PUTTING SCHIZOPHRENIA`S DEMONS TO SLEEP

Throughout history, patients with schizophrenia wrestled with internal “demons” while being demonized by society. One doctor sought to quiet the demons through insulin coma therapy. To appreciate the significance of insulin coma therapy is to understand how schizophrenia was viewed in the first half of the 20th century. Hospitals were filled with people with schizophrenia, and insulin coma therapy represented hope. This article looks at the discovery of insulin coma therapy, describes its administration, chronicles its rise and fall, and takes note of its contributions to psychiatric care.

An Accidental Discovery

The search for a cure for schizophrenia became the Holy Grail of world psychiatric research in the early 20th century. Worcester State Hospital (Massachusetts) statistics for 1929-1930 reflect the immense therapeutic challenge of patients with schizophrenia. Eighty-three of 414 first-time admissions (20%) had the diagnosis of dementia praecox schizophrenia). Of readmissions, 36 of 86 (42%) were people with schizophrenia. Of those who died in the hospital, 42 of 202 (21%) carried a diagnosis of schizophrenia. And of those patients with schizophrenia who died, 50% had been in the hospital 20 or more years!1 Even accepting the tendency at the time to make the diagnosis of schizophrenia, a significant number of psychiatric institutionalized patients were people with schizophrenia.

To a world crying out for a treatment for schizophrenia came Manfred Joshua Sakel, MD, from Vienna. Dr. Sakel, described as “a strange, withdrawn, and sometimes difficult man,” was working at a Berlin addiction sanatorium catering to artists, actors, and physicians.2 In the course of treating a well-known diabetic actress in 1927, he accidentally put her into a mild insulin coma. This produced in her a remarkable diminution in her opiate craving. He reasoned that an insulin coma could reduce the excitement during morphine withdrawal.

Dr. Sakel published his research on curing morphine addiction with insulin coma in 1930. By then he had been putting patients with addiction and psychosis into deep hypoglycemic coma and having them reemerge into consciousness, as this treatment resulted in marked improvement of their psychotic symptoms. Following initial animal experiments, Dr. Sakel started treating psychotic patients with deep insulin coma, with good results. By 1933 he had moved to the Neuropsychiatric University Clinic in Vienna, and in 1934 and 1935 published 13 reports indicating an 88% improvement rate for patients with schizophrenia treated with insulin coma. This was an outstanding result and was eagerly received by both the psychiatric community and the general public.

How It Worked

A patient was started on a small dose of insulin, such as 20 units, and this dose was increased for each session until a full coma for at least one hour was achieved. Although insulin was administered subcutaneously in the early years, it later became the practice to administer insulin and glucose (which ended the coma session) intravenously for more accurate control over the coma state.

Insulin coma therapy was felt to be most effective when the patient went into a stage three coma, i.e., loss of corneal and deep tendon reflexes. The patient was allowed to remain at this level for one to five hours before being given carbohydrates slowly via a stomach tube or intravenously to be gradually aroused.

Although the minority, some patients experienced seizures while in a hypoglycemic state. Some therapists felt that this was desirable, causing marked improvement. Others were wary of the possibility of neuronal damage and felt that seizures should be avoided. Interestingly, a survey of geriatric patients with schizophrenia who had been institutionalized for a long time, published in 2000, found no difference in cognitive decline between patients who had received insulin coma therapy in earlier years and those who had not.3 In fact, a study in 2004 demonstrated it would take a flat EEG, caused by prolonged hypoglycemia (fewer than 18 ml/dl of glucose), to result in neural injury, and this was below the level used in insulin coma therapy.4

Patients received insulin coma therapy three to five times a week and received around 50 treatments in a series. Upon awakening from a coma, a typical patient felt hungry, asked for food, and was no longer aware of delusions. The fatality rate varied from 1 to 10%. A typical patient might experience complete relief of symptoms during and after a course of treatment, only to relapse gradually over the subsequent months, perhaps requiring retreatment.

Waxing and Waning Interest

The publication of Dr. Sakel's work and visiting psychiatrists’ direct observations led to the widespread adoption of insulin coma therapy. By May 1936 the successful use of insulin coma therapy in 22 countries was reported to the Swiss Psychiatric Society.5 In the United States by the early 1940s there were three major treatments for patients with schizophrenia: insulin coma therapy, Metrazol, and electroshock therapy. Between 1935 and 1941, in 305 psychiatric hospitals, at least one of the three therapies had been administered to 75,000 patients; 54% of all American mental institutions offered insulin coma therapy during these years.6

Despite its widespread use, some confusion surrounded the term “insulin coma.” It often has been referred to in the literature as “insulin shock therapy.” The original German term for the treatment (Insulin-shock-behandlung) was translated into English as “insulin shock treatment.”5 Dr. Sakel interposed “shock” to emphasize that lowering blood pressure and accelerating heart and respiration rates “shocked” the body, accounting for the improvement. Later he appreciated that the key aspect was the coma, but the “shock” name stuck, perhaps as a parallel with electroshock therapy.

It is easy to see why insulin coma therapy was so well received. Below is how Dr. Sakel described its efficiency:

In 1961, John Nash, the subject of the movie A Beautiful Mind, received a six-week course of insulin coma treatment at Trenton State Hospital in New Jersey, with partial remission noted.5 Despite the persistence of insulin coma therapy into the second half of the 20th century, its use began to wane because of several factors, including its dangerousness, lack of permanent results, and the development of chlorpromazine, the first of the truly effective antipsychotic medications.

Evidence-based scientific studies do not support the efficacy of insulin coma therapy.8 Insulin coma treatment also was expensive, requiring considerable psychiatric and nursing care.2 As recently as 1992, insulin coma therapy was still in frequent use in Ukraine; 98% of Ukrainian psychiatrists felt that insulin coma therapy was an acceptable and perhaps necessary treatment.9 According to the Ukrainian psychiatrists surveyed, insulin coma therapy had proven to be effective in psychiatric patients in long-term facilities. With improved and instant control of glucose a current possibility, one has to wonder if insulin coma therapy could make a comeback in Western psychiatry.

Conclusion

The use of insulin coma therapy signaled a recognition of schizophrenia as a biologic condition. As Dr. Sakel wrote in 1937 about insulin coma therapy, “I think we can now say without much fear of contradiction that psychological factors are not likely to be the only ones involved in a mental dislocation as serious as that found in schizophrenia.”10

References

1. Department of Mental Diseases. Annual Report of the Trustees of the Worcester State Hospital for the Year Ending November 30, 1930. Boston, 1930.
2. Alexander FG, Selesnick ST. The History of Psychiatry: An Evaluation of Psychiatric Thought and Practice From Prehistoric Times to the Present. New York:Harper & Row, 1966.
3. Stephens JH, Richard P, McHugh PR. Long-term follow-up of patients with a diagnosis of paranoid state and hospitalized, 1913 to 1940. J Nerv Ment Dis 2000; 188:202-8.
4. Auer RN. Hypoglycemic brain damage. Metabolic Brain Disease 2004; 19:169-75.
5. American Experience. A Brilliant Madness. Primary Sources: Insulin Coma Therapy. Available at: www.pbs.org/wgbh/amex/nash/filmmore/ps_ict.html.
6. Valenstein ES. Great and Desperate Cures: The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness. New York:Basic Books, 1986.
7. Sakel M. Origins and nature of hypoglycemic therapy of psychosis. Arch Neurol Psychiatry 1937; 38:188-203.
8. Lifshutz JE. Insulin coma therapy. Am J Psychiatry 1954; 110:466-9.
9. Gluzman SF, Golovakha EI, Panina NV. Ukrainian psychiatrists’ assessment of current problems in psychiatric services. Bekhterev Review of Psychiatry and Medical Psychology 1992; 2:41-50.
10. Sakel M. The methodical use of hypoglycemia in the treatment of psychoses. 1937. Am J Psychiatry 1994; 151 (6 suppl): 240-7.