For long time schizophrenia and other psychoses in psychiatry were treated with insulin. The essence of the method was to induce a hypoglycemic coma in a patient artificially. To do this, he was injected with large doses of insulin – a hormone of the pancreas, disruption of which occurs with diabetes mellitus.

Today this technique is rarely used. It is very labor-intensive and requires a high level of training from all medical personnel, including nurses and orderlies. Nevertheless, we will tell you about its peculiarities because in rare cases, a doctor may decide to prescribe insulin-coma therapy (ICT) to a patient with schizophrenia.

Insulin coma in schizophrenia

 

Story

Insulin shock therapy for treating psychiatric pathologies was proposed by the American psychiatrist Manfred Sakel in 1933. A little earlier, scientists discovered the hormone insulin and began prescribing it to diabetics. It was a real breakthrough in medicine since, until then, diabetes caused the most severe complications and often resulted in death.

Sakel suggested treating heroin addicts with this hormone, believing that insulin would help overcome the withdrawal syndrome of drug addicts less painfully. But it turned out that after administering a hefty drug dose, the patients fell into a hypoglycemic coma. Sakel decided to use it to treat schizophrenia and called it insulin shock therapy.

In his opinion, shock therapy acts as a shake for the brain, the failure of which causes schizophrenia. However, such “shaking” led to a high mortality rate among patients, 2-5%, which resulted in abandoning the method.

But it was occasionally used in various clinics. One of the most famous people who underwent insulin-coma treatment was the mathematician John Nash, whose biography was the basis for the movie “Mind Games” with Russell Crowe. I completely stopped using this therapy by the sixties of the last century. But we are talking only about the West.

In some countries, the method has not been abandoned now. They developed their principles of insulin-coma therapy (ICT) application. After the appearance of neuroleptics, the procedure became less in demand, but it still exists as a reserve procedure, and future psychiatrists are necessarily taught the basics of such treatment.

 

Indications

Schizophrenia is a complex psychiatric illness that takes many forms. It is found in one form or another in 1 person out of 100. Not all patients see hallucinations and become insane. There are also milder forms of the pathology. However, treating it isn’t effortless, much less predicting it.

It is prescribed by insulin-coma therapy (ICT) in extreme cases, for example, when seizure-like schizophrenia is detected. It is most effective in acute seizures during which hallucinations and paranoid syndrome are observed. ICT allows to bring a person out of the seizure phase and prolong remission.

Recurrent schizophrenia, which also has seizures, can be treated with insulin-coma therapy (ICT). Usually, this form is relatively benign when compared to others. However, if Kandinsky-Clerambaut syndrome and other complications develop, A decision may be made to prescribe insulin therapy.

There is another indication for this type of treatment – intolerance to psychopharmacotherapy. In cases where the patient can not be administered drugs, insulin therapy has almost no alternatives.

 

Contraindications

There are many contraindications to the prescription of insulin-coma therapy (ICT). Therefore, the patient is examined before the therapy. Limitations for putting him into an insulin coma may be:

These are absolute contraindications. There are also relative ones – a mild form of tuberculosis, endocrine and vascular diseases, cholecystitis, gastritis, and emphysema. If they are present, insulin-coma therapy (ICT) can hypothetically be applied. It is up to the physician to decide in each specific case.

Prepared by

First, you need permission to perform an insulin-coma therapy (ICT). This is given to the doctor by the patient. In emergencies, you can do without their opinion. For incompetent patients and minors, the decision is made by guardians, parents, and other legal representatives.

For treatment, the patient is allocated a separate room, which is equipped in advance with the necessary equipment and medications. The clinic should have nurses and orderlies trained to work with patients in a hypoglycemic coma. Often insulin-coma therapy (ICT) is done in the psychotraumatology department since this is a typical psychotraumatology technique.

Before therapy, the patient is subjected to blood and urine tests, electrocardiography, and a lungs X-ray. Other tests are also possible, depending on the patient’s condition. He is constantly consulted by a general practitioner, who may prescribe additional procedures.

The last meal before insulin-coma therapy (ICT) is dinner. It would help if you did not eat before the next day. In the morning, the patient should go to the toilet, after which he is brought to the ready room. Here he undresses (so that the veins are accessible) and lies on the bed. The extremities are tied so the patient will not fall during hypoglycemic excitement.

Methods of conducting

Insulin-coma therapy (ICT) is conducted using a variety of methods. One of them, the classical one, was suggested by the founder Manfred Sackel. First, an appropriate insulin dose is selected for the patient and injected for several days. After each injection, the patient is kept comatose for 1-2 hours (sometimes a few minutes).

The coma is suppressed with a 40% glucose solution. Usually, 20-40 ml is sufficient. The patient regains consciousness almost immediately. They are asked questions, her condition is checked, and further treatment is determined. There may be many such sessions, from 8 to 40. Their number depends on the patient’s condition and general dynamics.

Subshock and nonshock therapy methods were also used at different times, which involved prolonged coma. But they did not bring the desired result. Scientists further developed the insulin-coma therapy (ICT) principle, hoping to find more effective methods. One of them was proposed in the 1980s by the Moscow Research Institute of Psychiatry. It was called boosted insulin-coma therapy. Its main features:

  • Injection of insulin into the vein at a strictly prescribed rate allows the patient to enter a coma more quickly and reduces the duration of treatment;
  • The therapeutic effect can manifest itself even before the comatose state;
  • Closer monitoring of the patient, which helps reduce the risk of complications;

The technique uses only pure, high-quality insulin to rule out allergies and phlebitis (inflammation of the vein walls). A short-acting hormone is always used. There are also long-acting insulins, but they are dangerous for the patient in such cases.

See Also: What Is Hebephrenic Syndrome?

During the first session, the hormone is injected in 300 IU at a rate of 1.5 IU/minute. The duration is about 3.5 hours. However, these figures may be less. According to the Russian psychiatrist A.I. Nelson, if the rate is lowered to 1.25 IU/min, the session is milder. In general, 1/240 part of the daily dose of the drug should enter the patient’s blood within 1 minute.

A treatment course can consist of many sessions, which are divided into three stages:

  • Glycogen depletion (1 to 3 sessions). The administered dose of the hormone is constant (300 IU/min), and the duration of the coma gradually increases;
  • Decreasing doses (4 to 6 sessions). Coma must occur before the standard dosage is administered;
  • “Comatose plateau” (from session 7 to completion of the course). The dose of insulin to put the patient into a coma is stable. The average dose is 50 IU;
  • The coma is permanently terminated in its entirety. For this purpose, glucose is administered intravenously at the highest possible rate. When the patient wakes up, warm sugar syrup (100 g sugar in 200 ml water) is given.

It is essential to bring the person fully out of the coma so that it does not recur until the next session, even without injections. Start knockdown begins 3 minutes after the patient falls into a comatose state. More extended coma stays have also been practiced in the past but without positive results.

Sessions of insulin shocks are performed daily, including on weekends. Therefore, it is necessary to select personnel who will be ready to work at any minute during the entire course of treatment of the patient.

 

Anti-infective regimen

During insulin-coma therapy (ICT), the patient’s immunity decreases. He becomes vulnerable to infectious diseases. To prevent their development, the following measures are taken:

  • The patient is not allowed to cool down, especially in cases where he is very sweaty. He should be wiped and changed into dry clothes. Caregivers also change the bedding periodically;
  • All windows in the room should be closed to prevent draughts. Doors are not kept open;
  • The patient is examined daily for inflammation. Even a simple boil can cause sepsis;
  • The body temperature is measured twice a day. If it rises so much that infection is suspected, the insulin-coma therapy (ICT) course is interrupted.

If necessary, additional medications – antibiotics, anti-inflammatory drugs, etc. – are prescribed to the patient.

Levels of unconsciousness:

  • Somnolence – the patient is asleep but awakens quickly under the external influence;
  • Deafening – the patient can answer questions but slowly and unilaterally;
  • Soporus – the person fixes his eyes on the doctor or orderly but can no longer answer questions. His attempts to follow instructions become weak and ineffective;
  • Coma – the patient completely stops responding to external stimuli.

Staff must differentiate between these levels to administer sugar or medication in time.

 

Complications

The main reason why insulin-coma therapy (ICT) is rarely used is because of possible complications. Seizures are not one of them. They are a standard reaction to such therapy. In such cases, you must ensure that the patient does not bite his tongue, choke on his saliva, hurt his hands or feet, etc.

A serious complication is a prolonged coma when it is impossible to bring the patient out of this state with the usual methods, i.e., glucose administration. You have to use caffeine, and if it does not help, then adrenaline. It is important not to lead to an overdose of glucose since a hypoglycemic coma can turn into a hyperglycemic coma.

Rather dangerous are nocturnal insulin shocks. There may be cases when the patient falls into them even when the coma could not be achieved during the session. Therefore, monitoring the patient should be continuous around the clock to have time to stop the signs of hypoglycemia.

Today, if prescribed, insulin-coma therapy (ICT) is under the strict control of many specialists. All risks are reduced, so severe complications are rare. The probability of a lethal outcome is practically zero. The main thing is to protect the patient from overdoses and infections. Other complications associated with weight gain, phlebitis, etc., are eliminated quickly.

 

Alternative

Insulin coma therapy has many alternatives – psychotropic agents, neuroleptics, psychotherapeutic techniques, electroconvulsive therapy, etc. Schizophrenia is an understudied pathology being treated by all currently available methods. There is a lot of data on it, but the exact causes and mechanisms of its development remain unknown. The symptomatology is so extensive that only a voluminous monograph can enumerate all the signs.

Moreover, schizophrenia is quite challenging to predict. Even an experienced physician cannot always give guarantees about the outcome of the disease. The techniques used are not capable of leading to a complete cure. But doctors use all means to save the patient and improve his quality of life. The use of insulin-coma therapy (ICT) as one of the radical methods of treatment is not excluded.