Insulin Coma Therapy

   (ICT)

   (1927 and after)

   After the discovery of insulin in 1922, efforts to employ it in psychiatry at subcoma levels began almost immediately. Manfred Sakel (pronounced SOK-el) (1900–1957) won a place in the history of psychiatry because he used insulin to induce hypoglycemic comas (hence the term "insulin shock therapy") in the treatment of schizophrenia, some of which were accompanied by convulsions. This was the first treatment of even partial effectiveness for schizophrenia. Sakel, who graduated with an M.D. from the University of Vienna in 1925, became assistant physician at an exclusive private nervous clinic in Berlin-Lichterfelde. In 1927, he began treating the symptoms of morphine withdrawal with insulin, accidently inducing a coma in one patient, and deliberately putting some of his patients in comas thereafter. In 1930, he announced his insulin treatment of withdrawal symptoms in the German Medical Weekly (Deutsche Medizinische Wochenschrift), not mentioning that he was inducing comas in the patients. (In a more extensive account in the Journal of Combined Neurology and Psychiatry [Zeitschrift für die gesamte Neurologie und Psychiatrie] in 1933, he did say that many of the patients became comatose.) In 1933, after the Nazi seizure of power, Sakel returned to Vienna and persuaded psychiatry chief Otto Pötzl (1877–1962) to let him try the insulin cure on schizophrenics. (Apparently, Sakel had treated schizophrenics successfully in Berlin as well— some say inducing comas by accident—without writing about it.) Beginning in November 1934, in a 13-part series in the Vienna Medical Weekly (Wiener Medizinische Wochenschrift), Sakel described what the local population of Vienna was already starting to celebrate as a "miracle cure" for schizophrenia. In 1935, Sakel brought his findings together in a book, A New Method of Treating Schizophrenia (Neue Behandlungsmethode der Schizophrenie). The following year, in 1936, Sakel traveled to the United States to treat a wealthy private patient with the new therapy and then soon thereafter emigrated to New York. It was not, however, Sakel who introduced the procedure to an American audience but Joseph Wortis (1906–1995), then a staff psychiatrist at Bellevue Hospital in New York, who began insulin coma therapy there in 1934 after watching Sakel conduct it in Vienna, reporting his first results at a meeting in November 1936, and thereafter in the Journal of Nervous and Mental Disease in 1937. Bernard Glueck (1883–) at Stony Lodge, a private psychiatric hospital in Ossining, New York, should also be mentioned, for he had journeyed to the cantonal hospital in Münsingen, Switzerland, and watched Max Müller (1894–1980) perform it, describing his very favorable impressions in the Journal of the American Medical Association in September 1936.

   * Ciba and Geigy merged in 1970; in 1996 Ciba-Geigy, merged with Sandoz, becoming Novartis.

   The true effectiveness of ICT was much debated at the time and remains controversial among historians today. It is fairly clear that the effective element in the therapy was the convulsions that the treatment occasionally induced and not the insulin itself. Sakel was parsimonious with numbers, and it was difficult to tell from his account to what extent ICT was superior to placebo. Kurt Kolle (1898–1975), head of psychiatry in Munich, said in an obituary of Sakel in the German Medical Weekly (Deutsche Medizinische Wochenschrift) that 45% of the schizophrenic patients at the Munich university clinic received "lasting full remissions" from ICT, compared to 10% who improved spontaneously. Linford Rees said in 1950 that in a trial with historic controls, ICT had beaten electroconvulsive therapy and leukotomy in the treatment of schizophrenia. But in 1953, Harold Bourne, a resident at the Fountain Hospital in London, had looked at the literature on insulin treatment vs. electroconvulsive therapy and, in an article in the Lancet entitled "The Insulin Myth," found it no more effective. (Bourne had little sympathy for somatic therapies of any kind and later found himself a central figure in the "therapeutic communities" movement.) The article was strongly challenged by William Sargant, Rees, and Willi Mayer-Gross, all of whom had had quite favorable experiences with insulin. In time, insulin coma clinics arose in psychiatric hospitals around the world. Yet, it was a randomly controlled trial of chlorpromazine and ICT at Hillside Hospital in Glen Oaks, New York, led by Max Fink and published in the Journal of the American Medical Association in 1958, that wrote the death sentence of ICT: the authors found that "chlorpromazine had the advantage of being safer, easier to administer, and better suited to long-term management" (p. 1846).

   In 1941, Sargant and Nellie Craske (née Wilson, M.B. 1929) described in the Lancet "modified insulin therapy," or insulin subcoma therapy, for high-grade anxiety in war neuroses. Their basic procedure was to administer a small enough dose of insulin to produce "a state of drowsiness," then to break the session an hour or two later by giving the patients sugary tea. The effect was quite salutary on the "anxious, hysterical and depressive symptoms of a reactive type" in men "who had broken down in the Flanders retreat [Dunkirk] or as a result of other severe war stress" (p. 213). Subsequently, giving schizophrenics small doses of insulin over longer periods of time came into vogue as well.

   Historically, ICT is important because it represents the first of the somatic therapies for the "functional psychoses," namely schizophrenia and manic-depressive illness.