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Intelligence Squared
Does modern medicine need to drop the distinction between mental and physical health? With Professor Edward Bullmore
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- [00:00]
Commercial Narrator
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Mia Sorendi
Welcome to Intelligence Squared, where great minds meet. I'm producer Mia Sorendi. What if the centuries old divide between mind and body isn't just wrong but has been harming our understanding of mental illness or all along? On today's episode, Regis professor of Psychiatry Edward Bulmore joins us to discuss his new book, the Divided A New Way of Thinking about Mental Health. In conversation with Ganesh Taylor, he traces the historical and philosophical roots of the mind body split from 17th century medicine to the rise of psychiatry and the horrors of eugenics and explores how modern scientific discoveries could transform the way we diagnose and treat mental illness. Today, let's join our host, Ganesh Taylor, now with more.
- [02:02]
Dr. Ganesh Taylor
Welcome to intelligence squared. I'm Dr. Ganesh Taylor, Chancellor's Fellow at the center of Reproductive Health in the University of Edinburgh. Today. Our guest is psychiatrist and neuroscientist Professor Edward Bullmore, who is currently the Regis professor of Psychiatry at King's College London. His highly acclaimed first book, the Inflamed Mind, focused on the links between inflammation and depression. He's here with us today to talk about his groundbreaking new book, the Divided Mind, which is both a study of the evolving science of schizophrenia and an illuminating exploration of the history of psychiatry. Welcome to Intelligence Squared. Professor Billmore, welcome.
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Professor Edward Bullmore
It's a great pleasure to be here.
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Dr. Ganesh Taylor
Well, so you know, the first thing that I obviously have to ask you is, you know, you've been in psychiatry for a long time, from what I understand of the book, and you've been dealing with many patients over the years. What is it exactly that inspired you to write this particular book at this particular time?
- [03:03]
Professor Edward Bullmore
Well, you know, I think there are some messages that work better for a book than for a, you know, journal article or some other kind of way of communicating. And I wanted to write this book partly because I think there's still a lot of stigma and a lot of silence around severe mental illness. And I wanted to kind of try and break that silence and perhaps do something to help with stigma. And that I think means reaching a bigger audience. That was one motivation. I also think, you know, you sometimes hear people say, well, we don't really know much about schizophrenia. We don't know anything more than we did. And there's a slightly sort of nihilistic attitude to where the research has gone in the field. And of course I have a, you know, conflict of interest in the sense I've been a professional scientist in this space for 20 years. But as far as I can see, there's been enormous progress in terms of our understanding of schizophrenia. And I wanted just to make sure that people are fully aware of how that science has changed and why it now looks to me like a very different sort of scenario compared to what I was taught about schizophrenia when I first started back in 1990.
- [04:14]
Dr. Ganesh Taylor
Okay, so just so that we're all on the same page here, what is schizophrenia like? We all hear about it, like, you know, the term is used, but, you know, this is not just a mild condition, right? This is not just another run of the mill mental health, to use that phrase, situation. So what is the difference? What is schizophrenia as a definition in this context or as best as you can? Because I understand the science is a bit gray. And how is that different to this concept of just sort of general mental health?
- [04:49]
Professor Edward Bullmore
Right. Well, I mean, you know, there has been tremendous sort of increase in conversation about mental health well being, but that is mostly focused on what we would call sort of mild to moderate or common mental health problems. Anxiety and depression, for example, account for a lot of conversation publicly about mental health. There is also a group of people that suffer from severe mental illness. And schizophrenia is one of those severe mental illnesses. Bipolar disorder is another one. Severe major depression, another one. So there are people living with really disabling long term conditions that are not, you know, they're not in the same category as, you know, the sort of lifestyle level, mental Problems that we hear about in terms of depression and anxiety. So it can be a severe problem. What is it? Well, in practice, it's a psychotic disorder. So that means it's a disorder associated with some kind of disruption in terms of people's sense of reality. They hear things that aren't really there, they see things that aren't really there. So they're hallucinating. They will often also have beliefs about how the world is working. They might think the world is out to get them. They might feel very paranoid and persecuted. And these beliefs are not sort of evidence based, if I can put it that way. And they're not really amenable to reason. You know, you can talk to somebody at length about their delusions of persecution and typically you won't be able to shift their core belief that they are, you know, subject to surveillance by the CIA or whatever it might be. So those two characteristics, delusions, hallucinations, the disrupted sense of reality, those are very characteristic of psychotic disorders. Schizophrenia is a psychotic disorder that comes along typically in early adult life. And for some people it can last the whole of their lives.
- [06:55]
Dr. Ganesh Taylor
Oh, that's really interesting. Thank you for being so clear on that front. I mean, one of the lines in the book that really jumped out at me actually talking about the sort of the hearing of the voices and things was I believe the statistic was 15% of 18 to 24 year olds will hear voices at least once. And so this, you know, for me, this touches on something else about the sort of comparison between the sort of mental health and the schizophrenia thing, which is this idea. It seems to me anyway, from having sort of read the book a little bit, that there's this sort of this idea of a scale. Right. In mental health, we talk about a scale or a gradation, but schizophrenia falls into a different level. Right. It's much more severe, basically is kind of where you're at. But this statistic about so many young people hearing voices kind of, for me, pulls that together in a sense. Right. That I guess that's assumed to be normal. Right. That was the implication in the book, I think. So is schizophrenia a condition that once it happens, that's it, you live with it? Or is it possible to sort of reel it back? Or do you only get a diagnosis once you sort of permanently get sort of fixed in that state?
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Professor Edward Bullmore
Yeah. So, you know, I think you've touched on a number of things there. And I think one important angle that we might want to draw out, or I want to draw out a little bit is that we really need to think of schizophrenia as a kind of, you know, a process that evolves over time and it usually kicks off in late adolescence. And the bit in the book you're referring to describes the experience I had when I started as a consultant psychiatrist in Cambridge. And we set up a service specifically designed to focus on young people who are experiencing their first psychotic symptoms. So those delusions and hallucinations that we were talking about earlier, and what we found and others have found, is that if you ask people the questions about delusions and hallucinations, something like 15% of young people that are seeking treatment from mental health services. So not necessarily 15% of the sort of young people out there in the general population, but when they come through to see their doctor, their gp, or they come through to psychiatric services, actually transient experience of hallucinations or delusions is quite common. And also when you get into the detail of it, it can be quite difficult to draw the line between a hallucination and a more normal experience of hearing one's thoughts or talking to oneself. Likewise, on the delusional side, you know, there's a gray zone between somebody thinking with total certainty and despite any evidence that they're being persecuted by the CIA, that sort of grades away to people thinking, you know, as a lot of people do in adolescence, quite self consciously, you know, the world is looking at me, the world is commenting on me. These are quite normal experiences, but there is a kind of spectrum which gradually shifts to these kind of more bizarre beliefs that are less amenable to reason. As I've already said, so psychotic symptoms are quite common in young people. Briefly, psychotic symptoms aren't that sharply demarcated from normal experiences that we've all had and will continue to have. Ideas of people paying more attention to us than they really are, or occasionally hearing our voices internally quite clearly. So there's that level of ambiguity to bear in mind about psychosis. But then of those 15% that have some brief experience of a proper psychotic symptom, only a small percentage will end up with a diagnosis of schizophrenia. Because as your question implies, to get a diagnosis of schizophrenia, you have to have had those symptoms, delusions, hallucinations, and some other psychotic symptoms for at least a year. So what we used to do in this service that I was talking about, the first episode service in Cambridge, we'd follow people up for a year and many of the patients that we saw who had psychotic symptoms initially, they just faded away and they more or less return to normal. But a minority, it becomes A long standing chronic problem. And that's the group that we're talking about, schizophrenia.
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Dr. Ganesh Taylor
Yeah. I mean, one of the big themes in the book, obviously is about this idea that it's, I mean, both historically, but also, I think from what I understood of what you were talking about is there's this idea of a sort of degeneration. Is that fair to say, to use that word?
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Professor Edward Bullmore
Well, that's quite a loaded word.
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Dr. Ganesh Taylor
Okay.
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Professor Edward Bullmore
Yeah. But, you know, for an interesting reason, which is that when schizophrenia first kind of emerged in medical thinking, which was kind of around the 19th, end of the 19th century, beginning of the 20th century, it wasn't actually called schizophrenia. It was called dementia precox, which is a kind of made up Latin word, the phrase that means precocious dementia. And in other words, the idea at the time was that these young 20 somethings with chronic delusions, hallucinations, were actually at the start of a precocious dementia. And that their cognitive function, their mental functions would just inevitably deteriorate over time. And that's why they called dementia precoxibly. And that was a very, that's a very, very negative conception of the disorder. Obviously, you know, you're saying that this is something that happens to young people, we don't know why, and it's not curable and it's only going to get worse. And that mindset was part of the sort of background justification, if you will, for the way that German psychiatry, or German speaking psychiatry in particular, progressed over the course of the 1920s and 30s to the point that under the Nazi regime, people with schizophrenia were systematically persecuted, they were sterilized against their will, or ultimately they were killed. It was all consistent with this very, very negative concept of an incurable, progressive disabling disorder. Now we look at it now, is there any evidence of progression of degeneration? And there is some evidence in a small group of people with schizophrenia that they will get worse over time. They may lose cognitive function, there may be changes in the brain that are ongoing that make it, you know, progressively more disabling. But also, I think we have to acknowledge that, you know, the drugs that we use to treat people with schizophrenia are not without significant side effects that may contribute to things actually getting worse in some ways rather than better. And also, you know, if you've been, you know, imagine you're a young adult who finds themselves embroiled in this psychotic experience, it is completely disabling or can be completely disabling in terms of making friendships, getting to university, you know, acquiring, you know, Cognitive capital, some people call it, you know, degrees, life experience, finding a secure career, finding a partner. All of those things that, you know, you and I and others going through that critical transition from, let's say, 18 to 30, all of those things that people do in that period can be disrupted by schizophrenia. So that by the time you're 30 year old with a diagnosis of schizophrenia, you may find that, you know, you haven't got many friends, you've lost contact with your family, you haven't got secure employment, that makes it even more difficult to recover fully.
- [15:09]
Dr. Ganesh Taylor
No, that's quite. I mean, there's a. Obviously we've touched on a lot of things there. There's the dark history, which of course you talk about a lot in the book. There's this idea of, you know, these things don't happen in isolation. The idea of the environment and environmental factors, which again, of course you do talk about in the book that, you know, there's environmental conditions that can be triggering of this condition. And of course the important point that you sort of ended upon there also, which is this idea that the onset is usually within adolescence, which is during quite a dynamic time anyway, so I'd like to, I just wanted to ask there as well. So, as a reproductive biologist, I was really interested by the fact that there is a sort of sex difference also or a sort of apparent difference there. I wondered if you could comment on that as an expert on this matter. Do you think that there is actually a sort of fundamental biological aspect, manifestation there of the sex differences between males and females? Or do you think actually that the different sort of environmental conditions that males and females operate under those sort of adolescent years might be contributing to this sort of apparent difference in numbers?
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Professor Edward Bullmore
Well, I mean, the sex difference which is pointing to males being more vulnerable to schizophrenia than females is quite well reproduced. It's quite replicable, has been for, you know, across many different geographies and over time, I think that probably counts against it being entirely environmental and points more towards a biological explanation. It's also true that male children tend to be more vulnerable to a number of other brain developmental problems. For example, ADHD and various other kinds of, you know, quite subtle cognitive difficulties. Dyspraxia, clumsiness, dyslexia. Many of these issues are more common in males than females. And I think what that probably suggests is that there is a greater biological vulnerability of males compared to females in terms of brain development generally. And that that is why we see a greater instance of schizophrenia, because as we've already touched on A couple of times it is. We have to think about it as a neurodevelopmental disorder. I think, you know, it's. It's a process that evolves, you know, over decades to culminate in the point of somebody actually appearing in front of the psychiatrist with the symptoms of psychosis. It doesn't come out of the blue. It's something that grows and builds over time. And I think males we can see from a number of other disorders tend to be more vulnerable to extreme variation, let's say, in those developmental trajectories.
- [18:09]
Dr. Ganesh Taylor
That's really interesting. I mean, also particularly because in the book you talked a bit about, and please correct me if I got this wrong, but I got the sense that you were saying that there seems to be a sort of correlation between a sort of stressful event, basically high cortisol, these sorts of events tend to happen that then sort of trigger these sort of episodes and this sort of step in the progression of what's going on. Did I get that correct? And could you talk about what sort of triggers can sort of chivy along this neurodevelopmental condition?
- [18:47]
Professor Edward Bullmore
Okay. Well, I'd say right at the start, you know, it's not a question of nature or nurture. It's not a question of genes or environment. In fact, one of the sort of big themes of the book is that we've tended to kind of split our thinking about schizophrenia. Historically. People got very entrenched in the idea that it's all in the mind or it's all in the brain, or it's all genetic or it's all environmental. I think where we now see the situation through the lens of recent genetic research in particular, is we've got to think about both. We've got to recognize that there is a heritable element to it. You can inherit risk genes that put you at higher than normal risk of developing schizophrenia. But what is probably happening is that people who have inherited those genes and are then exposed to an environmental trigger or an environmental stimulus, particularly in early life, it's that combination that is probably most risky. And the kind of environmental factors that might be relevant include things that you're probably familiar with from other sort of reproductive biology side of things. So if you're exposed to an infection in pregnancy or in early life, that is a risk factor for schizophrenia. It's been known for, like, decades that children who were born in the winter months, you know, let's say between November and March in. In the Northern hemisphere, have a higher risk of schizophrenia. When they're 20 or 30 years old, in other words, decades later. And people are puzzled over that for a long time. And I remember with my colleagues joking, you know, it must be something to do with astrology. Maybe there are star signs that put you at higher risk of schizophrenia. But what it almost certainly is indicating is that children born in the winter months have a higher risk of exposure to viral infections, either in pregnancy or immediately after birth. And it's that exposure to early infection, coupled with an inherited genetic risk that is accounting for the increased incidence of schizophrenia in children many years after they were born during the winter. So that's an example of that kind of interaction.
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Dr. Ganesh Taylor
Yeah, I think it's really, really important to sort of reiterate this point that so many of the traits that we're interested in, especially in a world now where genome editing exists and we're thinking a lot more about how we're going to use tools in the future and whatn. It's really, really important, and you cover this obviously amply in the book, that many of these traits that we think about and have thought about historically are polygenic is the term for it, meaning they have many different causes and most of them are very much in the realm of having an inheritable part and also, of course, operating within the realms of environmental impact also. So I really wanted to reinforce that point that you made there. I think this is also a good moment to dive into the. The sort of opening theme of the book, which is about these divisions. Exactly. As you said, there is always this idea about the mind body separation thing. And of course, all this talk at the moment broadly about mental health, trying to normalize it and sort of bring it into the realms of. All of them are analogies about how it's like physical health. You wouldn't ignore a broken leg and all that sort of stuff. So I found it quite interesting that the book actually has quite a sort of philosophical and historical vein to it. And I wondered if you could sort of share your reflections from looking into the sort of historical side of things. What most sort of struck you, what was the most surprising part of looking through all of that literature into these sorts of mind body separations and how that then got manifested into dealing with schizophrenia.
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Professor Edward Bullmore
Yeah, well, you know, that's quite a deep, that is quite a deep question. I think the, the point that I made in the book is that this split, let's just talk about the split between body and mind, you know, goes back a long, long way. I mean, you can find echoes of it in the Hebrew Bible, in Genesis, you know, the idea that man is made of flesh and spirit is a very early representation of that basic idea, and that is still with us. And it went through, you know, it went through that long, ancient tradition. And then during the sort of Renaissance, Descartes in particular picked up that idea and reframed it in terms of the God in the machine. You know, so you've got a sort of soul, you've got a spirit or a mind which is completely separate from the body. And the body is like a machine. In other words, we can analyze it mathematically, we can experiment with it, we can work on it scientifically, the body, but the mind is something different. And that is called Cartesian dualism, the split between body and mind as Descartes formulated it. And that was important for science because it basically said to scientists, you know, in the 17th century and subsequently that, you know, bodily disease was something that science could tackle, and it could tackle it without sort of infringing on any kind of religious sensitivities around the soul. So, you know, you've got to think back in the 17th century, religion was really the dominant ideology in Europe, and science had to kind of emerge kind of alongside it. But that was always quite a turbulent relationship. Galileo, for example, the kind of pioneering astronomer, was persecuted by the Catholic Church because some of his claims about the solar system conflicted with the theological doctrines at the time. So the scientists of the 17th century, and subsequently, they had to be quite careful in terms of their relationship to religion. And Cartesian Judaism was a way that allowed them license to think scientifically about the body without getting into trouble with the people that had authority in terms of spiritual matters. That then evolved through the 19th century, and as we all know, the sort of physical side of medicine became ever more successful, and people began to understand infectious disease and began to treat infectious disease, for example, as a body problem. And then psychiatry began to emerge towards the back end of the 19th century, mainly in Germany. And the German tradition was firstly focused on the concept that mental illness must have its roots in the brain. In other words, they wanted to treat it as a physical problem. And they got quite a long way, at least conceptually, in doing that. But as I tell the story in the book, what happened from about, you know, let's say 1900 to 1930 was a split within psychiatry, and the dominant sort of orthodox position became very, very biological, very focused on the genetics, very focused on postmortem examination of the brain, trying to find the lesions in the brain that explained the mental illness. And Freud, who had trained as a neuroscientist, flipped and became the first psychoanalyst, as we all know. And around him clustered a completely different tribe of practitioners who thought of psychosis as all in the mind rather than all in the brain. So this split that actually you can see going back such a long way in terms of the Western philosophical and scientific tradition when it came to psychiatry, beginning of the 20th century got very sharply polarized between the followers of Freud on the one hand, and the followers of Emil Kraepelin on the other hand, who was the leader of the German Orthodox tradition. And then that dynamic became embroiled in the emergence of the Nazi state and the Second World War. The psychoanalysts, who are mostly Jewish, were either killed or exiled, and the the biological psychiatrists became partners in the eugenic policies of the Nazi state. So that really was a disaster. It was obviously a disaster for all the patients that got caught up in it. But it was a disaster also for the coherence of psychiatry and the coherence of our concept of schizophrenia, because it really pulled those two tribes a long way apart and made our thinking about schizophrenia very fractured for decades following the Second World War.
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Dr. Ganesh Taylor
Style Every home.
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Dr. Ganesh Taylor
In Tulum.
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- [30:58]
Dr. Ganesh Taylor
So is it fair then to say that in part what you're sort of hoping to achieve in this book is to sort of highlight the fact that this fractious divide is maybe sort of drifting a little bit closer or has done, or there's strong evidence of that?
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Professor Edward Bullmore
Yeah, I mean, we have to get over the history and we have to be able to look at what the science is telling us now and try and recognize the reality of schizophrenia as it is, rather than what we've been historically conditioned to think it might be. And again, that's another reason to write a book, because I spend most of my professional careers I'm sure you do, in your professional career, writing peer reviewed scientific articles which have to be three or four thousand words long. And they don't really allow philosophy in there, they don't allow history. It's got to be very focused on the current experiment. But I think we need to step back and take a slightly wider look at this and say, okay, here's what we know about schizophrenia now, here's how the history has brought us to this point and how can we now use the science that we have that we didn't have previously to escape our history and think of a way forward for schizophrenia and severe mental illness, which kind of dodges this old, you know, dualistic divide and kind of finds a way of thinking about things more joined up between brain, body and mind, rather than always trying to sort of force the argument either one way or the other?
- [32:30]
Dr. Ganesh Taylor
Yeah, no, quite. I mean, really appreciate the sort of optimism of that and reasonableness, really. On that note, I wanted to ask you, you know, if you could envisage a future for the field, as it were, what would that be? What would the perfect, as you understand it, or perfect as best as you could imagine right now, what would be the ideal sort of changes that need to be put into place that could allow for a manifestation of a future that is much more joined up as you describe it?
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Professor Edward Bullmore
Well, there are a few things. I mean, we have a diagnostic system in psychiatry called DSM or dsm. The Diagnostic and Statistical Manual is the sort of the bible, if you will, of psychiatric diagnosis.
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Dr. Ganesh Taylor
And sorry to interrupt. This is a really important point, right, because this is the document that legitimizes the existence of something, allows for its diagnosis. If it's in the dsm, it's real. If it's not in the dsm, it's not real. Is that a fair, if somewhat damning.
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Professor Edward Bullmore
No, that is the convention. But just to add to what you've just said, if it's in dsm, it's regarded as a sort of official diagnosis. That means in practical terms you can get paid for treating somebody with a DSM diagnosis. If you're working in the States, let's say, where it's a mostly private healthcare system, remuneration is constrained by dsm. You know, it's more difficult to be remunerated for treating somebody with a diagnosis that doesn't exist in DSM than one that does. Right. It's also very relevant to drug development. You know, so if you're thinking, how can we create a new drug for schizophrenia or a new drug for, you know, mental health, you have, it's much easier. It's not easy, but it's easier than the alternative to go for a DSM diagnosis. Because the regulators read dsm, they take it as, you know, a given that there is a diagnosis of schizophrenia. And they're happy enough for drug companies and others to come forward and say, we want to develop a new drug for this existing indication. If you come as a drug company to a regulator and say, you know, we've got a great new drug and it makes people feel better, but it doesn't really line up with the diagnostic system. That is a much, you know, that's a much tougher sell from an industry point of view. So dsm, it sounds kind of like abstract and academic and who cares really what the diagnostic system in psychiatry is? But it does have very significant real life impacts in terms of what can get paid, what kind of treatment can be offered, what kind of treatments can be developed. So one change I would like to see is reform of dsm. And one reason I've dwelt on the history so much in the book is because I think we need to be very, very clear with ourselves that DSM is a historical product. It's not science, pure and simple. Okay. It's a document that has evolved over multiple editions. And the first edition came out in the first few years after the war. And as a, as we've already discussed, the war was a massively traumatic event, obviously for many, many millions of people, but it was a massively traumatic event for psychiatry and dsm, which originated in the States as part of the sort of post war recovery of psychiatry. So it's a historically conditioned document. It's not science, pure and simple. I think that's one thing that we need to just be clear about. And there are good reasons why, you know, it evolved historically the way that it did. But now I believe the science is telling us that we really need to think about it quite differently. I'll just give you one example. In dsm, bipolar disorder and schizophrenia are categorically different. You can't, you can't have both those diagnoses at the same time. It's one or the other. And that is basically built on the idea that those disorders are a little bit like infectious diseases. You know, you can have cholera or you can have tuberculosis, but cholera and tuberculosis have different causes, as you know. I mean, they're different bacteria. Mycobacterium tuberculosis causes tuberculosis, something else causes cholera. In psychiatry, if schizophrenia and bipolar disorder were really as distinct from each other as tuberculosis and cholera, they should have distinct causes. And they're both heritable and they both have genes that increase the risk. But many of the genes that increase the risk of schizophrenia also increase the risk for bipolar disorder. In other words, there isn't a clean separation between those diagnoses when you get down to the biological level. And I think that is going to be an increasingly powerful driver to rethink how we diagnose mental illness as a whole. That is going to help us in future. So that's one really important thing. I also think we need to change the training process for doctors, at least in this country. You know, you come out of medical school as a doctor and you're basically faced with a binary choice. If you're interested in anything to do with the brain and mind, you either become a psychiatrist or you become a neurologist. You either become a mind specialist or a brain specialist. So we've got that. We've got that split actually hardwired in to the.
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Dr. Ganesh Taylor
Wow, I did not realize that. Sorry to cut you off. That's incredible.
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Professor Edward Bullmore
Yeah. And you know, in terms of the health service, if you look around the health service in the NHS in the uk, most hospitals are either mental hospitals or physical hospitals, acute medical hospitals, they're called. There are very, very few places in the NHS that actually provide an opportunity for patients to have both their mental health and their physical health expertly treated under the same roof.
- [38:56]
Dr. Ganesh Taylor
That's really particularly interesting given. So one of the most shocking things that you showed in the book, for me at least, was you showed a plot from a GWA study, a study of different genetic variants across a large pool of people who have schizophrenia. And it showed that the gene most linked to having schizophrenia is a gene called mhc, major histocompatibility complex, which won't mean much to most people, but it's basically a gene that is really, really central to the immune system. Right. And so this is obviously related to your previous work about the inflamed mind and is part of your academic work and legacy here. But it's in the context where we now have so much evidence generated by people like yourself and your peers, that immunological genes are part of the foundation of these kinds of psychological conditions. It's really quite shocking to think that actually, you know, they're still being treated very separately as completely separate things. This is not just a philosophical comment on the mind body separation. So that's a really fantastic way of driving that point home. I hadn't really grasped that.
- [40:16]
Professor Edward Bullmore
Yeah, yeah, no, definitely. I mean, you know, you can, we can talk about it philosophically, but even though I'm an academic, I don't really want to spend a lot of time just talking about philosophy for the sake of talking about philosophy. I think, I think it's useful to kind of take a sort of philosophical look at it, just because it helps us see things in context a little bit. It helps see that long historical process. But we've also got to be aware that these kind of quote unquote philosophical issues have really, you know, I think quite detrimental real life impacts.
- [40:52]
Dr. Ganesh Taylor
Yeah, they've shaped the way we operate, clearly. Wow. Okay, so let's revise the dsm, let's update it to include some of the science. Let's address the fact that we have separation between psychiatry and neurology and sort of get that reflected there. Is there anything else that you would, in your ideal future that we would do?
- [41:17]
Professor Edward Bullmore
We shift much more to Prevention, in terms of how we are trying to deal with this issue overall and instantly, that is, it's interesting to me, the recent NHS plan. One of the priorities that has been highlighted politically is the shift from intervention to prevention. And I think for psychiatry and schizophrenia and so on, that's particularly important. And it goes back to what we were saying earlier. If somebody becomes schizophrenic or has that diagnosis from, let's say, the age of 22, and they go in and out of hospital and they get various fairly heavy duty drugs that interfere with their normal capacity to kind of, you know, make relationships, build a career, etc. You know, it's very, very difficult to kind of recover beyond a certain point. Whereas if we could prevent that from happening, obviously it would be, you know, infinitely preferable. And I think prevention is where we ought to be focusing our intention strategically. I think that perhaps we have sort of veered away from the concept of prevention in recent decades, partly because, you know, there is some uncertainty about exactly where schizophrenia is coming from. And how can you prevent something if you don't understand its origins, but also I think because of this history that we talked about, because if you go back to the 1930s in Germany, they would have argued we want to prevent dementia precox, as they called it, and that's why we're going to sterilize all the patients with that diagnosis so they can't reproduce. So we will prevent that, those risk genes getting into the gene pool and that will prevent schizophrenia in the long term. So there is a history of psychiatry taking a brutal and ethically unacceptable approach to prevention. And I think that's, in a sense, kind of tarnished the brand of prevention for psychiatry. But now that we know more than we do, than we did rather, I think we could look afresh at prevention and we could think, you know, more positively about how do we do that and when do we intervene. You know, we could try and intervene very early or in the course of development. We could try and pick up the kids that had the combination of, you know, inherited risk genes and toxic exposures and were most likely to develop schizophrenia long into the future. And we could do what we, you know, there are things that we could do there, particularly around modifying exposure to environmental risks. You can't change somebody's DNA very easily, as you know, but you can change to some extent the environment that they're exposed to. So that's one strategy for prevention. I think the other area, place, the other point in time where prevention could really make a Difference is as, again, we were talking about earlier people in their, you know, 18, 19, 20 year old phase, they might have some experience of psychotic symptoms. Some people will develop schizophrenia, many people will fully recover. If we could find out what makes the difference, you know, what is it that puts some patients on that longer term path to, you know, long standing schizophrenia and prevent that from occurring. So that in the jargon that would be called secondary prevention because the patients have already appeared seeking treatment for psychotic symptoms. And what you're trying to do is prevent that becoming a long term disabling disorder. And the other strategy I was mentioning earlier would be called primary prevention. So that's trying to deal with children or adolescents who haven't experienced any psychotic symptoms but look to be at risk of doing so in future. So I think there are a couple of points in time where we could think about being preventive and predictive and trying to, you know, rather than just damping down symptoms and looking people up when they become most disturbed, try and intervene more, you know, proactively and predictably to kind of prevent those problems becoming so severe in the first place.
- [45:42]
Dr. Ganesh Taylor
Yeah, that's, I mean, that all sounds fantastically reasonable. I mean, especially in a, in a world now with, you know, where we have the projects sampling newborn blood and whatnot, you know, we have all this information about the genes, the risk factors. But of course, as we said already, even in the course of this conversation, a risk factor is not a diagnosis. It's just something that needs to be managed and sort of catching people early so that they can be, you know, personal. We're talking about personalized medicine, basically, aren't we, in a sense, and putting sort of better strategies in place for young adults so that if you haven't been, if you're not aware that you have a genetic risk factor, if things do start to manifest, there's a better system for catching those individuals so that they can then be sort of better monitored there, basically leveraging our deepened understanding of the sort of genetic and environmental impacts on the conditions that we care about and we've learned from the past and we hold it to be morally abhorrent to interfere too much with the genetic basis of things. But actually there's a lot to be played for in the environmental context and that's something that we should be doing far better at. So this is fantastic. Thank you so much, Edward, for your time. Thank you for coming to talk to us about this and for your lucidity and clarity. Just to remind our listeners again, this is the book The Divided Mind. It is available now online and in stores. And you know that go out there, buy it, read it. It's interesting. It's challenging. Thank you again, Edward, for your time. That was Professor Edward Bulmore, author of the Divided Uncovering Psychiatry's Dark Past and Reimagining Its Future, which is available now online and in Stores. I'm Dr. Ganesh Taylor. You've been listening to Intelligence Squared. Thank you for joining us.
- [47:40]
Mia Sorendi
Thanks for listening to Intelligence Squared. This episode was produced by Ginny Hooker and it was edited by Mark Roberts. For ad free episodes and full length recordings. Become a member@intelligencesquared.com membership and to join us at future live events, head to intelligencesquared.com attend to see our full program. You've been listening to Intelligence Squared.
- [48:04]
Dr. Ganesh Taylor
Thanks for joining us.
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Professor Edward Bullmore
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Professor Edward Bullmore
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