Being depressed is experiencing five or more of nine diagnostic criteria within a two-week period of time. And despite other mood disorders like bipolar disorder, dysthymic disorder, cyclothymic disorder or depressive disorder NOS, (not otherwise specified), there is not a clear distinction between these kinds of depression. The older conceptualization suggested we had a problem of nerves—that it was an illness of the entire body. But according to Edward Shorter, “The current classification is a jumble of nondisease entities, created by political infighting within psychiatry, by competitive struggles in the pharmaceutical industry, and by the whimsy of the regulators.”
Today, with the ubiquity of the diagnosis of depression, we have the idea that low mood and an inability to experience pleasure are our main problem; we see ourselves as having a mood disorder situated in the brain and in the mind that antidepressants can correct. But this is not science; it is pharmaceutical advertising.
Depression is conceptualized and presented as if it exists on an interval scale, ignoring the possibility it may be two or more disorders overlapping one another. In How Everyone Became Depressed, Edward Shorter persuasively advocated that there are two kinds of depression, “as different as tuberculosis and mumps.” He said it made no sense to lump them together under the general term of “depression.” The first kind of depression was nonmelancholic and nonpsychotic, “heavily admixed with anxiety and fatigue.” It is laced with obsessive thinking and often overcome by somatic complaints. The second kind of depressive disorder was melancholia:
It is an independent and unmistakable disease entity, often not combined with anything, and fearsome in a far different way than nervousness, for it may lead to despair, hopelessness, a complete lack of pleasure in one’s life, and suicide. By the late nineteenth century, the difference between these two depressions lay clear in view and observers often distinguished between them. Subsequently, both swim out of focus; nervous disease is broken up, and what we have emerged with today as “depression” bears little resemblance to these historic ancestors.
According to Shorter melancholia is a disease of the whole body. “The endocrine system is intimately involved, and the blackness of affect reaches into the adrenal gland.” Affect is profoundly flattened. Stupor and dejection can alternate with periods of agitation. Oswald Bumke said in 1908, “The essential characteristic of melancholia is a sadness of mood that is not founded in external circumstances, a strongly depressive affect, from which a gloomy assessment of one’s own situation arises, as well as ideas of having sinned in the past and anxious fears about the future.”
Melancholia appears to be sadness, but is often described by patients as pain. A Florida psychiatrist said, “Most of my patients suffering from major depression have described their malady as the worst pain they have had to beat.” Melancholics often look dejected. They have empty eyes and frozen features. They also have slowed thought and movement—psychomotor retardation. “All movements are conducted slowly, any change of bodily position is avoided; the speech is soft, halting and limited to what is absolutely necessary.”
Melancholics at risk of suicide can be difficult to assess because they complain of everything but their mental pain. Shorter suggested it could be that admitting depression in these circumstances “would cause others to thwart your desire for suicide.” In 1911 The New York Times described a doctor at St. Francis Hospital in Pittsburgh who was suffering from a complete nervous breakdown. After shaving under supervision, he asked a male nurse to accompany him to a bathroom and when there, sent the man on an errand. The man had concealed a razor in his pajamas. A few minutes later a doctor saw a stream of blood running from under the door. “Dr. Miller was found with his throat cut from ear to ear.”
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.
Shorter said from the seventeenth century medical writers have described melancholia similar to what was said here. This suggests that we are dealing here with a relatively unchanging biological type, according to Shorter. Other psychiatric illnesses seem to be influenced by personal beliefs and social attitudes. However, in medical writing what changes historically is the distinction of melancholic depression from other kinds. “But the basic melancholic prototype has been visible from the beginning.”
Shorter reserves a distinct, biological niche for melancholia and it seems to fit within a modern dispute over the effectiveness of antidepressants with more severe cases of depression. The melding of melancholia into depression brought about confusion with diagnosis and generated the “jumble of nondisease entities,” which we will examine in the second part of this article. I suggest first that we should look back to the origins of the term and how it too has changed its meaning over time.
Melancholia stems from the Greek melan (black, dark) and chole (bile). Medical practitioners once thought the human body had a system of humors—bodily fluids that included black bile, yellow bile, blood and phlegm. An imbalance of the humors was thought to result in sickness of the body and mind. An excess of black bile (thought to be secreted by the kidneys or spleen) meant the person could become unsociable, liable to anger, irritable, brooding and depressed.
Telles-Correia and Gama Marques said in “Melancholia before the twentieth century” that Richard Burton commented in his 1621 book, The Anatomy of Melancholy, on the confused state of melancholia: “The tower of Babel never yielded such confusion of tongues as the chaos of melancholy doth variety of symptoms.” The authors went on to note Hippocrates (460-379 BC) attributed melancholy to the excess of black bile, which was characterized by several symptoms, including fear and sadness. Galen (129-216 AD) followed Hippocrates in his theory of the four humors, but saw melancholics also having what we would call delusions. Aretaeus of Cappadocia (1st century AD) also saw melancholy as having a delusional element. Andreas Laurentius (1560-1609) followed Galen and Hippocrates in seeing it was caused by an excess of black bile and saw melancholics having “a disturbed imagination.”
Richard Burton (1577-1640) began to move away from the humor theory of depression and likened the task of gathering the meanings of melancholia to “capturing [a] many-headed beast.” While people suffering from melancholia present with multiple symptoms, the most frequent are fear and sorrow. He defined melancholy as follows:
Melancholy, the subject of our present discourse, is either in disposition or in habit. In disposition, is that transitory Melancholy which goes and comes upon every small occasion of sorrow, need, sickness, trouble, fear, grief, passion, or perturbation of the mind, any manner of care, discontent, or thought, which causes anguish, dulness, heaviness and vexation of spirit, any ways opposite to pleasure, mirth, joy, delight, causing forwardness in us, or a dislike. In which equivocal and improper sense, we call him melancholy, that is dull, sad, sour, lumpish, ill-disposed, solitary, any way moved, or displeased. And from these melancholy dispositions no man living is free, no Stoic, none so wise, none so happy, none so patient, so generous, so godly, so divine, that can vindicate himself; so well-composed, but more or less, some time or other, he feels the smart of it. Melancholy in this sense is the character of Mortality… This Melancholy of which we are to treat, is a habit, a serious ailment, a settled humour, as Aurelianus and others call it, not errant, but fixed: and as it was long increasing, so, now being (pleasant or painful) grown to a habit, it will hardly be removed.
Phillipe Pinel (1745-1826) abandoned the humoral theory entirely and favored a more descriptive psychopathology. He narrowed the field of mental disorders into four groups: Melancholia, Mania, Idiocy and Dementia. For Pinel, melancholia had two opposite forms, seemingly describing what we now call bipolar disorder. The first sense was “a heightening of pride and the chimeric idea of possessing infinite richness and power without limits.” And the second form was “the most fearful despondency, a profound dejection or even despair, therefore considering two forms of melancholia: depressive and expansive.”
In the beginning of the twentieth century the term melancholia was replaced by the term depression, largely under the influence of Emil Kraepelin. Today it carries some significance with certain cases of severe depression, but is known as endogenous depression—not a distinct kind of depression. Melancholia (endogenous depression) is characterized by profound sadness, anhedonia, a loss of emotional resonance, insomnia, anorexia, motor retardation, circadian variability in mood, and the presence of delusions and/or hallucinations. In Part 2 we will look at how Emil Kraepelin and Robert Spitzer finally “killed off” melancholia as a separate disease from depression.