Things that have given psychiatry a bad name #2 Insulin Coma Therapy

 

Insulin is a hormone produced in the body by the pancreas; its main role is to cause cells to take up glucose from the blood thus regulating its level. The history of the discovery of insulin is an interesting one, albeit involving the death of a pack dogs.

In 1889, the physicians Oscar Minowski and Joseph von Mering removed the pancreas from a dog to test its assumed role in digestion. Several days after the dog’s pancreas was removed, it was noticed that there was a swarm of flies feeding on the dog’s urine. On testing the urine they found that there was an unusually high sugar content, establishing for the first time a relationship between the pancreas and diabetes mellitus.  In 1901, it was established that the diabetes was caused by the destruction of a part of the pancreas called the Islets of Langerhans. These islets had been identified by Paul Langerhans whilst a medical student in 1869. 

We now know that what the islets were producing was insulin, but this proved difficult to isolate. Nicolae Paulescu a professor of physiology in Bucharest was the first one to succeed and published his work in 1921. Use of his techniques was patented in Romania , but no clinical use resulted.  At almost the same time, Canadian Frederick Banting hypothesised that the reason for the difficulties was that some of the other products of the pancreas, digestive enzymes, were destroying the islet secretions before they could be extracted.  In the summer of 1921 he was supplied with a laboratory, Charles Best, a medical student assistant, and ten more dogs.  The idea was to ligate the dog’s pancreatic ducts; the pancreatic secretions would then pool in the pancreas, but the digestive elements would be reabsorbed leaving the islets.  It was found that an extract from these islets was able to keep a pancreatectomized dog alive all summer as the extract lowered the level of sugar in the blood. 

Efforts continued by Banting and Best to purify the extracted insulin enough to allow administration to humans, which was underway by late 1921; commercial quantities were available by 1923.  Banting received the Nobel Prize for his work, although controversially Paulescu was not recognised.

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In the sadly now departed spirit of have-a-go experimentalism, the newly discovered insulin was then tried out on patients suffering with illnesses for which no treatment was known. In Berlin , between 1928 and 1931, Dr. Manfred Sakel used insulin to reduce the unpleasant symptoms of patients undergoing opiate withdrawal. With insulin, they became calm, gained weight, and were much more cooperative.  When the dose of insulin was high, the patient went into stupor; after such events, the patients were less argumentative, less hostile, and less aggressive. 

Noting these results, Sakel moved to Vienna , and was assigned to treat patients with schizophrenia.  He further investigated the benefits of insulin, and reported that when the patients developed stupor or coma, they lost their psychotic thoughts.  His experience was reported to the Vienna Medical Society in January 1933, and by May 1936, favorable reports of the benefits of insulin coma therapy in schizophrenia from 22 countries were presented at a major meeting of the Swiss Psychiatric Society.

The German name for the treatment was ‘Insulin-shock-behandlung’. Translated into English, the phrase became ‘insulin-shock-treatment’.  Sakel interpolated the word ‘shock’ to emphasize his belief that the essential element of ICT was the lowered blood pressure, sweating, increased heart rate, and increased breathing rate that resulted from the stresses produced.  It was later understood that, that the medical shock aspects were not important to the treatment results, and any benefit was mostly likely due to the insulin induced coma.  Insulin coma therapy was regarded as a specific treatment for schizophrenia, and was probably the first in this regard.

Essentially the treatment involved a large dose of insulin which lowered the patient’s blood glucose enough to produce a coma.  This would be maintained for one to three hours and terminated by either tube feeding or intravenous glucose.  A course of treatment could include up to 60 comas.  Serious side effects were common, and a mortality of at 1-10% could be expected depending on the standard of the clinic and physical state of the patient.  Epileptic seizures could occur during the beginning stages of treatment, roughly 45–100 minutes into the procedure, but before the onset of the comatose state.  Seizures occurring during the coma were more dangerous, requiring immediate interruption of the procedure and coma termination, and were often followed by delayed recovery or severe hypotension.  Complications would also occur from the unconsciousness reaching excessive depths and that the coma would not end despite the administration of feeding or glucose.   Administrators would monitor the patient’s vital signs, to determine the level of danger.   

Despite these risks, insulin coma treatment was rapidly taken up throughout Europe and many specialized treatment units were built.  It is worth remembering that at this time there were no effective treatments for psychotic disorders and that the physical effects of prolonged psychosis were also severe, such that it was felt at the time that the risks were worth taking.  Indeed there was a great improvement in the morale of patients and staff because of the belief that this dramatic treatment could cure symptoms of the most serous psychiatric disorders. 

There were always some doctors who doubted the efficacy of insulin coma treatment.  Their doubts were reinforced by a controlled trial by Acker and Oldham (1962) who found that, in patients with schizophrenia, insulin coma was no more effective than a similar period of unconsciousness induced by barbituates.  It may be that the treatment had a tranquillising effect on patients by inducing brain damage through the prolonged deprivation of the brain cells of glucose, as suggested in a journalist Robert Whitaker’s book Mad in America*. It was also a very dramatic procedure, with patients being put into a long coma, and then re-awoken quite suddenly by the injection of glucose. This raises the possibility that coma therapy may have owed its perceived effect to a placebo effect, and a result of the drama of the whole procedure.

The Acker and Oldham study was published about the same time that chlorpromazine was introduced and both factors lead to a rapid decline in the use of insulin coma treatment.  It should be said though that some controlled studies did not exclude the efficacy of insulin treatment in certain circumstances and a number of workers continued to maintain that it was effective**.  Recent experimental studies have shown that insulin administration causes changes in the release of monoamine neurotransmitters, suggesting a possible mechanism of action**.

Links:

The Insulin Treatment of Schizophrenia From An Introduction to Physical Methods of Treatment in Psychiatry (First Edition) by William Sargant and Eliot Slater (1944, Edinburgh, E & S Livingstone).

A History of Shock Therapy in Psychiatry by Renato M.E. Sabbatini, director of the Center for Biomedical Informatics and Chairman of Medical Informatics of the Medical School of the State University of Campinas Brazil

Drug Treatments in Modern Psychiatry: A History of Delusion Dr Joanna Moncrieff Senior lecturer UCL UK

A Brilliant Madness PBS minisite about Nobel Prize winning schizophrenia sufferer John Nash.  In the same site Dr. Max Fink, the head of the insulin coma unit at the Hillside Hospital in Glen Oaks, Queens, New York from 1952 to 1958 writes about the treatment

Wikipedia on insulin shock therapy

* I haven’t read this, Joanna Moncrieff, Senior Lecturer in Social and Community Psychiatry UCL and chair of the Critical Psychiatry Network cites it in the above presentation.  He’s a journalist though, so I can’t shake the suspicion that he’s making it up.

**Source Shorter Oxford Textbook of Psychiatry by Michael Gelder, Richard Mayou and Philip Cohen Oxford 2001 pg 648.  They don’t cite a source.

6 Responses to “Things that have given psychiatry a bad name #2 Insulin Coma Therapy”

  1. NorthernIrelandExile says:

    Ok.

    I’ve thought about this, and to be fair, I wouldn’t be too damned happy if my predecessors had gotten up to things that hurt people. However, let us assess the facts if we may.

    According to this (admittedly uncomprehensive)blog, there are a couple of things that have given psychiatry a bad name; namely Lobotomy and Insulin Coma.

    Well…

    If your average psychiatrist feels bad about that, then thank god they never became a lawyer!!!

    Not only did we start out by drowning supposed witches, but we have then gone on to be bought be every goverment of the day. We ignore human rights so we can keep people in Guantanamo in orange jump suits and we have abandoned habeus corpus…

    And aparently psychiatrists are the bad guys?????????? LOL!!!!

  2. NorthernIrelandExile says:

    and one more thing, lets have a look at the courts in Zimbabwe.

    Luckily, whilst I may be disgusted at Mugabe’s henchmen, inc the judiciary, I can be proud of international human rights.

    It is certainly an inefficient system, but it’s doing a job; and I feel like we are winning.

  3. Milo says:

    I am a paranoid schizophrenic and having been suffering from this illness for more than half of my life, i think that i have managed to figure out a thing or two about this entire issue as a whole… yes psychiatry does have a bad name when it comes to its history but at the same time, i really think that it is one of the most scrutinized jobs on this planet! Having been to see soooo many of them over the years (yeah, seriously!), I think majority of them are really fine people, really trying to make a difference. I especially liked the ones who did not just focus on drug therapy and had more of a holistic approach towards treating mental illness. I thought they were the coolest!

  4. I too believe in making a difference in one’s life through the power of your own thoughts

    Some drugs are necessary for some illnesses but should be a very last resort

  5. researchdirector says:

    “Sakel interpolated the word ‘shock’ to emphasize his belief that the essential element of ICT was the lowered blood pressure, sweating, increased heart rate, and increased breathing rate that resulted from the stresses produced.”

    Unfortunately what Sakel himself said was more like this:

    In a popular book on the state of psychiatry published in 1942, Dr. Sakel was quoted as follows: “With chronic schizophrenics, as with confirmed criminals, we can’t hope for reform. Here the faulty pattern of functioning is irrevocably entrenched. Hence we must use more drastic measures to silence the dysfunctioning [brain] cells and so liberate the activity of the normal cells. This time we must kill the too vocal dysfunctioning cells. But can we do this without killing normal cells also? Can we select the cells we wish to destroy? I think we can”

    I thought your coverage of ICT was a wee bit glib considering that far from feeling they had benefitted many patients considered they had been systematically tortured over extended periods. If the following patient account doesn’t make you feel chastened, nothing will. It is ridiculous for you to posit yet another (far fetched!) mechanism for ICT ‘working’ without properly addressing the most probable scenarios. I’d have thought your concluding line should not have been a weak attempt to rehabilitate ICT, rather you should be jolting the field into questioning whether what is being done now is any more scientific than what was being done then. Amazingly enough it is not- for example read the 2007 Cochrane review of 50 years chloropromazine research. The vast majority of papers were binned, and the remaining RCT’s were so fundamentally flawed they deserved to be. Chlorpromazine is a key comparator drug, no antipsychotic has ever been shown to be more efficacious, and as was
    pointed out in the review research on atypicals is if anything worse, and is even more fraudulently biased.

    Anyway to return to ICT:

    Diabetes:

    “A patient admitted with severe hypoglycemia is immediately given glucose as a standard treatment. This restores consciousness right away, but may not always prevent the subsequent death of neurons and possible cognitive impairment….

    The cause of this brain cell death: hypoglycemia triggers the activation of an enzyme called PARP-1, which in turn prevents neurons from metabolizing glucose into pyruvate, which is used to power cells. Deprived of pyruvate, the neurons starve and die.”

    Patient testimony (L.Frank)
    According to my psychiatric records, on December 26, close to seven weeks after entering McLean, Dr. Sharpe started me on 5 units of insulin and rapidly built up the dosage to 75 units a day. Altogether there were 110 insulin subcoma shocks forcibly administered to me. During each session, I perspired heavily and after each one ate like a pig, because the insulin lowered my blood sugar and made me ravenously hungry. The doctors call it hypoglycemia. Before the shocking began, I weighed roughly 145 pounds and by the time it ended I weighed 194 pounds.

    My insulin-induced hunger or forced starvation was intense and excruciatingly painful. It went to the core of my very being. There are two types of insulin shock — coma and subcoma — I got the latter. However, I remember once going into a coma which neither Dr. Sharpe nor anyone else warned me about, and which was omitted from my medical chart.

    Subcoma shock, also called hypoglycemic shock, was extremely debilitating and torturous. Each insulin session lasted three-to-four hours, “mercifully” terminated by drinking fruit juice laced with glucose or dextrose.

    The rest of this account consists of verbatim excerpts of the nurses’ observations of and comments on the insulin subcoma sessions I was made to endure. These are followed, in some instances, by my comments in brackets. Note especially my complaints and attempts to resist the treatment.

    Day 6 — Treatment 15
    “Dramatically calling out, ‘I can’t take this any longer. It’s too unjust. I’m not strong enough.’ mild perspiration.” [Within a week they were giving me each day three shots of insulin in doses of 25 units. This routine lasted six weeks — it felt like six years.]

    Day 10 – Treatments 25 and 26
    “Sweating profusely…. Skin very cold & clammy. Does not want insulin anymore, he stated. He asked to see the Head Nurse to discontinue the treatment — he terminated himself with cookies and oranges, etc breakfast. [A few hours later] Dr. Sharpe notified about termination and said to just continue as usual.”

    Day 12 — Treatment 31
    “Perspiring moderately. Alert and responsive. Whining that, ‘He can’t stand it.’” [“Whining that he can’t stand it.” I felt tortured.]

    Day 17 — Treatment 49
    “Profuse sweating. Drowsy and tossing in bed. Patient saying: ‘I can’t take it.’ Still perspiring profusely, pupils dilated. Patient very drowsy yelling, ‘I can’t take it.’ Perspiring profusely. No response from patient. Patient still had cough reflex so juice was given until revived. Just before terminated patient had muscle spasms, eyes became glassy and starry pupils and no response could be obtained. Patient was terminated with difficulty with p.o. [by mouth]. Patient remembers nothing. Patient was seen by Dr. Horwitz.” [I was probably in a coma but the staff either didn’t notice it or didn’t have the honesty to report it in their clinical-nursing notes. At that time, I was being subjected to a total of 270 insulin units every day — 90 units in each of three sessions.]

    Day 20 — Treatment 52
    “‘What happened?’“ [That’s a quote from me. I didn’t know what was going on .] “Patient showed moderate perspiration, slowness of speech and mild tremor just prior to termination at end of full course. Patient could not remember last end of treatment — says he fell asleep again.” [I was probably going into a coma or about to. Tremors are very common as the insulin dose is increased. I also remember sometimes shaking and convulsing uncontrollably.]

    Day 22 — Treatment 57
    “Severe twitching — tremors — face very pale. No response. Terminated with some difficulty, weeping occasionally.” [The staff likes to use the word “terminate.” For weeping and uncontrollable emotional outbursts, the staff often uses the euphemism “insulin excitement.” These are common effects of insulin shock. As the insulin dose increases, there is usually loss of emotional and physical control. There is pain, big. There is suffering such as I’ve never experienced before, or since. My weeping, shouting, and screaming were to no avail. The torture continued.]

    Day 23 — Treatment 60
    “Some tremors, response poor, face very pale, some twitching of face, hands trembling, moderate to severe crying”

    Day 24 — Treatment 63
    “Pt. became drowsy about 4pm and had to be awakened several times. Continued progressive drowsiness, perspiration, facial tremors & fits of crying”

    Day 25 — Treatment 66:
    “Perspiring profusely, very slow response, skin cool, Pt. remarked, ‘I can’t take it.’“

    Day 29 — Treatment 77
    “Slow tongue-mouthing [?], grimacing, twitching of facial muscles and extremities.”

    Day 32 — Treatment 84
    “Pt. seeking reassurance. Says he’s had enough of this insulin. Pt remarked this was the biggest reaction. Skin was moist. Response slow.”

    Day 33 — Treatment 86
    “Apprehensive about going into coma — states he was very worried about his condition this AM.”

    Day 34 — Treatment 90
    “Emotional outburst, mildly moist, shouting and sobbing up and down hall that he must get out of here, that he can’t stand insulin any longer, etc…. In his own room now and a bit more quiet, but still sobbing frequently and unpredictably, faint tremors…. Sl[ight] twitching of facial muscles in addition to above. Becoming quite confused…. Very confused, responses slow.”

    Day 36 — Treatment 98
    “Perspiring freely. Myoclonic [sudden, irregular] twitching of the face. Tremor of the hand. Bizarre movements. Resistive to termination. Terminated with a great deal of resistance, using pure dextrose.” [Twitching, shaking or convulsing indicates that the brain is suffering a bad reaction. Luckily, I didn’t suffer any brain damage, as far as I know.]

    Day 40 — Treatment 104
    “Stumbled twice on returning from bathroom (? incoordination) — jerky movements of arms & legs.” [After these incidents, one of the nurses wrote in an “Accident Report” that I had received an insulin injection at 5:30 a.m. and that] “on return to his room at 7:45 he fell (was seen raising his buttocks off the floor), got up moving quickly and stumbled again. The latter occurred so rapidly that no one could assist him. As he stumbled the 2nd time, however, a nurse reached him and assisted him to bed. The reason for his stumble could also have been due to ill-fitting slippers…. Upon examination no abrasions or bruises or any kind were noted, and on questioning, patient states ‘he doesn’t hurt anywhere.’”

    Day 45 — Treatment 110 [last treatment]
    “No tremors. Delayed reaction. Recovery.”

    At this point, I felt wasted physically, emotionally, and intellectually. I was totally wiped out from this supposedly “safe and effective treatment” for “schizophrenia.” I wasn’t the only McLean patient to be insulin shocked; there was also a 17-year-old blond man getting the treatment.

    I still recall asking Dr. Sharpe, “Why are you torturing me?” He just smiled at me patronizingly and said, in so many words, that my complaints were “part of my illness.” This was what I came to know as typical shrink logic — blame the patient-victim!

    The following is an excerpt from Dr. Sharpe’s clinical summary of my “case.” “From time to time in his temper tantrums he would be destructive of furniture in his room. The patient was finally placed on sub-coma insulin and after a month of sub-coma insulin three times a day he showed tremendous improvement in his general over-all picture. There was [sic] no longer the outbursts of temper…. He spends most of his time trying to figure out what the effect of insulin has on him.”

    I was damn lucky to have escaped the worst that psychiatrists were doing to people at the time.

  6. Lucas Porter says:

    i actually thought the whole process was a thrill

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