Depression and Mood Disorders: Emergence

   The word "depression" has a number of meanings, depending on the discipline. Within neurophysiology, it refers to a decrease in the brain’s electrical activity causing, for example, "cortical depression." For the pharmacologist, depression means drug actions that decrease the activity of the central nervous system, such as barbiturates and anesthetics. In psychology, depression stands for any decrease in performance, such as in psychomotor activity or intellectual agility. As for psychiatry, depression can mean a normal human emotion, a symbol of mood that may become pathological if it is retained too long or too deeply; a depressive syndrome that may, or may not, include a depressed mood; or a reactive depression precipitated by certain life events. First described as melancholia, a term of such amplitude reverberates across the history of psychiatry. There follow some important concepts in the emergence of the diagnosis of depression. (For more current events, see Depression and Mood Disorders: Recent Concepts.)

   Traditional depressive-equivalents. Before the mid-nineteenth century, several diagnostic terms in medicine were historically equivalent to depression, such as "vapours" and "hysteric fits." In 1707, London physician John Purcell (1674?–1730) said of patients with "vapours," "Those who have laboured long under this distemper are oppressed with a dreadful anguish of mind and a deep melancholy, always reflecting on what can perplex, terrify, and disorder them most, so that at last they think their recovery impossible. . . . They decline all diversions." "Melancholy in hysterical people is easily cured in the beginning, but when it has taken deep root, and the patients avoid and shun company, then . . . it is to be feared they will endeavour to make themselves away" (A Treatise of Vapours or Hysterick Fits, 2nd ed., pp. 13–14, 170). Such terms clearly include many other symptoms than those conventionally reckoned to depression, yet they do embrace depression.

   By mid-eighteenth century, spleen and "hyp" [-ochondria] had become fashionable diagnoses. As society physician George Cheyne (1671–1743), then practicing in the spa town of Bath, explained to novelist Samuel Richardson (1689–1761) in a letter in 1742, "We call the hyp every distemper attended with lowness of spirits, whether it be flatulence from indigestion . . . head-pains, or a universal relaxed state of the nerves, with numbness, weakness, startings, tremblings, etc., so that the hyp is only a short expression for any kind of nervous disorder with whatever symptoms" (Mullett, ed., Letters, p. 108). In 1786, James M. Adair (1728–1802), who had a tony practice for nerve patients in Bath, suggested that both spleen and hyp had been ascribed to the recent nervous illness of Queen Anne, who "was frequently subject to depression of spirits, for which, after the courtly physicians had given it a name, they proceeded to prescribe Rawleigh’s confection and pearl cordial. This circumstance was sufficient to transfer both the disease and the remedy to all who had the least pretensions to rank" (Medical Cautions for the Consideration of Invalids, p. 13).

   "Depression" as a term (pre-1850). Although melancholia was the preferred expression for dysphoria and insanity, the term "depression," from the Latin "de" (down) and "premere" (to press), nonetheless appeared in medical writing as early as the seventeenth century in the context of mood disorder, or emotional disorder. In 1765, Edinburgh physician Robert Whytt (1714–1766), one of the founders of neurophysiology, in his Observations on the Nature, Causes, and Cure of those Diseases which Have Been Commonly Called Nervous, Hypochondriac or Hysteric, described "depression of mind" associated with hypochondriasis and dysphoria (p. 312). He added: "When low spirits proceed from a suppression of the menses or haemorrhoids, if these evacuations cannot be restored, some others must be substituted in their place: but nothing has such sudden good effects as bleeding" (p. 519).

   "Depression of mind may be induced by causes that are forgotten," noted American psychiatrist Benjamin Rush in 1812 in his Medical Inquiries and Observations upon the Diseases of Mind (quote from 3rd ed., 1827, p. 44). In 1818, Johann Christian August Heinroth, an asylum psychiatrist in Leipzig (1773–1843) (see German "Romantic" Psychiatry), in his Textbook of the Disturbances of Mental Life (Lehrbuch der Störungen des Seelenlebens), became one of the first psychiatric writers to use the terms "depression" and "exaltation" in an account of mood disorders. "The principle and the stimulus of evil affect men in two ways, just as poison works in two opposite manners: positively or negatively, stupefyingly or paralyzingly. A life affected by the first kind is distinguished by exaltation and that affected by the second, by depression" (Mora’s English translation, I, 125).

   Karl Wigand Maximilian Jacobi (1775–1858), director of the Siegburg asylum in Germany, often used the term "depression" in its modern sense in his descriptions of clinical cases. In his 1844 text on The Main Forms of Mental Illness (Die Hauptformen der Seelenstörungen), Jacobi described one patient who alternated "episodes of raucous and boisterous excitement" with delirium and "depression" (I, p. 121).

   Differential diagnosis of depression from dementia (1814). Étienne Esquirol was among the first to differentiate dementia from the form of depression that he termed lypemania. In his essay "On dementia" in the Dictionary of Science and Medicine (Dictionnaire des sciences médicales), he illustrated the difference: "The anger [of the demented] lasts only a moment. It has nothing of the tenacity of those with mania and above all of those with lypemania [melancholic depression]" (pp. 221–222).

   Lypemania (1820). (See also Psychosis: Emergence: Esquirol’s monomania.) Although Esquirol earlier introduced the term "lypemania" as a virtual synonym for melancholia, it was only in 1820, in an essay "On Lypemania or Melancholia" ("De la lypémanie ou mélancholie"), that he fully characterized the disorder and differentiated it from other illnesses. He considered lypemania primarily an affective, or emotional, form of melancholia and scorned the term "melancholia" itself as associated with discredited humoral theories involving "bile." Esquirol’s lypemania represents the first occasion in which a prominent psychiatrist presented melancholic depression as a disturbance of affect rather than a form of "insanity."

   Dysthymia (1844). Carl Friedrich Flemming (1799–1880), chief physician at a newly opened asylum in Sachsenberg bei Schwerin in Germany, proposed "dysthymia atra" as a replacement for melancholia, which had become a heterogeneous kind of grab bag of symptoms. (Atra means black in Greek, and atrabile was a classical Greek term for melancholy.) It consisted of "sadness, fear and anxiety, mistrust, and irritability (Übelwollen)" (General Journal of Psychiatry [Allgemeine Zeitschrift für Psychiatrie], p. 114). Flemming considered "dysthymias" to be "emotional disorders" (Gefühlskrankheiten). Yet, Flemming’s own ardor for his new concept was tepid, and he had abandoned it in favor of "mood depression" (Gemüths-depression) by the time he wrote his big textbook in 1859, Pathology and Treatment of the Psychoses (Pathologie und Therapie der Psychosen) (p. 66). Circular insanity (1851). See Manic-Depressive Illness: circular insanity (1851).

   Hypochondria as a subform of depression (1860). Although hypochondria had been associated with melancholia since the Ancients, what was previously understood by melancholia had little to do with depression and much with undifferentiated madness. In the early nineteenth century, a whole generation of psychiatrists began to use "depression" and "melancholia" in the modern sense: hence the relationship of depression to hypochondria became of renewed interest. Unlike publicasylum psychiatrists, who rarely saw such conditions as hypochondria, those in the private sector did. Vienna psychiatrist Max Leidesdorf (1819–1889) had extensive experience with private psychiatric clinics, where the threshold of illness was lower. In 1860, in addition to lecturing at the university, he had just joined the staff of a prestigious private clinic in Vienna’s Ober-Döbling suburb when he brought out his psychiatric textbook, Pathology and Therapy of Psychic Illnesses (Pathologie und Therapie der psychischen Krankheiten). In the section on "conditions of psychic depression," he distinguished among hypochondria, which was the milder stage, and melancholia, the more severe stage. In hypochondria, "the patients’ feelings turn entirely about their health, the condition of which occupies their whole attention." The difference between hypochondria and melancholia, said Leidesdorf, was that "the hypochondriac seeks medical advice and assistance constantly; he makes contact and has confidence, albeit tenuous and short-lived. The melancholic does not seek medical advice, and occupies himself with plans for his suicide" (p. 154 of the second edition, in 1865, entitled Textbook of Psychiatric Illnesses [Lehrbuch der psychischen Krankheiten]).

   Dysthymia (revived) (1863). Karl Kahlbaum distinguished systematically between underlying diseases, which might produce affective disorders, and the actual symptoms of melancholia, which he called dysthymia. He made this discrimination in a larger work on nosology called The Classification of Psychic Illnesses (Die Gruppirung der psychischen Krankheiten). Kahlbaum thus nailed down a distinction begun by Flemming and others (Psychosis: Emergence: distinction . . . [1844]) between primary disease and momentary illness presentation. Some scholars feel that Kahlbaum’s dysthymia is significant as "the hour of birth of endogenous depression" (Schmidt-Degenhart, p. 65). In the book, Kahlbaum also distinguished between psychotic melancholy (a Vesania, as he borrowed William Cullen’s term for the class) and nonpsychotic dysthymia (a kind of partial insanity for which he coined the term "Vecordia": vecordy was a seventeenthcentury English expression for madness). (Elsewhere, Kahlbaum also chiseled out pieces of what would later be called schizophrenia, thus narrowing dysthymia to its modern meaning of emotional disorder, rather than a synonym for "madness.") (See Schizophrenia: Emergence: Vesania typica [1863]; catatonia [1874].) Also among the Vecordia was "paranoia," a "disturbance of intelligence" (not paranoia in the sense of delusional disorder, which latter he called "diastrephia"). It is noteworthy that for dysthymia and paranoia, as "partial mental diseases," the personality remains intact, unlike the Vesaniae (p. 90).

   Periodical melancholia (1875 and following years). Although Falret and Baillarger had by 1854 described the periodic alternation of depression and mania (see MANIC-DEPRESSIVE ILLNESS), it was not until the work in 1875 of Russian emigré physician and New York electrotherapist William Basil Neftel (1830–1906) that recurrent unipolar depression was characterized. (See his article "On Periodical Melancholia," in the Medical Record in 1875.) Apparently unaware of Neftel’s article, in 1878 Ludwig Kirn (1839–1899), a student of Christian F. W. Roller (1802–1878) and a staff psychiatrist at the Illenau asylum, in his book The Periodic Psychoses (Die periodischen Psychosen) gave a sharply defined picture of all the periodic affective disorders, including the circular psychoses; thus, Kirn provided a kind of collective label for these recurrent illnesses.

   In 1886, Danish physician Carl Georg Lange (1834–1900), professor of pathological anatomy at the University of Copenhagen and considered Denmark’s "first neurologist," described "periodic psychic depression" as an independent illness with sudden onset, retardation, and numerous bodily changes such as loss of appetite and physical collapse. This constituted "an energetic declaration," in Danish psychiatrist Hans Jacob Schou’s words (H. J. Schou lived from 1886 to 1952 and was the father of Mogens Schou—see Lithium Therapy), that endogenous depression had a possibly physical cause (Lange found elevated uric acid in the patients’ urine). (The work was published in Danish; see the German translation of the second Danish edition, Periodische Depressionszustände [1896]. See also Schou’s 1927 summary of it in the Acta psych. et neurol. An English translation [2001], edited by Johan A. Schioldann, is also available.) In 1898, Ewald Hecker (1843–1909), chief physician of a private nerve sanatorium in Wiesbaden, Germany, voiced the suspicion that most of these cases of periodic depression really corresponded to Karl Kahlbaum’s cyclothymia (see Manic-Depressive Illness [1882]) ("Cyclothymia: a Circular Mood Disorder" ["Die Cyclothymie, eine circuläre Gemüthserkrankung"], Journal of General Practice [Zeitschrift für praktische Ärzte], p. 7).

   Anxiety as a fundamental part of depression (1880). Although clinicians had always noted that depression and anxiety tended to occur together, among the first psychiatry writers to characterize depression as including anxiety was Christian Roller (?–1897), the son of Christian F. W. Roller (1802–1878), who practiced in a private asylum in Strasbourg. Writing in the General Journal of Psychiatry (Allgemeine Zeitschrift für Psychiatrie), Roller said that, "If anything is typical of the large group of mental disorders that we are inclined to group together under the name of melancholia, it is anxiety" (p. 197). Subsequent generations of psychiatrists debated whether anxiety and depression were really the same disorder or two separate disorders.

   See Hypomania and Mania (1881).

   Cyclothymia (1882). See Manic-Depressive Illness. See Paranoia (1883) as a late complication of melancholia. Exogenous vs. endogenous (1893, 1909). In his 1893 textbook on nervous diseases, Paul Julius Möbius (1853–1907), a neurologist in Leipzig, initiated the distinction between "exogenous" nervous diseases, meaning illnesses having a specific and definable cause, and endogenous nervous diseases, "for which the only essential precondition [is] a certain inborn predisposition; once this is present, the disease may be caused by a variety of factors" (Outline of the Doctrine of Nervous Diseases (Abriss der Lehre von den Nervenkrankheiten; p. 140). Möbius, who prided himself on having devised a system of practical use, said, "From the practical viewpoint, it must be emphasized that we are almost powerless against all endogenous illnesses. . . . Once the illness is manifest, direct influencing of it is impossible" (p. 141).

   The distinction was not widely noted until the terms were again picked up in 1909 by Karl Bonhoeffer (1868–1948), then psychiatry professor in Breslau, who distinguished between exogenous causes of affective disorders (meaning organic causes coming from outside, such as alcoholism, poisoning, or peripheral organ disease) and endogenous (meaning inborn, intrinsic, or constitutional). In affective disorders, he considered some kinds of mania (such as febrile) to be exogenous, whereas manicdepressive illness and pure depression were endogenous. In his article in the Central Journal for Nervous Diseases and Psychiatry (Zentralblatt für Nervenheilkunde und Psychiatrie), Bonhoeffer did not confine himself to affective disorders. (Note: In Bonhoeffer’s parlance, exogenous is restricted to biological causes; it does not mean "reactive.")

   See Anhedonia (1896 and later).

   Involutional melancholia (1896). In the 1896 edition (fifth edition) of his influential textbook, Psychiatry, Emil Kraepelin distinguished between forms of melancholia that were acquired, such as the melancholia of middle and old age (the result of "involution," which required no predisposition), and all the other forms of mania, depression, and circular insanity, which were constitutional, or inborn, in nature. (In this edition, Kraepelin started using the term "depression" rather than "melancholia" for all the others.) Kraepelin, however, abandoned the notion of involutional melancholia in the eighth edition (1913) of his book, after familiarizing himself with Georges L. Dreyfus’s (1879–1957) finding (in Melancholy [Die Melancholie], 1907) that almost all cases of involutional melancholia in fact displayed the features of manicdepressive illness. The concept of involutional melancholia itself, however, went on to a hearty life outside of Kraepelin’s textbooks and was put to rest only by the demonstration in the 1970s that depression in the elderly responded in the same way to medication as in other age groups.

   Manic-depressive illness (das manisch-depressive Irresein) (1899). See MANIC-DEPRESSIVE ILLNESS: Kraepelin (1899).

   "Depression" becomes preferred to "melancholia" (ca. 1904). After Emil Kraepelin abandoned melancholy for depression in the fifth edition (1896) of his text, he lent his great prestige to this change. Then, in the United States, Adolf Meyer, professor of psychiatry at Johns Hopkins University, gave the decisive push. In 1904, he told a meeting of the New York Neurological Society that, in the words of the stenographer, "On the whole, he was desirous of eliminating the term melancholia, which implied a knowledge of something that we did not possess. . . . If, instead of melancholia, we applied the term depression to the whole class, it would designate in an unassuming way exactly what was meant" (Journal of Nervous and Mental Diseases, 1905, p. 114).

   Neurotic depression (1911). The Berlin psychoanalyst and psychiatrist Karl Abraham (1877–1925) initiated the use of this concept in the psychoanalytic literature, writing in the Central Journal of Psychoanalysis (Zentralblatt der Psychoanalyse): "The neurotic becomes overwhelmed with anxiety when his drive aims at a satisfaction that his repression forbids him from achieving. Depression eventuates when, unsuccessful and unsatisfied, he abandons his sexual goal." Abraham noted that the literature contained "strikingly little about the psychology of neurotic depression" (p. 303).

   Vital depression as an aspect of endogenous depression (vs. reactive depression) (1920). Building on the work of philosopher Max Scheler (1874–1928) about the layering of the psyche, in 1920 Kurt Schneider (1887–1967), then an academic psychiatrist in Cologne, distinguished between endogenous and reactive depression. The term "endogenous" he would have borrowed from the eighth edition in 1913 of Kraepelin’s textbook (see Schizophrenia: Emergence: Kraepelin), where Kraepelin had used it as a qualifier for dementia praecox (schizophrenia). Endogenous depression in Schneider’s view represented a disturbance of the body’s "vital" feelings, situated in a very physical plane of vitality. Schneider summarized Scheler’s views about this vital feeling of life (Lebensgefühl) as follows: "[It] participates in the body’s entire feeling of corporization (Gesamtausdehnungscharakter des Leibes), without being localized in any particular part." "In such a feeling we grasp life itself, and in this feeling something is imparted to us: ascent, decline, health, illness, [and] danger." Endogenous depressions, therefore, were unprovoked, or autonomous ("motivlose"), disorders of these vital feelings; reactive depressions were disorders of the mental plane (seelische Gefühle) as such, often caused by external problems. Endogenous depressions were characterized by disturbances of the body’s physical functions, such as diurnal variation (feeling worse in the morning), weight, and menstruation. For Schneider, vital depression and endogenous depression were synonymous. "Reactive depressions," by contrast, produced sadness (Traurigkeit) at the level of "emotional feelings" (Empfindungsgefühle), rather than unmotivated dysphoria (motivlose Verstimmung) at the vital level. Yet, vital depressions could occur in reaction to external events. For Schneider, the difference between "reactive" and "vital" was that they occurred at different "emotional layers," not that one was caused by events, the other uncaused. Schneider’s article, in 1920 in the Journal of Combined Neurology and Psychiatry (Zeitschrift für die gesamte Neurologie und Psychiatrie) had great influence on subsequent generations of psychiatrists in Europe, and the term "endogenous depression" remained part of the standard vocabulary of mood disorders until the appearance of DSM-III in 1980. Vital depression itself later became understood as physical symptoms in depression, or psychosomatic issues in depression. (See the work of Maarten H. Cohen-Stuart (1922–), at the Delta Hospital of Rotterdam, in Psychiatria, Neurologia, Neurochirurgia, 1965).

   Benign stupor (1921). In an effort to get away from the straightjacket of the Kraepelinian system and its two great disease entities—dementia praecox and manicdepressive illness—New York psychiatrist August Hoch (1868–1919), who was born in Basel but emigrated to the United States in 1887, proposed "benign stupor" as a disease entity resembling manic-depressive illness and having a favorable outcome, as contrasted with "malignant stupor," a kind of catatonic stupor characteristic of dementia praecox. (Stupor means being unreactive to and unaware of one’s surroundings.) Hoch, was Swiss-born Meyer’s successor as director of what was then called the Psychiatric Institute of the New York State Hospitals. He was among the first Americans beside Meyer and Neftel—all had come from the Central European nosological tradition—to contribute to the international narrative of depression or schizophrenia. His book Benign Stupor was published posthumously in 1921, 2 years after his death.

   Psychogenic depression (1926). Although earlier authors had alluded to nonconstitutional forms of "acquired neurasthenia," it was Emil Kraepelin’s student Johannes Lange (1891–1938) at the German Psychiatric Research Institute (Deutsche Forschungsanstalt für Psychiatrie) in Munich who fleshed out the concept of "psychogenic forms of depression" ("psychogene Depressionszustände") as opposed to melancholic depressions in a 1926 article in the Journal of Combined Neurology and Psychiatry (Zeitschrift für die gesamte Neurologie und Psychiatrie). Psychogenic depressions, he said, were reactive in nature (unlike melancholy), were not characterized by retardation, and improved as the patients’ situation changed. All of the somatic events of melancholy such as diurnal variation, stubborn constipation, and the feeling that the entire body was somehow involved were absent in psychogenic depression, where fatigue, irritability, and an inability to get going at work were, as well as sadness, the main symptoms.

   Depressive neurosis (1927). Sándor Radó differentiated depressive neurosis from melancholia, saying at a meeting in 1927, "The most striking feature [of depression] is the fall in self-esteem and self-satisfaction. The depressive neurotic . . . attempts to conceal this disturbance; in melancholia it finds clamorous expression in the patients’ self-accusations and self-aspersions, which we call ‘the delusion of moral inferiority’ " (International Journal of Psychoanalysis, 1928, p. 421).

   British debate about "two depressions" vs. "one" (1920s). As the German concepts of endogenous depression vs. reactive filtered into Britain, they ignited a debate. In 1929, Ronald Dick ("R. D.") Gillespie (1897–1945), who 3 years previously had just become physician for psychological medicine at Guy’s Hospital in London, wrote an article in Guy’s Hospital Reports about depressed patients he had seen earlier on a studentship at Cassel Hospital in Penshurst. He divided them into two main groups: the "reactive" depressions, who displayed a host of "psychoneurotic" features, were quite anxious, and worried a lot about their health; and the "autonomous" depressions, who did not clear up at good news, tended to express ideas of unworthiness, and did not blame the environment for their problems: their dark mood seemed to come more out of the blue and less from their previous personalities. Thus, from Gillespie’s work, the dichotomy "reactive-autonomous" arose.

   Meanwhile, in 1926 Edward Mapother (1881–1940), who had recently become the first medical superintendent of the Maudsley Hospital in London, had weighed in with quite different views. He agreed with Kraepelin that there was just one disorder, manic-depressive psychosis, and apparent types of depression were just differences in degree. "Kraepelin, if anyone, has the right to settle what conditions the term ‘manicdepressive psychosis’ shall connote. . . . I entirely agree with his . . . views in this matter" (British Medical Journal, p. 872).

   As the big authorities at these two different London power centers—Guy’s and the Maudsley—dueled, in 1934 Aubrey Lewis (an assistant physician at the Maudsley) published his contribution: it was a paper on "melancholia" that he had written in 1931 on the basis of cases collected in 1928–1929, just after he had come to the Maudsley as a resident ("registrar"). Enormously self-confident for such a junior scholar, Lewis announced that subtyping was very difficult because of "the interaction of organism and environment" (p. 370). "Gillespie even gives a table showing the differences, so that the general practitioner and the student can carry out the diagnostic exercise readily. But it has been made sufficiently apparent in the various sections of this study that these criteria fail" (p. 374). For Lewis, too, there was just one depression.