Chapter 1
A very short history of melancholia
In ancient times the word melancholia rather than the word depression was used to describe mood disorders characterized by despondency. The word melancholia probably originated in the ancient civilizations of Greece and Mesopotamia. As such, we begin by highlighting the descriptions of melancholia and theories about its causes that held sway from ancient times until about the 19th century. For more detailed accounts, readers may wish to consult some of the excellent textbooks on this topic, such as Stanley Jackson’s Melancholia and Depression or relevant chapters of German Berrios’s The History of Mental Symptoms.
From black bile to the Stoic philosophers
Probably the first description of melancholia as a specific disease was written by Hippocrates, a Greek physician often referred to as the Father of Medicine, who lived in the 4th century bc. Hippocrates stated that melancholia was characterized by despondency, aversion to food, sleeplessness, irritability, and restlessness. He explained the development of this state using humoralism, a theory that suggested melancholia was an illness with a physical cause, which differentiated his model from primitive theories that blamed supernatural forces. Although humoral theory had many advocates, it was Hippocrates who is especially credited with the introduction of the concept of black bile.
In his book The Nature of Man, Hippocates described four humours within the body: black bile, yellow bile, phlegm, and blood. When all the humours were in equilibrium the body was healthy, but imbalances were thought to lead to disease. It was suggested that the humours were linked to the four elements air, water, earth, and fire (see Figure 1). Melancholia, due to an excess of black bile, was thought to be associated with autumn and with coldness and dryness. Hippocrates also recognized a condition that was akin to mania, which was described as a condition marked by periods of great excitement and overactivity. Hippocrates argued that this condition was related to an excess of yellow bile during the summer and with warm, dry air. It was proposed that treatments should target the restoration of humoral balances, which often involving purging and blood-letting.
1. Diagram of the humours and their relationships.
The ideas expressed by Hippocrates were further developed in the 3rd century bc by the Greek philosopher Aristotle and his followers in a work entitled Problemata. This proposed that the temperature of bile was the most important factor and if it was too cold it caused ‘groundless despondency’. He suggested that less severe imbalances of bile led to a melancholic temperament rather than illness, which was one of the few attempts to describe a continuum between personality and mental disorders since Plato’s writings on universality. Also, Aristotle is one of the first to suggest that melancholic temperament could be associated with creativity and intellect, and he reported that it was often found in philosophers, politicians, artists, and writers.
The 1st century ad saw further developments in the theories and treatments of melancholia. For example, Soranus of Ephesus was one of the first physicians to recognize that mania and melancholia were chronic diseases associated with loss of reason. Further, he promoted the idea that treatments to improve physical health could improve mental health and that psychological interventions, such as the sound of dripping water to induce sleep, might be beneficial.
At around the same time, Rufus of Ephesus provided descriptions of melancholia that remained influential for many centuries. He noted that the people he described as melancholics were sad, gloomy, fearful, and doubting, and that their physical appearance changed during these episodes. Rufus suggested that there could be an inborn (congenital) form and an acquired form of melancholia, which is the first description of the idea that melancholia may be the final outcome of a number of different processes and could have multiple causes. Historically, his name became associated with the sacred remedy—a mixture of herbs purported to prevent melancholia.
One of the most famous Greek physicians was Galen of Pergamum (1st–2nd century ad). Galen was the physician to Marcus Aurelius and he is important because he had some influence over Roman medicine. Until his emergence, Roman society had often regarded melancholia as a punishment from the gods. In his book On the Affected Parts, Galen developed detailed theories of how different humoral abnormalities led to varying sub-types of melancholia and that different personality types were related to the humours, such as sanguine, choleric, melancholic, and phlegmatic temperaments. This is one of the earliest descriptions of the idea that individuals could have a personality style or temperament that may be associated with developing a mental condition. According to Galen, treatments should include blood-letting if the melancholia was thought to be a brain disease sub-type, but bathing, rest, and a well-balanced diet if it had different origins (e.g. the blood or the stomach). Like Rufus, Galen produced a remedy called theriac (a term which is sometimes translated as antidote).
Over the following centuries there was general acceptance of humoral disequilibrium as the cause of melancholia in many cultures. For example, the Arabian physician Avicenna (the Latin version of his name), who is also known as Abu Ali al Husain ibn Abd, wrote about melancholia and the four humours in the highly influential Canon of Medicine. In this book, he suggested that both the body and soul were affected by melancholia and advocated the use of persuasive talking as a method of treatment, which some have suggested may have been a forerunner to cognitive behaviour therapy.
In this era, there were further developments in regard to views about the nature of the problem and its treatments. For example, Aretaeus of Cappadocia highlighted the cyclical nature of episodes of melancholia and noted that it may be associated with mania. Similar observations were made by others, such as Alexander of Tralles (ad 525–605), but Aretaeus is regarded as the ‘clinician of mania’, which he described as a state characterized by furor, excitement, and cheerfulness. Aretaeus proposed that some cases of melancholia might be precipitated by external events such as bereavement, and that love (which he referred to as The Physician Love) could help alleviate the symptoms of melancholia, as could eating blackberries and leeks and talking about symptoms.
In the era this was written, medicine and philosophy occupied parallel worlds with limited cross-fertilization of ideas. Whilst most of the texts by physicians focused on melancholia, there were other observations on human emotions, including dejection and sadness, recorded by the philosophers of the time. For example, Epictetus, a Stoic philosopher of the 1st century ad, wrote that ‘Men are disturbed not by things but the views which they take of them.’ In modern psychiatry, the Stoics are often quoted in discussions of stress-vulnerability models, as their ideas offer potentially simple insights into why the experience of the same life event, such as loss or the breakup of a relationship, may be followed by an episode of clinical depression in one individual but not in another.
The Middle Ages
From about ad 500 onwards, there was a significant shift away from the notion that mental disorders had similar causes to physical disorders and should be treated by physicians towards a revival of beliefs that mental disorders were signs of immorality, sin, and evil. Christianity dominated the social order and religious doctrines were evident not just in the anti-science of that era and the shifting explanations of the causes of melancholia but also in ideas about what constituted appropriate interventions, which increasingly became the responsibility of the clergy rather than clinicians.
In her book The Nature of Melancholy, Jennifer Radden chronicles many classical accounts of these views such as the story of Hildegard of Bingen (1098–1179). Hildegard was a German nun who wrote the Book of Holistic Healings, which drew upon humoral theories of melancholia but then proposed that black bile had come to exist because of original sin. Similar views were reported by other influential people of the time and any mental condition characterized by loss of reason was regarded as evidence of God’s punishment. As such, melancholia was viewed as a challenge to Christian faith and morals. This inevitably led to the sufferer being demonized and many melancholics were burned at the stake as witches. In 1486, a manual on witch-hunting, the Malleus Maleficarum (The Hammer of the Witches), was written for Pope Innocent VIII by a famous inquisitor for the Catholic Church, Heinrich Kramer (see Figure 2). Amazingly, the text was revised and reprinted more than sixteen times over the next 200 years and it remained influential across Europe until the early years of the Renaissance.
2. The cover of Malleus Maleficarum (The Hammer of the Witches).
It is worth noting that some European groups rejected the notion that mental disorders offered evidence of evil or possession by the devil. For example, the Saturnists believed that melancholia was caused by celestial influences that especially afflicted the most talented and creative members of society, and so melancholia was an experience to be admired. Marsilio Ficino (1433–99) is the person most commonly regarded as a leader of the Saturnists. He was born in Italy and trained in philosophy and medicine and experienced episodes of melancholia himself. Ficino advocated treatments such as exercise, alternative diets, and music. He believed that the horoscope dictated character and he also supported the Aristotelian idea that melancholia was linked with intelligence, which was connected to the planet Saturn.
Historical accounts of the Middle Ages largely focus on the negative and hostile reactions towards people with melancholia from all classes and subgroups within society. However, it is worth highlighting that these attitudes were not universal across all cultures. The emphasis on the ideas expressed in the literature originating in Europe, and then later in the New World, often fail to include the range of views expressed in other cultures and religions (see Box 1). We do not examine these views and attitudes in detail, but offer a brief synopsis to raise awareness of these cultural differences.
Box 1 Cultural differences in views of melancholia
Islam: The teachings of the prophet Muhammad stated that individuals with mental disorders were dear to their God and should be treated humanely and cared for by society. It was thought that illnesses such as melancholia were a sign of supernatural intervention and that it was important to provide the individual with a calm and restful atmosphere. This probably explains why this culture is regarded as possibly the first to develop asylums.
Ayurveda: The ancient Hindu scriptures of Ramayana and Mahabharata contain descriptions of depression. Ayurveda, an Indian system of medicine, was first described in the 1st and 2nd centuries ad. In Ayurveda there are three bodily humours or doshas: Vata, Pitta, and Kapha. Disturbances of the doshas relative to each other lead to illness (similar to humoral theory). Depression was and still is classified according to which dosha is dominant. Vata depression is characterized by anxiety, guilt, and insomnia and may be caused by upsetting experiences. Pitta depression is shown by irritability, low self-esteem, and suicidality and can be associated with overwork and lack of sunlight. Kapha depression is associated with excessive sleep, overeating, and lethargy and may be caused by lack of stimulation.
Judaism: Ancient Judaism viewed mental illness as possession by demons and was seen as a punishment from God for failure to uphold traditions. Those afflicted were treated well in the main, but law reduced their responsibilities in society.
Traditional Chinese medicine: According to traditional Chinese medicine, depression is caused by a blockage of the internal organs and meridians that connect them and it is proposed that this restrains the flow of Qi (which represents energy) to various organs, which causes stagnation. Suggested treatments included acupuncture, exercise, and the ‘mood smooth’: a specific mixture of Chinese herbs with some similarities to thearic (an ancient remedy).
From the age of enlightenment to the birth of modern psychiatry
From the 1500s onwards new attitudes towards melancholia began to emerge. Joan Luis Vives (1492–1540) expressed the idea that individuals with mental illness should be respected and treated rather than denigrated by society. Likewise Johann Weyer (1515–88) stated that individuals should not be punished or blamed for their ‘disordered imaginations’ and highlighted the importance of building a therapeutic relationship between a patient and a physician; an idea that holds to this day.
Perhaps the best-known text from the Renaissance is The Anatomy of Melancholy or to give it its full title The Anatomy of Melancholy, What it is: With all the Kinds, Causes, Symptomes, Prognostickes, and Several Cures of it. In Three Maine Partitions with their Several Sections, Members, and Subsections. Philosophically, Medicinally, Historically, Opened and Cut Up. Written by the Oxford academic Robert Burton and first published in 1621, it offers a somewhat eccentric (the text is presented in the voice of an imaginary Greek philosopher, Democritus Junior) but detailed account of all aspects of melancholia. Although Burton’s work is often regarded as a medical treatise, it is really a historical overview of differing ideas about melancholy from the perspective of philosophy, psychology, physiology, demonology, cosmology, meteorology, etc. Despite all its flaws, the book remains the most widely quoted historical account of different types of melancholy, the proposed physical and psychological causes, and various potential cures including prayer, healthy living, entertainment, talking with friends, and ancient remedies such as purgation. Interestingly, Burton also made one of the first known references to treatment with St John’s Wort (‘if gathered on a Friday night in the hour of Jupiter’), which has been proposed as a modern-day natural remedy for depression.
Another great chronicler of the 17th-century period was Richard Napier, an English physician and clergyman. He recorded observations on over 2,000 mentally ill patients and believed that 20 per cent of these patients had some form of melancholia. Napier subscribed to the view that the term melancholia should be reserved for individuals from higher social classes. He suggested that poorer patients with similar clinical problems were described as being ‘mopish’, which was a lower status and more stigmatizing diagnosis. Napier’s social classification of the disorder suggests he was influenced by assumptions that true melancholia was associated with moral superiority and intellectual prowess. Indeed, during this era melancholia became a sought after disposition or diagnosis by some.
Thomas Willis (1621–75) is another important figure from this era, and he is remembered as one of the first proponents of chemical as opposed to humoral theories of the causes of melancholia. He identified the weather, excessive thinking, and insufficient exercise as causes of chemical disruptions in the body and advocated treatments such as spa waters containing iron. The rise of chemical theories signalled the demise of humoral theories. However, studies of the human body were evolving rapidly and new understandings of the circulatory systems, such as described by the English physician William Harvey, meant that chemical theories were soon surpassed by the so-called mechanical theories of physical and mental illnesses.
Mechanical theories of melancholia suggested that it developed when the flow of blood, lymph, and animal spirits in the body was slowed down or stagnated. Freidrich Hoffman (1660–1742) suggested this was due to disequilibrium of different types of fluids whilst others, such as the Dutch physician Herman Boerhaave (1668–1738), cited thickening of the blood with ‘oily and fatty stuffs’. By contrast, William Cullen (1710–90) focused attention on the nervous system and proposed that melancholia resulted when there was disturbed nerve fluid flow and reduced excitability in the nervous system.
At about the same time as these developments in the theories about the causes of melancholia a number of clinicians began to report that melancholia was a problem that tended to be recurrent and that it could be linked to mania. For example, a Spanish physician named Andrés Piquer-Arrufat diagnosed King Ferdinand VI with ‘affectivo melancholico maniaca’. Interestingly, his contribution is often overlooked as two French psychiatrists described a similar disorder within weeks of each other in 1854 (but 100 years later than Piquer-Arrufat). Jules Baillarger called it ‘la folie a double form’ (dual form madness) whilst Jean Pierre Falret named it ‘la folie circulaire’ (circular madness) and recorded ‘this succession of mania and melancholia manifests itself with continuity and in a manner almost regular’.
The 18th century also heralded a change in the way patients were viewed and treated. One of the best-known reformers was Philippe Pinel, a French psychiatrist trained in literature, religion, mathematics, and medicine. In his text Traité médico-philosophique sur l’aliénation mentale, he categorized mental disorders into mania, melancholia, dementia, and idiotism. Pinel recognized that mania (that often presented with exalted self-importance and pretensions of unbounded power) and melancholia (that often presented with depression of the spirits, apprehensions, and absolute despair) were different expressions of the same disorder. An idea that was reinforced by others, such as Esquirol during the following century. Pinel also contributed to the developing dialogue about the potential causes of these disorders. For example, he suggested that melancholia could occur as a consequence of domestic misfortunes, obstacles to marriage, and disappointed ambition. He also observed that it occurred as a result of a combination of the makeup of the person and the meaning of the stress they experienced; ideas that echo those of the Stoic philosophers.
In the USA, Benjamin Rush (1745–1813), who is often described as the Father of American Psychiatry, was working as a physician in Philadelphia and began to develop his own rather complex theory about melancholia. He coined the term tristimania for a less severe form and amenomania for a more severe form of illness. Rush proposed that a reaction in the blood vessels of the brain (convulsive motions that he termed ‘morbid excitement’) caused these symptoms and believed that spinning the patient would reduce the inflammation, and devised a tranquilizing chair. Although this particular treatment was both unpleasant and ineffective, Rush remains a well-regarded clinician and renowned as a social activist who advocated free treatment for the poor.
The late 18th and early 19th centuries saw an ongoing debate about biological or psychological causes of melancholia. Psychological models still retained religious or moral overtones. For example, Johann Christain Heinroth (1773–1843), a member of the German Psychiker School (literally meaning psychologically orientated school), viewed the sins of the patient as the root of their mental illness. In contrast, Wilheim Greisinger (1817–68) stated that ‘mental diseases are somatic diseases of the brain’. He suggested that each disorder represented a stage of a single brain disorder, a concept termed ‘Einheitspsychose’ (the unitary psychosis). In 1845 he published Pathology and Therapy of the Nervous Diseases which emphasized his view that psychiatry was a medical scientific specialty. Greisinger’s views on psychosis and psychiatry were influential in Germany and beyond and led to a debate that continues to this day.
We conclude this chapter with a man whose name lives on into the modern times because a famous psychiatric institution, the Maudsley Hospital, is named after him. Henry Maudsley (1835–1918) suggested that insanity could be divided into affective and ideational categories. This represents an important idea as it begins the process of separating disorders associated with mood disturbances from mental disorders that were characterized by delusions (psychotic disorders); he also believed that there was a physical cause for mental disorders. In many ways Maudsley provides a bridge between the ancient and the modern era and he was practising psychiatry at around the time that the term depression was being used more frequently, with the word melancholia increasingly reserved for the most severe forms of the illness. This was the start of an era in which medical theories about melancholia began to be integrated with ideas about sadness and dejection described by philosophers, psychologists, and also by Freud.