After his important History of Psychiatry from the Era of the Asylum to the Age of Prozac (1997) and the several works that followed, Edward Shorter has become the historian of record for psychiatry: we rely on his extensive research into the highways and byways of its clinical and academic terrain for signposts in this most complex, multifaceted, and obscure field of medicine. His latest book, How Everyone Became Depressed: The Rise and Fall of the Nervous Breakdown, takes on the many-stranded history of anxiety and depression, tracing the advent and eventual demise of appeals to "nerves," "nervousness" and "nervous complaints," together with the subsequent emergence of the "Depressive Disorder" that has been the target of drug treatments and diagnostic practices since the last quarter of the twentieth century.
As a disease category, the influential – and hugely consequential – "depressive disorder" associated with the 1980 DSM, whose development is detailed here, has had more than its share of critics. Concern has been directed to its clinical, its pharmacological, its nosological, its epidemiological, and its social and cultural implications. One strand of these challenges, which has acquired increasing recognition in the first years of the twenty-first century, is associated with attempts to separate out true melancholia (or melancholic depression) from related clinical syndromes believed to have been confused with it - rather analogous to attempts, in an earlier era, to separate endogenous from reactive depression. On the more recent contrast, associated with Bernard Carroll, Gordon Parker, Max Fink, and others, melancholia is distinguished in several ways. First, it is seen to have a true biological marker, dysfunctionally elevated cortisol levels within the endrocrine system that can be identified through a dexamethasone suppression test (DST). Second, it is unaffected by the usual remedies, including antidepressant drugs, and effectively treated by ECT alone. Third, it is a mood disorder in that the patient experiences unrelieved, distressing sadness and ahedonia as primary symptoms. In addition, it is associated with suicidality, and with psychotic dimensions absent from more ordinary depression.
Shorter throws his lot in with this analysis. In How Everyone Became Depressed he provides us with both the history of its emergence as a serious challenge to standard DSM categorizations, and a justification for its claims based on its deep historical roots.
As well as revising and dividing the present-day category of depressive disorder to acknowledge true melancholia, Shorter would return to earlier observations that grouped as "nervous illness" the other traits often associated with depressive illness: not merely mild depression or low mood, but also mild anxiety, pathological fatigue, and somatic symptoms such as chronic pain and insomnia, as well as mild obsessive thinking – i.e., the cluster of complaints today employed, menu-fashion, to attribute the broad diagnosis of Depressive Disorder. When nervous illness came to be displaced by "depressive disorder," one of those traits, low mood, acquired misleading prominence, Shorter explains, since not all diagnosed as depressed experience sad and despondent mood states. An increasing trend in psychiatric understanding, which he applauds, returns to the earlier concept of a nervous disorder rather than a disorder of mood in conceiving of depression as a "total body experience" that encompasses anxiety and pain quite as much as sadness and despondency.
This is a captivating book. Shorter is a lively writer, equally at home with historical references, telling case material, and the sciences of endocrinology and physiology that underlie the claims of the melancholia cabal. And, whether explaining the influence on psychiatric theorizing, classification and research of elements such Big Pharma, psychoanalysis, and the lack of physiological knowledge on the part of American trained diagnosticians, or explaining the role of the great figures of psychiatric history (Wilhelm Griesinger, and Kraepelin, or nearer our own time, Robert Spitzer and Bernard Carroll), his subject matter is endlessly fascinating.
My quibbles with this otherwise valuable work are few. But first, it does seem worth noting that the reader may be left confused by some of the contrasts and categories employed, including mood. No definition is offered of this key term, and "mood" is of course something of a term of art in clinical and theoretical psychiatry. But moods are affections, in everyday and psychiatric understanding. And sometimes Shorter places mood in contrast to bodily or organic: the implied contrast being that moods are psychic. To rely on the standard division between the mental or psychological and the organic might be unacceptable here however, as philosophers working on moods, especially those in Phenomenological traditions, have emphasized (See Heidegger 1962, but also Ratcliffe 2008). Fatigue, for example, is a complaint that seems to straddle the divide: it is not merely a psychically affected (or psychogenic) state, but one experienced holistically, as a bodily and psychic totality. (A second implied contrast is less misleading. Nerves, it is stated, were taken to affect the whole body while disorders of mood were "situated entirely in the brain and mind" (pages 4-5). Certainly this view runs counter to much phenomenology and modern-day neuroscience. But Shorter makes claims, we must assume, about the perceived contrast only.) A classification resting as heavily on the category of mood as does the melancholia-based one Shorter documents could nonetheless have benefited from further initial clarification of this slippery concept.
My second comment is more historical than conceptual, and merely an observation. In endorsing the distinction between the common or garden depression better seen as afflicted "nerves" and melancholia proper, Shorter appeals to the ancient lineage of the category of melancholia, commenting that since the seventeenth century, "medical writers have described melancholia in a manner quite similar to our own, suggesting that we are dealing here with a relatively unchanging biological type, like diabetes or stroke…"(pages 93-4, emphasis added). Unless heavy stress is placed on the qualifying "medical," this claim is somewhat misleading. As Fink and associates wish to distinguish melancholia (or melancholic depression), it may be a disorder of intense, distressing sadness. But we can hardly then equate this usage with that of the ancients, who consistently added fear and apprehension to the sadness and despondency they identified in melancholic patients. And once we reach the renaissance and early modern era, we find in Burton's Anatomy (and much other at least quasi-medical writing, including McDonald's account of Napier's cases), a syndrome comprising unfounded fears, worries, obsessional thought and bodily ills as well - one that if anything corresponds more closely to the portmanteau category of depressive disorder these researchers want to place in contrast to melancholia (or melancholic depression) proper. So while the term "melancholia" is employed in the long stretch between Hippocrates and Fink, its meaning undergoes shifts, or is at best debatable. My concern is not so much that Shorter does not recognize this, but rather that his streamlined generalizations leave little room for it.
That said, this is a fascinating and authoritative look at much recent history, cultural as well as medical.It should be added to every practitioner's library to foster historical perspective and suitable humility.
Burton, R. 1632/1989-2000. The Anatomy of Melancholy. 6 vols. Eds. Thomas Faulkner, Nicolas Kiessling, and Rhonda Blair. Vols I-III: Text; vols IV-VI: commentary by J.B. Bamborough and Martin Dodsworth. Oxford: Oxford University Press.
Heidegger, M. 1962 Being and Time. New York: Harper and Row.
MacDonald, M. 1983. Mystical Bedlam. Cambridge: Cambridge University Press.
Ratcliffe, M. 2008. Feelings of Being: Phenomenology, psychiatry and a Sense of Reality. Oxford: Oxford University Press.
Shorter, E. 2007. History of Psychiatry from the Era of the Asylum to the Age of Prozac. New York: John Wiley&Sons.
© 2013 Jennifer Radden
Jennifer Radden, University of Massachusetts, Boston