a lot of sincerity is. sincerity doesn't cut it in my book. and yes very often, you know, the asylum experiment when it was launched it was small, intimate institutions. i really do think in the early years they did a lot of good. they had charismatic figures at the head, they had a dedicated staff, but to try to do that on a routine basis with the hordes of patients who flowed into state hospital, that just was impossible. i don't think we're that far apart. >> you know, it's a weird to note that two of the nobel prizes given out to psychiatry

were given out to really horrific treatments. there was wagner of unwarranted got the nobel prize for injecting mentally ill patients with likely general paresis of the insane with malaria. yes, malaria was used as a treatment for tertiary syphilis. and then of course the great portuguese neurosurgeon got the nobel prize for the invention of the prefrontal lobotomy. >> i should add that was 14 years after the first lobotomy, so one might have thought there'd been time to accumulate enough contrary evidence by then, but no. there really wasn't. and into the '50s the operation continued in some instances even into the '60s to era there were a couple of enthusiasts in england and at

yale as well. so you know, and the other thing to bear in mind is these were not necessarily patients visited on the poorest. we often think, oh well, the experimentation would have taken place on the most vulnerable, the poorest of the lot. but, in fact, perhaps the most famous case of a botched lobotomy, except they were all a botched as far as i'm concerned, but one of the worst outcomes was rosemary kennedy, jack kennedy's sister whose father had her lobotomized by freeman and watched in the early 1940s. and she could barely walk. she was incontinent. she had to be trained to speak again and she was locked away and the qb sam kept her out of sight and out of mind. i don't think they ever visited. so you know, and again the

earliest lobotomy patients were all outpatients. they were people with money and they came because he heard about this miracle cure. they volunteered for it. the institute of living in hartford, connecticut, is, was and probably is still a rather prominent private psychiatric facility. it was the first mental hospital to build a special surgical suite to perform lobotomies. and the mcaleenan which is probably still the most expensive psychiatric hospital in the country also lobotomized a substantial number of its patients, particularly women. so you know, the narrative is very complicated. and i think mental illness brings with it a great deal of vulnerability, enormous amount of suffering. it is, as one of my fellow historians, psychiatry once put

it, once the most soldiers of affliction and the social of maladies for the mentally ill person is often very nightmarish place to be there can do for everyone around them is just a family disruptive and disturbing and threatening and all of those things. >> i would like to highlight the word desperate in the title of your book, and this is an all mosh to dr. steve grove man who i have the good fortune of having here today. he's an emeritus psychiatrist here in san diego who has trained hundreds and hundreds of psychiatrists over his career. and what is so important to learn in psychiatric training is the experience of desperation that you have. you have patients that are suffering in the most horrible ways, some of them are violent. when we have one violent patient

on our 30 bed inpatient psychiatric unit, that's very disruptive. i think about asylums with hundreds of violent disruptive patients with no thorazine. what could you do? and it's very scary to go to work being afraid that you might be assaulted. that's very real. that's not an excuse in any way for putting in an ice pick in somebody's brain. but, unfortunately, it helps me understand how people got to such a desperate place and what he has taught me is when you feel that desperation, and a part of your brain should be turning on and saying, oh, i know what happens next. so whatever i think i'm going to do next, i'm going to observe and maybe get a second opinion and spend some time thinking

about before i run off and try and save the world. >> i think that's very right. i think it's precisely the desperation which is the desperation felt by the patient, why the family, by the therapist to do something, something surely that sometimes doing something is worse than not doing anything at all. and that's a history we see it again and again. and it's the desperation that makes it possible for people to conceive a bright idea that takes them down a rabbit hole and persuades families and patients to accompany them down the rabbit hole. so yes, the title is meant to have multiple meanings. not just, again, it's just such a, it's hard to avoid despair when i was writing the book my

editor kept saying to me, can't you say more positive things? i mean, this is so depressing. [laughing] your conclusion, you are like yes, the drugs are better then not having the drugs but the drugs are, they create theatric jenna, and illness as bad or worse than the disease they are treating. it really, and i look at modern psychopharmacology, i see patients falling into three groups. part of the problem for psychiatrists, forgive me for suggesting it, we don't know in advance when a patient presents -- i shouldn't say we. they don't know. i don't like to pretend to have expertise i actually don't. but they don't know which group somebody is going to fall into. for some of the patients come antidepressants and

antipsychotics make a radical difference in in a positive direction. they transform somebody who is raising, somebody who is hallucinating and is delusional. a damp that down and then it possible to contact with what the rest of us like to call reality. then there's a a group of pats in the middle, because of all medical treatment there's no free lunch. they're always side effects can things we don't want that come with the things we do. and with psychiatric medications no side effects are often very severe, sometimes lifelong once your contracted them, and so with the middle group of patients you are trying to way because they are experiencing the side effects more than the first group i spoke of, waive the benefit the drug press produces against the problems that it creates. and then you have another group of patients who just don't respond, who, if they get

anything they get the side effects and that's not quite what we're supposed to be about. and the dimensions of this problem are really very great. in 2005 a lot of the research that's done on drugs is being funded by the drug companies and it's unfortunately deeply contaminated by that. it looks like evidence-based medicine. it's often evidenced by his medicine because they suppress the data they don't like and the cook the books. but in 2005 there was a very large study called katie which appeared in "the new england journal of medicine" led by jeffrey lieberman who recently was forced to step down as the chair of the columbia psychiatry department afternoon some rather unfortunate public remarks. but what that study showed, it looked at an original antipsychotic, what is the first generation along with the working from the 50s, and three so-called atypical modern

drugs, and he said is the old drug inferior to the current drug? and how well do these work? the answers on both fronts were not very reassuring. the new drugs didn't perform better than the old drug. they cost a lot more money because a patented but they were not better. they had a different side effect profile but is equally as series, and the other thing that i found striking reading that study, depending on which drug, it were for lack of them in the trunk, between 67-82% of the patients dropped out either because the drug wasn't working or because they couldn't stand the side effects. so we don't have psychiatric penicillin. we have pills that help some people, and if, god for bid, i had a relative who needed psychiatric care, i would not stand in the way of a trial, a careful trial of drug treatment

but i would be very aware of that the odds were mixed about what is going to work in that particular case and and i we delighted if it did, but not surprised if it didn't. what do you think, david? >> i am big pro-pharma. i don't know if it's unexpected given this discussion, but i would be so sad to think of a career in psychiatry without the benefits of modern chemistry that the pharmaceutical companies have provided. lord knows they have been naughty at times in their marketing styles and brushing things under the rug, it's true. but big pharma has really provided the possibility of relief for so many patients.

and i am so thankful for that. >> on the other hand, and i agree with that, i mean come i don't dissent. it's very important to understand that we have had some progress and that progress in many ways has been tied to the drugs ability to reach a substantial number of the people suffering, but by no means all. but the other sad thing, , as yu know, big pharma has pulled out. they are no longer looking for new treatments, improved drugs. partly their reputation took a battering over the naughtiness that david was talked about and i describe in a book, but more than that they couldn't see a way to make a profit. they were still obvious new avenue to explore. there are some fly-by-night operations now using ketamine

and psychedelic treatments, and there are some people advocating for deep brain stimulation as a solution to depression, as though we know where depression resides in the brain. we don't. so there are those things, but the companies that for 60 years? were heavily involved in the process of doing research on possible pharmacological treatments for mental illness, have gone away. they have disbanded their departments. they have stopped. they found other areas of medicine are more profitable, and in our system research follows profit. it won't come to start an old touristic phenomenon, or at least it might be if their public funding affect if the can of research but there's not enough of that around.

>> that's another facet of our contemporary situation that unless your somebody somebody who just like with scientologist dismisses psychiatric medications as poisons that have no therapeutic value, you can't see that as a positive development for all the bad things that the drug companies did along the way. >> should we take questions? >> i would love to take their questions. i would love to respond to anybody out there. >> you both talked about the issue of the homeless and the mentally ill. and indeed when you read the current voter pamphlet, i think anybody running from the board of equalization to governor to anything you can think of, director finance, they all make reference to, and i wish to solve the problems of the

homeless. can you share your thoughts about what possibly might be effective? >> well, i don't think anybody has a good solution to that particular problem. and simply throwing money at it isn't going to resolve it. san francisco spends on average i think $35,000 per head a year and anybody who spends time in the city as i do realize is that they ain't getting much value for the money. it's a mess. one of the issues, and it's one we sort of skirted around, back in the days of the old mental health, most people cut into mental hospital forcibly, so to speak. they were certified as insane, and if necessary the cops showed up and took them. all right?

so that there was compulsid they couldn't leave even if they wanted to. these days that whole situation is very tricky and it's one of those political minefields,, apparently there's some new ideas about this which potentially involved some degree of compulsion and the civil libertarians are up in arms about that. and i get that, having seen what it was like when people were shut up, as i said, in both senses of the term. it's a very dangerous situation. on the other hand, many of those people are very resistant to getting treatment and that texture of life in our cities is being undermined by their presence. and so i think politicians are responding to the fact, when i wrote my first book called the

incarceration of institutionalization, i said these people were largely being returned to the poorest, most deprived areas of the cities. that's what the social services such as it were were, those people have no political voice. they had no political clout so the couldn't protest. but what has happened is the numbers have multiplied is everywhere. and so we used to be able to, we respectable folks used to shut our eyes to what was going on and that you are in the biz, and now it's inescapable and it is provoking a backlash, even in cities that think of themselves as aggressive like san francisco. and i think san francisco's politics, oh, my goodness, , dot get me started. that city is in a really strange place. so i don't know, you have anything to add on, david?

>> my perspective is that psychiatrists are not the people the solve the housing problem. i think economists would be a much better place to start. and so many mental health practitioners who weigh in on this question have absolutely no training in economics, which to me seems bordering on fraudulent. and i think milton friedman had a lot to say on the issues of supply and demand, and if you don't have enough supply and how to address it, and maybe a way to start would be to look at those questions. >> well, i agree substantially there. i think nimby-ism in california and the overload of regulation which is really stymied the supply of housing, the level

that is needed, contributed to this. by no means all the people you see in the street are people who are mentally ill or drug addicted or alcoholic. many of them are people who literally can no longer afford a roof over their heads. and anybody who's watched what happens to california housing crisis, it's a surprise. you wonder how anybody with an ordinary job manages to put a roof over their head, feet and clothes themselves and the kids and at any margin on that pic and it just gets worse and worse, and it is. it's a supply and demand problem. ..

it is dirty money from all over the world. many of those houses sit empty. they are a pocket place. fi think in new york there is a bit of that, too.re here, not so much. we really have created a problem for ourselves. houses just get ignorant bigger. they get more complicated and more expensive. for ordinary people, that is not something we could ever afford. they need a decent place to live the whole institutionalization problem has created problems in some ways. it is the product of much larger

socialov movement and social forces. to look to psychiatry, it seems a category mistake. >> you made reference thinking about that in terms of is this our new desperate remedy? >> it is a little early to tell. but it has some of the signs of it. [laughter] >> i was reading a couple of papers this afternoon before i came down about the emergence of huge startups. billion-dollar companies that are investing in these things. once that genie is out of the bottle, it will be very hard to put back. the has-been, the survival in lsd, magic mushrooms, blah blah

blah. the same thing with ketamine. ketamine changes mood. we have known that for years. it was a party drug. it wasls special k. it produces hallucinations. it can produce damage to the bladder. once it is given some sort of tlicense, there will be unscrupulous companies in people who will set up shop.i i have been hearing about this. people who have been giving infusions for other medical things. here's a great new source of revenue. unregulated. i do think those things have a potential to be a new remedy.

you could have some damagingt remedy take hold and then be out of control. you see figures like michael poland, for example who has become a cult figure because of it's veryw interesting writings on the food chain. it sounds like timothy leary reborn. it is very dangerous, i think. i do worry about exactly those developments, yes. >> you have any idea if it compares to canada or europe in regards to the treatment of the mentally ill and so forth? especially socialized medicine. are they worse off than us,

better than us? >> i know a little bit more. i was a little bit surprised. out of the blue a british psychiatrist that i know actually member of the house of lords wrote to me and she said one off the artifacts of the covid epidemic was the government swept those people off the streets because they sell them as reservoirs of infection of covid. they moved them into shelter. now they are leaking back out. on the whole, i argue that one of the things that drove the institutionalization was states were able to move on to the dgfederal budget.

medicare prompted a flood of people, old people being moved out of the asylum and into nursing homes. when ssi came in, supplemental security income which provided some support regardless of your work history, then the young people started to be moved out. it was possible here to move. it was a shell game. and then as the feds cut back on some forms of welfare, that was not replaced and so the situation in some ways got worse. britain,eu like most of europe, has a more developed welfare state. nonetheless, i will tell you talking with well-informed and well-intentioned british psychiatrist in whom we trust, psychiatry always has short into the stick. even when the health service was funded route the better underir

tony blair, very few of those new resources trickled into psychiatry. it was always a stepchild. partly, as david was saying earlier, this is not arg politically powerful if we are seeing arguments now about homelessness, it is not because we have sympathy for the people in the street, it is because they are affecting our quality of life and we do not like it. that is the honest truth. a little bit better because there is a more developed set of social services. in the last dozen years under the first of the coalition and conservative government and now with brexit, public services haveed been slashed in britain. they will probably be slashed more because their economy is going down the toilet. it is hard to find things.

that is one of the things, i think politically you have to understand.ti if the productive part of the economy is not driving, you cannot afford to do all of these nice things you think you would like to do. as we move towards potential recession, it is a very worrisome time. i have seen it, until health budgets are prime candidates to be cut. texas cut its mental health budget and they redirected it to the show game of we will control the border. because the feds are not doing it. and then there was a shooting and instead of saying that we have a problem with guns, it is blamed on mental illness. lethe problem is not that we hae to manyo crazy people, it is tt

we have absolutely crazy gun laws.aw that i do not see any fix for. when you 4 million guns out there, it is. hard. maybe you do not allow 18 -year-olds onrt their birthday o by two high-powered rifles and 350 rounds of ammunition and body armor. maybe you have some sensible restrictions. rather than thoughts and prayers afters. the slaughter of the innocents. that one really angers me. mental illness being blamed all the time. what that does as well as exacerbate something i talked about earlier this evening. mainly the stigma that attaches. mental illness sometimes produces violence. by no means is that the case that everyone that is mentally ill turns violent. ncto the extent that we encourae

that equation of mental illness and violence, we make that population fearsome. something we want to lock away rather than deal with humanely. any more questions? >> i get the last question. i have a question for you. favorite topic of mine. involving psychiatric and allen frances, the editor of the dsm for has allowed the explosion of psychiatric diagnoses and of course expanding to dsm-v. he fought a losing battle trying to prevent from growing even bigger. where do you stand on that.

the problem of what someone is called diagnostic crete can be seen. i think it happened in the asylum era. a lot of people got scooped up b and probably could have been helped with in other ways. the solutionn was to institutionalize them. it is a very controversial topic dsm is the diagnostic statistical manual. the thing that creates all the diagnoses that you have to have to get insurance reimbursement. alan france was the editor of chief of the fourth edition. i created a nightmare here. particularly with respect to autism which exploded in numbers that was very controversial.

the parents with the difficult child. difficulty sometimes putting it very mildly. access toet that diagnosis was something that they sought. things that otherwise would not have got. when it was leaked that the task force was considering changing the boundaries, there was backlash. it is easy to think that this is the product of an imperialistic impression. it is also public demand. i think we will be thinking of the next couple of months. which has become a huge thing and a huge industry. the one exception which was revolutionary to being a

theoretical, taking no stand somewhere, cts d. it had a very clear ideology and it was not rain disease, it was a product of dramatic experience that first immersion against the war, they allied themselves to harvard psychiatrist and eventually they succeeded to a point. they wanted to call it post vietnam syndrome. it became posttraumatic stress disorder. over time, it expanded in ways that made sense to me intellectually. for example, women who have been victimized by rape and sexual assault. very profound change in their

identity. people who -- pretty soon, it was my college student is upset what he or she is being asked to read. we need trigger warnings. if we don't get trigger warnings we will suffer from posttraumatic stress disorder. that diagnostic creep is very dangerous. there always will be people willing to pander to that. if we supply it publicly, there will be even more of them. >> what do you say, david? >> okay. all right. thank you for being such a patient audience. i would like to thank david who i have known on-and-off for a lot of years now.

david knows from time to time when i have had a student either with serious problems themselves or with family issues that needed, somebody that i trust boand referred. it is a sign that i wish i knew more clinicians. let me say that. >> thank you both very much. thank you for this very enlightening evening. i invite you back. thank you all very much for coming. enjoy the evening. [applause] >> american history tv. saturday on c-span2. explore people and events that tell the american story. 8:00 p.m. eastern.

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