Insulin shock therapy
Encyclopedia
Insulin shock therapy or insulin coma therapy (ICT) was a form of psychiatric treatment in which patients were repeatedly injected with large doses of insulin
in order to produce daily coma
s over several weeks. 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.
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 and the Soviet Union
.
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.
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. In 1936 Sakel moved to New York and promoted the use of insulin coma treatment in American psychiatric hospitals. By the late 1940s the majority of psychiatric hospitals in the USA were using insulin coma treatment.
The daily insulin dose was gradually increased to 100–150 units until comas were produced, at which point the dose would be levelled out. Occasionally doses of up to 450 units were used. 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. Courses of up to 2 years have been documented.
After the insulin injection patients would experience various symptoms of decreased blood glucose: flushing, pallor, perspiration, salivation, drowsiness or restlessness. Sopor and coma—if the dose was high enough—would follow. Each coma would last for up to an hour and be terminated by intravenous glucose. Seizures sometimes occurred before or during the coma. Many would be tossing, rolling, moaning, twitching, spasming or thrashing around.
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. 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. Patients required continuous supervision as there was a danger of hypoglycaemic aftershocks after the coma.
In "modified insulin therapy", used in the treatment of neurosis, patients were given lower (sub-coma) doses of insulin.
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." 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.
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". The most severe risks of insulin coma therapy were death and brain damage, resulting from irreversible or prolonged coma respectively. 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". Mortality (death) risk estimates varied from about one percent to 4.9 percent.
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.
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".
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.
One retired psychiatrist who was interviewed by Doroshow "described being won over because his patients were so sick and alternative treatments did not exist". Doroshow argues that "psychiatrists used complications to exert their practical and intellectual expertise in a hospital setting" and that collective risk-taking established "especially tight bonds among unit staff members". She finds it ironic that psychiatrists "who were willing to take large therapeutic risks were extremely careful in their handling of adverse effects". Psychiatrists interviewed by Doroshow recalled how insulin coma patients were provided with various routines and recreational and group-therapeutic activities, to a much greater extent than most psychiatric patients. Insulin coma specialists often chose patients whose problems were the most recent and who had the best prognosis
; in one case discussed by Doroshow a patient had already started to show improvement before insulin coma treatment, and after the treatment denied that it had helped, but the psychiatrists nevertheless argued that it had.
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 1930
encouraged psychiatrists to experiment with physical treatments.
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.
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.
Catherine Fawley is treated with insulin in London after becoming deranged in Iris Murdoch
's 1958 novel The Bell
.
Esther Greenwood in Sylvia Plath
's 1967 novel The Bell Jar
receives insulin shock therapy while hospitalized.
Insulin shock therapy was featured and dramatized in the 2001 film A Beautiful Mind
, based on the life of John Forbes Nash, Jr.
Dr. House in the US TV series House
, initiated insulin shock therapy on himself in a 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.
Insulin
Insulin is a hormone central to regulating carbohydrate and fat metabolism in the body. Insulin causes cells in the liver, muscle, and fat tissue to take up glucose from the blood, storing it as glycogen in the liver and muscle....
in order to produce daily coma
Coma
In medicine, a coma is a state of unconsciousness, lasting more than 6 hours in which a person cannot be awakened, fails to respond normally to painful stimuli, light or sound, lacks a normal sleep-wake cycle and does not initiate voluntary actions. A person in a state of coma is described as...
s over several weeks. It was introduced in 1933 by Polish-Austrian-American psychiatrist
Psychiatrist
A psychiatrist is a physician who specializes in the diagnosis and treatment of mental disorders. All psychiatrists are trained in diagnostic evaluation and in psychotherapy...
Manfred Sakel
Manfred Sakel
*Fink, M , "Meduna and the Origins of Convulsive Therapy", American Journal of Psychiatry, 141: 1034-1041 *Fink, M (1984), "Meduna and the Origins of Convulsive Therapy", American Journal of Psychiatry, 141(9): 1034-1041 *Fink, M (1984), "Meduna and the Origins of Convulsive Therapy", American...
and used extensively in the 1940s and 1950s, mainly for schizophrenia
Schizophrenia
Schizophrenia is a mental disorder characterized by a disintegration of thought processes and of emotional responsiveness. It most commonly manifests itself as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking, and it is accompanied by significant social...
, before falling out of favour and being replaced by neuroleptic
Antipsychotic
An antipsychotic is a tranquilizing psychiatric medication primarily used to manage psychosis , particularly in schizophrenia and bipolar disorder. A first generation of antipsychotics, known as typical antipsychotics, was discovered in the 1950s...
drugs.
Insulin coma therapy and the convulsive therapies (electro
Electroconvulsive therapy
Electroconvulsive therapy , formerly known as electroshock, is a psychiatric treatment in which seizures are electrically induced in anesthetized patients for therapeutic effect. Its mode of action is unknown...
and cardiazol/metrazol) were collectively known as shock therapy
Shock therapy
Shock therapy or shock treatment may refer to:* A form of aversion therapy in which an electric shock is used as a negative stimulus* Electroconvulsive therapy, or electroshock, a psychiatric treatment in which seizures are electrically induced in anaesthetized patients for therapeutic effect*...
. 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
Soviet Union
The Soviet Union , officially the Union of Soviet Socialist Republics , was a constitutionally socialist state that existed in Eurasia between 1922 and 1991....
.
Origins
In 1927 Sakel, who had recently qualified as a doctor in ViennaVienna
Vienna is the capital and largest city of the Republic of Austria and one of the nine states of Austria. Vienna is Austria's primary city, with a population of about 1.723 million , and is by far the largest city in Austria, as well as its cultural, economic, and political centre...
and was working in a psychiatric clinic in Berlin
Berlin
Berlin is the capital city of Germany and is one of the 16 states of Germany. With a population of 3.45 million people, Berlin is Germany's largest city. It is the second most populous city proper and the seventh most populous urban area in the European Union...
, 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.
Joseph Wortis
Joseph Wortis
Josef Wortis was an American psychiatrist, longtime editor of the scientific journal Biological Psychiatry, and a professor at the State University of New York at Stony Brook.- Career :...
, after seeing Sakel practice it in 1935, introduced it to the USA. British psychiatrists from the Board of Control
Board of Control for Lunacy and Mental Deficiency
The Board of Control for Lunacy and Mental Deficiency was part of the United Kingdom's Ministry of Health, but was independent in that it reported to the Lord Chancellor . The Board had previously been under the responsibility of the Home Office, moving to the Ministry of Health in about 1930...
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 promoted the use of insulin coma treatment in 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, 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. There were no standard guidelines for treatment; different hospitals and psychiatrists developed their own protocols. Typically, injections were administered six days a week for about two months.The daily insulin dose was gradually increased to 100–150 units until comas were produced, at which point the dose would be levelled out. Occasionally doses of up to 450 units were used. 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. Courses of up to 2 years have been documented.
After the insulin injection patients would experience various symptoms of decreased blood glucose: flushing, pallor, perspiration, salivation, drowsiness or restlessness. Sopor and coma—if the dose was high enough—would follow. Each coma would last for up to an hour and be terminated by intravenous glucose. Seizures sometimes occurred before or during the coma. Many would be tossing, rolling, moaning, twitching, spasming or thrashing around.
Some psychiatrists regarded seizures as therapeutic and patients were sometimes also given electroconvulsive therapy
Electroconvulsive therapy
Electroconvulsive therapy , formerly known as electroshock, is a psychiatric treatment in which seizures are electrically induced in anesthetized patients for therapeutic effect. Its mode of action is unknown...
or cardiazol/metrazol convulsive therapy during the coma, or on the day of the week when they didn’t have insulin treatment. 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
Eric Cunningham Dax
Dr Eric Cunningham Dax, AO, BSc Lond, HonMD, FRACP, FRANZCP, HonFRCPsych was a British psychiatrist resident in Australia from 1952.-Clinical Work in England:...
, instructs nurses to take their insulin patients out walking and occupy them with games and competitions, flower-picking and map-reading, etc. Patients required continuous supervision as there was a danger of hypoglycaemic aftershocks after the coma.
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 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 at the time was somewhere in between - claiming a success rate of about 50 percent in patients who had been ill for less than a year (about double the spontaneous remission rate) with no influence on relapse.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." The shock therapies in general had developed on the erroneous premise that epilepsy
Epilepsy
Epilepsy is a common chronic neurological disorder characterized by seizures. These seizures are transient signs and/or symptoms of abnormal, excessive or hypersynchronous neuronal activity in the brain.About 50 million people worldwide have epilepsy, and nearly two out of every three new cases...
and schizophrenia rarely occurred in the same patient. Another theory was that patients were somehow "jolted" out of their mental illness.
The hypoglycemia
Hypoglycemia
Hypoglycemia or hypoglycæmia is the medical term for a state produced by a lower than normal level of blood glucose. The term literally means "under-sweet blood"...
(pathologically low glucose
Glucose
Glucose is a simple sugar and an important carbohydrate in biology. Cells use it as the primary source of energy and a metabolic intermediate...
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". The most severe risks of insulin coma therapy were death and brain damage, resulting from irreversible or prolonged coma respectively. 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". Mortality (death) risk estimates varied from about one percent to 4.9 percent.
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 HospitalSeveralls Hospital
Severalls Hospital in Colchester, Essex, UK was a psychiatric hospital built in 1910 to the design of architect Frank Whitmore. It opened in May 1913....
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.
In 1953 British psychiatrist Harold Bourne published a paper entitled "The insulin myth" in the Lancet
The Lancet
The Lancet is a weekly peer-reviewed general medical journal. It is one of the world's best known, oldest, and most respected general medical journals...
, 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".
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.
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".One retired psychiatrist who was interviewed by Doroshow "described being won over because his patients were so sick and alternative treatments did not exist". Doroshow argues that "psychiatrists used complications to exert their practical and intellectual expertise in a hospital setting" and that collective risk-taking established "especially tight bonds among unit staff members". She finds it ironic that psychiatrists "who were willing to take large therapeutic risks were extremely careful in their handling of adverse effects". Psychiatrists interviewed by Doroshow recalled how insulin coma patients were provided with various routines and recreational and group-therapeutic activities, to a much greater extent than most psychiatric patients. Insulin coma specialists often chose patients whose problems were the most recent and who had the best prognosis
Prognosis
Prognosis is a medical term to describe the likely outcome of an illness.When applied to large statistical populations, prognostic estimates can be very accurate: for example the statement "45% of patients with severe septic shock will die within 28 days" can be made with some confidence, because...
; in one case discussed by Doroshow a patient had already started to show improvement before insulin coma treatment, and after the treatment denied that it had helped, but the psychiatrists nevertheless argued that it had.
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 1930
Mental Treatment Act 1930
The Mental Treatment Act 1930 was an Act of the Parliament of the United Kingdom that permitted voluntary admission to, and outpatient treatment within, psychiatric hospitals. It also replaced the term "asylum" with "mental hospital".- See also :...
encouraged psychiatrists to experiment with physical treatments.
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.
Leonard Roy Frank
Leonard Roy Frank
Leonard Roy Frank is an American human rights activist, electroconvulsive therapy survivor and writer from New York. Since 1959 he has lived in San Francisco, where he managed an art gallery before he began collecting great quotations.Leonard Roy Frank (born July 15, 1932) is an American human...
, an American survivor
Psychiatric survivors movement
The psychiatric survivors movement is a diverse association of individuals who are either currently clients of mental health services , or who consider themselves survivors of interventions by psychiatry, or who identify themselves as ex-patients of mental health services...
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
Euphemism
A euphemism is the substitution of a mild, inoffensive, relatively uncontroversial phrase for another more frank expression that might offend or otherwise suggest something unpleasant to the audience...
, and a violation of basic human rights.
Pop culture
In Dr. Kildare's Strange Case (1940), Dr. Kildare uses the insulin treatment to treat a patient ("an insane man").Catherine Fawley is treated with insulin in London after becoming deranged in Iris Murdoch
Iris Murdoch
Dame Iris Murdoch DBE was an Irish-born British author and philosopher, best known for her novels about political and social questions of good and evil, sexual relationships, morality, and the power of the unconscious...
's 1958 novel The Bell
The Bell (novel)
The Bell is a novel written by Iris Murdoch in 1958. It was her fourth to be published, and is set in Imber Court, a lay religious community situated next to an enclosed order of Benedictine nuns in Gloucestershire.-Plot summary:...
.
Esther Greenwood in Sylvia Plath
Sylvia Plath
Sylvia Plath was an American poet, novelist and short story writer. Born in Massachusetts, she studied at Smith College and Newnham College, Cambridge before receiving acclaim as a professional poet and writer...
's 1967 novel The Bell Jar
The Bell Jar
The Bell Jar is American writer and poet Sylvia Plath's only novel, which was originally published under the pseudonym "Victoria Lucas" in 1963. The novel is semi-autobiographical with the names of places and people changed...
receives insulin shock therapy while hospitalized.
Insulin shock therapy was featured and dramatized in the 2001 film A Beautiful Mind
A Beautiful Mind (film)
A Beautiful Mind is a 2001 American drama film based on the life of John Nash, a Nobel Laureate in Economics. The film was directed by Ron Howard and written by Akiva Goldsman. It was inspired by a bestselling, Pulitzer Prize-nominated 1998 book of the same name by Sylvia Nasar...
, based on the life of John Forbes Nash, Jr.
Dr. House in the US TV series House
House (TV series)
House is an American television medical drama that debuted on the Fox network on November 16, 2004. The show's central character is Dr. Gregory House , an unconventional and misanthropic medical genius who heads a team of diagnosticians at the fictional Princeton-Plainsboro Teaching Hospital in...
, initiated insulin shock therapy on himself in a season 5 episode (Under My Skin
Under My Skin (House)
"Under My Skin" is the twenty-third episode of the fifth season of House, which aired on May 4, 2009.-Plot:House and the team are given the challenge of diagnosing a ballerina, Penelope whose lungs collapse during rehearsal...
) in an attempt to eliminate hallucinations caused by Vicodin abuse.
The American singer-songwriter Townes Van Zandt
Townes Van Zandt
John Townes Van Zandt , best known as Townes Van Zandt, was an American Texas Country-folk music singer-songwriter, performer, and poet...
was given insulin shock therapy, as a result of which he lost most of his memories of his childhood.
External links
- The History of Shock Therapy in Psychiatry
- Drug Treatment in Modern Psychiatry
- 1944 textbook extract on 'The Insulin Treatment of Schizophrenia'
- Insulin Coma Therapy by the head of the insulin coma unit at the Hillside Hospital in New York from 1952 to 1958
- Shock Treatment - The Killing of Susan Kelly A poem by insulin/electro shock survivor Dorothy Dundas