The ancient Greeks recognised depression as a medical condition, but did not distinguish it from other forms of mental disturbance. This attitude persisted right through to modern times. Europeans in the 17th and 18th century frequently used the word melancholia to describe a whole range of mental illnesses.
People with depression often escaped the attention of doctors, however, because the main interest of early ‘psychiatry’ was the diagnosis and containment (rather than cure) of conditions which presented a problem to society. People experiencing delusions, hallucinations, periods of mania, etc. were much more likely to present a ‘nuisance’ in the overcrowded and cramped conditions of European cities, and the solution was generally to lock them away. Depression is, in general, a much ‘quieter’ condition – sufferers become introverted, they keep to themselves, lose the urge to communicate with others, spend much of the day asleep or slumped in a chair. This meant that, in previous centuries, people with depression were generally spared the horrors and indignities of the ‘lunatic asylums’, but it also meant that many were left to suffer in silence, with no hope of a cure.
Where depression was recognised, it tended to be thought of as a lesser concern, lumped along with hypochondria and hysteria as a ‘nervous’ or ‘neurotic’ complaint. For the rich, the solution was to travel to one of the many European spa towns, and ‘take the waters’. Resorts such as Wiesbaden and Bath had a reputation for being able to cure ‘nervous complaints’.
By the close of the 18th century, ‘nerve doctors’ had a thriving industry across Europe. In 1763, one such practitioner, Pierre Pomme, who had been physician to the French king, claimed to have discovered the condition of ‘vapours’ along his wealthy clientele. Its symptoms? ‘Fatigue, pain and a sense of dullness. Sadness, melancholy and discouragement poison all of their amusements’. And the cure, for a condition that sounds suspiciously like clinical depression? Pomme recommended chicken soup and cold baths!
By this time, doctors were in no doubt that most forms of mental illness were due to disorders within the brain itself, although it was thought that the ‘nervous’ disorders, such as depression, anxiety and hypochondria were not hereditary. ‘The cause of madness is seated primarily in the blood vessels of the brain…’ wrote American physician Benjamin Rush in 1812. Others developed complicated – and untested – theories around the notion that muscular spasms caused weakness in the blood vessels, and this in turn gave rise to various mental problems, including anxiety.
Others took the view that mental illness had social and cultural causes. Factors such as one’s family, upbringing, living conditions and employment were taken into account. In 1823, the German professor Johann Christian Heinroth gave a list of factors that could affect mental well-being: ‘food, drink, sleep, exercise, air pollution…’ Few doctors working nowadays would deny that a poor diet, overindulgence in alcohol, lack of sleep and exercise and an unhealthy environment can contribute to clinical depression.
There was a strong sense that, whatever the causes, ‘nervous’ complaints like depression, phobias and chronic fatigue were not serious or life-threatening, and a great deal of effort was made to distinguish them from the sort of conditions that might lead to a person being confined to the asylum. Largely due to the public horror of these places, and their inability to effect any sort of cure on the people locked up in them, mental illness was viewed with suspicion. But ‘nervous’ complaints carried none of these negative associations – the upper and middle classes were quite happy to admit to suffering from them.
Progress in 19th century
Through the 19th century, the spa towns grew in popularity as more and more Europeans sought the ‘water cure’ (sometimes called hydrotherapy) – believing that drinking and bathing in waters which were rich in mineral deposits would being them relief. In some cases it might have worked – spa water is often rich in potassium, iodine and iron, and all of these substances can be in short supply in the bodies of people with clinical depression.
Towards the close of the 19th century, a number of practitioners had begun to experiment with hypnosis as a treatment for ‘nervous’ complaints. This method influenced the work of Sigmund Freud, who believed that buried childhood memories were the cause of neuroses and depression in adult life. These could be treated, without drugs, through a lengthy process of psychoanalysis. For forty-five minutes a day, usually five times a week, the patient would lie on a couch, with the analyst behind him or her and out of view. The patient would be encouraged to use ‘free association’ – to say whatever came into his or her mind. The idea was that, with the analyst’s guidance, the unfulfilled needs and unresolved conflicts buried in the patient’s subconscious mind would become conscious, and that, by discussing them until the patient understood them, they lost their power to cause depression, anxiety, etc.
20th century – Scientific Research on Depression
For a while, this idea proved more popular than ‘biological’ explanations, which stressed that the cause of depression was an imbalance in the chemicals of the brain. Psychoanalysis became an extremely popular treatment across Europe and then, as thousands fled before, during and after WWII, in the USA. It proved so popular that some doctors even believed more serious conditions, such as manic depression and schizophrenia could be understood and treated in the same way.
Meanwhile, science lagged behind. Early treatments for depression at the beginning of the 20th century involved dosing patients with barbiturates, keeping them unconscious for several days, in the hope that sleep would restore them to a healthier frame of mind.
It was then discovered that, in certain cases, patients who experienced epileptic fits also experienced less severe symptoms of mental illness. By causing a person to have a controlled fit (first by dosing the patients with camphor, then in 1938, by the use of electricity), Doctors found they could lessen the effects of depression. Electro-convulsive therapy (ECT) is still used as a treatment for severe depression.
The understanding of depression depended on our understanding of the brain itself. This took a leap forward in 1928, when Austrian scientist Otto Loewi discovered the first neurotransmitter in the brain, acetylcholine. He concluded, rightly, that this substance was necessary to help tiny electrical messages pass through the brain, from one nerve ending (neuron) to the next. It was another 24 years before scientists would discover the presence of other neurotransmitter substances in the brain, such as serotonin, noradrenaline and dopamine. By the 1980’s, scientists had isolated 40 different neurotransmitter substances in the brain.
Advances in the understanding of brain chemistry happened at the same time as the popularity of psychoanalysis began to fall. Bizarrely, the unpopularity of medical practices like ECT and lobotomy (surgical removal of the frontal lobes of the brain), seemed to colour the whole profession, and this included treatments like psychoanalysis, which were right at the other end of the spectrum. There was a popular image of the psychoanalyst as a sex-obsessed crank who had the power to pronounce people insane and confine them to hospitals. Among analysts themselves, Freud’s ideas began to be seen as old-fashioned and often inappropriate to modern needs. As more and more drugs became available, psychoanalysis began to feature less and less as a feature of treatment in hospitals and health centres. It was seen as time-consuming and costly while its results were unpredictable.
1950s – The Breakthrough in Depression Treatment
Two scientific breakthroughs occurred in 1955. Firstly, a Swiss doctor noticed that a new anti-tuberculosis drug, when given to people who also had schizophrenia, simply made them more agitated. He tried giving it to people with depression and noticed that they became more sociable and their interest in their surroundings returned, as did their appetites. This drug was imipramine (still available nowadays as Tofranil) – the first tricyclic anti-depressant medication. (The term ‘tricyclic’ simply refers to the drug’s atomic structure).
This was also the year when American scientists began to examine whether levels of serotonin fell or dropped when people were experiencing mental illness. This work led to the discovery in 1960, by English scientists, that when a person was given anti-depressant drugs, the levels of serotonin in their blood fell dramatically – suggesting that the serotonin was all going elsewhere, i.e. to the brain.
A second type of anti-depressant was also developed in the 1950’s. This was known as the Monoamine Oxidase Inhibitor (MAOI). Like tricyclics, these are still available today, under brands names such as Nardil, Marplan and Manerix. These work by blocking the action of certain substances in the brain (oxidases) which break down neurotransmitters. The brain thus remains ‘bathed’ in extra quantities of neurotransmitters, and is able to fight off the depression. Though an effective remedy, these drugs can have an unpleasant reaction when taken alongside certain foods and drink. Patients taking MAOI’s have to observe quite strict dietary rules because the side-effects can be fatal.
1960s – Targeting the Root Cause of Depression
Most of the early anti-depressants worked by affecting several different neurotransmitter chemicals at the same time. But scientists began to work on drugs that would target one specific neurotransmitter, while leaving others unaffected. In 1968, a Swedish scientist Arvid Carlsson, made discoveries that would eventually lead to the creation of the drug Prozac. He found that, when an electrical impulse passed from one neuron to another, the substance serotonin was released into the space between the neurons – the synapse – to help the ‘message’ be transmitted. After it had done its job, the serotonin was reabsorbed by the neuron. But anti-depressants prevented the neurons from taking the serotonin back. It remained in the synapse, where its presence seemed to help the patient recover from depression.
Present Day And Future of Research on Depression
By 1974, American scientists were testing a drug which prevented the neurons from reabsorbing serotonin, while not preventing the absorption of other brain chemicals, such as noradrenaline. They termed this drug a Specific Serotonin Re-uptake Inhibitor (SSRI). Its name was fluoxetine. In tests, they discovered that it provided rapid relief from the symptoms of depression, without any of the unpleasant side-effects associated with the older, tricyclic anti-depressants (dry mouth, constipation, blurred vision, sweating, weight gain) or the dietary restrictions that were necessary with MAOI drugs. By 1987, the drug was being prescribed to patients as Prozac. By 1994, it was the number two best-selling drug in the world.
Despite widespread media hype, Prozac is not the ‘wonder drug’ that some people have made it out to be. It has helped millions overcome depression, but it is not the right treatment for everyone. Recently, there have been reports that it may lead to suicidal thoughts and violence in certain individuals.
Other remedies for depression continue to be developed all the time. Two new additions are Venlafaxine, which targets both serotonin and noradrenaline, and Reboxetine, which targets nordrenaline. Since the 1960’s, herbal and homeopathic remedies have also gained popularity – particularly St John’s Wort (hypericum). Cognitive behavioural (psycho)therapy, is also being used increasingly for people with depression, often alongside anti-depressant medication. Cognitive Behavioural psychotherapy concentrates, not on past experiences, but on alerting the patient to negative and destructive patterns of thought, and on providing them with alternative, ‘positive’ models of thinking.
There is still no single accepted explanation for the biological and chemical causes of depression. For instance, though many of the remedies prescribed work immediately to increase the availability of neurotransmitters in the brain, it is usually 2-6 weeks before the patient reports an improvement in mood, sometimes longer and sometimes not at all. So to say that ‘more neurotransmitters equals less depression’ is inaccurate. Scientific interest has moved away from the neurotransmitter substances themselves and onto the mechanisms which allow them to be absorbed – and these have been found to be much more complex than was first thought. Other studies are examining the body’s response to stress – it has been suggested that people who experience depression produce abnormally large amounts of the hormone cortisol when they are under stress. This might be a genetic fault, or due to high levels of stress at an early age.
In terms of its attitude to depression, its causes and treatment, psychiatry is no longer so deeply divided as it once was. Although most healthcare professionals are unable to provide counselling and psychotherapy, and access to these services tends to be for the priveliged few, it is generally agreed that medication is a far more effective remedy when it is accompanied by some kind of ‘talking cure’ (even if this is merely a weekly opportunity to let off steam!) Meanwhile, very few therapists would try and dissuade a depressed patient from visiting their doctor and obtaining a prescription for anti-depressants.