Psychotic Depression

by Conrad M. Swartz MD, Edward Shorter

Overview

Psychotic Depression aims to help clinical practitioners and trainees describe their observations of psychotic depression, formulate treatment, and express expectations of recovery from illness. It focuses on all facets of the disorder, from clinical history to coverage of the current state-of-the-art diagnostic and treatment protocols. Medical readers of this book will come away able to diagnose and readily treat psychotic depression and thus will be able to serve their patients better. Non-physician readers will come away with the message that this is a terrible illness, but there is hope. This book fills an important gap in the realm of psychiatric literature.

Product Details

ISBN-13:	9780521878227
Publisher:	Cambridge University Press
Publication date:	04/16/2007
Series:	The Practitioner's Guide to Patient-Centered Psychiatric Treatment Series
Pages:	344
Product dimensions:	6.34(w) x 9.33(h) x 1.02(d)

About the Author

Dr Conrad M. Swartz is a board-certified psychiatrist who has written and lectured extensively on the topic of the use of electro-convulsive therapy for the treatment of severe depression.

Edward Shorter is a psychologist and historian who has written three books on the history of psychiatry and psychosomatic illness.

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Cambridge University Press
9780521878227 - PSYCHOTIC DEPRESSION - by Conrad M. Swartz and Edward Shorter
Excerpt

I

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Introduction

ON JUNE 20, 2001, Andrea Yates of Houston, Texas, drowned her five children one by one in the bathtub in her home. She was clearly seriously ill and had been treated with the drugs sertraline (Zoloft), olanzapine (Zyprexa), haloperidol, and lorazepam among other remedies. Her attending psychiatrist had rejected electroconvulsive therapy (ECT) for her on the grounds that it was “for far more serious disorders” (Denno, 2003). She was said to have committed this terrible act in the grips of major depression. But that cannot be right. “Major depression” is not a specific illness. She had psychotic depression. She was improperly diagnosed, evaluated, and certainly inadequately treated. Her illness gave her an overwhelming compulsion or she would not have pushed the heads of her children underwater in the delusive belief that she was saving them from Hell.

Andrea Yates herself was caught in the jaws of Hell. An editorial in the British medical weekly Lancet in 1940 called depression “perhaps the most unpleasant illness that can fall to the lot of man” (Lancet, 1940), and in the midst of a psychotic depression, Yates had opportunity to experience this. Psychiatry could have rescued her, but confusion about herdiagnosis and her treatment interfered.

The Andrea Yates story had one more chapter, in which the reality of her illness from psychotic depression was finally understood. An appeals court overturned her original conviction because of inaccurate evidence from Park Dietz, a forensic psychiatrist who had testified for the prosecution. In July 2006, Yates again went before a jury, which found her not guilty. “The jury looked past what happened and looked at why it had happened,” said her former husband. “Yes, she was psychotic. That’s the whole truth.” This time Yates was sentenced to an indefinite term in a maximum security hospital (Associated Press, 2006). Thus the story had an end that lifted slightly the flap of public ignorance about this disorder.

What happened to Andrea Yates between her 2002 and 2006 courtroom trials is also noteworthy. In 2002 she was physically fit. In 2006 she was hardly recognizable, flabby and overweight. In television views of her in prison before the 2006 trial she was unkempt and poorly groomed. Under psychiatric treatment her appearance strikingly deteriorated. What types of psychiatric treatments cause such deterioration, and what do not? People avoid psychiatrists because they are afraid of being stigmatized or controlled by psychiatric treatment. Success in treatment includes avoiding stigmatization and behavioral deterioration from the treatment.

Marc Cherry was the producer and scriptwriter of the TV series Desperate Housewives. He said that, like Andrea Yates, his mother was at the cusp of a similar experience. He and his mother had been watching the news coverage of the Yates trial one evening and she grunted, “I was once almost there myself.” Cherry was so surprised that he said to himself, “If my own mother was once so desperate, then every woman has probably felt the same thing” (Kreye, 2005).

But no! Andrea Yates killed her children in the grips of a delusional depression. However stressed, every woman does not have a psychotic depression, any more that every woman has a pancreatic tumor or a spinal infection. Psychotic depression is as much a medical illness as tuberculosis. It is not a blip on the stress continuum. Mrs Cherry, at one point, as her son said, set to throw her children out the car window, may or may not have had a psychotic depression. But it is a disease, not a normal response.

What is psychotic depression?

There is a classical psychiatric tradition of dividing depression into two types. As Michael Shepherd, the dean of British psychopharmacology, pointed out in 1959, there were hospital depressions and then there were “large groups of loosely termed ‘neurotic,’ ‘reactive,’ or ‘exogenous’ depression often admixed with the clinical manifestations of anxiety. Many of them run a chronic, fluctuating course.” They were certainly not suitable for admission to hospital. Most of these patients “do not come to medical attention at all but rely rather on the advice of the chemist [pharmacist] or on self-medication” (Shepherd, 1959).

In one type of depression – Shepherd’s hospital depression – brain biology takes over. The depression happens out of the blue. The patients are very sick and may have delusions and hallucinations or sink into stupor. In 1920 German psychiatrist Kurt Schneider, then in Cologne, proposed a term for this kind of depression in which the patients were terribly slowed. He called it endogenous depression, borrowing from the great German nosologist Emil Kraepelin the term “endogenous,” by which Kraepelin meant biological, indwelling in the brain, and dominating the body. Schneider contrasted endogenous depression with a second type, which he called “reactive” depression, usually seen outside of hospital settings. Reactive depression has almost nothing in common with psychotic depression except maybe sadness. Yet reactive depression can also be quite serious, the patients hovering on the brink of suicide. But reactive patients are not psychotic nor do they experience the same kind of “psychomotor retardation,” to use the technical term for thought and action being slowed. There are two different illnesses here, one involving a terrible, pathological slowing among other symptoms and the other dependent on external events.

Whether there are two depressions or one – and, if two, whether they may be divided into endogenous and reactive – has long been controversial. We step into a snake pit here. But the massive evidence of the history of psychiatric illness does indeed suggest that there are two. For the sake of convenience we call them here endogenous and reactive-neurotic, fully aware that future generations may find these terms inadequate. Yet the present state of science does not permit us to go beyond them, and whatever one chooses to call them the fundamental reality is that two classes of depressive illness exist, as unalike as chalk and cheese. Most practitioners will probably agree with this, even though they are forced into the procrustean one-depression bed by the official diagnostic schema – the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association – that is now current.

One distinguished believer in the two-depression concept is Joe Schildkraut at Harvard. In 1965 Schildkraut devised one of the most influential ever biological theories in psychiatry. He said that affective disorders (depression and mania) result from disturbances in the metabolism of the neurotransmitter norepinephrine. Chemically, norepinephrine belongs to the “catecholamine” class of neurotransmitters, and Schildkraut’s ideas became famous as the “catecholamine hypothesis of affective disorders.” Schildkraut, as other observers, saw that there were two kinds of depression. Later, he characterized the endogenous disorders as “running out of gas depressions” and the reactive as “chronic characterological depressions.” (He actually did not use the term reactive but rather “depressions with much more in the way of … self-pity and histrionics.” Yet it means the same thing: a chronic character meets a distressing environmental event.) Schildkraut called the endogenous concept “more a European notion, a notion that might be called by some vital depressions, because you didn’t have to have a depressed mood. It was based on having a loss of vitality, anergia, anhedonia and psychic retardation.” He said that such depressions, unlike the reactive, “did not readily change with ongoing interpersonal interactions or environmental events. It was a kind of fixed-stuck disorder.”

A tradition exists of calling endogenous depression melancholia. Psychiatrists once resisted the term melancholia because it harked back to the days when deep depression was associated with humoral theories of “black bile” and the melancholy constitution. Yet the term melancholia has such historical heft that many prefer it to the rather jargonish-sounding “endogenous.” Bernard Carroll affirmed emphatically in 1982, after discovering that a biological test (the dexamethasone suppression test) was relatively specific for melancholia, “Our results give unequivocal support to the view that melancholia is a categorically distinct entity from non-endogenous depression” (Carroll, 1982). In 2006 Michael Alan Taylor and Max Fink re-endorsed in a comprehensive overview the existence of melancholia as a separate diagnosis (Taylor and Fink, 2006). In our view, melancholia is one type of endogenous depression, but when speaking generalistically the two terms are interchangeable.

There are various types of endogenous depression. In catatonic depression, the extreme form of which is stupor, movement and speech are slowed. In melancholic depression, the patient has a sickly persona, and movement and speech may also be “retarded.” In this book, we are interested in the type of endogenous depression called “psychotic,” characterized by delusions and hallucinations. As Chapter explains, there are various forms of psychotic depression that are really more or less independent illness entities in their own right. Psychotic depression is not actually a disease of its own but a collective term for a number of illnesses having the common properties of depression and psychosis. Of hospitalized patients with endogenous depression, about half are psychotic.

Psychotic depression is highly dangerous. The patients’ thinking becomes so delusive that, having lost contact with reality, they contemplate suicidal behavior, taking poison perhaps to kill off the hallucinated bug infestation (although it kills them). As London psychiatrist Thomas A. Munro, a psychiatrist at Guy’s Hospital in London, pointed out in 1949, “The treatment of depression is always a great responsibility. The patient’s life is at stake” (Munro, 1949).

Psychotic depressions can also be risky for others. As with Andrea Yates, periodically there are terrible stories of psychotically depressed parents who murder their children to save them from the fires of Hell or the doom the parents know lies ahead. Thus, the English Drug and Therapeutics Bulletin advised in May 1965 as follows: “Another reason for admitting severely depressed patients to hospital is that on occasion they murder relatives or friends in an attempt to spare them imagined pain.”

In psychotic depressive illness we are therefore discussing a variety of endogenous depression, depressions that may end up in hospital. Reactive depressions, on the other hand, come on slowly, under stress, and are filled with anxiety, anger, or dissatisfaction. The symptoms of reactive depressions tend to be vague, formless, and primarily subjective. In today’s psychiatry, reactive distress tends to be called by a range of terms that are really all over the map, from adjustment reaction, major depression, depression “not otherwise specified,” or dysthymia, to the whole anxiety spectrum, such as generalized anxiety disorder or some other anxiety diagnosis, to personality disorders such as borderline personality, or even dissociative disorder. The term neurosis formerly applied in many cases. The psychoanalysts once considered these patients, perhaps not incorrectly, as having a character disorder. A number of additional conditions doubtless huddle under the shelter of reactive distress, including chronic fatigue syndrome (formerly neurasthenia), weltschmerz, and the emotional consequences of poverty, pain, and threatening medical illness.

In the vast mass of “depression” diagnoses that are handed out today, many patients will have such a reactive depression: the depression comes on in response to bad news rather than out of the blue. The patients’ thought and movement are not abnormally slowed as in endogenous depression. Unlike psychotic depression, which answers readily to ECT, reactive depressions do not respond so well to ECT. The phrase “reactive depression,” by the way, was abolished in 1980 in American psychiatry with the advent of a new recipe-based classification manual called DSM-III. Yet, the term reactive depression delineates a basin of distressed patients with a mixture of sadness, weariness, and anxiety that is difficult to circumscribe well, and there is no reason why it should not soldier on.

Endogenous depression is an entirely different beast. The patients are not necessarily sad but slowed in thought and deed, sometimes to the point of stupor. The patients complain that their minds move slowly and their movements are laborious and painful. In the psychotic variety of endogenous depression the patients are not always slowed, and may have a hint of mania, exhibiting such features of agitation as pacing and repeating “It’s my fault, it’s my fault.” Yet the main point is that the patients are tormented by delusions of various kinds; in an earlier era their delusive thoughts often involved their irremediable sinfulness; today, hypochondriac delusions about one’s organs turning to concrete and the like come to the fore. Endogenous illness does not have the same favorable promise of remission that is lent to reactive depression, although after about 8 months most untreated endogenous patients get over it (for the time being). Patients with endogenous depression are often inclined to seek oblivion, so that suicide is always to be feared, as actually happens in perhaps one in seven of the untreated cases. (But in nonendogenous depression too the patients may attempt suicide, and the psych emergency wards are very familiar with them.)

“Endogenous depression should be looked upon as an acute disease, like appendicitis; it cannot wait,” one Swedish psychiatrist told a Scandinavian symposium from the floor in 1960. He remembered a patient from his practice in Linköping, referred with the following information, “The patient is recommended for examination at a psychiatric clinic.” There was nothing more. “We phoned the doctor but he was not in, and then we wrote – as we usually do – requesting details of the case. Three days passed before we got any news and the same day the patient committed suicide, taking with him a daughter of five years.”

Finally, endogenous depression is “autonomous”; it does not get better with good news. Your lover has just moved back in? Guess what, your psychotic depression has not improved. As psychopharmacologist Donald Klein once told Robert Spitzer, the mastermind of DSM-III, in a moment of irritation, “I think that the distinction between the relatively autonomous depression and the relatively reactive depression is a strikingly important one that should be present in this edition [the forthcoming DSM-III-R in 1987]. That also speaks for the utility of a mood-reactive depressive disorder.”

DSM-IV in 1994, no longer under Spitzer’s control, did incorporate the notion of mood reactivity, but made it a characteristic of major depression with “atypical features,” meaning what is often called “atypical depression.” Yet the disease designers included alongside “mood reactivity,” “interpersonal rejection sensitivity,” which means basically thin skin (American Psychiatric Association, 1994). The disease designers had in effect asserted that thin skin is the autonomous dimension of major depression.

The basic problem with DSM, though, is that it fails to recognize endogenous depression. The manual styled itself as “atheoretical,” meaning making no assumptions about causation. But by dismissing causality, DSM is more agnostic than diagnostic. In all other fields of medicine, causality is crucial in diagnosis and intimately tied to evidence and scientific observation. Psychiatrists must not be so totally agnostic (if they want to be effective or to practice on the basis of modern science).

After Kraepelin lumped mania and depression together in 1899 as a single illness, “manic-depressive psychosis,” for about the next half century endogenous depression often was referred to as manic-depressive illness. Yet the majority of patients had no evidence of mania, and many patients with mania had no history of depression. Today, authors distinguish between genuine manic-depressive illness, also called “bipolar-1” disorder, and unipolar disorder (depression without mania). This book is mainly about unipolar disorder and about psychosis in the depressive phase of bipolar illness. But, to be frank, some clinicians think that sooner or later many of the depressed hospitalized patients will develop an episode of mania, and that on a lifetime basis the distinction between unipolar endogenous depression and bipolar disorder is meaningless.

To recap, this basic distinction between endogenous and reactive depression has today almost been lost sight of. Since Kurt Schneider, the classification of depression has become rather a parlor game for insiders, with countless varieties being proposed. In particular, the all-encompassing amorphous label of major depression and a pseudospecific

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© Cambridge University Press

Table of Contents

1. Introduction; 2. History of psychotic depression; 3. Diagnosis in psychotic depression; 4. Patients' experience of illness; 5. Treatment in historical perspective; 6. Treatment: pitfalls and pathways; 7. Treatment: ECT, medications, and more; 8. Treatment by type of psychotic depression.

Editorial Reviews

Reviewer: Michael Schrift, DO (University of Washington School of Medicine)
Description: This is an important and timely book, written for both clinicians and laymen, on a serious life-threatening disorder that is all too frequently misdiagnosed and undertreated, psychotic depression. (I must disclose that my assessment of this book cannot be totally unbiased, since I have been trained by, and was subsequently a colleague of, Dr. Swartz. Dr. Swartz has been an extremely productive investigator of the neurobiology of convulsive therapy and is highly influential in this field.) With this caveat in mind, this book is written and edited by a nationally recognized clinician-researcher and psychiatric historian and is a welcome addition to the medical and psychiatric literature.
Purpose: According to the authors, "this book aims to help the clinicians and trainees describe their observations of psychotic depression, formulate treatment, and express expectations of recovery from illness." It is highly informative for clinicians, patients, and their families about the kinds of experiences patients suffer and as a guide to successful treatment outcomes. The book helps readers to view psychotic depression as a distinct clinical entity with specific treatment implications.
Audience: The intended audience includes psychiatric residents, practicing psychiatrists, and nonphysician readers. It should be required reading for any clinician involved in the care of seriously ill patients with psychiatric disorders.
Features: The book is a mixture of scientific evidence, clinical opinion (albeit with some idiosyncrasy) based on many years of experience, and historical facts. The history of the concepts regarding psychotic depression as well as the differential presentation and diagnosis of the illness are thoroughly covered. Empathic understanding of patients' psychopathological experiences that is integral to the doctor-patient relationship is detailed in a very readable fashion. It is one of the factors that make this book invaluable. ECT and psychopharmacological treatment algorithms, which are quite helpful to clinicians, are covered as well. The two appendixes covering general psychiatric concepts and psychopharmacologic classes are informative.
Assessment: This is an excellent and enlightening book, written for clinicians and the public, on a "mortally dangerous" disorder. All psychiatrists need to be able to recognize and properly treat this serious condition and need to be thoroughly versed in the information contained in this outstanding book.

Doody's Review Service

"..provides a detailed discussion of a topic that may be understudied. ...the in-depth discussion of ECT and its efficacy in the treatment of psychotic depression is thorough and convincing. ...the supporting literature appears quite robust and even includes meta-analytic research (Parker, Roy, Hadzi-Parlovic, & Pedic, 1992)."
Lisa J. Cohen
PsychCRITIQUES, APA Review of Books

"Psychotic Depression is not quite a textbook, not quite a monograph on a specific illness, not quite a collection of psychiatric case histories, and not quite a scholarly history...The book is a mixture of these genres...the most interesting parts of the book are the discussions of historical cases such as Sylvia Plath and Andrea Yates".
New England Journal of Medicine

"This is an important and timely book, written for both clinicians and laymen...All psychiatrists need to be able to recognize and properly treat this serious condition and need to be thoroughly versed in the information contained in this outstanding book."
Doody's Book Review Service

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