Throughout human history, and long before our current definition for major depression or major depression disorder treatment, the concept of depression has been repeatedly molded and reconceived. As society changes, so does its view of depression, with philosophers, social theorists, artists, and laypeople all adding their own input into what constitutes this hard to pin down experience, which, for many, is part of their daily lives.
Today’s view of depression, as a mood disorder characterized by feelings of emptiness and sadness, contains the echoes of past views and its associations with different characteristics. For this reason, a deeper, more comprehensive understanding of depression necessitates a more in-depth look at how this condition has developed over time.
A Melancholic State of Mind
Considered the “Father of Medicine,” Hippocrates (460 – 370 BCE) was an ancient Greek physician who saw all bodily mechanisms as caused by the relative amount of four internal fluids, called humors: blood, black bile, yellow bile, and phlegm. He believed that a balance between the four brought on good health, while an extreme deficiency or excess of one caused physical ailments.
Greek physician and philosopher Galen (129AD – c. 200/c. 216) expanded upon Hippocrates’ theory, by stating that personality types were also derived from an excess of one of the four humors.
According to the humors theory, melancholic personality type was created by an excess of black bile. Melancholics were accordingly seen as introverted, deep thinkers, who typically related more to the sadder part of the emotional spectrum. It is from this perception of melancholia that our current concept of depression eventually evolved.
Depression and a Dual Approach to Mental Illness
It was 19th Century German psychiatrist Emil Kraepelin who began referring to various forms of melancholia as “depressive states,” due to the low mood that defines it. Kraepelin also took a dual approach to mental illness, separating depression into two categories: manic depression and dementia praecox.
Kraepelin’s distinction was based on whether the depression’s source was external or internal: if the depression was caused by an external tragedy, such as the death of a loved one, it was considered a form of manic depression and expected to be episodic and passing.
However, depression that did not stem from a known, external cause was understood to have “grown” out of the individual’s psyche, and as such was considered a break from reality that is similar to present-day schizophrenia.
The distinction Kraepelin made between both types of depression is still relevant today: many patients continue to recount how people are more willing to offer sympathy if the source of their depression is clearly understood: as such, an individual whose depression was caused by witnessing a traumatic event is likely to receive more social support than someone whose depression appeared during adolescence.
Mourning a Love with No Name
Sigmund Freud, the father of psychoanalysis, published his own thoughts on depression in his 1917 essay, Mourning and Melancholia. In it, Freud described melancholy in a similar manner to our current view on depression, elaborating that melancholy is defined by a sense of loss that arises when the object that has been lost is unknown, due to the mental process of repression.
Freud posited that depression interferes with the normal mourning process, causing the individual to feel a general sadness when coming in contact with the world at large, while experiencing the anguish and hopelessness assailing them as inescapable. Rather than internalize the positive aspects of the person or object that has been lost, and come to terms with their shortcomings, the person experiencing melancholy redirects any lingering resentment toward themselves, while maintaining the memory of their lost loved one as an ideal, untouchable version of who they were in real life.
A More Grounded View of Depression
Moving away from psychoanalysis, in favor of a more empirically-based approach to depression, was Swiss psychiatrist Adolf Meyer. The eventual President of the American Psychiatric Association, Meyer argued in favor of considering biological factors, together with mental and familial ones, as elements that significantly contribute to the appearance of depression.
ICD, DSM and a Consensus of Diagnosing Mental Illness
With mental health theories abounding from the end of the 19th Century, it became necessary to reach a working consensus on how to identify, group and treat mental health conditions based on statistical field data. Thus, a number of attempts were made to create a comprehensive mental health classification system.
Eventually, two main systems emerged: the International Statistical Classification of Diseases, Injuries and Causes of Death (ICD) in 1949, and the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1952. While the ICD examines both physical and mental ailments and is used across the globe, the DSM specifically examines mental disorders and is primarily used in the US. Both are periodically updated to reflect the changing times and their shifting approaches to mental health.
The 1960s and ‘70s saw a push for greater reliance on statistical analysis, with the field of psychiatry aiming to solidify its status as an empirical medical profession. As a result, more sophisticated tools were developed for assessing depression, chiefly the Hamilton Rating Scale for Depression (HDRS) from 1960, and the Beck Depression Inventory (BDI) from 1961. Both are considered gold standards and are still used today.
Following these changes, the DSM-III, which was published in 1980, aimed to reassess how people talk about mental health, by moving away from pathologizing language and offering a more compassionate approach. This helped counter some of the stigmas that individuals battling depression had to face (and still often do).
As times changed, so did the ICD and DSM’s definitions of depression, with the various symptoms that go into the diagnosis reflecting up-to-date field data. As an example of this change, the DSM-IV, which was published in 1994, excluded instances of depression that can be better explained by bereavement.
DSM-V, which was published in 2013, added a “mixed features” sub-diagnosis of depression that includes manic episodes, in addition to an “anxious distress” sub-diagnosis that is defined by having at least two of the following symptoms: tension, restlessness, difficulty concentrating due to worrying, fear that something awful might happen, and feeling a loss of control.
Biological Breakthroughs in Treating Depression
In addition to the diagnostic developments of the ICD and DSM, the mid-20th Century saw a revolution in treating depression when antidepressant medication was introduced as an efficient and increasingly common healthcare option. Addressing depression through medication highlighted the possible biological and genetic causes behind it, and offered many patients long-awaited symptom relief.
Antidepressants affect the brain’s secretion of neurotransmitters, which are chemicals that relay information between nerve cells. Over the years, several generations of antidepressants have been approved and made publicly available, with each influencing the neural pathways involved in depression in a different way.
The three classes of antidepressants most commonly prescribed today are:
Tricyclic antidepressants (TCAs), which work on norepinephrine and were introduced in the late 1950s and early ‘60s. Examples include Elavil and Tofranil
Selective serotonin reuptake inhibitors (SSRIs), which were introduced in the mid- 1980s. Examples include Prozac and Zoloft.
Serotonin and norepinephrine reuptake inhibitors (SNRIs), which were introduced during the mid-‘90s. Examples include Cymbalta and Effexor.
All three classes of medication have been found to effectively alleviate symptoms of depression, though their efficacy can only be gauged after several months’ treatment. In addition, their accompanying side effects can sometimes be severe, and include weight gain, sexual dysfunction, nausea, blurred vision and increased heart rate.
Offering an Alternative View: Existentialism, Humanism, Cognitive Psychology
The writings of earlier visionaries (in particular Freud) helped the modern world begin to conceptualize and approach depression. Eventually, though, these consensus points of view were given a somewhat humbler perspective, as more contemporary approaches to depression began to be considered, as well. Enter existentialism, humanism and cognitive psychology, as three branches of psychology that developed during roughly the same time period, while offering their own takes on depression.
Existentialism: Existentialism gained popularity following WWII, due to its focus on the individual’s search for meaning in a world that often seems incomprehensible. Among the leading existential theorists was psychologist Rollo May, who described depression as “the inability to construct a future.” He posited that when a person is unable to imagine a future where they can truly live out their passions, they experience a deep helplessness that can develop into depression. To counter this, May encouraged accepting sadness as part of the human experience, rather than deny its existence.
Humanism: Humanism views people as agents of change in their own lives, with depression arising when meeting one need comes at the expense of another.
Psychologist Abraham Maslow illustrated this point in his 1943 paper on the “hierarchy of needs,” describing how depression is caused when more urgent survival needs (such as food, shelter or security) are met at the expense of social and emotional needs. As a result, someone who, for example, invests all their time and energy in working toward financial security, may become depressed and emotionally depleted due to a lack of close relationships.
Cognitive Psychology: Cognitive psychology grew out of the “cognitive revolution” of the 1950s-’80s, striving to understand the mind through empirical tools. A leading figure in this movement was psychiatrist Aaron Beck, who developed the BDI assessment tool for depression, as well as Beck’s cognitive triad for depression.
Looking at the factors contributing to depression, Beck reasoned that an individual’s beliefs regarding themselves, the world and the future influenced each other and determined their susceptibility to depression: as such, an individual who believes they are to blame for their depression, that the world is a fundamentally sad and lonely place, and that none of this will ever change, will likely develop depression as a result.
Medical Technology Breakthroughs: ECT, TMS and Deep TMS
During the 20th Century, several cutting edge medical technologies were invented and shown to effectively treat depression. Out of the different options that were made available, ECT, TMS and its most recent advancement, Deep TMS have gained greater professional and public recognition
ECT: Electroconvulsive therapy was originally used to treat schizophrenia, before it was shown between the 1960s-‘80s to be even more effective in treating mood disorders, depression in particular. As a result, it is presently primarily used to treat this condition.
ECT works by using electric pulses to stimulate the brain and induce a brief set of seizures. While it has been shown to be highly effective in treating severe depression, ECT does have its drawbacks: namely, that it requires full sedation, the possibility of short-term memory loss, and its negative public perception, much of which has to do with misinformation characterizing it as a traumatic, personality-altering procedure.
TMS: Transcranial Magnetic Stimulation has been clinically available since 2008, as a non-invasive option for treatment-resistant patients with depression who are wary of ECT. The procedure initiates a series of electromagnetic pulses, held inside a figure-8-shaped handheld device. Once activated, the pulses regulate the neural activity of brain structures that have been shown to be related to depression.
Though TMS has been shown to be both safe and effective in alleviating symptoms of depression, certain limitations have been shown in regard to this original, standard form of TMS: first, the figure 8-coil’s relatively narrow scope means that standard TMS can only regulate a few structures at any given moment. This means that TMS sometimes suffers from targeting issues, as the regulating pulses may miss some of the relevant structures. Additionally, standard TMS at times BrainsWay’s Deep TMS has trouble directly stimulating deeper brain structures,
Helmet which can also possibly decrease the treatment’s efficacy.
Deep TMS: Deep Transcranial Magnetic Stimulation, or Deep TMS, an advancement of the standard, figure-8 TMS treatment, answers some of the issues raised with its predecessor. Deep TMS was first introduced in 1985, and gain FDA clearance in 2014, as a form of noninvasive brain stimulation, and like standard TMS, utilizes magnetic fields to safely and effectively regulate brain structures associated with depression, as well as other mental health conditions.
Deep TMS’s patented H-Coil technology is held inside a cushioned helmet that is fitted onto the patient’s head. The magnetic fields produced by the H-Coil not only manage to reach wider areas of the brain, but also to directly stimulate structures located in deeper regions of the brain, which contributes to the treatment’s efficacy.
Depression Today
These days, our perception of depression is the most diverse and well-studied it has ever been. The vast interest in this condition has, however, caused a divergence in fields of study, treatment methods and takes on what constitutes depression as a mental health disorder. All these possibilities can understandably confuse those dealing with depression, as well as their caregivers and others around them. It is thus important to stay well-informed as to the different available options you have for battling depression, and figure out what works for you in a supportive, professional and caring environment. Consulting a mental health professional familiar with your medical and mental health history is highly advisable, as is considering both tried-and-true methods and newer, low-risk alternatives.
Be it through deep psychoanalytic treatment, a more existential approach, exploring scientifically proven treatment options like Deep TMS, incorporating medication into your healthcare regimen or taking a look at the detrimental set of beliefs that define it, individuals battling depression today are able to benefit from those who came before them. The philosophy, research and cultural shifts that continue to this day have resulted in a multitude of perspectives, a range of available treatment options, and the somewhat comforting knowledge that our passion to gain a better understanding of depression has already progressed us as a society toward a fuller, broader and more compassionate view of this complex condition.
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