How Everyone Became Depressed (17 page)

Kr aepelin’s influence in renaming melancholia “depression” was enormous. But that alone would not suffice to explain why, an ocean away and a hundred years later, everybody became depressed. Mediators were needed to carry the doctrine of depression to the discipline of psychiatry, and then to individual patients. Those mediators were the American psychoanalysts, many of them distinguished migrants from Europe, and they gave pride of place to neurotic depression. Other mediators extracted depression and anxiety from the pool of nerves and yoked them together, making mixed depression-anxiety the favored disorder.

To gain some perspective: In the first third of the twentieth century, in a great paradigm shift that transferred behavioral disorders from neurology to psychiatry, the spotlight shifted from nerves, a diagnosis that implicated the whole body, to mood, a diagnosis that implicated mainly the mind. Mental illness triumphed over nervous illness, and depression became the main mood diagnosis. In 1908, Oswald Bumke, a psychiatrist then at the university psychiatric hospital in Freiburg, Germany (later to become professor of psychiatry in Munich), scolded the family physicians who never suspected depression in their wealthy patients whom they sent from spa to spa and sanatorium to sanatorium for the treatment of nondisease (symptoms without organic causes). The family doctors, who doubtlessly suspected the symptoms were of psychological origin, focused on the symptoms themselves; Bumke, more interested in mental than in physical symptoms, focused on what he believed the underlying cause to be: “depression,” as manifest in symptoms such as tiredness or an anxious preoccupation with their bodily health.
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For clinicians of Bumke’s generation, depression was a familiar concept.

In understanding the rise of depression there are two questions that have to be sorted out: Why the depression diagnosis becomes so common and why depressive symptoms become divorced from the nervous syndrome and take on a life of their own as an affective disorder. Because events on both tracks happen around the same time, the narratives interblend, but they are separate stories.

To foreshadow, it was American psychoanalysis that first put depression in the spotlight. The analysts took the neurosis diagnosis, which had been around for a century or more, and made the commonest of the neuroses depressive neurosis. This became the workhorse of everyday psychoanalytic practice. Most psychiatrists were not psychoanalysts, but because of the prestige of psychoanalysis, analytic formulations became the meat and drink of everyday psychiatry. This explains why depression triumphed as an affective disorder: The analysts were interested in affect; they were not interested in fatigue, insomnia, or any of the rest of the nervous syndrome.

But quite outside of psychoanalysis, attention became focused upon mood as well. As mainline psychiatry shifted attention from nerves, hysteria, and neurasthenia, its glance fell upon the mood disorders depression and anxiety, and in particular that they were usually hooked together. In the community, the main psychiatric complaint was mixed anxiety-depression. Beginning in the 1920s and culminating in the 1970s, this mixed disorder became the commonest psychiatric illness. It was in fact the core of the former nervous syndrome, with fatigue, the somatic symptoms, and the obsessiveness stripped away.

The triumph of the American analysts’ neurotic depression, and of the nonanalysts’ mixed anxiety-depression, put an end to anything nervous. Nerves and the like were common terms term until World War I, then began to seep away from medicine. Outside medicine, people would still use the term nervous breakdown—as indeed they do today—but within medicine nerves became pass é , old-fashioned. Thus changes in fashion in medical diagnoses eclipsed a fundamental reality for millions of people: Their problems were not really owing to their depressed or anxious mood, depressed or anxious although they may have been, but to a disorder of mind, brain, and body together. This disorder had previously been called the nervous syndrome. It now took on a different cast entirely.

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Just two words up front: Long before Freud, the term depression was
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alive in popular culture. Late in eighteenth-century England, young Fanny the page Burney, in addition to recording her own panics (see p. xxx), noted as well number her father’s downcast mental state. In 1792 she wrote in her diary of “My dear father … lower and more depressed about himself than ever. To see him dejected is of all sights, to me, the most melancholy.”
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The 29-year-old English parliamentarian—later Prime Minister—William Gladstone noted in his diary in 1838 of the day’s sessions in the House of Commons, “Through the debate I felt a most painful depression.” Later that year, attending someone’s funeral: “The Cemetery beautiful and soothing. I am tempted to desire to follow. I ought to be happy here, having the means to be useful: yet I live almost perpetually restless and depressed.”
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These examples could be multiplied many-fold. Mental depression, as we understand the term, was a solid concept in people’s vocabulary from the late eighteenth century on.

Second, for physicians, depression and melancholia were in one pool, nerves in another. We have seen this in earlier chapters. Nervosity, nervosisme, and cognate terms designated garden-variety distress, not depression. Depression was considered a “difficulty in the exercise of the intellect”—as one English asylum doctor put it in 1854—and was seen as part of melancholia before the doctrine of the two depressions arose (see Chapter 6).
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The term neurosis itself had been in common use since the late eighteenth century to mean any disease of the central nervous system. It was only with Parisian internist Auguste Axenfeld in 1863 that neurosis (n évrose) came explicitly to mean disorder without a lesion.
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In German-speaking Europe, in 1879 Richard von Krafft-Ebing, professor of psychiatry at the time in Graz, coined the term psychoneurosis to mean a behavioral disorder in an individual who was not genetically predisposed, not degenerate, in the language of the day. “For those mental disorders that affect individuals with healthy brains let us use the designation psychoneuroses; for those that arise on the basis of predisposition, the expression psychic degeneration will serve.”
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Thereafter, neurosis and psychoneurosis did yeoman service in the description of nonpsychotic disorders, which was the situation up to Freud.

Kraepelin’s manic-depressive illness (MDI) was a powerful concept. It abolished the notion that there were two depressions—melancholia and neurasthenia—and said that all the clinical pictures of depression and mania boiled down to more or less the same thing, “MDI.” Yet like nerves, the concept of two separate depressions as illnesses as different as measles and tuberculosis had a good deal of face value and did not die out with a snap of the Kraepelinian fingers. The continued coexistence of melancholia alongside neurasthenia, neurosis, spleen, and the rest of it meant that there must be two depressions: a terrible psychotic illness leading to suicide versus a kind of blues that, although unpleasant, were not the end of the world. Even though Kraepelin had admitted a “psychogenic depression,”
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his doctrine of manic-depressive illness said that there was just one depression. Something had to be done about that.

In 1913, Karl Jaspers, a student of Kraepelin’s in the Heidelberg university psychiatric hospital, identified reactive depressions in his influential book on psychopathology. “Reactive depressive conditions are especially frequent,” he said, differentiating understandable reactions to events from incomprehensible attacks of psychosis that seemed to come out of the blue.
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This put an alternative to manic-depressive illness on the table, making a second depression conceptually available, in other words.

This second depression was quickly taken up. In 1920 Kurt Schneider, a 33-year-old assistant physician at the university psychiatric hospital in Cologne who had just returned from military service (he had studied in Tü bingen and was not a Kraepelin pupil), proposed a division of the depressive illnesses that would endure right until 1980, and represented the most powerful illness dichotomy that psychiatry had to offer until the advent of DSM-III: It was Jaspers’ reactive depression versus endogenous, or vital, depression. (Kraepelin himself had suggested the category endogenous psychosis.) Every psychiatric reader of this book who trained before 1980 will recall from his or her residency the distinction between reactive and endogenous depression––reactive taught as a reaction to an unhappy event and endogenous as a kind of physical depression that seemed to well up within the body without an external cause. This is not exactly what Schneider meant. Schneider wrote, “In considering depressive conditions let us begin with both of the characteristic types in their extreme forms: the pure unmotivated ‘endogenous’ and the pure reactive depressions … In the endogenous depressions disturbances of vital feelings have a very much greater role.” Schneider was referring to “disorders of body feeling and life feeling,” a physical concept dating back to the notions of vitality of the nineteenth century. With reactive depressions, by contrast, “The primary issue is disturbances of psychic feeling.” Both endogenous and reactive depressions could be triggered by external events. Take, for example, the death of a loved one. Patients with endogenous depression experience the loss at a different “emotional layer” than do patients with reactive depression: vital body feelings versus emotional sadness. It was thus thoroughly possible for a vital depression to be precipitated by external events, just as a reactive depression was triggered—merely that they would be experienced differently, at a total body level or at an emotional level.
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(Vital depression did not even necessarily mean sadness, said one of Schneider’s colleagues, but probably represented an endocrine disturbance.
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) This was a concept of huge power, one that had doubtlessly dawned slowly on Schneider, even as a kind of visceral insight, as he treated the men invalided back from the trauma of trench war at the front. It is rather unfortunate that it became misunderstood in American psychiatry, because its “disproof,” showing that endogenous depressions had as many unhappy external events as reactive depressions, opened the way to DSM-III and the disaster of “major depression.”
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Sigmund Freud’s literary career in Vienna lasted from about 1890 to 1930, and in these years he launched the doctrine of psychoanalysis as a way of understanding “mental” illness, an illness he saw as arising in the mind rather than the brain, and of treating it—his technique of psychoanalysis used free association and dream analysis. Freud himself had little interest in depression. For him, unlike hysteria, phobias, and so forth, depression was not one of the classical neuroses, and he doubtless felt what Jerome Frank at Johns Hopkins articulated much later, that it was almost impossible to do psychoanalytic work with the morbidly depressed patient “who interacts sparsely with others, is dull and unproductive [unwilling to confess interesting fantasies], sees the world in an impoverished and stereotyped way, and really wants to be left alone.”
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So Freud wrote little about depression with the exception of “Mourning and Melancholia” in 1916, in which he laid the groundwork for future analytic writing on depression by explaining it as the threatened loss of a beloved “object,” which usually meant the mother.
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The rise of psychoanalysis was to have deep consequences for total-body views of psychiatric illness. Simply put, the psychoanalysts did not believe in the body as the locus of disease. They situated “mental illness” in the mind, and ascribed its origins to unconscious conflicts within the psyche. In 1926 Freud noted that “A physician experiences in a medical faculty approximately the opposite of what he needs in preparation for psychoanalysis. His attention is directed to objectively determined anatomic, physical and chemical facts, whose correct appreciation and suitable treatment determine medical approaches.” Psychoanalysis, by contrast, is “the science of the psychic unconscious.”
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Amazingly, for therapists who had been educated as physicians, many analysts did not believe even in touching their patients, especially the females, fearing interference with the transference relationship and loss of control over themselves in these sexually highly charged consultations. Freud said, “The attempt to reciprocate the tender feelings of the patient is not entirely without danger. The analyst may not have sufficient self-control and suddenly find himself further along the road that he might have envisioned.”
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Thus, avoid physical contact in order to avoid conveying to your patient that her erotic ambitions with you might be realized. The intention here is of the best. Yet it was a fatal development that such antiembodiment views, so to speak, were brought to the study of depression at the same time that the diagnosis was growing by leaps and bounds.

The first member of Freud’s circle to write about depression as a neurosis, rather than about melancholia or manic-depressive illness, was Berlin psychiatrist Karl Abraham, who noted in 1911 at the Third Psychoanalytic Congress in Weimar that there was a hole in the psychoanalytic coverage: “While the conditions of nervous anxiety have been treated in detail in the psychoanalytic literature, the depressive conditions have not found similar consideration. And yet depressive affect is just as widespread in all forms of neurosis and psychosis as anxious affect.” He noted that both conditions often occurred in the same individual. Both were also linked, he said, to the process of repression: “One of the earliest results of Freudian neurosis research is that neurotic anxiety stems from sexual repression. This is neurotic anxiety separated from fear. By the same token we are able to separate the affects of mourning or dejection [Niedergeschlagenheit] from affects originating in the unconscious, which is to say, neurotic depression based on repression.”
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This was the beginning of neurotic depression as a diagnosis separate from the other big depressive illnesses.