Download Biological and Somatic Treatment of Severe Mental Illness Before Modern Times

Biological and Somatic Treatment
of Severe Mental Illness
Before Modern Times
Zachary Lane, MD
September 8, 2015
Some Early Treatments
• Trepanation
• Bloodletting
• Surgical Bacteriology
Some Early Treatments
• Tranquilizer Chair
• Sensory Deprivation Chair
Some Early Treatments
• Restraints
Asylum Reformation Movement
• 18th and 19th Centuries
• Moral therapy
– Philippe Pinel
– Benjamin Rush
– Dorothea Dix
Early Drug Therapies
•
•
•
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Used for behavioral control and sedation
Decrease the use of restraints
Many nonspecific indications
Classes:
– Natural remedies
• Plant based (Alkaloids)
– Synthesized in the lab
• Strengthened the link between medical research and
psychiatric treatment
• Legitimized psychiatric conditions
Early Drug Therapies
• Natural remedies:
– Opium, Morphine
• Treat aggression, melancholy, and delusions
• The addictive nature, toxicity, and side effects later
became evident
Early Drug Therapies
• Synthesized in the lab (19th Century):
– Mercury – treatment for mania
– Bromides - treatment for seizures, stress,
psychosis, mania, morphine addiction, alcoholism
– Chloral Hydrate – hypnotic, “knockout drug”
– Paraldehyde - hypnotic
Early Drug Therapies
• Synthesized in the lab:
– Barbiturates (20th Century):
• Barbital, Phenobarbital
– Hypnotic, anxiolytic, anti-epileptic
– Addictive, overdose potential
Early Drug Therapies
• Synthesized in the lab:
– Amphetamines (20th Century):
• Antidepressant, weight loss
• “Pep pill” or inhalers
• Addictive, led to anxiety/psychosis
Prolonged Sleep Therapy
(Continuous Narcosis)
• 1910’s - 1930’s
• Continuous administration of bromides or
barbiturates
• Sleep for 6-8 days
• Briefly awaken to eat and toilet
• Believed to give rest to an overactive nervous
system
Prolonged Sleep Therapy
(Continuous Narcosis)
• Treatment for psychosis, mania, agitated depression, &
addictions
• Effective for “shellshock” (PTSD) in World War I
• Required intensive monitoring
• Replaced by Insulin Coma Therapy in 1930’s
• Later scandals – CIA’s MKULTRA (mind control) experiments,
Australian Chelmsford Scandal
Hydrotherapy
• 1800’s to mid-1900’s
• Using water to relieve “cerebral congestion”
– Bring blood away from the brain and to the skin
Hydrotherapy
• Wet Sheet Pack
– Sheet dipped in water and wrapped snuggly
around patient for hours
– Cold – agitated patient
– Warm – frail patient
Hydrotherapy
• Continuous Bathing
– Patient placed in tub with replenishing warm
water and fastened in hammock for hours to days
Hydrotherapy
• Jet Streams and Steam Cabinets
Malaria Fever Therapy
• Neurosyphilis (General Paresis of the Insane)
– Around 20% of patients institutionalized in early
20th Century
– Physical and psychiatric problems, high mortality
– Immoral patients seen as deserving of their fate
– No cure (Penicillin not discovered until 1928)
Malaria Fever Therapy
• Hippocrates and Galen noted improvements
in some patients after malaria
• Julius Wagner-Jauregg – injected malaria into
patients with Neurosyphilis to induce fever
– Later would cure their malaria with Quinine
• First full cure for a specific mental illness
– Mental illness seen as having a biological cause
Malaria Fever Therapy
• Why it worked?
– High fevers destroyed spirochetes
– Stimulated the body’s immune response
• Wagner-Jauregg won 1927 Nobel Prize in
Medicine
Malaria Fever Therapy
• Malaria later replaced by other fever inducers
into the 1950’s: inject foreign
protein/chemicals, immerse in hot bath,
electromagnetic currents, full body fever
machine
Shock Therapies
• Shock Therapies:
– Insulin Shock Therapy
– Metrazol Convulsive Therapy
– Electroconvulsive Therapy (ECT)
• Initially used for treating psychosis based on
erroneous belief that people with epilepsy
cannot have comorbid psychosis
• All found to be more effective for depression
Shock Therapies:
Insulin Shock Therapy
• 1930’s - 1940’s
• Daily injections of high doses of Insulin until
coma induced
• Treatments lasted hours and were terminated
with glucose via IV or NG Tube
• Courses lasted for ~60 days and required close
monitoring
• Replaced in 1940’s by ECT due to Insulin
shortage during World War II
Shock Therapies:
Insulin Shock Therapy
Shock Therapies:
Metrazol Convulsive Therapy
• 1930’s - 1940’s
• Metrazol (Pentylenetetrazol) – circulatory and
respiratory stimulant
• Given via injection 2-3 times/week for several
weeks
• Caused “explosive seizure” one minute after
administration that could cause fractures
– Dread after administration
• No antidote to reverse
• Replaced in 1940’s by ECT
Shock Therapies:
Electroconvulsive Therapy (ECT)
• 1930’s - Present Day
• Electrically induced convulsions
• Thought convulsions produced vitalizing
compounds that had defense properties
(“acro amines”)
Shock Therapies:
Electroconvulsive Therapy (ECT)
• Easier to use, lower cost, fewer complications
• Curare used in late 1940’s as muscle relaxant to
decrease fractures
• Amnesia viewed positively – “forget your
depression”
• ECT declined due to public opinion and the
antipsychiatry movement in the 1960’s and
1970’s – more recent resurgence and still in use
today as one of the most effective treatments in
psychiatry
Shock Therapies:
Electroconvulsive Therapy (ECT)
Warning
The video on the following slide shows graphic
medical procedures. Viewer discretion is
advised.
Shock Therapies:
Electroconvulsive Therapy (ECT)
Lobotomy
Warning
The video on the following slide shows graphic
medical procedures. Viewer discretion is
advised.
Lobotomy
Prefrontal Lobotomy
• 1930’s – Egas Moniz
• Some patients more docile after accidental
frontal lobe damage
• Cut strands connecting prefrontal cortex and
thalamus
– Rationale: neuronal pathways became “fixed” and
needed to be disrupted
• Initially used as “last resort” in severe cases
• Moniz won 1949 Nobel Prize in Medicine
Transorbital Lobotomy
• 1940’s – Walter Freeman & James
Watts
• Exploded in popularity
– Attempt to relieve state hospital burden
– Expanding indications – no longer “last resort”
– Took just minutes, no anesthesia, done in clinic
– Children and adolescents as well
Lobotomy
• Initially thought to be a permanent cure but
results turned out to be poor
• Side effects: personality changes (childlike,
disinhibited, apathetic), apraxia, cognitive
problems, “lost the sparkle”
• Waned in popularity in 1950’s with
introduction of antipsychotic medication
• Other types of psychosurgery still performed
today in select cases
Beginning of Modern Era
of Psychiatric Treatment
Early Modern
Antipsychotic Medications
• Chlorpromazine (Thorazine)
– Synthesized in 1951 for use in general anesthesia
– Also found to produce “euphoric quietude” where patients lost
interest in their surroundings
– First drug effective for psychotic symptoms (and not just sedation)
• Dopamine antagonist -> led to dopamine excess theory of Schizophrenia
Early Modern
Antipsychotic Medications
• Chlorpromazine (Thorazine)
– Adopted by psychiatrists worldwide by mid-1950’s
– Led to further development of 1st generation
antipsychotics (neuropleptics)
– Began deinstitutionalization movement
Early Modern
Antidepressant Medications
• Iproniazid (1951)
– Medication for Tuberculosis
– Improved mood in depressed patients
– Weak monoamine oxidase inhibitor
• Led to monoamine theory of depression
Early Modern
Antidepressant Medications
• Imipramine (1956)
– Found serendipitously while trying to manufacture
an antipsychotic medication
– Improved mood in depressed patients
– First Tricyclic Antidepressant (TCA)
• Led to creation of other TCA’s and later SSRI’s
Concluding Thoughts