The effect of insulin coma and E.C.T. on the three-year prognosis of schizophrenia.

The evaluation of the effects of the special physical methods oftreatment ofschizophrenia-insulin coma and electroconvulsive therapy-requires not only an assessment of the short-term results but also continued follow-up of the patients over a long period. Three factors in particular make assessment of the effects of any form of treatment in this disease difficult: first, the elusive character of the illness which defies exact definition and measurement in the individual patient; secondly, the variability of the interaction between the patient and his illness and the social environment; and thirdly, the tendency of schizophrenia to spontaneous remission. Several authors (David, 1954; Malamud and Render, 1939; Lewis, 1945) have pointed out the methodological shortcomings of many previous attempts to evaluate the results of the treatments in schizophrenia and have suggested reasons to account for the large discrepancies and even contradictions in the various findings. In a previous communication Hoenig, Leiberman, and Auerbach (1956) discussed this problem and attempted to overcome the difficulties by three measures. (1) Two groups of patients from the same hospital, admitted at different periods, that is before and after the introduction of physical methods of treatment, were compared. The admission policy of the hospital had remained unchanged throughout. (2) The cases selected for investigation were all the patients suffering from schizophrenia admitted in the periods under investigation, who had been ill for not longer than one year; the two groups were comparable in all relevant respects. One group had been admitted to the Maudsley Hospital in the years 1934-35, the other group had been admitted to the combined Bethlem Royal and Maudsley Hospitals in 1948-50. (3) The later group consisted of a treated and an untreated section; this allowed an internal check of the significance of any differences found between the two main groups. In the previous report referred to above (loc. cit.) the results at the time of discharge after the first admission were assessed, and there was suggestive evidence that physical treatment, in particular insulin coma therapy, might have been effective in the subgroup of paranoid schizophrenic, but in the subgroups of hebephrenics and catatonic and atypical schizophrenics, a beneficial effect could not be conclusively demonstrated. The present communication deals with the same group of patients after they have been followed up for three years. Appel, Myers, and Scheflen (1953) have summarized a large number of reports on the treatment of schizophrenia with insulin coma and electroconvulsion therapy. Most of these reports agree that after five years the results in treated and untreated cases are identical. As regards the short-term prognosis, this appears better in the treated groups (particularly the insulin coma-treated group), but the methods used in evaluating the results have rarely been properly controlled. The impression of Wilcox and Wilcox (1954) is that insulin coma therapy tends to be used less rather than more, in spite of the favourable results which continue to be reported from time to time. Kalinowsky (1954) is one of the few clinicians who still regard convulsive therapy as the method of choice in schizophrenia. It may be, therefore, that if the impressions of Wilcox and Wilcox are correct, either less physical therapy is being used for the treatment of schizophrenia or that Kalinowsky's view gains more followers and the place of insulin coma is being taken by E.C.T. (Bourne, 1953). While this is only speculation, based on rather scanty data, it would serve to indicate the need for more exact knowledge of the comparative effects of different physical treatments in this disease and of the results of physical treatments as a whole.