The age of depression

Public Interest, Wntr, 2005 by Allan V. Horwitz, Jerome C. Wakefield

A century later, Aristotle elaborated the distinction between normal and pathological mood states. He separated melancholic states that arose from the conditions of everyday life from disorders that involved "groundless" despondency of lengthy duration and thus stemmed from internal factors:

   We are often in the condition of feeling grief without being able to
   ascribe any cause to it; such feelings occur to a slight degree in
   everyone, but those who are thoroughly possessed by them acquire them
   as a permanent part of their nature.

As in Aristotle's passage, the key distinction in ancient definitions of melancholia was between states of sadness "without cause" and those that had similar symptoms arising from actual losses; only the former were mental disorders. "Without cause" does not mean uncaused, for throughout history depression has been attributed to postulated physical or psychological causes such as excessive black bile, disturbances in the circulation of blood, or depletion of energy. Rather, "without cause" means that the symptoms of depression were not associated with the sorts of environmental events that would appropriately lead to sadness, such as bereavement, rejection in love, economic failure, and the like. Conversely, ancient Greek and Roman physicians would not consider symptoms of depression that occur "with cause" as signs of a mental disorder. Such normal reactions express, in the words of the second-century Roman Physician Aretaeus, "mere anger and grief, and sad dejection of mind." The symptoms could be identical in the two conditions; the distinction lay in the relation of the symptoms to the context in which they appeared. Symptoms that arose in contexts that could be expected to produce them, and that abated in a reasonable period of time after the triggering events ended, indicated normal functioning. Comparable symptoms that arose without appropriate triggering events, or had greater duration or intensity than was appropriate to the triggering events, potentially indicated disorder.

The same distinction can be found in Robert Burton's classic work The Anatomy of Melancholy, published in 1621. Burton defined melancholic disorder as "a kind of dotage without a fever, having for his ordinary companions fear and sadness, without any apparent occasion" (emphasis added). Burton considered such states "contrary to nature," and thus disordered. He considered the propensity to self-limiting melancholic feelings in response to loss and disappointment to be a normal part of human nature. He describes

   that transitory melancholy which goes and comes upon every small
   occasion of sorrow, need, sickness, trouble, fear, grief, passion, or
   perturbation of the mind, any manner of care, discontent, or thought,
   which causeth anguish, dullness, heaviness, and vexation of spirit
   .... And from these melancholy dispositions, no man living is free,
   no Stoic, none so wise, none so happy ... [none] so well composed,
   but more or less, some time or other, he feels the smart of it.
   Melancholy, in this sense is the character of mortality.