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Psychotic DepressionReview - Psychotic Depression
by Conrad M. Swartz and Edward Shorter
Cambridge University Press, 2007
Review by Marion Ledwig, Ph.D.
Jul 29th 2008 (Volume 12, Issue 31)

The authors of this cutting edge volume on psychotic depression with its eight excellent chapters and two appendices are the board-certified psychiatry professor and practicing psychiatrist Conrad M. Swartz from the Southern Illinois University School of Medicine and the historian of psychiatry and health practitioner Edward Shorter from the University of Toronto. According to the authors (p. xi this volume) "Psychotic Depression is an alloy of psychosis and depression that is not separable into psychosis and depression. Psychosis is a symptom that thought and behavior have become unrelated to reality. It is, in other words, a symptom of madness just as biological as delirium."

This book deals with all aspects of psychotic depression covering such diverse areas as its clinical history, current state-of-the-art diagnostic, and treatment protocols. It includes two appendices: The first is a summary guide to psychiatric concepts with respect to the disorder and the second is a summary guide to different kinds of medication for treatment and/or management of psychotic depression. While the book is mainly aimed at physicians, it is written in such a way that even patients themselves, their friends, and families and everyone else who is interested in the subject matter can understand it including many case studies so that one gets a realistic and vivid picture of the illness.

The authors mainly advocate their own classification of seven different forms of psychotic depression and the use of electroconvulsive therapy (ECT for short) as the best means of treating psychotic depression giving extensive evidence for its effectiveness including meta-studies and trying to prove the prejudices against it wrong. Electroconvulsive therapy which is described in the book in detail has become unpopular with the public by for instance such movies as One Flew Over the Cuckoo’s Nest with Jack Nicholson (p. 154 this volume) in 1975 and was shunned by many psychiatrists who were fond of Freudian psychotherapy and psychopharmacology.

The book gives an interesting insight into the politics of the American Psychiatric Association (APA) and how their Diagnostic and Statistical Manual (DSM) with its different versions up to the DSM-IV got developed. Especially the shortcomings of the different versions of the manual are highlighted and even inconsistencies with the International Classification of Diseases, Tenth Edition (ICD-10) are pointed out. Also insights into how the pharmaceutical industry is connected to the different treatment practices are presented.

What I found of particular interest is that the authors elucidate how psychotic depression is connected to other disorders or illnesses such as post-traumatic stress disorder (PTSD), schizophrenia, epilepsy, Parkinson’s, and/or Alzheimer’s disease. Also that severe depression is mainly not characterized by sadness but by pain, I considered of particular value. That bipolar disorder, where a patient normally swings back and forth from depression to mania, might be very difficult to diagnose in certain cases because of the summation of depression and mania at the same time was quite an insight.

The authors make reasonable distinctions such as between symptom management and treatment of the disorder and are very careful and very elaborate in their diagnosis of cases, distinction between cases, treatment prescriptions, the effectiveness of diverse medications, their side effects and interactions with other medications, and short- and long-term prognoses in cases of psychotic depression. Additionally, they also consider the influence of genes on the disorder, which brain areas are involved, which neurotransmitters are connected to the illness, and how electroconvulsive therapy leads to an improvement of psychotic depression, that is, what kind of mechanisms are involved in its improvement. Finally, it was interesting to see that over the decades the delusional content of patients with psychotic depression has shifted from sinning against God to crime or at least away from sinning.

With regard to shortcomings of the volume, in my opinion there are two minor ones. It is very difficult to verify whether the politics of the American Psychiatric Association are correctly portrayed. While the authors draw on a huge number of studies to support their view, they also heavily rely on their own personal experience as therapists.

After having given an overall evaluation of the book, here is an overview of the respective chapters of this volume: Chapter one gives a short introduction into the subject matter. In chapter two the history of psychotic depression is portrayed pointing out the significance of German psychiatrists in the nineteenth century "giving rise to the aphorism that if French was the language of diplomacy, German was that of psychiatry" (p. 26 this volume).

The authors give their own classification of seven different forms of psychotic depression (p. 80ff), which cannot be found in the DSM-IV manual, in chapter three which deals with the proper diagnosis in psychotic depression. The seven forms are: (1) Melancholic psychotic depression, (2) psychosis-dominant depression, (3) catatonic psychotic depression, (4) psychotic-equivalent depression, (5) tardive psychotic depression, (6) drug-induced psychotic depression, and (7) coarse brain disease psychotic depression. All of these forms are explained and characterized in a very detailed way in the book.

Chapter four is on the patients’ experience of their own illness, while chapter six deals with pitfalls in treatment and the pathway to a proper treatment. Chapter seven explains the procedure of electroconvulsive therapy, what kind of mechanisms make it work, which kind of medications should be taken after electroconvulsive therapy, and whether other medications are better than electroconvulsive therapy. Finally, chapter eight gives specific treatment directions for each form of psychotic depression.

© 2008 Marion Ledwig

Marion Ledwig is currently visiting assistant professor at the University of Nevada, Las Vegas. She has studied psychology and philosophy at the University of Bielefeld, Germany, and received her Ph.D. in philosophy from the University of Konstanz, Germany. She is the author of "Reid's Philosophy of Psychology" (2005), "Emotions: Their Rationality and Consistency" (2006), "Common Sense: Its History, Method, and Applicability" (2007), and "God’s Rational Warriors: The Rationality of Faith Considered" (2008).


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