Jay Ámsterdam:Letter from Jonathan Cole (March 16, 2004)

Jay Amsterdam, Tom Ban, Max Fink and Sam Gershon: E-mail exchange

(June 11, 2019 – July 11, 2019)

From Tom Ban to Max Fink

Dear Max,

You might have noted already that Jay Amsterdam’s e-mail exchange with Janusz Rybakowsky relevant to Jon Cole's e-mail to him several years ago with his e-mail to us relevant to same was posted this week. Please find in the attachment an updated collating document of this project.

Warm regards,

Tom

From Max Fink to Tom Ban

Dear Tom,

The interest and use of insulin coma therapy that began in 1933 ended with the introduction of chlorpromazine. The Hillside Hospital RCT of ICT and CPZ offered well studied evidence that CPZ was as effective, with fewer adverse events, and much less expensive than ICT. The JAMA 1958 report is attached.

By the mid-1960s the era had ended, although reports of continued use in China and Russia occasionally surfaced. I recall a transient blip in interest in Israel with the flood of Russian Jewish emigres in the 1990s by Haim Belmaker, but the excitement was unproductive.

The single best explanation of ICT efficacy was its singular induction of grand mal seizures, reported between 5% and 20% of coma inductions. In my ICT days, senior MDs who admitted patients often added ECT seizures to comas for the very psychotic ill. ICT as a weaker form of ECT, much like the much-touted MST — magnetic seizure therapy — that has a small cadre of supporters at NIMH (Susan Lisanby) and Germany (Thomas Schlaepfer).

Best regards

Max

From Samuel Gershon to Jay Amsterdam and Tom Ban with copy to Max Fink

This topic and its discussion are important to illustrate the need for psychiatry to demand a more critical assessment of findings that too quickly become accepted as the best treatment available for whatever. I went to Dr, Cade’s hospital in Melbourne because of his paper on lithium treatment. I was informed that by that time he had banned its use because of toxicity, that’s another story.

But back to this topic. A fellow resident and I were assigned to work in in the ICT unit and then follow the patients in the Outpatient Department. We both felt that after ICT the patients were in much better physical condition, but over the time we followed them as outpatients they returned to their pre-treatment symptoms. We both went to speak to our teachers and were told quite firmly that ICT was the specific treatment for schizophrenia and what did we know — a cautionary warning. Over the next few years I had the opportunity to travel and found (as stated in the correspondence above) that in every country I went, ICT was the specific treatment for this condition

It was clear this was a pandemic delusion.

Then in 1959, a group at the Maudsley compared ICT versus barbiturate sleep and found no significant difference.

So, psychiatry needs to be aware of the next wonder treatment.

Regards, Sam

From Jay Amsterdam to Max Fink

Dear Max:

Thank you so much for sending along your thoughtful comments on ICT.

I just re-read, with renewed interest, your seminal article comparing ICT to CPZ from JAMA 1958. In many respects, this article itself is an important, if unrecognized, slice of psychiatric research history for our field. In this regard, it harks back to a time when psychiatry researchers published the unvarnished truth of their experimental observations (and did not simply provide some post hoc, “positive,” whitewashed and doctored outcome of the study results in order to facilitate its publication in a high-impact journal).

In fact, as I now re-read through your JAMA article, I wondered whether the observations that you reported would even be considered by most of today’s journal editors for the peer-review process, much less for publication. In this regard, I wonder if JAMA, or any of our other current tier 1-4 psychiatry research journals, would even consider publishing your “negative” findings (which proved so consequential for the field of psychiatry). It would surely be a tough uphill battle for you to get such a manuscript published. And just imagine the uphill publication struggle that would be experienced if you had performed this same experiment today and had chosen an atypical antipsychotic for a comparator to ICT! I fear that the unrecognized publication pressures that are now brought to bear upon investigators by academic institutions and their publication imperatives, the largess of Pharma grants to these investigators and their institutions, the pressures to solidify potential business partnerships between academic and industry stake holders and the financial support of Pharma industry to the editors and owners of scientific journals would surely mitigate against the likelihood of you getting your excellent experimental observations published. Moreover, “negative” findings are akin to “bad news” which does not sell journals or journal subscriptions; does not facilitate the placement of Pharma advertisements in journals or other financial support for future journal publications; and does not result in high journal impact factors, which result in high journal income.

Furthermore, your post hoc finding, from a decade earlier, that “usual care” for these psychosis patients results in a similar outcome to the two unique interventions would also not bode well for the likelihood of you getting your excellent research findings published. And finally, of course, there’s the looming (but at the time, in 1958, completely unknown) issue of the tardive adverse effects of neuroleptic drugs, like CPZ (and all of its successors).

Although I may sound a bit cynical, I have always wondered over the past 45 years of my reading various psychiatry reports (like that of your excellent article), how few “negative” findings were ever published in psychiatric research journals and how vast was the surfeit of interesting “positive” findings that were published – although it was always a conundrum to me just how little clinical progress all of these positive findings made to our field writ large.

In any event, as one of the last living clinical purveyors and researchers of ICT in our field, I thank you for your continued wisdom and insight on this topic.

With my very best wishes,

Jay

From Max Fink to Jay Amsterdam

Jay asks whether our 1958 JAMA RCT of CPZ and ICT would be published today. I am sure it would. It was my first RCT, followed by the CPZ – IMI – PLO at Hillside, a study that found IMI as antidepressant and useful. In anxiety too. CPZ effective in schizophrenia and also in psychotic depression. Best of all the EEG records for the three meds were distinguishable. Sad, pharmaco-EEG is discarded.

Those early studies were productive more so than the million-dollar CATIE, STEP-BD and STAR*D capers.

Regards, Max

From Max Fink to Sam Gershon

Insulin Coma Therapy (ICT) was a high nursing care treatment. In retrospect, it acted as a weak form of electroshock. Many patients, especially the more severely ill , were much improved but we did not have a maintenance treatment (that we now have in continuation OPD ECT).

ICT was the best available Rx for psychosis until CPZ appeared. No, not a pandemic delusion, but the best available, weak toxic treatment.

Jay Ámsterdam:Letter from Jonathan Cole (March 16, 2004)

Jay Amsterdam, Tom Ban, Max Fink and Sam Gershon: E-mail exchange

(June 11, 2019 – July 11, 2019)

American Society of Clinical Psychopharmacology

Model Psychopharmacology Curriculum

For Psychiatric Residency Programs,

Training, Directors and Teachers of Psychopharmacology

Third Edition

2004

Terence A. Ketter

Pharmacokinetics of Psychotropic Drugs