Talk:Insulin shock therapy
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Having examined the Wikipedia entry for "insulin coma therapy", I saw the request for updates on references. I have edited the version adding necessary references.
The treatment is best identified as "insulin coma therapy" as the aim of each treatment was the induction of coma (defined by absent deep tendon reflexes and pupillary response to light") for periods of 30 to 60 minutes. The technical term "shock," as in surgical shock, is not applicable.
The additional references are to the detailed history in Chapter 4 of Shorter and Healy; the 1938 book by Manfred Sakel; the texts by Kalinowsky and Hoch (1946) and Sargant and Slater (1946); the articles on insulin coma by Fink: JAMA 1958 reporting the results of the RTC or ICT vs Chlorpromazine; the description of insulin coma as presented in the film about the treatment of the Nobelist John Nash, cited as "A Beautiful Mind"; the theoretical explanation of ICT in the Harvard Review of Psychiatry. (The editor is requested to cite these properly.)
In 1917 the Professor of Psychiatry in Vienna, Julius Wagner-Jauregg reported the successful relief of neurosyphilis by inducing fevers with infections of malaria. This success became a milestone in thinking when the Nobel Prize in Medicine was awarded in 1927 for this work. Many attempts to treat other mental diseases were tried, but the two techniques that were considered successful were the induction of coma by insulin (1933) and the induction of seizures by chemicals (1934). These treatments were considered remarkable, much as the introduction of chlorpromazine and reserpine in the early 1950s was considered remarkable. Until the new drugs were introduced in the 1950s, ICT and ECT were widely used (much like drug treatments are today.)
ICT was replaced by the antipsychotic drugs, not because these are more effective (they are not for hospitalized schizophrenic patients) but because they are less expensive and have lower mortality rates. The risks of ICT were great. The risks of antipsychotic drugs were not known at the time that the RCT for ICT vs CPZ was published in JAMA in 1958. That study, and the cost factor, effectively ended ICT. (Its continuation in some Asian countries was occasioned by the ready availability of insulin but not chlorpromazine.)
Sakel's treatment was based on the same principle which encourages doctors to try any treatment at hand for difficult cases, as widely described as "off-label" uses. Sakel was in charge of an in-patient unit of severely ill schizophrenic patients and had no effective treatment. Insulin had been introduced in 1922 and in 1928 he found it useful in reducing the withdrawal symptoms of opiate dependence. The trial in schizophrenia was a heroic and logical medical experiment.
The induction of seizures by Ladislas Meduna was not fortuitous. He was a neuropathologist; had described a paucity of glia cells in the brain of schizophrenic patients and a marked increase in patients with epilepsy. His hypothesis was to ask, whether inducing seizures would increase gliosis and improve schizophrenia. He was successful in his first experiments which, fortunatelky, were done in catatonic schizophrenics. (See Gazdag et al. J ECT 2009; 25:3-11). (Recent studies in animals report an increase in gliosis with seizures. See citations in Medline to "seizures" and "Glia" -- references by Bolwig in Copenhagen, Henn in Germany.)
Insulin coma therapy was successful to the extent that seizures were induced (neither insulin nor coma were the effective therapeutic agent) and that patients were selected with catatonic schizophrenia and schizo-affective form of schizophrenia.
Deborah Doroshow was a senior at Harvard College in the History of Science program. She elected to seek an understanding of the rise and fall of insulin coma as her thesis topic. She interviewed physicians who had experience with insulin and examined the patient records at Hillside Hospital in New York who had undergone ICT. The negative views ascribed to her are not in the published report.(She is at present a student in medicine at Harvard University and a concurrent student in history at Yale University.)
The history of insulin coma therapy is a story of a successful treatment for a horrendous disease, schizophrenia. In the normal march of medicine, it was replaced by another experimental treatment.
- That was an old request for references you saw. Since then the article has been rewritten and plenty of references put in. I have reverted because you hadn't formatted the references correctly. They should be footnotes, not just scattered around the text. I don't think there is anywhere in the article at the moment where a citation is needed, but if you think a mention of any additional books, articles, etc would be useful, why not start a "further reading" section?
Message to Staug73: The study by Fink et al (JAMA 1958) was the single random assigned control study of insulin coma and chlorpromazine. It was the definitive evidence for the replacement of insulin coma by chlorpromazine. Its reference should be reinstated.
The story of John Nash (A Brilliant Mind) represents the successful use of ICT. The details should be replaced.
Article needs references
I'm about to go through adding specific cite tags where I feel the article most needs them; I appreciate this can make the page look cluttered, but at the moment the total absence of references means the whole article looks dubious. A pubmed search turns up a few papers, but the most recent is from 1981 and was published in a deeply obscure Chinese medical journal (PMID 7343233); the only items in more mainstream journals are from the late 60s and early 70s (PMID 5739562, PMID 4383208). It looks like it was only ever a slightly bizarre footnote to medical history, and should in any event be referenced. Nmg20 (talk) 17:52, 10 July 2008 (UTC)
- Since no-one was interested in adding references, I have replaced unsourced material with sourced material.
- I have removed first sentence from Fiction section because it wasn't supported by what followed. Also this example because I couldn't find any source for it (other than comments on imdb)- has anyone got anything better?:
- It is also the basis for the successful recovery of a fictional patient in the 1940 MGM movie "Dr. Kildare's Strange Case".
- Removed the citation tags from the book and film, since there are links to wiki articles.
- I also removed the Silverman bits although they were sourced because the book only has a couple of sentences on insulin treatment with no footnotes and the author's account of the origins of insulin treatment is at odds with all the accounts I have come across, including Sakel's own.Staug73 (talk) 16:37, 10 September 2008 (UTC)
- Nice work. The point about occasional reports of continued use in china/former soviet union, is in one of the external links, so might readd that. Get the impression it continued to be used regularly well into the latter part of the 20th century in some countries, so need to add reliable sources on that. The point about 1% mortality, I read that even with close surveillance patients died at a rate of 1 to 2 percent, and in some places as many as 10% (and that's in developed countries) so will have to try and source that.
- Found a 2000 article Insulin coma therapy in schizophrenia and a letter in response, which suggests it can teach us something about modern medical practice & validiation of treatments, as does this 2006 article Performing a Cure for Schizophrenia providing a very nice analysis which will use to source some points, including how it was an unproven contested treatment but gave psychiatrists "something to do" and to "feel like real doctors", who formed close-knit separatist "gung-ho" teams who sometimes "experienced" it as an affective treatment in their narrow short-term environment (scarily like ECT then), how they cherry-picked the healthiest least progressed cases (ugh...), gave a lot of special attention, care & support to patients of this "somewhat rough" treatment (who, the above article notes, invariable came out of it grossly obese), and how they used the procedures to experiment on patients. Also quotes:
"“Insulin shock, the new, violent method of dealing with certain forms of insanity, is as dramatic as medieval magic. And it really works. Dr. Manfred Sakel, its inventor, has brought hope to hundreds of thousands of persons otherwise condemned to a life of constant nightmare.” — J. D. Ratcliff, 19381
“With all these people—tossing, moaning, twitching, shouting, grasping,” remembers one psychiatrist, “I felt as though I were in the midst of Hell".
- The Kingsley Jones article is a good introduction to the subject and very readable (I struggled a bit with the 2006 article which is very academic and seems very psychatrist-centred). I put the link into the footnote. I found a source for China, Russia etc. That was Kalinowsky writing in 1979. Do you know of any more recent ones? I haven't been able to find an end date for the use of insulin coma therapy US and GB. Kalinowsky was saying that it had disappeared in US in his 1979 article, but it might have been gone a while. On the other hand there are usually stragglers.Staug73 (talk) 15:20, 11 September 2008 (UTC)
- I called Sakel a doctor with reason, because apparently - at least according to Kalinowsky - he had no formal psychiatric training and his first application to join the American Psychiatric Association was turned down for this reason. Then - also according to Kalinowsky - this was criticised in New York Times and so they changed their mind and he became a member. But I am not bothered about it.Staug73 (talk) 12:29, 13 September 2008 (UTC)
- You mean in the lead? Did'nt realise it was an issue and am not bothered, just went by the Sakel wikipedia article saying psychiatrist and there's a Time article there referring to himn as a psychiatrist. Be good to have it accurately described as you mention. Disconcerting that APA gave him respectability.... EverSince (talk) 13:58, 13 September 2008 (UTC)
- Btw do you know about the other unclear thing about him in the Sakel article, him being polish - yet born in then austria-hungary/ukraine, studied in austria, & have also seen him called american after he moved there? Incidentally looks like the University of Conneticut thinks insulin coma therapy was great - recently named a "Distinguished Chair in Psychiatry" after him EverSince (talk) 17:24, 13 September 2008 (UTC)
- Interesting. This is what Sabbatini said (I don't know how reliable he is):
- "Manfred Joshua Sakel, Polish neurophysiologist and psychiatrist, was born on June 6, 1900, in Nadvorna, in the former Austrian-Hungary Empire (now Ukrania). Sakel studied Medicine at the University of Vienna from 1919 to 1925, specializing in neurology and neuropsychiatry. In 1933 he became a researcher at the University of Vienna's Neuropsychiatric Clinic, but was forced to immigrate to the United States in 1936, when the National Socialist Party came to power in Austria. In the USA, he became an attending physician and researcher at the Harlem Valley State Hospital."http://www.cerebromente.org.br/n04/historia/sakel_i.htm Staug73 (talk) 13:28, 14 September 2008 (UTC)
- The matter of Sakel's nationality has been befuddled, as it often happens with cities and regions in Mitteleuropa which changed frequently of nation, as they were annexed by warring powers and a maze of post-war agreements. Nadvorna was granted Polish status after the Versailles treaty after the I World War, and remained so for 20 years until the Ribbentropp-Molotov pact allowed the Soviet Union to invade Poland from the East at the same time that Germany aninhilated Poland from the West. After the II World War, the city was annexed to Ukrainia, where it remains to this day. So, Sakel could be either an Austrian subject until 1919, a Polish subject until 1939 and a Ukrainian subject afterwards. All the literature I have read stems from after the II WW, and cosidered Sakel as Polish. He got his education and worked in Austria, however. R.Sabbatini (talk) 15:07, 27 December 2009 (UTC)
- Thanks. I have looked Sakel up on the Ancestry website and it has a document from US immigration in 1937. He was described as Nationality - Austrian; Race or people - Hebrew; Place of birth (country) - Poland. Normally someone could be described as Polish-born Austrian but would that work with Sakel as it was not Poland when he was born and is not Poland now? I am curious to know how he acquired Austrian nationality as he came from a place that is on the other side of the Hungarian part of the Austro-Hungarian empire. Did people just get to choose? (That is not usually what happens when empires break up). Was he actually a psychiatrist?Staug73 (talk) 14:20, 21 January 2010 (UTC)
Misrepresentation of Doroshow
In EverSince's "potted summary of Doroshow" they claim "ICT secured its reputation at the time not because of evidence ..." This is directly contradicted by Doroshow in the abstract of her paper, where she says that in the insulin unit, "psychiatrists often experienced wondrous recoveries of individual, formerly intractable patients." That is evidence. Was it anecdotal evidence? Yes. Was the evidence misinterpreted? Apparently so. But the claim that ICT's reputation had nothing to do with evidence is quite obviously not one that the cited source supports. -- 188.8.131.52 (talk) 16:57, 26 October 2008 (UTC)
In fact, looking at how much of the article is derived from Doroshow, it might be good for someone to contact Doroshow directly (an e-mail address for her is here) and ask if what is attributed to her is in fact a reasonable equivalent of what she wrote. -- 184.108.40.206 (talk) 17:06, 26 October 2008 (UTC)
- 220.127.116.11, umm it doesn't make the claim "had nothing to do with evidence", it says its reputation wasn't secured on that. And you only quote half the sentence - the remainder includes the very point that it made "personal impressions" on practitioners. You could I suppose call the latter evidence too (as per innumerable unscientific magical "cures" through the ages) but it's not (scientific) evidence in the commonly acepted sense. The ambiguity over the term could be clarified (perhaps by simply inserting the word "scientific"); this is indicated by the abstract as you say. If you had your own username as well as making use of mine, I would be able to email you the full text so you could add any additional perspective you wanted to from your POV. Your edit comments "This is NOT what Doroshow says" and "truth problems" and your comments above have a sense of not assuming good faith or competency; I trust this is not intended. As another editor notes above, the language of the full text is academic/idiosyncratic; Wikipedia's must not be.
- You have now split the section in the article so that the comment on evidence no longer directly follows the bit which (potentially misleadingly, imho) implies that a mechanism of action was known or evidenced, which it wasn't. Also, your change to "Doroshow describes" is innacurate, because it's not just her personal description, e.g. "To most modern observers, this seems a barbaric, unnecessarily risky process without scientific foundation." "...those who were involved in its use are often ashamed to admit their implication in a procedure they now recall as unscientific and inhumane.". Doroshow does explore how ICT became "...so firmly entrenched in the psychiatric regimen and how psychiatrists came to believe in its efficacy despite uncertainty in the published literature." Re. the bit from the abstract you quote ("psychiatrists often experienced wondrous recoveries of individual...") it is clearer from the full text that she is deliberately including the subjective term "experienced" - she concludes that it allowed psychiatrists to "feel efficacious" or to "understand it as efficacious" in certain narrow confines, which is what has been reported here...
- Incidentally, this issue doesn't necessarily need to be seen as supported only by Dorowshow: "Yet beyond the university clinic, Sakels' results were considered a joke, the main himself a charlatan, and Poetzl's patronage of him a mystery" ... "Sakel died in 1957, having spent his life zealously defending his reputation and priority." ... "People trust me, not Sakel', Muller boasted. ..."Adolf Meyer was there and gave insulin coma "a verbose blessing", as he gave everything his blessing regardless how absurd. Unsurprisingly, Ewen Cameron made a "forceful contribution advocating insulin coma therapy" EverSince (talk) 15:56, 27 October 2008 (UTC) p.s. I'm not a "they"...?? EverSince (talk) 16:21, 27 October 2008 (UTC)
- EverSince, what is your basis for deciding that doctors' own experience, what they saw happening on the insulin units, is not "evidence"? It is anecdotal evidence, a notoriously deceptive category of evidence, but still evidence. To phrase the matter as "X was due to personal impressions, not to evidence" is to mislead the reader about what really happened decades ago to make doctors think that insulin shock therapy was a valuable tool in the medical toolbox. If you wish to resolve this problem by clarifying "evidence" to "scientific evidence", that seems a good step in the right direction. I also think that the term "personal impressions", which is frankly puzzling in the context, could do with a replacement; if one does not already know what "personal impressions" are being referred to, one would probably never guess that we are talking about the first-hand observations of medical men as well-trained as any of their time about the patients under their care.
- I would be violating WP:AGF if I started to speculate on why you produced text which you described as a summary of Doroshow and which reads to another's eye as significantly differing from what Doroshow says on the subject. Merely pointing out a discrepancy perceived between Doroshow's original and your paraphrase of Doroshow is not a violation of WP:AGF. Your trying to read into my comments "a sense of not assuming good faith or competency", on the other hand, may itself be read as violating WP:AGF.
- The only source you cited when you added this text was Doroshow. If everyone who writes on the subject would agree with all Doroshow's analyses, then it should not be problematic to find a second source to support each claim. If not everyone who writes on the subject would agree with Doroshow's analyses, then it should be described in the text as Doroshow's analyses.
- Why, exactly, do you feel that the quotes that you give support the claims that are in question here? I honestly am at a loss to quite understand what logical connection you are trying to make by selecting these quotes as 'supporting' the material you added to the article. For reasons of WP:AGF I will refrain from detailing the only theory I can form as to why one might think these (frankly gossipy) observations pertaining to the personalities mentioned is relevant to the text in question.
- In regards to your p.s., I have no idea whether you are a he or she; I therefore went with the grammatically correct singular they. I could try even more exotic alternatives, if that does not please thee. -- 18.104.22.168 (talk) 23:48, 27 October 2008 (UTC)
- Not sure how to make constructive use of that. I've already appreciated your observation on the ambiguity of the term "evidence", and explained it was meant in the more typical scientific sense. Doroshow herself makes the distinction between "experienced as helpful" vs "scientific evidence", as well as noting the ambiguity academically and leaving open the issue of evaluation by modern scientific standards, saying it was never definitively proven less effective but also that it fell out of use "saddled with inconsistent and inconclusive clinical trials." I've also already said I trust you didn't intend your comments to seem judgemental; your stating now that you would be violating AGF if you speculated on the discrepancy with your perception of the abstract (a link to which I included in the citation) does now however suggest your speculations are about bad faith. Regarding the term "personal impressions", it already says "on the minds of practitioners", which are Doroshow's terms: "ICT was able to secure its foothold in psychiatry by making indelible impressions on the minds of practitioners who had seen amazing recoveries for themselves" (and again she repeatedly states in the full text that she means "experienced" as such (italics hers) within local interpersonal settings, she's not asserting actual recovery). I don't btw know the source of your assumptions about their relative training or that they were all men. EverSince (talk) 02:35, 28 October 2008 (UTC)
Query Staug73: The article warrants additions and update. I attempted such and the suggested changes were deleted and article reverted to original. Your suggestion as how to submit the suggested additions again? Scidata (talk) 12:21, 3 May 2009 (UTC)
- It would be a good idea to become familiar with formatting and some of the conventions of Wikipedia. It is not difficult, just a little time-consuming. Here are some links that should help to get you started
- If you need any help, post your question at the Help Desk. Don't worry about making the occasional error - other editors are usually prepared to correct these.Staug73 (talk) 12:54, 3 May 2009 (UTC)
I am not sure that the intro to this article is the best place to get into a discussion of which psychiatric treatments induce coma and I am not even sure what the exact definition of coma is. What is the difference between: unconsciousness, sleep, coma, for example? Nobody is disputing that insulin coma therapy involves a coma - that is the point about it. But ECT? Are patients after the electric shock and before regaining consciousness in a coma? If so the best place to point this out might be the ECT article.Staug73 (talk) 12:27, 17 August 2013 (UTC)
- I didn't intend to indicate that ECT had been classed as a coma therapy. I'd be interested in the answer to the question about levels of unconsciousness (also 'narcosis') and how these treatment methods were categorised back then, presumably depending whether they (deliberately) caused physiological shock, seizures (convulsive), deep sleep and/or coma. Sighola2 (talk) 16:11, 17 August 2013 (UTC)