Introduction

Insulin shock therapy involves the use of insulin to induce hypoglycemia in a patient. The primary use of this treatment was to provide relief from the symptoms of schizophrenia, however it was also used in the treatment of anorexia and morphine addiction.

This treatment has fallen out of favor in the United States, much like electroshock convulsive therapy (or "ECT). The movie A Beautiful Mind presented a good depiction of the therapy when the mathematician John Nash received insulin shock treatments in an effort to cure his schizophrenia. Other famous patients included: James V. Forrestal (the first US Secretary of Defense, who committed suicide in 1949), Russian ballet dancer Vaslav Nijinsky, and Zelda Fitzgerald (wife of author F. Scott Fitzgerald).

History and uses of insulin shock therapy

The hormone insulin was discovered in 1921. Soon after that insulin was found to be effective in treating anorexia when given in small dosages. Then in 1927 a major breakthrough came when Manfred Sakel, a 27-year-old Polish doctor, discovered that insulin-induced hypoglycemia was effective in the treatment of morphine addicts.

Sakel later discovered through an accidental insulin overdose that the treatment was useful in alleviating the symptoms of certain psychosis and in particular schizophrenia. After working on his technique for about 3 years, he officially released reports on his method in late 1933. This was the first known biological treatment for schizophrenia. In 1939 American Psychiatric Association praised "Sakel's Therapy" and another study in 1942 further demonstrated its effectiveness. This praise led to the widespread use of the technique for nearly 30 years.

The technique remained largely unchanged for many years, but it gradually came out of favor as more effective techniques were developed. The procedure in not used at all in the U.S. anymore and its use in other countries is minimal.

The technique

Treatment usually started with 20 units of insulin given intramuscularly and the dose was increased by 20 units each day until sopor (or "deep sleep") occurred. Once coma was induced, the insulin dose was adjusted until the minimum satisfactory coma dose was found.

Once the patient began to go into coma the length of the coma period allowed was increased gradually from five minutes on the first day up to the individual's maximum safe duration -- anywhere from 20 minutes to a few hours.

The coma stage was particularly dangerous as doctors had to monitor vital signs to make sure the patient didn't fall too deeply into an irreversible coma or death. Epileptic fits begin to occur within approximately 45 minutes to 1 hour and they could last for several minutes or even up to an hour.

The patient was brought out of the coma through the use of a sugared tea solution fed through nasal tube into the stomach. If the coma didn't subside after 20 minutes intravenous (or IV) injections of glucose were used. Once the patient fully awoke he could be given a light meal. After-shocks sometimes would occur even after the patient awoke and these typically began within 4 hours.

It could usually be determined within a few treatments whether or not successive treatments were likely to be effective. Upon wakening the patient will experience an hour or two of coherent thought and improved mental state. The patient's paranoid delusions would subside and he could be friendly with his doctors and nurses. He will then relapse into his old state for the rest of the day. After many weeks of the treatment this period of coherent thought lengthens and in many cases a complete cure is afforded.

Sometimes electroconvulsive therapy was used in conjunction with insulin shock treatment, but never on the same day. Psychotherapy was typically reserved for the periods of coherent thought and for readjustment to society once the patient was deemed "cured".

Effectiveness

Manfred Sakel's own tests showed that up to 88% of his patients conditions improved after treatment with his therapy. A 1939 study, published for the American Psychiatric Association by John R. Ross and Benjamin Malzberg, showed 1757 cases of schizophrenia treated with insulin shock therapy: 11 % had prompt and total recovery, 26.5 % were greatly improved and 26 % had some improvement. A second study by a Pennsylvania Hospital in 1942 showed a 63% improvement rate -- with 42 % of the patients still well after two years of follow-up.

The technique was remarkably effective -- but prior to this treatment there was no treatment at all -- so any result was deemed a positive. Eventually even better techniques were developed and by the late 1970s the use of insulin (and ECT) was nearly zero.

Side effects

• Epileptic fits - possibly lasting for several hours. Could often be reduced through the use of other drugs in combination with the therapy. Injury could often result if proper protections were not taken to secure a patient undergoing these fits.
• Respiratory problems - usually due to the aspiration of saliva during the coma. The patient's airways could become blocked. If this was detected early enough the patient could be placed on his side to let the saliva flow out of his air passages. If not detected, death or serious brain damage could result
• Irreversible coma - comas lasting for up to seven days could occur, resulting in a marked impairment of mental function.
• Dehydration - hypoglycemic reactions greatly increase fluid loss through sweating. Epileptic fits only acerbate this problem.
• Death - occurred in approximately .75% of patients. Hypoglycemic encephalopathy is the most common cause, but other causes of death included heart failure and aspiration pneumonia.

Conclusion

Insulin Shock Therapy was the first biological treatment for schizophrenia. It was far more successful than any other treatment tried prior to its use and it continued to be used for nearly 40 years throughout the world. The development of this technique led to further investigations into biological cures for mental diseases. The field of psychiatry in general began to see astronomical gains as a direct result of this technique as doctors around the world were led to study the field.

Many people undoubtedly have had their lives greatly improved as a result of undergoing insulin shock therapy -- but since the 1970's it has rarely been used. The technique now is considered barbaric (like ECT). The thing is -- schizophrenia itself, left untreated, is even more barbaric and deadly. Luckily patients now have a variety of safer treatments to choose from.