The History of Depression

Accounts, treatments, and beliefs through the ages

Hippocrates, polychrome majolica, detail, cloister of Old Cemetery, Padula charterhouse (Certosa di San Lorenzo), Padula, Campania, Italy

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While no single person can be credited with the discovery of depression, there have been a whole series of great thinkers who have contributed—and continue to contribute—to our growing understanding of just what this illness really is. In order to better understand how researchers, doctors, and psychologists think about this condition today, it can be helpful to take a look back at the history of depression.

Earliest Accounts of Depression

The earliest written accounts of what is now known as depression appeared in the second millennium B.C. in Mesopotamia. In these writings, depression was discussed as a spiritual rather than a physical condition. Like other mental illnesses, it was believed to be caused by demonic possession. As such, it was dealt with by priests rather than physicians.

The idea of depression being caused by demons and evil spirits has existed in many cultures, including the ancient Greeks, Romans, Babylonians, Chinese, and Egyptians. Because of this belief, it was often treated with methods such as beatings, physical restraint, and starvation in an attempt to drive the demons out.

While many believed that demons were the root cause of depression, there were a number of ancient Greek and Roman doctors who believed that depression was a biological and psychological illness.

Greek and Roman doctors used therapeutic methods such as gymnastics, massage, diet, music, baths, and a medication containing poppy extract and donkey's milk to treat their patients.

Ancient Beliefs in Physical Causes of Depression

As far as physical causes, a Greek physician named Hippocrates is credited with the idea that depression, or melancholia as it was known then, was caused by an imbalance in four body fluids, called humors: yellow bile, black bile, phlegm, and blood. Specifically, melancholia was attributed to an excess of black bile in the spleen. Hippocrates' treatments of choice included bloodletting, baths, exercise, and diet.

A Roman philosopher and statesman named Cicero, in contrast, believed that melancholia was caused by psychological causes such as rage, fear, and grief. 

In the last years before the common era, in spite of some steps toward believing in more physical and mental causes of depression, it was still a very common belief among even educated Romans that depression and other mental illnesses were caused by demons and by the anger of the gods.

Depression Causes and Treatment in the Common Era

During the common era, many barbaric and primative treatments for depression continued to be the norm. Cornelius Celsus (25 BC-AD 50) reportedly recommended the very harsh treatments of starvation, shackles, and beating in cases of mental illness. A Persian doctor named Rhazes (AD 865-925), however, did see mental illness as arising from the brain and recommended such treatments as baths and a very early form of behavior therapy which involved positive rewards for appropriate behavior.

During the Middle Ages, religion, especially Christianity, dominated European thinking on mental illness, with people again attributing it to the devil, demons, or witches. Exorcisms, drowning, and burning were popular treatments of the time. Many people were locked up in so-called "lunatic asylums."

While some doctors continued to seek physical causes for depression and other mental illnesses, they were in the minority.

During the Renaissance, which began in 14th century Italy and spread throughout Europe during the 16th and 17th centuries, witch hunts and executions of the mentally ill were still quite common; however, some doctors were revisiting the idea of mental illness having a natural rather than a supernatural cause.

In the year 1621, Robert Burton published a book called Anatomy of Melancholy in which he outlined both social and psychological causes of depression such as poverty, fear, and loneliness. In this volume, he made recommendations like diet, exercise, travel, purgatives (to clear toxins from the body), bloodletting, herbs, and music therapy in the treatment of depression.

The 18th and 19th Centuries

During the 18th and 19th centuries, also called the Age of Enlightenment, depression came to be viewed as a weakness in temperament which is inherited and cannot be changed, with the resulting idea that people with this condition should be shunned or locked up.

During the latter part of the Age of Enlightenment, doctors began to suggest the idea that aggression was at the root of this condition.

Treatments such as exercise, diet, music, and drugs were now advocated and doctors suggested that it was important to talk about your problems with your friends or a doctor.

Other doctors spoke of depression as resulting from internal conflicts between what you want and what you know is right. And yet others sought to identify the physical causes of this condition.

Depression treatments during the Age of Enlightenment included water immersion (people were kept underwater for long as possible without drowning) and a spinning stool to induce dizziness, which was believed to put the brain contents back into their correct positions. Benjamin Franklin is also reported to have developed an early form of electroshock therapy during this time. In addition, horseback riding, diet, enemas, and vomiting were recommended treatments.

Recent Beliefs About Depression

In 1895, the German psychiatrist Emil Kraepelin became the first to distinguish manic depression, what we now know as bipolar disorder, as an illness separate from dementia praecox (the term for schizophrenia at the time). Around this same time, psychodynamic theory and psychoanalysis—the type of psychotherapy based on this theory—were developed.

Psychoanalytic Explanations

In 1917, Sigmund Freud wrote about mourning and melancholia where he theorized about melancholia as being a response to loss, either real (for example, a death) or symbolic (failure to achieve the desired goal). Freud further believed that a person's unconscious anger over his loss leads to self-hatred and self-destructive behavior. He felt that psychoanalysis could help a person resolve these unconscious conflicts, reducing self-destructive thoughts and behaviors. Other doctors during this time, however, saw depression as a brain disorder.

Behavioral Explanations

The behaviorist movement in psychology contributed to the idea that behaviors are learned through experience. The behaviorists rejected the idea that depression was caused by unconscious forces and instead suggested that it was a learned behavior. Just as these depressive behaviors had been learned, they could also be unlearned. Principles of learning such as association and reinforcement could be used to establish and strengthen more effective, healthier behaviors.

While psychologists today recognize that experience is not the sole determinant of behavior, behaviorism led to the development of a number of treatment approaches that continue to play an important role in the treatment of depression and other mental disorders.

Cognitive Explanations

During the 1960s and 1970s, cognitive theories of depression began to emerge. The cognitive theorist Aaron Beck proposed that the way that people interpret negative events could contribute to symptoms of depression.

Beck suggested that negative automatic thoughts, negative self-beliefs, and errors in processing information were responsible for depressive symptoms. 

According to Beck, depressed people tend to automatically interpret events in negative ways and view themselves and helpless and inadequate. 

The psychologist Martin Seligman suggested that learned helplessness could play a role in the development of depression. According to this theory, people often give up on trying to change their situation because they feel that nothing they do will make a difference. This lack of control leaves people feeling helpless and hopeless. 

The emergence of these cognitive models of depression played an important role in the development of cognitive-behavioral therapy, which has been shown to be effective in the treatment of depression.

Biological/Medical Explanations

Where older conceptualizations of depression stressed the role of early experiences, more recent approaches increasing stress the biopsychosocial model that looks at the biological, psychological, and social factors that play a role in depression.

During the 1970s, the medical model of mental disorders emerged and suggested that all mental disorders are primarily caused by physiological factors. The medical model views mental health conditions in the same way as other physical illnesses, which means that such conditions can also be treated with medication. Biological explanations for depression focus on factors such as genetics, brain chemistry, hormones, and brain anatomy. This view played an important role in the development and increased use of antidepressants in the treatment of depression.

Treatments for Depression in the Recent Past

During the late 19th and early 20th centuries, treatments for severe depression were generally not enough to help patients, leading many people desperate for relief to have lobotomies, which are surgeries to destroy the frontal portion of the brain. These surgeries were reputed to have a "calming" effect. Unfortunately, lobotomies often caused personality changes, a loss of decision-making ability, poor judgment, and sometimes even led to the patient's death. 

Electroconvulsive therapy, which is an electrical shock applied to the scalp in order to induce a seizure, was also sometimes used for patients with depression.

During the 1950s and 60s, doctors divided depression into subtypes of "endogenous" (originating from with the body) and "neurotic" or "reactive" (originating from some change in the environment). Endogenous depression was thought to result from genetics or some other physical defect, while the neurotic or reactive type of depression was believed to be the result of some outside problems such as a death or loss of a job.

The 1950s were an important decade in the treatment of depression thanks to the fact that doctors noticed that a tuberculosis medication called isoniazid seemed to be helpful in treating depression in some people. Where depression treatment had previously been focused only on psychotherapy, drug therapies now started to be developed and added to the mix.

In addition, new schools of thought, such as cognitive-behavioral and family systems theory emerged as alternatives to psychodynamic theory in depression treatment.

One of the first drugs to emerge for the treatment of depression was known as Tofranil, which was then followed by a number of other medications categorized as tricyclics. Such drugs provided relief for many people with depression but were often accompanied by serious side effects that included weight gain, tiredness, and the potential for overdose. 

Other antidepressants later emerged, including Prozac in 1987, Zoloft in 1991, and Paxil in 1992. These medications, known as SSRIs, target serotonin levels in the brain and usually have fewer side-effects than their predecessors.

Newer antidepressant drugs that have emerged in the past couple of decades include atypical antidepressants such as bupropion (Wellbutrin), vortioxetine (Trintellix), and serotonin-norepinephrine reuptake inhibitors (SNRIs). 

Our Understanding of Depression Today

The term major depressive disorder (MDD) was first introduced by clinicians in the United States during the 1970s. The condition officially became part of the DSM-III in 1980. The current edition of the diagnostic manual is the DSM-5 and is one of the primary tools used in the diagnosis of depressive disorders. 

While the condition is much better understood today than it was in the past, researchers are still working to learn more about the causes of depression. At the present time, doctors believe that depression arises from a combination of multiple causes including biological, psychological, and social factors.

Modern views of depression incorporate an understanding of the many symptoms of this condition as well as the often cyclical effect that such symptoms can have. For example, depression can cause disturbances in sleep, appetite, and activity levels; in turn, poor sleep, diet, and exercise can exacerbate symptoms of depression.

In addition to considering the psychological factors that contribute to depression, doctors are also aware that certain medical conditions such as hypothyroidism may cause depressive symptoms. The diagnosis of depression includes checking for such medical conditions and ruling out other possible causes such as alcohol or substance misuse.

Thanks to the improved understanding of the causes of depression, effective treatments have emerged. Psychotherapy and medications that target molecules called neurotransmitters are generally the preferred treatments, although electroconvulsive therapy may be utilized in certain instances, such as in treatment-resistant depression or severe cases where immediate relief is required.

Other, newer, therapies, including transcranial magnetic stimulation and vagus nerve stimulation, have also been developed in recent years in an attempt to help those who have failed to respond to therapy and medications.

Unfortunately, the causes of depression are more complex than we yet understand, with no single treatment providing satisfactory results for everyone. Because depression is such a complex condition, mental health professionals often recommend a treatment approach that includes medications, psychotherapies, and lifestyle modifications.

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