The Natural History of Mania, Depression, and Schizophrenia

By George Winokur and Ming T. Tsuang. 372 pp. Washington, D.C., American Psychiatric Press, 1996. $42.50. ISBN 0-88048-726-7

In these times of overflowing information, when the medical books and articles published every year number in the thousands, it is difficult to recommend a new book to readers of the Journal. This is even harder in the case of a book such as Winokur and Tsuang's The Natural History of Mania, Depression, and Schizophrenia, which is a summary of previously published articles. Nevertheless, I enjoyed this book and found it worthwhile.

The book summarizes the "Iowa 500," a landmark, long-term study of the natural course of psychosis in approximately 500 patients admitted to the Iowa Psychiatric Hospital from 1934 to 1944. The excellent records kept make it possible to diagnose the patients' illnesses again with modern diagnostic criteria. The disorders were rediagnosed blindly on the basis of the patients' 30-to-40-year disease course. The prevalence of familial psychiatric illness was studied in the patients' relatives and in a group of controls who were undergoing surgery.

The book describes the background, methods, and results of the Iowa 500 study, but because it is limited to 372 pages some historical aspects of the study are not covered. For instance, during the 1960s and 1970s there was a revolution in American psychiatry that originated in the psychiatry department of Washington University in St. Louis. Some psychiatrists, including Winokur, thought that the only way of advancing in psychiatry was to return to the concepts of Kraepelin, the German psychiatrist who began early in this century to use symptoms, the disease course, and the outcome in diagnosis. To improve diagnostic reliability they decided to define research diagnostic criteria. In a few years this led to the development of the Diagnostic and Statistical Manual of Mental Disorders (third edition) and to the boom of biologic psychiatry. The Iowa 500 study is one of the main products of this "Neokraepelinian" movement. One would like to know how and when Winokur thought that a study such as the Iowa 500 was possible. The difficulty of long-term studies of psychotic patients in the United States is not sufficiently emphasized.

Reading this book would benefit medical students interested in specializing in psychiatry who think the diagnosis of psychosis is a challenging enough topic to consider as the basis of a career. The book gives an idea of the challenge and satisfactions of making such diagnoses. Psychiatry residents who think that this topic did not receive enough emphasis during their training should read this book to be exposed to the authors' clinical wisdom. Finally, I recommend the book to the growing number of family members willing to acknowledge that a relative has a serious mental illness and who are interested in knowing the natural lifetime course of such illnesses.

Winokur and Tsuang should be commended for reminding us that the long-term course of an illness is crucial in diagnosing psychoses. For busy clinicians, I suggest, as an alternative, reading a two-page article ("'Cause the Bible Tells Me So," G. Winokur, M. Zimmerman, and R. Cadoret. Archives of General Psychiatry 1988;45(7):683-4) that summarizes the wisdom that Winokur and his colleagues have been trying to communicate for the past 30 years. This article should be essential reading for psychiatry residents.

Jose de Leon, M.D. University of Kentucky College of Medicine Lexington, KY 40508

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