Tuesday, 17.10.2017

Shridhar Sharma: Insulin coma treatment: Facts and controversies

Comments by Vimal K. Razdan

Prof. Shridhar Sharma’s article on Insulin Coma Treatment (ICT) – Facts and Controversies, gives a scholarly account of the development and use of Sakel’s ICT and other improvements done on it by Sargeant, Slater & others. However, he has not given details of his own experience with the treatment though he has also used it personally for quite some time.

It is true that this treatment met with controversies and died a premature death. My experience with it extends for a long period of four decades, from 1964 and an average of about 30 patients per day of insulin (Coma & Sub-coma) therapy, including about fifteen on ICT.  My patients with schizophrenia experienced a definite improvement in their aggression, weight gain and improved feeling of well-being.

Prof. Sharma has mentioned some possible mechanism of action of insulin on neurotransmitter and receptors, which is highly probable. Some other authors have suggested that “Insulin is a very powerful stimulant of the endocrine and the neuroendocrine systems, as is the coma produced by it. It is probable that insulin coma's benefits may have been achieved by redressing hormonal imbalances, in a fashion similar to that of ECT. (During the ICT era, we did not have the knowledge of neuroendocrine interactions nor the methods of study that we have today.) Such actions would also explain the benefits achieved when ECT was added to ICT”.

I agree with Prof Sharma that seizures improve the outlook in patients. The relationship of seizures and Insulin Coma Therapy is given by Fink, Shaw, Gross and Coleman (1958).

  

Insulin Coma and Seizures

For insulin coma, Sakel rejected spontaneous grand mal seizures as unwanted, unpleasant, and unnecessary. Seizures did occur during ICT, appearing in the second and third stages of coma, especially during periods of "dry coma." Two schools of thought developed -- those who saw seizures as comparable to the seizures of ECT and therefore, favorable for a better outcome, and those who considered seizures as unwanted side-effects.

A spontaneous seizure called for protection of the patient's tongue and mouth, as well as restraint. (Every bed-stand had special tongue guards available to be used when a spontaneous seizure developed. These were wooden tongue depressors, about pen-length, 1/2" wide, covered at one end by gauze, or cotton and gauze, to make a soft mouthguard. Or, rubber-tubing doubled and covered by gauze to make a mouthguard.)

By the 1950’s, when a patient in ICT was not improving by 20-25 comas, some physicians augmented ICT by ECT given during the deep coma period, usually at three times a week. (I was taught, and taught others, and still believe, that seizures augmented the benefits of ICT. A spontaneous seizure in ICT was welcomed, and not seen as a bad sign.)

Spontaneous grand mal seizures were infrequent. Muscular twitching, jerking of the extremities, grimacing of the facial muscles, and tortuous twisting movements of the limbs and body were frequent. These occurred in the early stages of the treatment.

The premature death of ICT

In a 1953 Lancet article by a young author, Bourne, H., entitled “The Insulin Myth”, he strongly challenged the claims made by the protagonists of ICT, alleging that there was no sound basis for such claim. He invited comments and there were many who agreed with his view. After this the Insulin Coma Treatment went into disrepute and its use gradually declined to almost nil in 1970 in the USA.

I would call it a premature death because effective drugs remedies had become available. But we still do not know whether a combination of the ICT with the newer drugs would make the life of our patients more happy and useful, with far better recovery. I would suggest action in this direction, reviving ICT at least for research purposes.

References:

Bourne H. The insulin myth. Lancet 1953; ii:  964-8.

Fink M, Shaw R, Gross G, Coleman FS. Comparative study of chlorpromazine and insulin coma in the therapy of psychosis. Journal of the American Medical Association. 1958; 166: 1846-50.

Rinkel M, Himwich HE. Insulin Treatment in Psychiatry. New York: Philosophical Library; 1959.

Sakel, M. The Pharmacological Shock Treatment of Schizophrenia. (translated from the German original by Joseph Wortis). New York: Nervous and Mental Disease Publishing Co; 1938.

 

Vimal K. Razdan

June 2, 2016