For a long time, the treatment of schizophrenia and other psychoses in psychiatry was carried out with the help of insulin. The essence of the method is to artificially induce hypoglycemic coma in a patient. To do this, he was injected with large doses of insulin, a pancreatic hormone whose production is disrupted in diabetes mellitus.
Today, this technique is almost never used. It is very time-consuming and requires a high level of preparedness from all medical personnel, including nurses and orderlies. Nevertheless, we will talk about its features, since in rare cases a doctor may decide to prescribe insulin coma therapy (ICT) to a patient with schizophrenia.
Insulin shock therapy for the treatment of psychiatric pathologies was proposed by the American psychiatrist Manfred Sackel in 1933. A little earlier, scientists discovered the hormone insulin and began to prescribe it to diabetics. This was a real breakthrough in medicine since up to this point diabetes mellitus caused severe complications and often led to death.
Sakel suggested treating heroin-addicted patients with this hormone, believing that insulin would help overcome withdrawal symptoms in drug addicts less painfully. But it turned out that after the introduction of a large dose of the drug, the patients simply fell into a hypoglycemic coma. Sakel decided to use this for the treatment of schizophrenia and called such therapy insulin shock.
In his opinion, shock therapy acts as a shake-up for the brain, a failure that becomes the cause of schizophrenia. However, such a “shake-up” led to high mortality among patients – 2-5%, as a result of which the use of the technique had to be abandoned.
But occasionally it was used in various clinics. One of the most famous people who underwent insulin-comatose treatment was the mathematician John Nash, based on whose biography the movie A Beautiful Mind with Russell Crowe was shot. Completely stopped using this therapy by the 60s of the last century. But we are talking only about the West.
In the USSR and modern Russia, the method was not abandoned. They simply developed their own principles for the use of ICT. After the advent of antipsychotics, the procedure became less popular, but it still exists as a backup, and future psychiatrists must be taught the basics of such treatment.
Schizophrenia is a complex psychiatric illness that takes many forms. In one form or another, it is detected in 1 out of 100 people. Not all patients see hallucinations and become insane. There are also milder forms of pathology. However, it is incredibly difficult to treat it and even more so to predict.
ICT is prescribed in extreme cases, for example, when detecting paroxysmal schizophrenia. It allows you to get the greatest efficiency in acute attacks, during which hallucinations and paranoid syndrome are observed. ICT allows you to bring a person out of the attack phase and prolong remission.
ICT is also used in recurrent schizophrenia, which also occurs in the form of seizures. Usually, this form of pathology is quite favorable when compared with others. However, with the development of the Kandinsky-Clerambault syndrome and other complications, a decision may be made to prescribe insulin therapy.
There is another indication for this type of treatment – intolerance to psychopharmacotherapy. In cases where no drugs can be administered to the patient, there are practically no alternatives to insulin therapy.
There are many contraindications to the appointment of ICT. Therefore, before therapy, the patient undergoes an examination. Restrictions for introducing it into an insulin coma can be:
- Active phase of tuberculosis
- Infectious diseases
- Liver pathologies
- Severe kidney disease
- Stomach ulcer
- Heart defects
These are absolute contraindications. There are also relative ones – a mild form of tuberculosis, endocrine and vascular diseases, cholecystitis, gastritis, and emphysema. If available, ICT can hypothetically be used. This is decided by the doctor in each case.
First, you need to get permission to conduct ICT. It is given to the doctor by the patient himself. In emergency situations, you can do without his opinion. For incapacitated minors, decisions are made by guardians, parents, and other official representatives.
For treatment, the patient is allocated a separate ward, which is pre-equipped with the necessary equipment and medicines. The clinic should have nurses and nurses trained to work with patients who are put into a hypoglycemic coma. Often, ICT is done in the department of psycho-reanimatology, as this is a typical psycho-reanimatological technique.
Before therapy, the patient is tested (blood and urine), electrocardiography, and x-rays of the lungs are done. Other studies are possible depending on the patient’s health status. He necessarily undergoes a consultation with a therapist who can prescribe additional procedures.
The last meal before ICT is dinner. You can’t eat until the next day. In the morning, it is advisable for the patient to go to the toilet, after which he is brought to a prepared ward. Here he undresses (so that the veins are accessible) and lies down on the bed. Limbs are tied so that the patient does not fall during hypoglycemic excitations.
ICT is carried out using various methods. One of them, the classic one, was proposed by the founder Manfred Sackel. First, an appropriate dose of insulin is selected for the patient, then it is administered over several days. After each injection, the patient is kept in a coma for 1-2 hours (sometimes several minutes).
They stop someone with a 40% glucose solution. Usually, 20-40 ml is enough. The patient regains consciousness almost immediately. They ask him questions, check his condition and decide on further treatment. There can be many such sessions – from 8 to 40. Their number is determined by the patient’s condition and general dynamics.
Also, at different times, methods of subshock and non-shock therapy were used, which involve prolonged coma. But they did not bring the desired result. The very principle of ICT scientists continued to develop further, hoping to find more effective methods. One of them was proposed in the 80s. Moscow Research Institute of Psychiatry. It was called forced insulin coma therapy. Its main features:
- The introduction of insulin into a vein at a strictly specified rate, allows you to quickly enter the patient into a coma and reduce the duration of treatment;
- The therapeutic effect may appear even before the coma;
- More careful monitoring of the patient helps to reduce the risk of complications;
As part of the technique, only high-quality pure insulin is used to exclude allergies and phlebitis (inflammation of the walls of the veins). In this case, a short-acting hormone is always used. There are also prolonged insulins, but in such cases, they are dangerous for the patient.
During the first session, the hormone is administered in an amount of 300 IU at a rate of 1.5 IU/min. The duration is about 3.5 hours. However, these figures may be less. According to the Russian psychiatrist A.I. Nelson, if you reduce the speed to 1.25 IU / min, then the session proceeds more gently. In general, 1/240 of the daily dose of the drug should enter the patient’s blood within 1 minute.
The treatment course may consist of many sessions, which are divided into 3 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;
- Dose reduction (from 4 to 6 sessions). Coma should occur before the introduction of the standard dosage;
- “Coma plateau” (from 7 sessions to the end of the course). The dose of insulin for the introduction of a patient in a coma is stable. On average, it is 50 IU;
Buy someone always in full. To do this, glucose is administered intravenously at the highest possible rate. When the patient wakes up, he is given warm sugar syrup (100 g of sugar per 200 ml of water).
It is important to completely bring a person out of a coma so that it does not recur until the next session, even in the absence of injections. Cupping begins 3 minutes after the patient falls into a coma. Earlier, a longer stay of a person in a coma was also practiced, but this did not bring positive results.
Sessions of insulin shocks are carried out daily, including on weekends. Therefore, it is necessary to select personnel who will be ready to work at any moment during the entire course of treatment of the patient.
During ICT, the patient’s immunity decreases. It becomes vulnerable to infectious diseases. To prevent their development, the following measures are taken:
- The patient is not allowed to cool, especially when he sweats heavily. It should be dried and changed into dry clothes. Also, orderlies periodically change bed linen;
- Close all windows in the room to prevent drafts. Doors are not kept open;
- The patient is examined daily for inflammation. Even an ordinary boil can cause sepsis;
- Body temperature is measured twice a day. If it has increased so much that infection can be suspected, the ICT course is interrupted.
If necessary, the patient is prescribed additional drugs – antibiotics, anti-inflammatory, etc.
Levels of turning off consciousness
One of the most important moments of ICT is a clear tracking of the levels of turning off the patient’s consciousness. There are 4 in total:
- Somnolence – the patient is asleep, but quickly awakens to external influences;
- Stunning – the patient is able to answer questions, but slowly and in monosyllables;
- Sopor – a person fixes his gaze on a doctor or orderly, but can no longer answer questions. His attempts to follow instructions become feeble and ineffectual;
- Coma – the patient completely stops responding to external stimuli.
Personnel must be able to differentiate these levels in order to introduce sugar or drugs into the body in time.
The main reason why ICT is rarely used is related to possible complications. Convulsive seizures are not included. They are a standard response to such therapy. In such cases, you just need to make sure that the patient does not bite his tongue, does not choke on saliva, does not injure his arms and legs, etc.
A serious complication is a prolonged coma when it is not possible to get the patient out of this state using conventional methods, that is, the administration of glucose. You have to use caffeine, and if that doesn’t help, then adrenaline. It is important not to lead to an overdose of glucose, since a hypoglycemic coma can turn into a hyperglycemic one.
Nocturnal insulin shocks are quite dangerous. There are cases when the patient falls into them even when the coma could not be reached during the session. Therefore, monitoring of the patient should be around the clock in order to have time to stop the signs of hypoglycemia in time.
In general, today ICT, if appointed, is under the strict control of many specialists. All risks are reduced, so severe complications are rare. The chance of death is almost zero. The main thing is to protect the patient from overdoses and infections. The remaining complications associated with weight gain, phlebitis, etc., are eliminated fairly quickly.
There are many alternatives to insulin coma therapy – psychotropic substances, antipsychotics, psychotherapeutic techniques, electroconvulsive therapy, etc. Schizophrenia is a little-studied pathology that is treated with 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 it is possible to list all the signs only within the framework of a voluminous monograph.
Moreover, schizophrenia is quite difficult to predict. Even an experienced doctor cannot always give guarantees regarding the outcome of the disease. The applied methods are not able to lead to a complete cure. But doctors use all the means at their disposal to save the patient and improve his quality of life. The use of ICT as one of the radical methods of treatment is not excluded.