How Everyone Became Depressed (15 page)

Kahlbaum did in fact separate melancholia from nonmelancholia with the term dysphrenia nervosa, which meant organic neurological illness: A subtype of it, nervosa depressa, was nonmelancholic “depression,” and Kahlbaum used the d-word.
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Only when Kraepelin started to rethink the entire question of the psychoses and mood disorders years later did he stumble across Kahlbaum’s habilitation, cited it, and made it famous. Kahlbaum’s 1863 book itself was not influential.

The name of the game here was to separate melancholia from nonmelancholia, and this Kahlbaum had in fact done but in a manner so confusing and filled with neologisms that few understood it. The first step occurred with a small and often overlooked work in 1867 by Richard von Krafft-Ebing, then a staff physician at the Illenau asylum in Germany and later professor of psychiatry in Vienna and author of the international bestseller Psychopathia Sexualis; his little book was intended for use in forensic medicine. Krafft-Ebing said that it was necessary to distinguish between simple psychic depression and the varieties of psychotic depression, of which he discerned two: depression plus hallucinations and “melancholic delusional disorder, which as well might be marked with hallucinations.”
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This was the first formal distinction between depression and psychotic melancholia. But by “depression” Krafft seems to have understood mainly nonpsychotic melancholia, and he uses depression and melancholia as synonyms.

This basic distinction between nonmelancholic depression and psychotic melancholia was then refined in coming years. In 1879 Latvian physician Theodor Tiling, leader of a private nervous clinic in St Petersburg, tried to drum up business for this kind of open facility by distinguishing between a depressive dysthymia, suitable for such a clinic, and fully psychotic melancholic illness (“I shot the Kaiser!”) that was probably the beginning of the progression to madness and dementia and that belonged in a closed facility. The dysthymic were not silent and guarded but easily expressed their opinions to the physicians, and had merely pressures in the head and stomach from their “pangs of conscience.” (So in Tiling’s dysthymia there was a hint of psychosis.) Dysthymia was recurrent, but did not deteriorate into insanity, Tiling said.
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(Dysthymia may be conceived as the depressive component of the nervous syndrome, whereas psychotic melancholy occurred in nervous breakdowns.)

Carl Georg Lange, professor of pathological anatomy in Copenhagen and considered Denmark’s “first neurologist,” evidently did not know of Tiling’s work. Lange was much more influential, and in 1886 he formally distinguished between what he called periodic depression and melancholia. “It might at first glance appear singular that such a general and important kind of illness, such as the depressive conditions discussed here, are so little known and that in the literature one finds only slight traces here and there, and that as a result physicians as well have only very vague and unclear ideas of these matters.” He saw neurasthenia as a kind of rubbish bin, but made a fundamental distinction between melancholia and “periodic depression.” “The pathognomonic features of the illness,” he said of periodic depression, were “the heaviness, tiredness, and flaccidity which the patients complain about constantly, the feeling of a great burden that crushes them physically and mentally to the ground, the apathy, that makes them indifferent to everything . . . Under the influence of this ‘mental pressure,’ our patients tend to reject all work, all duty and . . . to surrender to their feelings of misery.” In fact, they are still capable of going to work, but report feelings of “mental rigidity, or petrification . . . as if the protoplasm in their brain cells had truly become fixed.” So this was one depression, a kind of running-out-of-gas feeling, as Harvard’s Joseph Schildkraut much later would characterize it.
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Lange did not use the term nervous syndrome, but periodic depression could well have been yet another term for the depression of that syndrome, given that, in addition to being tired, the patients were also anxious, and tended to obsess about their condition. “This anxiety has no particular foundation; they aren’t afraid of this or that, but rather are dominated by a general, indeterminate feeling of anxiety.” Men suffered more from an inability to get on with the job at hand and women from a deadening of feeling. Loss of appetite and insomnia completed the picture.

And then there was melancholia. “The depressives never become melancholics,” said Lange. “The characteristic aspect of the melancholic is, that his feelings of oppression and anxiety arise from obsessive thoughts, from imaginary persecutions or hallucinations, and that as a result the melancholic considers his desperation to be thoroughly justified.” Lange said that melancholia meant psychosis. Among the depressives there was no trace of psychosis: “Their illness consists solely and alone in an anomaly of mood, and they are always completely clear about this, that their mood is not justified by external circumstances.”
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Subsequent generations would squabble about what exactly constituted depression versus melancholia, but these early works offered the first clear statement that they were different diseases.

It was Emil Kraepelin who killed off melancholia and prompted its replacement with depression. Normally, we would not assess scientific progress in terms of the successive editions of a textbook, but Kraepelin’s textbook, which first appeared in 1883 and started to become highly influential with the fourth edition in 1893, dominated world discussion of the classification of illness. And to understand why the nervous breakdown became less fearsome, we have to understand how melancholia was turned into depression. This happened in Kraepelin’s Psychiatry: A Textbook for Students and Physicians.
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In the 1893 fourth edition, the discussion was quite conventional: “melancholia” was a separate illness, and depression was part of “the periodic mental illnesses,” a separate category.

It was then the fifth edition in 1896 that abolished melancholia and replaced it with depression. Among the “psychic disorders with a constitutional basis,” we find “periodic insanity,” and part of these periodically recurring illnesses was “depressive forms.” There were also “circular forms” of depression, the depressive conditions alternating with the expansive conditions—classic “circular insanity,” in other words, as the French had described it half a century before. Yet the term depression carried the main freight, which melancholia had previously borne.

But this fifth edition did retain “melancholia” in one particular sense: Melancholia was one form of involutional insanity, meaning illnesses that overcame people in mid-life as their sex organs began to shrink up, or involute. This was a serious illness, a crack-up. Patients took much longer to recover than with depression, if in fact they ever did. Of his older patients with melancholia, only 25% recovered completely.
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Involutional depression or melancholia went on to become a world-beating diagnosis, taken up in the discourse of psychiatry in every land—and even today we occasionally hear the term involutional, for those who fall ill later in life.

Why had Kraepelin substituted depression for melancholia? He never explained exactly, but in the “involutional” section he did say that he was retaining the term “melancholia” only for these illnesses with onset at midlife: “We designate with the term melancholia all pathological sad or anxious mood disorders [Verstimmungen] of the later years, which do not represent part of the course of other forms of insanity.”
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The Kraepelin story has two more chapters. In the sixth edition in 1899 he created manic-depressive insanity, collapsing a number of previous distinctions about depression in circular insanity and so forth, and lumping every kind of depression and mania, regardless of circularity or periodicity, together in one big pot. Every form of mood disorder became manic-depressive insanity. Note that this is not the same thing as bipolar disorder today, because we have a separate unipolar depression, and although Kraepelin had recognized that separateness in 1896, he no longer did in 1899. (Kraepelin retained involutional melancholia.) He said, by way of explanation for creating what became known as “MDI”: “In the course of the years, I have convinced myself more and more, that all these illness pictures [mania, circular and periodic mood disorders etc] are only presentations of a single disease process. . . . It is, as far as I know, entirely impossible to discern any particular boundaries among these individual clinical pictures, that until now have been held separate.”
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(This edition also executed the fateful separation between manic-depressive illness and dementia praecox—later schizophrenia—that has prevailed to this day and that ended the unitary psychosis doctrine: Kraepelin established the idea that these were separate disorders. They did not turn into one another, any more than mumps turned into tuberculosis.)

The great Kraepelinian shift from melancholia to depression was completed in the eighth edition in 1913—the last that Kraepelin personally was able to bring to a conclusion—when he abolished involutional melancholia and made it part of manic-depressive insanity. Georges Dreyfus’s 1907 work at Heidelberg convinced him that involutional melancholia had the same course and outcome as other mood disorders, and that it was pointless to keep it separate. Also, the term melancholia was superfluous, said Dreyfus, as the illness picture was part of manic-depressive disease.
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Yet involutional melancholia took wings as a diagnosis, even though Kraepelin had tried to withdraw it, and became the catch-all phrase for serious illness in those aged 50 or older. English psychiatrist Eliot Slater recalled the asylum scene in the 1930s: “The involutional melancholic would be a thin, elderly man or woman, inert, with the head lifted up off the pillow [a sign of catatonia]. There were some sort of Parkinsonian-like qualities, mask-like face sunk deep into misery, and speaking in a retarded way. If you could get them to say anything, it would be something about how hopeless things were, how they were wicked, doomed to disease, death, and a terrible afterlife, if there was one.”
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There remained this single trace of the great melancholia edifice.

A diagnosis like melancholia with such a long pedigree could not easily be decreed out of existence, and Kraepelin did make the occasional bow to it. He conceded that psychotic depression might be termed melancholia gravis, to emphasize its pathological fury.
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Elsewhere in this great work, that by 1913 had swollen to four volumes, he suggested that particularly malignant outcomes might be referred to as melancholic.
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Yet the term melancholia disappeared as an independent disease entity.

Not everyone was enchanted. Alfred Hoche, professor of psychiatry in Freiburg im Breisgau (the German Freiburg, not the Swiss), disliked the construction of these great disease entities such as manic-depressive illness and dementia praecox because their contents were too disparate. And he deplored the disappearance of melancholia. “It is characteristic,” he said in 1910, “of the uncertainty of our current clinical world that such an old and well-established heirloom of psychiatry as melancholia should go into liquidation and fall under the auctioneer’s hammer.” The whole debate about whether involutional melancholia should be part of manic-depressive illness was pointless, he said, because neither existed.
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[It is striking how these warnings foreshadowed the criticism of such categories as major depression of the Diagnostic and Statistical Manual ( DSM) of the American Psychiatric Association a hundred years later.]

Yet these warnings were soon forgotten. Kraepelin’s advocacy of depression over melancholia proved highly influential. On the other side of the Atlantic, in 1904 Adolf Meyer, who taught psychiatry at Cornell University Medical School in New York City and was already the most influential psychiatrist in the United States (even before taking the chair at Johns Hopkins), cast his ballot for the abolition of melancholia. He told a meeting of the New York Neurological Society that “On the whole, he was desirous of eliminating the term melancholia, which implied a knowledge of something we did not possess . . . [hard to know what he was getting at here] If, instead of melancholia, we applied the term depression to the whole class, it would designate in an unassuming way exactly what was meant by the common use of the term melancholia . . . ”
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Why is it so important, or even interesting, to learn how depression replaced melancholia? Because depression is a less terrible word. Nervous breakdowns that happened to the melancholic were catastrophic events; those in the merely depressed, though subjectively fearsome, sounded less fearful because so many people were calling themselves depressed. Novelist William Styron, in a poignant memoir of his own nervous breakdown, written in 1990, appreciated the importance of this semantic difference: Styron himself had experienced agonies that make the rabies comparison seem realistic, and after his recovery he wrote that “‘Melancholia’ would still appear to be a far more apt and evocative word for the blacker forms of the disorder, but it was usurped by a noun with a bland tonality and lacking any magisterial presence, used indifferently to describe an economic decline or a rut in the ground, a true wimp of a word for such a major illness.”
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And so, thanks to Kraepelin, melancholia began to shrink from center stage, giving way to the true wimp, depression. But the term melancholia had acquired huge historical momentum, and would persist decades after Kraepelin and Meyer turned up their noses at it. Henry Yellowlees, physician for mental diseases at St. Thomas’s Hospital in London, warned the Section of Psychiatry of the Royal Society of Medicine in 1930 not to make the mistake of adopting the “popular view that melancholia was a caricature of normal depression.” “The neurasthenic was a person of active emotional reactions, who bewailed the limitations which his illness imposed upon him; whereas the melancholic was the reverse.”
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