How Everyone Became Depressed (14 page)

*Electroconvulsive therapy, or ECT, means procuring a therapeutic brain seizure by applying two electrodes to either side of the cranium; this bilateral placement of electrodes is very effective. ECT is the most powerful treatment that psychiatry has on offer, and more may be learned about its history in Edward Shorter and David Healy, Shock Therapy: A History of Electroconvulsive Treatment in Mental Illness. New Brunswick, NJ: Rutgers University Press, 2007.

slyly about their plans to end their lives, which are often worked out well in advance, in contrast to nervous patients, who too may commit suicide but in a more impulsive manner.
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Melancholia is nothing if not cunning.

Or for other reasons melancholia may hide its face, even just to maintain the appearances of normality. John Scott Price, a psychiatrist at Northwick Park Hospital in Harrow, England, called such behavior in 1978 the “great cover-up”: The depressed patient refuses to “tell others how bad he feels. Most depressives, even severe ones, can cope with routine work—initiative and leadership are what they lack. Nevertheless, many of them can continue working, functioning at a fairly low level . . . The world leaves the depressive alone and he battles on for the sake of his god or his children, or for some reason which makes his personal torment preferable to death.”
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What emerges from the stories of melancholic patients is how different they are from patients with nervous disease. This is not a continuum of gravity that begins with the mildly nervous and ends with patients curled into a fetal ball, but a discontinuity as two different kinds of illness somehow end up with depression as their name. Melancholia was not neurotic depression. Among the women admitted to the closed ward of the Holloway Sanatorium just outside of London in 1889, there were plenty of melancholics. See if this sounds like nervous illness: Charlotte L, a single secretary of 36, came into Holloway Sanatorium on January 31. She had two medical certificates justifying her involuntary admission to a closed ward. One said, “Is suspicious, restless and sleepless, thinks she has done some crime and ought to go to prison.” The other said that “She thinks she has done some great injury to a lady of Torquay.”

History of present illness: She apparently suffered overwork in “keeping the accounts of a large house of business. The onset of the attack was marked by extreme depression, loss of sleep and appetite.” “Mentally,” said a staff psychiatrist, “she is suffering from simple melancholia . . . She has grossly deceived all her friends, that she has led a sinful life (which is untrue).”

Charlotte L spent half a year on the ward and improved steadily, though almost to her discharge in June “she states that her ideas cannot change since her past life has been so unpardonably sinful, and that when her true character is discovered she will be shunned by all good people.” Yet these notions, too, passed and in mid-June, at the request of her family, she was discharged “recovered.”
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Holloway Sanatorium had no particular treatments for melancholia and rarely used opium, the only effective medication. But melancholia has a natural history of its own, and most patients recover within 8 months spontaneously.

Some of the melancholic women who came into Holloway in 1889 were suicidal. Mary L, 44, housewife, depressed for a year, was said by the physician who issued her first certificate to be “listless, apathetic, profoundly depressed because of fancied ill-treatment of her husband, thinks she has conspired with others to ruin him, at times is excited at the probable consequences of her awful wickedness and wishes to end her life.” The second certificate said she imagined “her wickedness will ruin her husband and the entire world. That the cause of the wickedness is writing a letter. She threatens to drown herself.” At admission in February, the nurses were warned, “She is suicidal, but not dangerous to others.”

On the unit, “She thinks one of the companions (Miss R) is her brother in female dress, and attacks her whenever she comes into the ward. Of late she has more obstinately refused her food.” After the passage of some months she was well enough to travel down to the convalescent home of the sanatorium in the seaside spa of Bournemouth. “She has greatly benefited by the change. Occasionally she goes home for a day in charge of her husband.” Thus she slowly became better and in September she was discharged “recovered.”
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The gap between nervous illness and what was seen at the Holloway positively assails the reader! Emily T, 44 years old when she came into the Holloway in April 1889, was having her fourth attack of melancholia, the first having occurred at age 27. She had been hospitalized for all of them. This time, she had been sick for about a year, and now “was afraid the lady she lived with would murder her. Said she ran after strange men as her brother,” said certificate one. Certificate two noted that she “Washes herself with boiling water.”

At admission, “The skin both of face and hands and wrists is excessively coarse, thickened and uniformly red from the custom she has of washing them in hot soda [caustic lye] . . . Mentally she is suffering from melancholia and dementia.” (The clinicians took her habit of sitting motionlessly and staring fixedly all day long—possibly a sign of catatonia—as “dementia.”) She was generally mute, save for rising at every visit of the doctor to ask “Can I go now?” She also refused her food on the grounds that “It is too fearful to eat in this place!!” She was often tube fed.

By July 1891 she had been at the Holloway, on various wards depending on her behavior, for over 2 years. “She remains weak-minded and depressed, dull and listless. She is reported to be addicted to masturbation.” (Many of these female patients, in Victorian Britain, masturbated quite openly, alarming the staff for medical not moral reasons: Masturbation was believed to cause insanity and was carefully noted in the chart. Jane Hillyer, in a private sanatorium in the United States around the time of World War I, also admits to masturbating quite openly: She had the delusional belief that it had “appeared in the papers.”
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) Later in 1891 Emily was transferred to another private psychiatric hospital, and then to another, at which, in August 1892, she was declared “relieved,” meaning improved, but not well.
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It would be impossible to mistake any of these patients, psychotic and mute, some smearing their feces, for nervous, and the term nervous illness is almost never used in the charts. Yet contemporaries would have widely agreed that they had suffered nervous breakdowns.

Since the seventeenth century, medical writers have described melancholia in a manner quite similar to our own, suggesting that we are dealing here with a relatively unchanging biological type, like diabetes or stroke, rather than—as in the case of many psychiatric illnesses—with a phenomenon heavily influenced by personal beliefs and social attitudes. What changes historically in medical writing is the differentiation of melancholic depression from other kinds of depression. But the basic melancholic prototype has been visible from the beginning.

In 1602 Felix Platter in Basel described a number of “melancholic” patients, who were indeed sad, despairing, and psychotic. One was a peasant woman, “of great beauty,” who had given birth, then became melancholic during nursing. “She developed the habit of saying continuously, as she nursed her child and was in medical treatment, ‘I can no longer live and be in this world, I must leave it, I must die.’ In doing so she mentioned no cause that might have agitated her so greatly. She tried to hang herself with a rope that she had contrived at home, but was freed from death by someone who came along and tore the sling down . . . ”
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To be sure, Platter includes other cases that sound more directly psychotic than melancholic. Yet he certainly understood the core concept and did not use the term merely as a synonym for madness.

In 1799 James Sims, president of the Medical Society of London, gave a description of melancholy that would not be out of place in a learned seminar today. “In the first approaches of melancholy, the persons become silent and absorbed in thought, dislike being spoken to or roused, and seem always occupied in some grave contemplation. Jests, laughter, and every species of hilarity seem irksome to them.” This is a description, of course, of anhedonia, the inability to experience pleasure.

As the illness progressed, said Sims, “Their speech is slow, sedate, solemn, measured, and argumentative; and they are mostly buried in sorrow.” In addition to sadness, Sims describes here what later generations would term psychomotor slowing, a fundamental characteristic of melancholia.

At this point, continued Sims, they start to become psychotic, not his term. “They complain of some action that they have done against some friend or relative, or some crime that they have committed, which can never be forgiven by God or man. This action is often totally imaginary.”

Yet it gets even worse, said Sims. “They become suspicious of all around them and imagine that they see conspiracies against them in the most trifling occurrences. They think all their friends are become enemies, which induces a taedium vitae, ending often in suicide.”

And anxious! Sims painted a picture of melancholic anxiety: “They enjoy but little sleep, and that anxious, waking often in a fright. They become extremely silent, but have great anxiety painted on their countenance, which at the last becomes austere and morose, with eyes betokening treachery and despair.” They experience other somatic symptoms that much later generations of doctors would call “neurovegetative” in nature: “They may refuse nourishment, fasting for days, nay, often weeks.” They become indifferent to the ambient temperature, huddling close to the fire in summer, “whilst in winter they appear insensible of cold.”
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As a description of melancholia, this is spot on. Few would confuse it with the nervous syndrome.

In the course of the nineteenth century, a much tighter picture of melancholia evolved, one that differentiated it from nonmelancholic depression. But it is necessary to bear in mind an admonition in 1976 of Leo Hollister, an internist with a deep knowledge of psychiatry at the Veterans Administration Hospital in Palo Alto, California, and generally considered the dean of United States psychopharmacology: There is, he said, no given symptom that is pathognomonic, or absolutely characteristic, for any psychiatric illness. “They all overlap, so one cannot go on specific symptoms, which are meaningless.” Hollister said it was the constellation of symptoms that gives the diagnosis, and this constellation is often referred to as the syndrome.
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So this is not an exact science, and, aside from the few biological markers that do exist in psychiatry—such as the dexamethasone suppression test—diagnosis remains pattern recognition rather than peering at the laboratory results.

There were several big changes in psychiatric thinking about melancholia during the nineteenth century. For one thing, the medical conception of melancholia as a disease of intellect gave way to views of it as a disorder of the emotions, of affect. Doctors’ views are different from actual historic descriptions of the disease itself, which, as we saw above, are full of affective symptoms. But physicians, when they looked, saw more madness than sadness. John Ferriar, an asylum psychiatrist in Manchester and “physician to the Manchester Infirmary,” reflected this older view when he wrote in 1819, “A melancholic perceives, not wrongly [as in mania], but too intensely regarding some objects, which induces him to grant them an exclusive attention, and leads him to reason improperly.” What does this mean? “A melancholy patient, despairing of his circumstances without foundation, was persuaded with much difficulty to draw up a short statement of his affairs . . . He placed his debts in one column, and his property in another, opposite. But no argument nor intreaties could prevail upon him to compare the columns, by which it would have appeared that he was master of a considerable sum: his attention was wholly occupied with the list of his debts, and he obstinately averted his eyes from the other column.”
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What Ferriar is describing here is a thought disorder, or perhaps an example of obsessive thinking, but not a mood disorder.

Then the asylum doctors, the alienists, slowly began to pivot and to regard melancholia as a disorder of emotion rather than intellect. Etienne Esquirol, Pinel’s successor and staff psychiatrist at the Salpê tri ère hospice, later chief physician of the French state asylum at Charenton, was probably the first to conduct this pivot when, in 1821, he proposed the term lypémanie for melancholia, disliking the latter’s association with humoralism and black bile. Lypemanie was a psychotic “partial disorder” of mind and brain, rather than total insanity, and was characterized by a “sad passion” driving the delusional thinking.
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Many authors took this up, and the pivot was certainly accomplished by 1852, when Joseph Guislain, professor of psychiatry in Ghent, wrote, “All melancholia expresses the lesion of a sentiment; it represents a painful affect [une affection douloureuse].” Yet “Despite the sadness that strikes these patients, they almost never cry.”
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This is clearly the modern conception of melancholia, and it developed particularly in France in the first half of the nineteenth century—the heyday of the French domination of psychiatry.

In a second development, melancholia and mania came to be seen as the primary disturbances, or original disorders, in a chain of events that would inevitably lead through irrational thought to dementia. There was, in other words, really only one psychotic illness, and various symptoms and syndromes were just stages in an unfolding of that process; it became known as the “unitary psychosis” view (in German, Einheitspsychose). Wilhelm Griesinger, as a young asylum psychiatrist still in his 20s, was its chief initiator—though Griesinger was heavily influenced by the writings of his chief Ernst Albert Zeller. Those who took the unitary psychosis view were analogizing from neurosyphilis, a then common tertiary complication of syphilis: Neurosyphilis was indeed a single disease with a progression through stages, and no two patients might have the same symptoms at the same time because they were at different stages. Hence, psychosis might be like this too, an orderly march through stages from an initial episode of mania or depression to an abject end in the back wards of an asylum. Griesinger wrote in 1845, in the first edition of what was later to become a world-beating textbook, “There is on the whole a constant successive course [starting with melancholia] that can lead to the complete disintegration of psychic life.” The therapeutic consequences of this inevitable progression were rather grim: “Insanity is really only during this first group of primary affective mental anomalies curable; with the progression to the secondary [floridly psychotic] disturbances the disease becomes incurable.”
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We need a footnote here: Connoisseurs of the history of depressive illness may say that the first writer to break up melancholia on a meaningful basis (meaning not on the basis of symptoms but of clinical course) was Karl Kahlbaum, one of the great names in the history of understanding psychiatric illness. It was Kahlbaum who in 1874 coined the term catatonia
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and whose academic-habilitation essay in 1863 made him among the first to classify illness on the basis of course. At the time, Kahlbaum, age 35 years, was still an assistant physician at the Prussian state asylum in Allenberg, and saw mainly very sick people. He distinguished between melancholia as a “Vesania,” meaning insanity affecting the entire mind and brain, and as a “Vecordia,” meaning partial insanity limited to the sphere of feeling. Vesanic melancholy, he said, might well pass through a manic stage, and a stage of insanity, to end in dementia. Vecordic melancholy might well not progress. Hence there was a difference between vesanic (terminal) melancholy and vecordic (self-limiting) melancholy. (Kahlbaum used the term dysthymia as well as melancholia. Hence the dysthymia mel ä na was the typically sad Vecordia.)