How Everyone Became Depressed (13 page)

Motto: “ . . . considering the ill that trouble of mind and melancholy may in this sickly time bring a family into.”
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Samuel Pepys, 1665

Most organic illnesses go back in time to the appearance of the first medical records, and doubtless existed far before then. Melancholia is no exception. It is one of the classical evils to which the flesh is heir. The Ancients expanded the definition to many afflictions that we might today consider separately, yet they nonetheless drew attention to the core symptoms of profound dejection and slowing, complete lack of joy in life, and delusional apprehensions of the surrounding world.
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Galen, a Greek medical writer in the second century after Christ, said, “The melancholic derangements vary, by there being several kinds of false imaginings. In all these, however, one thing seems to be common, which has been stated by Hippocrates: ‘If fear or despair continues for a long period, such a thing is melancholia.’ For they are all despairing without reason, nor, were you to ask, would they be able to say they are distressed about anything . . . ”
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In the early modern period, melancholia remained sufficiently alive, though just barely in the fog of religion, that priests thought it necessary to differentiate melancholia as a clinical illness from demonic possession and bewitchment. How can you tell if your parishioner is ill or bewitched? Francesco Maria Guazzo, a priest in Milan, said in 1608, “The following is the usual practice to determine whether the sick man is possessed by a demon. They [the Church] secretly apply to the sick man a writing with the sacred words of God, or Relics of the Saints, or a blessed Agnus Dei, or some other holy thing. The priest places his hand and his stole upon the head of the possessed and pronounces sacred words. Thereupon the sick man [the bewitched individual] begins to shake and tremble, and in his pain makes many uncouth movements, and says and does many strange things. If the demon is in his head, he feels the keenest pains in his head, or else his head and all his face are suffused with a hot red glow like fire.” If the demon is in his stomach, there will be hiccups and vomiting, “so that sometimes they cannot take food.” Yet the melancholic will do none of these things.
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Even in the gloom of the Counter-Reformation, the clinical concept of melancholia survived, so powerfully did it speak to reality.

And patients, or potential patients, knew well what they had. Margaret, Marchioness of Newcastle, an early female scientist and an ambitious writer, described in 1656 at age 30 the turmoil the family suffered during the English Civil War. “But being not of a merry . . . disposition, I became very melancholy by reason I was from my Lord [husband], which made my mind so restless that it did break my sleep and distemper my health.” She clarified: “As for my disposition, it is more inclining to melancholy than merry, but soft, melting solitary and contemplative melancholy. And I am apt to weep rather than laugh, not that I often do either of them.”
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So she describes her melancholia both as a trait, a constant companion, and a state into which a reversal of circumstances might plunge her.

In 1763 English poet William Cowper, at 32 years of age a candidate for a post in the English House of Lords, and a highly nervous candidate at that, was disturbed in his preparations for the examination by yet another attack of melancholy, an illness that ran in the family. Beside himself with agitation, he attempted suicide three times. As he was discovered on the third attempt, any possibility of gaining a parliamentary post vanished, and, says his biographer, “The sense of total failure must have been as overwhelming as the feeling of moral degradation into which, apparently, all other concerns were channeled . . . In the days that followed his attempts at suicide, whenever he opened a book, he found it filled with allusions to his condition and with details and rhetorical figures that seemed addressed to him. In the streets people seemed to avoid him or laugh at him.” Cowper became preoccupied with “the wrath of God punishing the worst of sinners,” and his poetry in the midst of this psychotic depression reflects the lowness of his spirits:

“Hatred and vengeance, my eternal portion, Scarce can endure delay of execution, Wait, with impatient readiness, to seize my Soul in a moment.”

It is interesting that Cowper was not necessarily sad, or weepy. Rather he experienced his melancholia at a somatic level as pain and numbness. Writing to a friend of how he had spent the previous night, he said, “My ears rang with the sounds of torments, that seemed to await me. Then did the pains of hell get hold on me, and, before daybreak, the very sorrows of death encompassed me. A numbness seized the extremities of my body, and life seemed to retreat before it. My hands and feet became cold and stiff; a cold sweat stood upon my forehead; my heart seemed at every pulse to beat its last, and my soul to cling to my lips, as if on the very brink of departure. No convicted criminal ever feared death more, or was more assured of dying.”

In the course of the day, as he anxiously paced his apartment, “a strange and horrible darkness fell upon me. If it were possible, that a heavy blow could light on the brain, without touching the skull, such was the sensation I felt. I clapped my hand to my forehead, and cried aloud through the pain it gave me.”
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We can understand the comparison with rabies mentioned above: Psychotic melancholia is among the most terrible of illnesses and has little in common with the nervous syndrome. (Again, just to signpost this path strewn with “n” words: The nervous breakdown equaled melancholia, which is what Cowper had; the nervous syndrome equaled the five domains of nonpsychotic anxiety, depression, fatigue, somatic symptoms, and a touch of OCD, which is what most sufferers had.)

A poem from these years shows well that Cowper was aware of the difference between his own affliction and the kind of “spleen” and black-bile “humour” that would later be called nerves
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:

“Doom’d, as I am, in solitude to waste The present moments, and regret the past; Depriv’d of every joy, I valued most,
My friend torn from me, and my mistress lost; Call not this gloom, I wear, this anxious mien, The dull effect of humour, or of spleen!”

This was full-blast melancholia. And its expression in English romantic poets such as Cowper and Thomas Gray had a dramatic influence on striving young romantic spirits on the Continent. We like to think of melancholia as a predominantly biological illness, and the evidence of biomarkers such as the dexamethasone suppression test and serum cortisol suggest the correctness of that view. Yet there is a cultural component. And when German poets such as Johann Wolfgang von Goethe got their hands on the English romantics, they in turn became melancholic! Or at least they fashioned their subjective illness experiences on the template of those they had been reading about. Goethe said much later in his 1811 autobiography that if German youth at the end of the eighteenth century began to brood upon the transitory nature of passions such as romantic love, it was because the Germans had “an external occasion for these gloomy preoccupations . . . in the English literature, especially the poetry, whose great merits are accompanied by a serious melancholy, which comes across to every person who tarries at these pages.”
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It was indeed under these influences that Goethe himself wrote in 1774 The Sorrows of Young Werther, one of the great classics of Romantic literature—but highly depressive; Werther commits suicide at the end, as in fact Goethe himself had once attempted suicide.

A cardinal characteristic of melancholia is the inability of patients to experience pleasure, called in 1897 by French psychologist Théodule Ribot anhedonia: “insensibility relating to pleasure alone.”
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In 1913 the influential German psychopathologist Karl Jaspers termed it “the feeling of loss of feelings.” “The patients complain that they are unable to experience pleasure or pain.”
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(The notion of anhedonia then slumbered for a number of years until in 1974 Columbia psychiatrist Donald Klein revived it in the concept of endogenomorphic depression, the kind of depression not precipitated by external events.
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) Yet from the patient’s viewpoint, anhedonia, conceived as the loss of pleasure rather than the loss of interest, is a core component of the melancholic experience. (As English psychiatrist Philip Snaith at Leeds pointed out in 1992, “A gardener may retain an interest in the flowers he grows but no longer experiences pleasure at their sight or their smell.”
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) In 1821 Fanny Burney, depressed now in her own turn, lamented, “The spirit of enjoyment is gone!—gone!—though the animal spirits still, at times, are revived by social exertions.”
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The blackness of spirits in melancholia that echoes to us across the ages reflects the loss of any pleasure in life.

There are several other important points about melancholia. It is a recurrent illness, not a one-shot affair. “Virtually every patient experiences more than one episode,” said Jules Angst, professor of research psychiatry in Zurich, in 1973 apropos of a five-country study of hospital cases.
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Melancholia digs deep into the brain and body, putting patients in touch with their most primeval—and often sinister—impulses. Fantasies of murder and suicide are common themes. New York neurologist Landon Gray Carter believed that a vague feeling of distress in the back of the head and neck was a diagnostic sign of melancholia (which it is not); such symptoms in his patients often prompted him to prod a bit deeper. He reported in 1890 a “lady” who had come to see him with such a complaint: “I then asked her whether she had not at the beginning been very much depressed.” She said yes, and “with so embarrassed an air as to make me assured that there was something concealed . . . She burst into tears, and admitted that she also had passed through an attack of melancholia, and astonished me in her turn by telling me that she was the wife of a well-known physician, and that she had concealed all knowledge of her mental condition from her husband, because she was afraid that he would send her to an asylum. This poor woman had absolutely on several occasions felt so strong an impulse to kill her children and herself that she had been obliged to leave the house and get away from them.”
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Altruistic murder is often at the core of such impulses in melancholia, murdering someone else to save them from an imagined terrible fate. In Houston, Texas, in 2001, Andrea Yates—in the throes of a psychotic depression— drowned her five children one by one in the bathtub of her home to save them from the fires of hell.
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(That such a tragedy could have been prevented had she been diagnosed in a timely manner and treated with electroconvulsive therapy makes the importance of getting it right all the more urgent.)

A French psychiatry textbook noted in the early 1920s how common suicide was in melancholia, and that “in women it can co-exist with murdering the children, intended to save them from the tortures that await them.”
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And just apropos! Through the forensic infirmary of the Paris Prefecture of Police passed all kinds of melancholic cases, including in March 1921, Angelina-Maria A, age 44 years, housewife, husband a sommelier in a restaurant. In the telegraphic style of Ga ë tan Gatian de Cl érambault, the chief psychiatrist, she had “Delusions of persecution. Auditory hallucinations. Patient was also delusional: The malady is filled with consequences. Disordered internal sensations. Melancholic phase with a very marked tendency to suicide and to altruistic murder. For two weeks she had hidden a hammer under her pillow to kill her husband and her child, with the intention of suiciding afterwards by leaping from the window. On March 15, having dispatched the witnesses on a pretext, she began to beat her child with a brush, and tried thereupon to jump out the window. Formal, repeated confession of homicidal intent towards the child with the motive that, if she herself were to die, she would have left the child at the mercy of her own tormentors . . . Telepathy. Holes in the floor with a fluid rising up. Various odors.”
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Today we would probably say psychotic depression, rather than melancholia, yet such crazed depressions usually are melancholic.

Melancholic patients with the idea of making away themselves and others are often very secretive about their plans because they do not wish to be thwarted. As a result, clinicians may miss the gravity of the diagnosis. Miss Leila Herbert, daughter of the ex-Secretary of the Navy Hilary Herbert, deceived everyone when she committed suicide in 1897 by plunging herself head-first from the window of a house on fashionable New Hampshire Avenue in Washington. She had fallen from a horse and became melancholic in the course of a long convalescence. But on the day of her death, she disarmed the nurses who had been hired to watch over her by being “unusually bright and cheerful, and chatted animatedly with her married sister.” Who could have suspected? But then one of the nurses saw a small bloodstain on the patient’s bedding. “She inquired what it meant but the invalid endeavored to pass it by lightly. On making an investigation., however, the nurse found that the under bedclothes were saturated with blood, and that Miss Herbert had severed an artery of her wrist with a pair of scissors.”
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As the nurse rushed to the door to give alarm, Miss Herbert took advantage of the occasion to plunge from the window, landing on her scull.

Arthur Zankel, a financier and philanthropist who committed suicide in 2005 by leaping from the window of his New York apartment on Fifth Avenue, was secretive in the weeks before his death. “Everything aches,” he told his son Tommy. He asked about falling from the ninth floor, whether the fall would be uninterrupted. He invented excuses for not seeing people and lied to his secretary, said a story in the Wall Street Journal, “telling her he would be out for a few weeks because he was having ‘a minor surgical procedure.’” The tragedy of his death came as a huge surprise to everyone except his wife, who realized what was going on but thought he was being treated appropriately by his clinicians (the treatments for Zankel’s melancholic illness apparently did not include electroconvulsive therapy).
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It is, in other words, normal for melancholics to behave