Insulin shock therapy: Difference between revisions

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==Mechanism of action==
==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.''"<ref name="Sakel"/>
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.''"<ref name="Sakel"/>

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.<ref name = "Doroshow2007">Doroshow DB. (2007) [http://jhmas.oxfordjournals.org/cgi/content/abstract/jrl044v1 Performing a cure for schizophrenia: insulin coma therapy on the wards] J Hist Med Allied Sci. 2007 Apr;62(2):213-43.</ref>

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 had questioned it 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 istead they 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, with one unit director calling his team "gung-ho". While willing to take large therapeutic risks in administering ICT in the first place, the psychiarists 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 activites, 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.<ref name="Doroshow2007"/>


== In fiction ==
== In fiction ==

Revision as of 00:52, 12 September 2008

Insulin shock therapy or Insulin coma therapy was a form of psychiatric treatment in which patients were injected with large doses of insulin in order to produce a coma.[1] It was introduced in 1933 by Polish doctor Manfred Sakel and used extensively in the 1940s and 1950s 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, India and the Soviet Union.[4]

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] 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 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 were usually given treatment on six days a week for about two months, and were given increasing doses of insulin (usually 100-150 units) in order to produce a coma lasting about an hour[1] Treatment continued until about 50 to 60 comas had been induced.[2] Glucose was given intravenously to end each coma.[1] Fits would sometimes occur before the comas.[1] Insulin coma patients were sometimes given ECT or cardiazol/metrazol convulsive therapy during the coma, or on the day of the week when they didn’t have insulin treatment.[7]

In Modified insulin therapy, used in the treatment of neurosis, patients were given lower (sub-coma) doses of insulin.[8]

Alleged benefits and risks

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.[9][5] 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.[10] 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.[2][11]

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.[12][1] The mortality risk has been put at about one per cent.[2]

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."[5]

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.[13]

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 had questioned it 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 istead they 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, with one unit director calling his team "gung-ho". While willing to take large therapeutic risks in administering ICT in the first place, the psychiarists 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 activites, 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.[13]

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).

See also

References

  1. ^ a b c d e WL Neustatter (1948) Modern psychiatry in practice. London.
  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. ^ C Allen (1949) Modern discoveries in medical psychology. London: 261.
  8. ^ C Allen (1949) Modern discoveries in medical psychology. London: 219-220.
  9. ^ W Mayer-Gross (1950) Insulin coma therapy of schizophrenia: some critical remarks on Dr Sakel’s report. Journal of Mental Science 96:132-135.
  10. ^ BOURNE H. Lancet. 1953 The insulin myth. Dec 12;265(6798):1259. PMID 13110132
  11. ^ ACKNER B, HARRIS A, OLDHAM AJ. (1957) Insulin treatment of schizophrenia; a controlled study. Lancet. 1957 Mar 23;272(6969):607-11. PMID 13407078
  12. ^ WS Maclay (1953) Death due to treatment. Proceedings of the Royal Society of Medicine 46: 13-20.
  13. ^ a b Doroshow DB. (2007) Performing a cure for schizophrenia: insulin coma therapy on the wards J Hist Med Allied Sci. 2007 Apr;62(2):213-43.

External links


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