Early Treatments and Explanations
Doctors could do nothing to treat schizophrenia in the nineteenth and early twentieth century, although they did try to come up with some effective procedures.
Insulin Coma Therapy
Polish psychiatrist and neurophysiologist Manfred Joshua Sakel developed insulin-shock or insulin-coma therapy for schizophrenia in the 1930s. After accidentally inducing an insulin coma in a drug addict undergoing withdrawal, Sakel noted that his patient's mental state improved. Too much insulin drastically lowers the amount of sugar in the blood, which the brain and body use for energy. Deprived of its energy source, the brain begins to shut down, passing through states of mental confusion, listlessness, seizures, coma, and, unless blood sugar is provided, death.
Sakel began to induce convulsions and coma in people with schizophrenia by injecting them with insulin. For a little while it seemed to work and many clinicians followed his lead. Sakel reported improvement in symptoms in nearly nine out of ten patients. Doctors eventually found that the procedure didn't have much effect over the long term. The technique was abandoned when powerful tranquilizing drugs became available.
Another approach to treating schizophrenia and other mental disorders was popularized and over-promoted in the 1940s and early 1950s by the American neurologist Walter Freeman. Looking for a way to help mentally ill patients who had no hope of recovery, the ambitious Freeman adapted a psychosurgical procedure pioneered in Europe by two Portuguese physicians, Antônio Egas Moniz and Almeida Lima. This radical procedure involved cutting the nerve connections between the area of the brain above the eyes, known as the prefrontal cortex, and the rest of the brain.
Freeman developed a surgical variation called transorbital lobotomy that simplified the procedure. Using an ice pick-like instrument, he pierced the thin bone behind the eye socket and then inserted the instrument into the brain and moved it back and forth to sever the connections. The procedure was over in minutes. With Freeman's enthusiastic promotion, it became a medical fad, widely performed before any well-planned scientific studies were conducted to establish its effectiveness or determine its long-term effects. It could pacify some psychotic patients and even help a few. Unfortunately, many undergoing the procedure were irreversibly harmed by it. They were left passive, apathetic, emotionally stunted, and unable to concentrate.
The lobotomists confused the passivity they produced with relief of symptoms of mental illness. Unfortunately, it took years for it to become clear that rather than targeting and alleviating specific symptoms of mental diseases, the procedure amounted to little more than the production of brain damage that quieted patients and suppressed cognitive function.
How long were frontal lobotomies performed?
Lobotomy, or prefrontal leukotomy, was introduced in 1935. More than 18,000 lobotomies were performed in the United States between 1939 and 1951 before doctors realized it did more harm than good. Nevertheless, Moniz won the 1949 Nobel Prize in Physiology or Medicine for pioneering the procedure.
In the 1950s, mainstream psychologists and psychiatrists promoted one influential “cause” of schizophrenia: a poor upbringing blamed on the parents, particularly a cold, distant mother.
The American psychiatrist Seymour Kety, by contrast, promoted the idea that schizophrenia was a brain disease, not the result of bad parenting. His research helped promote understanding of the contribution of genetic factors in predisposing some people to the illness. He also laid the groundwork in the 1940s and 1950s for imaging the living brain using positron emission tomography (PET scanning) with his research on measuring blood flow to specific parts of the brain. PET scanning has since provided important insights into the differences in brain function in schizophrenia and in health.
Drug Therapy and Deinstitutionalization
In the United States in 1955, state mental institutions held approximately 560,000 patients. By the start of the twenty-first century, that number had dropped by nearly 90 percent.
The introduction of antipsychotic and other mental health medications accounts for a significant portion of the decline. Other reasons for the decline in long-term hospitalizations are public policies concerning deinstitutionalization and improvement in understanding and care.
Who first saw the potential benefit of an antipsychotic drug?
The drug that began the modern revolution in psychopharmacology — the use of drugs to improve mental health — was first used to relieve anxiety and prolong sleep in patients undergoing surgery and anesthesia. Chlorpromazine (Thorazine) was so effective in turning anxious patients into “disinterested” patients that French surgeon Henri Laborit advocated its use in psychiatry. The first tests took place in 1951.
A big move away from institutionalizing patients followed passage of the Community Mental Health Act in 1963. Some civil libertarians and other activists fought for the release of patients from hospitals because they claimed patients' rights were being violated by involuntary admission. Some politicians wanted to save government money that was used to maintain large hospitals.
Whatever the intentions or rationale, the results were mixed. Some patients benefited if they responded to antipsychotic drugs and could find a support network on the outside. Others dropped out of the health care system entirely. They were left to live on the streets because community mental health care programs hadn't been developed to provide needed services.