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Insulin Shock Therapy

Insulin shock therapy or insulin coma therapy was a form of psychiatric treatment in which patients were repeatedly injected with large doses of insulin in order to produce daily comas over several weeks.[1] It was introduced in 1933 by Polish-Austrian-American psychiatrist Manfred Sakel and used extensively in the 1940s and 1950s, mainly for schizophrenia, before falling out of favour and being replaced by neuroleptic drugs.[2] Insulin coma therapy and the convulsive therapies (electro and cardiazol/metrazol) were collectively known as shock therapy.[3] Although insulin coma therapy had disappeared in the USA by the 1970s, it was still being used at that time in some countries such as China, and the Soviet Union.[4]

Contents

Origins

In 1927 Sakel, who had recently qualified as a doctor in Vienna and was working in a psychiatric clinic in Berlin, began to use low (sub-coma) doses of insulin to treat drug addicts and psychopaths.[5] Having returned to Vienna, he treated schizophrenic patients with larger doses of insulin in order to produce coma and sometimes convulsions.[5] Sakel made public his results in 1933 and his methods were soon taken up by other psychiatrists.[5] Joseph Wortis, after seeing Sakel practice it in 1935, introduced it to the USA. British psychiatrists from the Board of Control visited Vienna in 1935 and 1936, and by 1938 thirty-one hospitals in England and Wales had insulin treatment units.[2] In 1936 Sakel moved to New York and also introduced insulin coma treatment into American psychiatric hospitals.[5] By the late 1940s the majority of psychiatric hospitals in the USA were using insulin coma treatment.[6]

Technique

Insulin coma therapy was a labour-intensive treatment that required trained staff and a special unit.[2] Patients, who were almost invariably diagnosed with schizophrenia, were selected on the basis of having a good prognosis and the physical strength to withstand an arduous treatment.[7] There were no standard guidelines for treatment; different hospitals and psychiatrists developed their own protocols.[7] Typically, injections were administered six days a week for about two months.[1] The daily insulin dose was gradually increased to 100-150 units until comas were produced, at which point the dose would be levelled out.[1] Occasionally doses of up 450 units were used.[8] After about 50 or 60 comas, or earlier if the psychiatrist thought that maximum benefit had been achieved, the dose of insulin was rapidly reduced before treatment was stopped.[9][7] Courses of up to 2 years have been documented.[9]

After the insulin injection patients would experience various symptoms of decreased blood glucose: flushing, pallor, perspiration, salivation, drowsiness or restlessness.[9] Sopor and coma - if the dose was high enough - would follow.[9] Each coma would last for up to an hour and be terminated by intravenous glucose.[1] Seizures sometimes occurred before or during the coma.[10] Many would be tossing, rolling, moaning, twitching, spasming or thrashing around.[7]

Some psychiatrists regarded seizures as therapeutic and patients were sometimes also given electroconvulsive therapy or cardiazol/metrazol convulsive therapy during the coma, or on the day of the week when they didn’t have insulin treatment.[9][10] When they were not in a coma, insulin coma patients were kept together in a group and given special treatment and attention; one handbook for psychiatric nurses, written by British psychiatrist Eric Cunningham Dax, instructs nurses to take their insulin patients out walking and occupy them with games and competitions, flower-picking and map-reading, etc.[11]Patients required continuous supervision as there was a danger of hypoglycaemic aftershocks after the coma.[2]

In modified insulin therapy, used in the treatment of neurosis, patients were given lower (sub-coma) doses of insulin.[9]

Effects

Although a few psychiatrists (including Sakel) claimed success rates for insulin coma therapy of over 80 percent in the treatment of schizophrenia, and a few argued that it merely sped up remission in those patients who would undergo remission anyway, the consensus of opinion at the time was somewhere in between - claiming a success rate of about 50 per cent in patients who had been ill for less than a year (about double the spontaneous remission rate) with no influence on relapse.[5][12] Sakel suggested the therapy worked by "causing an intensification of the tonus of the parasympathetic end of the autonomic nervous system, by blockading the nerve cell, and by strengthening the anabolic force which induces the restoration of the normal function of the nerve cell and the recovery of the patient."[5] The shock therapies in general had developed on the erroneous premise that epilepsy and schizophrenia rarely occurred in the same patient. Another theory was that patients were somehow "jolted" out of their mental illness.[13]

The hypoglycemia (pathologically low glucose levels) that resulted from ICT made patients extremely restless, sweaty, and liable to further convulsions and "after-shocks". In addition, patients invariably emerged from the long course of treatment "grossly obese".[7] The most severe risks of insulin coma therapy were death and brain damage, resulting from irreversible or prolonged coma respectively.[1][8] A study at the time actually claimed that many of the cases of brain damage were actually therapeutic improvement because they showed "loss of tension and hostility".[14] Mortality (death) risk estimates varied from about one percent[2] to 4.9 percent[15].

Decline

Insulin coma therapy was used in most hospitals in the United States and the United Kingdom during the 1940s and 1950s, but the numbers of patients were restricted by the requirement for intensive medical and nursing supervision and the length of time it took to complete a course of treatment. For example at one typical large British psychiatric hospital, Severalls Hospital in Essex, insulin coma treatment was given to 39 patients in 1956. The same year 18 patients received modified insulin treatment, whilst 432 patients were given electroconvulsive treatment.[16] In 1953 British psychiatrist Harold Bourne published a paper entitled "The insulin myth" in the Lancet, in which he argued that there was no sound basis for believing that insulin coma therapy counteracted the schizophrenic process in a specific way. If treatment worked, he said, it was because patients were chosen for their good prognosis and were given special treatment: "insulin patients tend to be an elite group sharing common privileges and perils".[17] In 1957, when insulin coma treatment use was already declining, the Lancet published the results of a randomized, controlled trial where patients were either given insulin coma treatment or identical treatment but with unconsciousness produced by barbiturates. There was no difference in outcome between the groups and the authors concluded that, whatever the benefits of the coma regime, insulin was not the specific therapeutic agent.[18]

Recent writing

Recent articles about insulin coma treatment have attempted to explain why it was given such uncritical acceptance. In the United States Deborah Doroshow writes that insulin coma therapy secured its foothold in psychiatry not because of scientific evidence or knowledge of any mechanism of therapeutic action, but due to the impressions it made on the minds of the medical practitioners within the local world in which it was administered and the dramatic recoveries they saw in some patients. Today, she writes, those who were involved are often ashamed, recalling it as unscientific and inhumane. Administering insulin coma therapy made psychiatry seem a more legitimately medical field. Harold Bourne, who questioned the treatment at the time, is quoted: "It meant that psychiatrists had something to do. It made them feel like real doctors instead of just institutional attendants".[7]

Despite the risks, the public and psychiatrists often felt that something had to be tried because of the large numbers of patients and the lack of alternatives. The prevalence of complications might have been overwhelming but instead were used as opportunities for medics to exert their expertise in a hospital setting. ICT specialists continuously experimented with the procedures on different patients. The teams who administered the treatment were often separate from the rest of the hospital and established tight bonds in support of collective risk-taking. While willing to take large therapeutic risks in administering ICT in the first place, they were cautious in their handling of the adverse effects that did occur. The physicians and nurses often treated ICT patients with excessive care and provided various routines and recreational and group-therapeutic activities, much more than for most psychiatrist patients. ICT specialists often chose patients whose problems were the most recent and who had the best prognosis; in some cases patients had already started to show improvement, and after the treatment denied that the ICT had helped, but the psychiatrists nevertheless argued that it had.[7]

In the United Kingdom psychiatrist Kingsley Jones sees the support of the Board of Control as important in persuading psychiatrists to use insulin coma therapy. The treatment then acquired the privileged status of a standard procedure, protected by professional organizational interests. He also notes that it has been suggested that the Mental Treatment Act of 1930 encouraged psychiatrists to experiment with physical treatments.[2]

British lawyer Phil Fennell notes that patients "must have been terrified" by the insulin shock procedures and the effects of the massive overdoses of insulin, and were often rendered more compliant and easier to manage after a course.[13]

Leonard Roy Frank, an American survivor of 50 forced insulin coma treatments combined with ECT has described it as "the most devastating, painful and humiliating experience of my life", a "flat-out atrocity" glossed over by psychiatric euphemism, and a violation of basic human rights.[19]

Pop culture

Insulin Shock Therapy was featured and dramatized in the 2001 film A Beautiful Mind (film), based on the life of John Forbes Nash, Jr.

Dr House in the US TV series House, initiated insulin shock therapy on himself in season 5 episode (Under My Skin) in an attempt to eliminate hallucinations caused by Vicodin abuse.

The American singer-songwriter Townes Van Zandt was given insulin shock therapy, as a result of which he lost most of his memories of his childhood.

Notes

  1. ^ a b c d e WL Neustatter (1948) Modern psychiatry in practice. London: 224.
  2. ^ a b c d e f K Jones (2000) Insulin coma therapy in schizophrenia. Journal of the Royal Society of Medicine 93: 147-149.
  3. ^ GL Jones (1948) Psychiatric shock therapy: current uses and practices. Williamsburg: p1.
  4. ^ LB Kalinowsky (1980) The discovery of somatic treatments in psychiatry. Comprehensive Psychiatry 21: 428-435.
  5. ^ a b c d e f MJ Sakel (1956) The classical Sakel shock treatment: a reappraisal. In F. Marti-Ibanez et al. (eds.) The great physiodynamic therapies in psychiatry: an historical reappraisal. New York: 13-75.
  6. ^ GL Jones (1948) Psychiatric shock therapy: current uses and practices. Williamsburg: p17.
  7. ^ a b c d e f g DB Doroshow(2007) Performing a cure for schizophrenia: insulin coma therapy on the wards Journal of the History of Medicine and Allied Sciences 62(2): 213-43.
  8. ^ a b WS Maclay (1953) Death due to treatment. Proceedings of the Royal Society of Medicine 46: 13-20.
  9. ^ a b c d e f C Allen (1949) Modern discoveries in medical psychology. London: 219-220.
  10. ^ a b WW Sargant and E Slater (1954) An introduction to the physical methods of treatment in psychiatry, 3rd edition. Edinburgh.
  11. ^ EC Dax (1947) Modern mental treatment : a handbook for nurses. London: 13-14.
  12. ^ W Mayer-Gross (1950) Insulin coma therapy of schizophrenia: some critical remarks on Dr Sakel’s report. Journal of Mental Science 96:132-135.
  13. ^ a b Phil Fennell (1996) Treatment Without Consent: Law, Psychiatry and the Treatment of Mentally Disordered People Since 1845 Routledge, 1996 ISBN 0415077877
  14. ^ Observations on organic brain damage and clinical improvement following protracted insulin coma (1955)
  15. ^ FG Ebaugh (1943) A review of the drastic shock therapies in the treatment of the psychoses. Annals of Internal Medicine 18(3): 279-296.
  16. ^ D Gittens (1998) Narratives of Severalls Hospital, 1913-1977. Oxford: 197-199.
  17. ^ H. Bourne (1953) The insulin myth. Lancet ii 265(6798): 964-8. PMID 13110026
  18. ^ B Ackner, A Harris, AJ Oldham (1957) "Insulin treatment of schizophrenia; a controlled study", Lancet i 272(6969): 607-11. PMID 13407078
  19. ^ LR Frank (2002) Psychiatry's Unholy Trinity--Fraud, Fear and Force: a personal account. The Freeman - Ideas on Liberty 52(11).

See also

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