Doctor's Review: Medicine on the Move

January 22, 2022
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Planet of the blues?

It seems to be human is to suffer from depression — and women suffer more

Depression in humans probably began shortly after Adam and Eve were cast out of the Garden of Eden – reason enough to be depressed. By the time the Greeks showed up, withdrawal from social interaction, excessive sleeping, inadequate eating, suicidal thoughts and relentless despair were common.

The condition was ascribed to an imbalance of the four humours – phlegm (water), blood (air), yellow bile (fire) and black bile (earth). An excess of black bile or malina chole was blamed for a litany of woes, including anxiety and listless behaviour.

Hippocrates took it further by suggesting that in addition to black bile, melancholia was a condition of the brain. Always early off the mark, he also noted postpartum depression, and speculated that lochial discharge -- the fluid that comes from the uterus after a birth -- if suppressed, could flow into the head and result in agitation.


Whether to treat the body or the soul has been a central dilemma from the beginning. Current thinking has it that both can be significant. Hippocrates would have agreed. He recommended a diet of mandrake and hellebores to eliminate an excess of both yellow and black bile, but also relied on the curative properties of advice and action -- and put them into practice. He cured melancholic King Perdiccas II by advising him to marry the woman he loved which he did and, we’re told, his depression disappeared.

Practitioners following in his footsteps were so astute. The post-Hippocratic Philotimus, observing that his depressive patients complained of "a light head, arid, as though nothing existed," fitted them with heavy lead helmets. Chrysippus of Cnidus promoted cauliflower as a panacea for the blues.


Plato and Aristotle introduced the notion that divine madness was associated with melancholia. While Aristotle sought ways to treat the condition, he also thought a certain amount of black bile as necessary to genius. "All those who have attained excellence in philosophy, in poetry, in art and in politics, even Socrates and Plato, had a melancholic habitus; indeed, even some suffering from melancholic disease," he wrote.

This view was vigorously suppressed by the rise of Christianity, a dangerous time to be depressed. Saint Augustine's assertion that reason separated men from beasts invited the conclusion that the loss of reason was a sign of God's disfavor. Melancholics themselves were to blame for their lack of joy in God's love and mercy.

By the time of the Inquisition, depressives were fined or imprisoned for their sin. The medieval Church defined acedia, or sloth, with its depression-like symptoms, as one of the deadly sins.

The Renaissance saw a return to the Greek idea of melancholy as a sign of philosophic depth. Those with depression were seen as victims of possession by demons rather than sinners.

In northern Europe, men who were depressed because their penises had been stolen by witches were found to be delusional -- since the stolen organs could easily be confirmed to be right where they always had been. This introduced the idea that the ones who had "stolen" the penises were also delusional. Witches were merely depressed and foolish old women, said the Englishman Reginald Scott in 1584. Gradually, this idea of illness rather than possession became commonplace.


The French were the first to effectively treat depression-related symptoms. Montaigne, himself a depressive, created a sort of anti-melancholic theatre of illusion. He cured one woman suffering from terror associated with the thought of having swallowed a needle by having her vomit and introducing a needle into the vomit by slight of hand.

Melancholy was a common affliction by the 17th century, one that could be as pleasurable as it was unpleasant. Writers all over Europe were swept up in romantic Aristotelian notions of melancholy. Brilliant men suffered and lesser pretended to suffer.

The dark-eyed, taciturn, disheveled, surly upper-class malcontent became a social prototype and fodder for a cast of Shakespearean characters, Hamlet being the most famous.

In 1621, Robert Burton's The Anatomy of Melancholy emphasized the real ties between medicine and philosophy and introduced the modern principle that everyone has a different level of tolerance for trauma. His cures for depression included addressing the "passions and perturbations of the mind" by "opening up" to friends and family and seeking out "mirth, music, and merry company."

Despite his insights, he continued to recommend eating certain foods including marigold, dandelion, ash, willow, tamarisk, violets, sweet apples, wine, tobacco, syrup of poppy, and St. John's wort, "if gathered on a Friday in the hour of Jupiter." Wearing a ring made from the right forefoot of an ass would also be a help.


The idea that depression changes the physical makeup of the brain was introduced in 1672 by the English physician Thomas Willis, who declared in his Two Discourses Concerning the Soul of Brutes that melancholic blood can "cut new Porosites in the neighbouring bodies."

Further scientific advances came when Nicholas Robinson proposed the fibrous model of the body in 1729, calling for "the most violent Vomits, the most purging Medicins, and large Bleedings, […] to be often repeated." He wasn't so big on talk therapy, saying, "You may as soon attempt to council a Man out of the most violent Fever."

As the Age of Reason ramped up, the social position of the depressive once again entered a slump. The association of depression with religious waywardness faded, replaced by reason's triumph over faith. In mental asylums one could hope the depressed would attract less attention than the noisy ranting and raving of many of their fellow inmates, and so escape the hideous treatments that passed for cures. It was not so, places like Bedlam, the famous British asylum, were equal opportunity torturers. Most prominent was the continued idea that great physical pain would distract the depressed patients, so all manner of grotesque devices were invented to simulate drowning or cause melancholics to swoon and vomit.

Women, who also suffered from such treatments, began to voice their malaise more audibly. The Marquise du Deffand wrote to a friend in England, "You cannot possibly have any conception of what it is like to think and yet have no occupation." In America, Cotton Mather, known in the early part of his life for extreme moral judgment, found himself sympathizing with his wife's depression which, he thought, was "little short of a Proper Satanical Possession." Still, he focused on treatments rather than causes, recommending the dubious cure of the application of "two living swallows, cut in two, and laid hott reeking onto the shaved Head."


The 19th century marked the beginning of a more humane treatment of mental illness. Wilhelm Griesinger, born in Germany in 1817 can be credited as the first to fully medicalize depression. He agreed with Hippocrates, and declared that all "mental diseases are brain diseases" and was the first to suggest that some mental illnesses are only treatable, while others are curable. Brain autopsies became common on the basis of his work, especially in the case of suicides.

Sigmund Freud's Mourning and Melancholia contributed significantly to the contemporary understanding of depression. "In grief," he wrote, "the world becomes poor and empty; in melancholia, it is the ego itself [which becomes poor and empty]." If Freud was the father of psychoanalysis, then Emil Kraepelin was the father of psychobiology. His work birthed the idea that depression is caused by internal chemical processes that are somehow beyond the control of the afflicted. He opened the door which eventually led to the discovery of antidepressants in the early 1950s.

Depression increasingly came to be associated with women. Charlotte Perkins Gilman captured the social backwardness of her time in her tale of a mother with postpartum depression who is misguidedly confined to a garret room and gradually loses her sanity. Virgina Woolf and Sylvia Plath were literary geniuses driven to suicide by depression.

Today, one in eight women will experience a major depressive episode in her lifetime. While men are more likely to die during suicide attempts, women report attempting suicide twice as often as men. One in four depressed women are dispensed medication while only 15% of men treated for depression are prescribed drugs. The difference in statistics between genders is thought to reflect both female hormonal fluctuations as well as social pressures that women face, particularly the modern pressures to balance motherhood and career. Premenstrual symptom and postpartum depression have gradually become recognized as medical conditions that can benefit from treatment.


The story of the origin of antidepressants describes a group of patients with tuberculosis who, when treated with a new compound called iproniazid, became curiously exultant. But the discovery popped up in a number of places: Nathan Kline, in the US, discovered the substance and may have been aware of its function as a MAO inhibitor. Lurie and Salzer showed good results with isoniazid, and Roland Kuhn in Germany discovered the tricyclic imipramine, still in use today by the World Health Organization. The first useable serotonin drug, citalopram (Celexa) was marketed in 1986.

Two kinds of talk therapy have evolved as having the best record for healing through insight. Cognitive-behavioural therapy (CBT), pioneered by Arthur T. Beck in the 1960s, works to transform unhelpful thought patterns or "automatic thoughts". Interpersonal therapy (IPT), developed at Yale University around the same time encourages insights into past experiences to find a strategy for moving forward in life.

More than 2,500 years have passed since Hippocrates had that heart-to-heart with sad King Perdiccas who was cured by marrying his sweetheart. Today, the father of western medicine, would doubtless follow up the chat with a prescription. He might also offer his new wife a little marital advice and suggest that she come back to see him if family life became more than she could bear.

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