#502 – Psychiatry, Insane Asylums, Mental Illness, ECT, Lobotomies, Freud & Jung

Andrew Scull begins by rejecting the idea that modern psychiatry has solved mental illness. He says there has been limited progress over roughly three-quarters of a century, particularly for milder distress and some severe disorders, but no psychiatric equivalent of penicillin. Antipsychotics and antidepressants are only partially effective, fail for a significant fraction of patients, and can create iatrogenic problems. PTSD treatment, for example, may improve someone when they confront a trauma but worsen another patient’s condition. Clinicians cannot reliably predict who will benefit, who will suffer, or who will experience a precarious balance between therapeutic effects and side effects.

Scull traces the modern diagnostic system to DSM-III in 1980, created after psychiatrists repeatedly disagreed about the same patients and after David Rosenhan’s controversial “On Being Sane in Insane Places” study. Robert Spitzer’s task force replaced broad, theory-laden judgments with symptom checklists designed to produce the same diagnosis in different locations. Scull distinguishes reliability—clinicians reaching the same conclusion—from validity—whether the conclusion reflects a real underlying disease. Later DSM editions multiplied categories, while DSM-5 abandoned hopes of grounding them in pathology. Leading figures Thomas Insel and Stephen Hyman ultimately called the system unscientific or inadequate.

Scull says psychiatry’s crisis includes the failure of neuroscience and genetics to deliver biological explanations for DSM disorders. The National Institute of Mental Health invested roughly $20 billion under leaders focused on brain disease, genetics, and neuroscience; Insel later said that the research was scientifically exciting but had improved the lot of the mentally ill “not one bit.” Scull also rejects a rigid brain-versus-mind dichotomy: brains change through social and psychological experience, so those factors become biologically embedded. He invokes Leon Eisenberg’s description of psychiatry as moving from “brainless psychiatry” to “mindless psychiatry,” losing important insights at both extremes.

Scull uses Emil Kraepelin’s distinction between dementia praecox and manic-depressive illness to explain the origins of today’s schizophrenia and bipolar categories. Schizophrenia refers broadly to severe psychosis, including hallucinations, delusions, emotional flattening, deteriorating language, and loss of social connection; bipolar illness involves episodes of extreme mania, little sleep, rapid speech, exhaustion, and depression. “Major depression” now covers both milder distress and melancholic depression with psychotic features. Scull also describes phobias, school refusal, dementia, and neuroses, while warning that the field is a minefield: diagnostic categories can medicalize social problems, expand through “diagnostic creep,” and differ from the experiences of patients and families.

Early asylums were founded with confidence that humane environments, work, and supervision could rescue people from jails and abusive conditions and cure perhaps 60–80% of patients. In practice, institutions discharged closer to 35–40%, leaving chronic patients behind; overcrowding and deterioration then made the asylum seem defined by people who spent decades there. Cure rates calculated across the whole population could fall to 10–12%. Scull says psychiatrists responded by blaming patients’ supposedly defective biology, describing them as degenerates who would reproduce without restraint. That logic justified sterilization: more than 60,000 Americans were sterilized by the 1960s, with California responsible for a disproportionate share.

Scull explains that eugenic language about mentally ill people as biological inferiors or “useless eaters” acquired its most lethal form under Hitler. The Nazi T4 program systematically killed psychiatric patients—possibly as many as 250,000—and developed the gas chambers, shower disguises, and cremation systems later used in the Holocaust. Scull says American and European eugenic ideas influenced this program, while the Rockefeller Foundation had funded German geneticist Ernst Rüdin, a major architect of Nazi sterilization and extermination policy. German psychiatry largely collaborated. He emphasizes that democratic checks had limited mass killing elsewhere, whereas Nazi power removed those restraints.

The conversation then turns to physical interventions that psychiatrists adopted while trying to act as healers. Lobotomy began with Egas Moniz’s 1930s procedure, which involved disrupting brain connections through the skull; Moniz received the 1949 Nobel Prize. Walter Freeman popularized the transorbital “ice-pick” method, knocking patients unconscious with electric shocks, driving an instrument through the eye socket, and severing tissue. He sometimes performed 20 or 30 operations in an afternoon and claimed he could teach “any damn fool,” even a psychiatrist, to do one in 20 minutes. His mobile “lobotomy” camper visited state hospitals. Younger doctors rejected the damaged, zombie-like patients left behind as antipsychotic drugs emerged.

General paralysis of the insane, or GPI, supplied one of psychiatry’s rare genuine diagnostic breakthroughs. Patients gradually lost motor control and developed grandiose delusions—believing they were Napoleon, Jesus, or extraordinarily wealthy—and by the early twentieth century they made up as many as 25% of asylum admissions. Rockefeller Institute researchers discovered that GPI was tertiary syphilis affecting the brain. Austrian psychiatrist Julius Wagner-Jauregg then deliberately infected patients with malaria, hoping fever would stimulate immunity or “burn out” the infection. Mental hospitals sometimes maintained malaria-mosquito colonies. He won the 1937 Nobel Prize, although later evidence showed cure claims were exaggerated; penicillin eventually made the dangerous treatment obsolete.

Seeking biological treatments, psychiatrists introduced insulin-coma therapy in 1933. Sakel placed patients into deep hypoglycemic comas, sometimes for hours or days, reviving them with glucose; courses could require up to 60 comas, with seizures, obesity, brain damage, and a reported 1–5% mortality rate. He claimed an 80% cure rate, and the treatment was even used on mathematician John Nash. Controlled trials in the 1950s failed to support it. Another approach injected Metrazol to provoke violent epileptic seizures, causing panic, fractures, and sometimes broken vertebrae or hips. These procedures reflected medicine’s growing faith in biological mechanisms despite weak evidence and uncontrolled experimentation.

Italian psychiatrists Ugo Cerletti and Lucio Bini developed electroconvulsive therapy after observing slaughterhouse pigs rendered unconscious by electricity. Early ECT caused generalized seizures, fractures, and breathing problems, and hospitals often used it to discipline or control patients rather than primarily to treat them. Muscle relaxants, anesthesia, and respiratory support later eliminated most fractures, but memory loss and possible brain injury remain concerns. Scull says ECT is ineffective for most schizophrenia but has evidence of benefit in severe, suicidal, or treatment-resistant depression, often requiring maintenance sessions because it is not a cure. He notes that legal restrictions and ex-patient opposition make it highly controversial despite some patients describing it as life-saving.

Scull says Ken Kesey’s novel drew on his experience in a veterans’ psychiatric hospital, while the film made McMurphy, Nurse Ratched, ECT, and lobotomy central cultural images of institutional psychiatry. Veterans’ psychiatric casualties in World War II were two or three times higher than in World War I, and the VA became deeply involved in mental-health care. The film accurately captures overcrowding, boredom, staff humiliation, and ECT’s use as discipline, though it exaggerates some details and cannot show the routine monotony of institutional life. Scull adds that women disproportionately received invasive interventions: roughly 60–70% of many lobotomy and ECT populations were female.

Freud’s work grew from neurology, Jean-Martin Charcot’s studies of hysteria, and Joseph Breuer’s treatment of “Anna O.” Freud and Breuer proposed that trauma and repressed memories could return in distorted physical or psychological symptoms. Freud replaced difficult hypnosis with free association, asking patients to say whatever came to mind while lying on a couch, and developed theories of dreams, slips of the tongue, sexuality, and the id, ego, and superego. Psychoanalysis initially required five 50-minute sessions per week and aimed to transform the personality rather than simply suppress a symptom. Freud’s 1909 Clark University visit attracted attention, but mainstream American psychiatry largely rejected talk therapy for what it regarded as biological illness.

Before World War II, American psychiatrists screened out 1.75 million recruits judged psychologically unfit, yet combat trauma still produced large numbers of breakdowns; in combat conditions, up to 25% of soldiers could become psychiatric casualties. The military rapidly trained psychiatrists and psychologists, and psychoanalytically influenced trauma treatment became influential. After the war, psychologists built university-based programs combining scientific research with clinical training, unlike psychoanalysts who controlled their own institutes and struggled to obtain grants. Cognitive behavioral therapy treated specific symptoms and maladaptive habits through structured exercises, interpersonal work, and homework rather than years of analysis. Scull says CBT helps some people, especially with milder depression, but evidence is weaker than advocates sometimes claim.

Chlorpromazine was discovered accidentally in the early 1950s as an antihistamine and anesthetic potentiator; psychiatric patients became calmer and less agitated, leading to Thorazine and the new “antipsychotic” category. These drugs reduce hallucinations and delusions for some patients but do little for negative symptoms such as apathy, social withdrawal, and impoverished language. Side effects include restlessness, Parkinsonian symptoms, tardive dyskinesia, weight gain, diabetes, and metabolic syndrome. The 2005 CATIE study found newer antipsychotics no more effective than an older one, while 67–82% of participants dropped out. SSRIs such as Prozac statistically outperform placebo, but often only marginally clinically; emotional numbing, sexual dysfunction, and difficult withdrawal are substantial concerns.

Scull argues that treatment decisions require humility because clinicians cannot yet predict which patients will respond or suffer severe side effects. He worries that neuroscience, genetics, drug companies, journals, and science media repeatedly overstate breakthroughs; genetic studies account for only about 10% of schizophrenia risk using roughly 300 small genomic variations, and overlapping genetic signals may undermine diagnoses such as schizophrenia, bipolar disorder, and autism. He supports continued drug research, but also more work on psychosocial care, family support, homelessness, loneliness, and agency. CBT, psychoanalysis, psychedelics, ketamine, and AI-mediated conversation may help some people, but none should be treated as a miracle. Progress, he says, is possible through more caring practice and less technocratic certainty.