In the April 16, 2017 New York Times online (free access) is an 11 minute video and article titled The Quest for a Psychiatric Cure, looking at the use of lobotomy. While many of us know of the history its always jarring; what psychiatrists thought of as an effective treatment in retrospect turns out to be unthinkable!
It’s easy to focus on Walter Freeman and his freewheeling lobotomy road tours. But in order to understand the history one needs to remember the context of the times.
Dr. Heinz Lehman, a Canadian psychiatrist, is remembered for having brought chlorpromazine (Thorazine in the US, Largactil in Canada) to clinical use. In 1985 he gave a talk on The Introduction of Chlorpromazine to North America (which is well worth reading and maybe using for an ACT education session)
A somewhat long excerpt:
“I should perhaps give some sort of a feel of what things were like in the 1950s, just immediately preceding and immediately following the discovery and introduction of the psychotropic drugs. I was working at the Douglas Hospital in Montreal. It was a small hospital – not small in the number of patients, we had some 1500 or 1600 – but we had very few physicians and very few nurses, one registered nurse for 600 or 700 male patients; the others were all untrained personnel.
It was pretty horrible to work under those conditions: I felt the only way to keep morale up in the 1940s with the few doctors we had then – most had gone to war – was to do some sort of research. So I did all kinds of things, always convinced that psychotic conditions and the major affective disorders differed in principle from neurotic and personality disorders, and they, I was convinced had some sort of a biological substrate. So I kept experimenting with all kinds of drugs, for instance, large doses, very large doses of caffeine, I remember, in one or two stuporous catatonic schizophrenics – of course, with no results… We experimented with an extract of the pituitary gland, which we thought might have some effect on psychiatric conditions. So I gave it to some of my schizophrenic patients. We kept good records of our patients then – actually daily progress notes – and there was suddenly, on October 16, you see a very long note, describing a miraculous, very dramatic improvement, almost overnight, from one day to the next: the patient was lucid, cooperative, rational, he had a different posture – it was dramatic… So we had great hopes for this “extract 47,” until we found out, within a week or so, what had really happened: this extract had a high alcohol content! It just shows you that even with the best efforts and looking at all kinds of different criteria, whether they are rating scales or other criteria, one has to be very skeptical, before one accepts even dramatic results as being promising or novel treatments.
We did all kinds of other things. I injected sulphur in oil which was painful and caused a fever; I injected typhoid antitoxin intravenously which produced pyrexia in schizophrenic patients. Nothing helped; I even injected turpentine into the abdominal muscles which produced – and was supposed to produce – a huge sterile abscess and marked leucocytosis. Of course, that abscess had to be opened in the operating room under sterile conditions. None of this had any effects, but all of this had been proposed in, mostly, European work as being of help in schizophrenia. The best results I could obtain were with prolonged sleep, which Klaesi had introduced in the 1920s, but that was quite a dangerous procedure, because it often led to pneumonia and we did not have penicillin in those days. All this led to a lot of frustration but no discouragement. I kept on looking for something.”
I’ve read this article a number of times over the years and always end up humbled. How, as a committed, caring mental health professional do you go to work every day in a hospital where there’s “one registered nurse for 600 or 700 male patients”. How unimaginable to be one of the 700 patients suffering in such a place. Many ACT clients would have been in such settings.
Psychiatrists want to help and we are all too often faced with problems for which we do not have effective treatments. This leaves us vulnerable to forgetting that critically important insight made by historian Leland Bell and which I blogged about 3 years ago in Cycling History. Bell wrote how
” … institutional psychiatry has supported a bewildering array of therapeutics that have followed a roller-coaster pattern of fashionability. A new therapy is introduced with great excitement and enthusiasm. Sophisticated, detailed reports verify its effectiveness and show remarkable cure and improvement ratios. This excitement and interest soon fade. Follow-up studies and additional research challenge the initial reports and reveal that the therapy has limited applications, that it should be given only a modest place in psychiatry’s armamentarium. Even the most dramatic therapeutics have followed this cycle of hope and disillusionment.”
These days there seems to be a lot of buzz around ketamine, an anesthetic used in veterinary medicine which may have benefit in treating refractory depression. Authors of a recent JAMA review note that “Even these data are limited by the fact that most of those studies evaluated efficacy only during the first week following a single infusion of ketamine,” the authors caution.
It’s not that I doubt that ketamine, or deep brain stimulation or other ‘cutting edge’ treatments are of benefit. I just think we should approach new treatments with a certain mindfulness (mindfulness is big these days), always keeping Bell’s words in the back of our minds.
Thanks for taking the time to read my musings.