insulin coma therapy

Insulin shock therapy

[in-suh-lin-koh-muh, ins-yuh-]
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. It was introduced in 1933 by Polish 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. Insulin coma therapy and the convulsive therapies (electro and cardiazol/metrazol) were collectively known as shock therapy. 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, India and the Soviet Union.

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. Having returned to Vienna, he treated schizophrenic patients with larger doses of insulin in order to produce coma and sometimes convulsions. Sakel made public his results in 1933 and his methods were soon taken up by other psychiatrists. 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. In 1936 Sakel moved to New York and introduced insulin coma treatment into American psychiatric hospitals. By the late 1940s the majority of psychiatric hospitals in the USA were using insulin coma treatment.

Technique

Insulin coma therapy was a labour-intensive treatment that required trained staff and a special unit. Patients were sometimes given psychological or physical tests to assess suitability for what was considered a "somewhat rough" treatment. Injections were usually administered six days per week for about two months. The insulin was initially "built up" through increasingly high daily doses (usually up to 100-150 units) until the patient started to have comas, at which point the dose was levelled out. Shortly after an injection, patients would become quiet, and then some would start to perspire excessively and salivate down their chins. Those on higher insulin doses would lapse into a coma. Many would be tossing, rolling, moaning, twitching, spasming or thrashing around. Each coma lasted up to an hour (sometimes preceded by fits) at which point glucose was given intravenously to end the coma. The insulin dose, the duration of coma, and how many comas a patient should receive, were decided by the psychiatrist in charge. Despite attempts at standard guidelines, there was almost a different protocol used by each hospital or in some cases by each physician. A course of treatment continued each day until about 50 to 60 comas had been induced and/or the treating psychiatrist felt that maximum benefit had been achieved, at which point the insulin dose was gradually reduced. 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.

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

Effects

Although a few psychiatrists (including Sakel) claimed success rates for insulin coma therapy of over 80 per cent in the treatment of schizophrenia, and a few argued that it merely speeded 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. However, a young doctor eventually managed to get a paper published pointing out that the figures were based on a biased selection of patients, unreliable diagnosis and the provision of much greater amounts of attention and reward to insulin patients. Despite much criticism from psychiatrists convinced of its benefits, a further controlled study in 1957 found no evidence that insulin coma therapy did any better than the existing practice of induction of coma by barbiturates.

The hypoglycemia (pathologically low glucose levels) that resulted from the treatment 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\". The most severe risks of insulin coma therapy were death and brain damage, resulting from irreversible or prolonged coma respectively. The mortality risk has been put at about one per cent.

Mechanism of action

Sakel suggested that insulin coma 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.\" The shock therapies in general had developed on the (wrong) premise that epilepsy and schizophrenia rarely occurred in the same patient. Another theory was that patients were somehow \"jolted\" out of their mental illness.

ICT secured its reputation at the time not because of evidence or any knowledge of any mechanism of therapeutic action, but due to the personal impressions it made on the minds of practitioners in the narrow short-term confines of hospital wards and insulin units. Today those who were involved are often ashamed, recalling it as unscientific and inhumane. Some analysts argue that there are still lessons to be learned from how it came to have such widespread acceptance.

It has been argued that administering ICT had the effect of helping make psychiatry seem a more legitimately medical field. Harold Bourne, the doctor who questioned the therapy at the time, reports that "It meant that psychiatrists had something to do. It made them feel like real doctors instead of just institutional attendants". 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 to exert 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 most psychiatrist patients got. 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. It has been noted 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.

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.

In fiction

Frederick Exley describes receiving insulin shock therapy in 1958 at Harlem Valley State Hospital in his semi-autobiographical novel A Fan's Notes. A treatment is depicted in the 2001 film A Beautiful Mind, based on the real insulin therapy of John Forbes Nash (which he received for six weeks in 1961).

"Dr. Kildare's Strange Case" from the 1930-40's popular series from MGM. Dr.Kildare treats a patient "behind closed doors" with Insulin Shock Therapy and saves his mind. Directed by Harold S. Bucquet, 1940, 1hr 16min, Rated NR.

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References

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