How Everyone Became Depressed (12 page)

In 1852, Joseph Guislain in Ghent was among the first to introduce the notion of “anxious melancholy, sometimes preceded by a painful feeling that the patient localizes in the region of the heart.” Suddenly the disorder erupts: “the patient is sleepless, assailed by sad ideas, his personality comes apart. A feeling of anguish accompanied by vague terror announces the beginning of the disorder.” Guislain demonstrated to the medical students a patient “who is terrified of her present situation. She says, ‘I don’t know what I’m doing. I’m capable of wreaking a tragedy. I’m good for nothing. It seems to me that I am suffocating.’”

Guislain continues the presentation: “Sometimes her feelings of anguish erupt suddenly. They compel her to be agitated in every possible way. She walks about her apartment and courtyard fifty times in a row. Frequently she repeats the name of someone or some thing. She’s filled with lamentations; her thinking grows cloudy and she acts impulsively. Each attack may last only a few hours, or days and weeks.” Guislain thought this was the same condition as Flemming’s precordial anxiety.
⁶⁹
But it is dramatically different from any form of anxiety previously considered in this chapter. Heinrich Schüle, director of the Ilenau asylum in Germany, said in 1878 of anxiety-melancholia (die Angst-Melancholie) that “restlessness of the muscles results in an illusory rerouting of all the senses in the direction of fear of destruction … There is an anxious agitation that lasts day and night with a pathological feeling of having sinned.”
⁷⁰

Anxious melancholia thus embedded itself in psychiatry for the next half century, the extreme form being a panicky, psychotic eruption that had little in common with the anxiety of nervous illness or that of phobias and obsessions. It borders on the delirious mania of catatonia. In 1896, Emil Kraepelin wrote in his psychiatry textbook, which became in his day what the “ DSM” of the American Psychiatric Association is in our own that “There are pronounced anxiety conditions, which take on an extraordinary force and degree. It is such cases that used to receive the name anxious melancholy [Angstmelancholie]. I have recently become convinced, that between them and simple sad mood disorders there are no sharp lines of division. Either anxiety accompanied the entire illness course with many fluctuations, or it occurs in single attacks, that suddenly erupt and are accompanied with severe, even psychotic, disturbances of conscience (Raptus melancholicus).”
⁷¹
Anxiety and anxious melancholy vanished from the 8th edition in 1913, as Kraepelin got rid of them altogether as distinctive illness entities.

It was Carl Wernicke, professor of psychiatry in the East German city of Breslau (and who in 1874 identified a brain region named after him), who in 1900 liberated extreme panic and anxiety from melancholia and made them, in the form of psychotic anxiety (Angstpsychose), a separate condition. Wernicke presents to the medical students a 55-year-old man who is anxious, groans lightly, answers questions slowly (there in front of the students), and has difficulty collecting himself. In addition to his anxiety, he seems to understand little of what is going on around him. His chief complaint is “incessant anxiety at the region of the heart.” He feels that it will “crush” him. Also, he cannot catch his breath. Why is he so anxious? He fears decapitation. He also believes that his family has suffered a catastrophe (untrue), that he hears the voice of his young son, who has had “nothing to eat for three weeks.” (In fact, he hallucinates the presence of the son in front of him.) And he believes that everything is his fault, above all, because he masturbated as a youth. He is “a great sinner and is persecuted by Satan.” Not panicky but severely anxious, the patient spontaneously recovers and is well again. In Wernicke’s view, such patients have “the primary symptom of anxiety as the exclusive basis of the illness.” It sits first of all in the epigastrium, next most commonly in the head, and third commonest “in the entire body.” The somatic symptoms are mainly motor agitation, crying, hand-wringing, and sweating. Almost all the patients with this disorder are suicidal. It is the anxious ideation, said Wernicke, that means the patients do not have an “affective melancholia.” He said this psychotic anxiety was very different from the neurotic sort.
⁷²
In retrospect, this is a kind of anxiety that certainly has a different feeling from the other anxieties in this chapter, and justifies weighing the possibility that there might be several different kinds of anxiety, though not the kinds featured in the DSM manual today. (It does not appear to be a subtype of melancholia.
⁷³
)

Wernicke’s “psychotic anxiety” never took off, probably because, as one researcher explained in 1905, “the disease cannot be accommodated in the Kraepelinian School’s forms of diagnosis.”
⁷⁴
Then the psychoanalysts gained the ascendancy in psychiatry and the field lost interest in these refined forms of diagnosis, particularly in the field of psychosis, with which the analysts never felt comfortable because psychotic patients could not enter into a transference relationship—essential in psychoanalysis for recovery from illness.

Once Freud had put “anxiety neurosis” on the table, many non-Freudians began to interest themselves in the study of anxiety as well. Inevitably, the term panic, a perfectly familiar word for a psychological state, began to appear as a synonym. The word panic seems to have been used in psychiatry for the first time in 1879 by Henry Maudsley at the West London Hospital, who described one melancholic patient’s sudden efforts to commit suicide: “These paroxysms of anguish or panic, which are a notable feature in some cases of melancholia—paroxysms of melancholic panic they might be called—deserve careful notice. They often come on quite suddenly; the patient has perhaps been lying down to rest … [then] starts up in great agitation, his heart beating tumultuously, his senses distraught, and rushes wildly to the window to throw himself out of it; he is overwhelmed for the time being, driven to desperation, and hardly knows what he does; the frenzy has all the characters of a convulsion affecting the mental nerve-centres. In some cases the convulsive panic is preceded by an anomalous and alarming sensation of distress about the region of the stomach … [and] is accompanied by an indescribable terror and dreadful feeling of helplessness.” Maudsley said that after the paroxysm the patient “trembles from head to foot, is bathed in perspiration and completely exhausted.”
⁷⁵

Others started to pick up on the presence of panic symptoms in serious psychiatric illnesses. Harvard professor of philosophy William James, who wrote Varieties of Religious Experience in 1902, was very interested in psychiatry and corresponded extensively on it. “The worst kind of melancholy is that which takes the form of panic fear,” he said, quoting a French patient whose letter he translates: “I awoke morning after morning,” said the patient, “with a horrible dread at the pit of my stomach, and with a sense of the insecurity of life that I never knew before, and that I have never felt since.”
⁷⁶

In 1910 August Cramer at the university psychiatric hospital in Gö ttingen mentioned the “panic-like” symptoms that overcame some people in situations that provoked anxiety, or, like posttraumatic stress disorder, reminded them of situations, such as railway accidents, that previously had made them anxious.
⁷⁷
On the other side of the ocean, Harry Paskind, a neurologist in Chicago, called attention in 1929 to “brief attacks of manic-depression” lasting from a few hours to a few days, and often occurring against a background of chronic mood disorder, “accompanied by a feeling of weakness, ready fatigue, head pressure,” and abdominal distress. The patients subjectively are sad, hopeless, and briefly inclined to suicide before their symptoms abruptly disappear. “Many patients with manic-depressive depression,” said Paskind, “have a peculiar feeling in the epigastrium or pit of the stomach.” And often the internist is called in to investigate, said Paskind, almost never the psychiatrist, who specializes in long-term illnesses seen in mental hospitals. There was much anxious vomiting and tightening of the throat, and the patients did not mention pounding hearts but perhaps only because Paskind did not ask them about it.
⁷⁸

It was then Oskar Diethelm, born and trained in Switzerland but who had come to Johns Hopkins in 1925 at age 28, who put the concept of panic on the map. In 1932, in articles published on both sides of the Atlantic, Diethelm explained that panic was “not merely a high degree of fear, but a fear based on prolonged tension, with a sudden climax which is characterized by fear, extreme insecurity, suspiciousness and a tendency to projection and disorganization.” Diethelm described a woman of 28 years facing a thyroid operation who became “panicky … knowing that she would have to stay in bed afterward and could not get away even if she should [continue to] feel panicky … She felt a tightening in her throat, palpitation, nausea and a fear that ‘here is something I do not know anything about.’” When she heard that a patient in a neighboring room had been visited by a psychiatrist, “she became afraid of being transferred to a psychiatric clinic. In the evening she became panicky.” She tried to read but was overcome by fear. “I got in a panic about having panics,” she said.
⁷⁹
This was the official introduction of panic disorder to psychiatry.

Events in the understanding of these matters were suspended as the Nazis came to power in 1933. Because so many investigators were Jewish, serious research closed down in German psychiatry, a national field that hitherto had been the world’s locomotive. Then there was the chaos of war and reconstruction in France and Germany so that, again, interest in arcane matters such as the classification of psychiatric illness—a matter that nonetheless affects the lives of millions of people—came to a halt.

Years passed without any serious interest in extreme forms of panic and anxiety until in 1950 the spotlight shifted to Spain. In 1950 Juan Lopez-Ibor, 43 years old and professor of psychiatry in Madrid, argued that a special kind of anxiety existed that he called “vital anxiety.” He did not realize that Josef Westermann had already used the term in 1923 and that his concept was not absolutely original.
⁸⁰
But what he had in mind was in fact quite innovative. Lopez-Ibor had studied with the great German psychopathologist Kurt Schneider (older psychiatrists will recognize the name from the so-called Schneiderian criteria of schizophrenia, such as thought-insertion). In 1920 Schneider had distinguished between vital depression and reactive depression.
⁸¹
Vital depression was a phenomenon of the entire body: Every pore oozed depression, and Lopez-Ibor thought vital depression must have a counterpart in anxiety: Let us call it vital anxiety, or la angustia vital, as he proposed in a 1950 book. Vital anxiety was serious, even psychotic, and quite different from neurotic anxiety, Lopez-Ibor argued; it constituted part of the “thymopathic circle” that otherwise included mania and depression.
⁸²
A “crisis di angustia” was tantamount to a panic attack. Lopez-Ibor explained that “What distinguishes the vital anxiety of the anxious timopath from … anxious reaction is its unmotivated appearance, and it is the violence of its manifestation.”
⁸³
Thus attacks of anxious timopathy came out of the blue and swept over the patient with a force having little in common with Freud’s anxiety neurosis.

It is now clear that anxiety nestles into the core of the history of the nervous breakdown. And this happened in two ways, each of them searing and life-changing. Anxiety in the nervous syndrome—together with depression, fatigue, and somatic ailments—was more a chronic illness, often lasting months and years, and leaving the individual what was once called a nervous wreck. Anxiety in the paroxystic attack, which is to say panic, was brief and brutal, leaving the individual psychically exhausted and fearful of the future.

Motto: “Depressive illness is probably more unpleasant than any disease except rabies.”
John S. Price, Northwick Park Hospital, Harrow, Middlesex, 1978

Feelings of low mood are not trivial. In 2010 the National Center for Health Statistics of the Department of Health and Human Services asked a random sample of the U.S. population about their mood. In reply to Do you feel hopeless?, 6.8%, or 1 in 20, said yes. In reply to Do you feel worthless?, 5.3% said yes. In reply to Do you feel that “everything is an effort”?, a whopping 16%, or one in seven, said yes.
²
Low feeling is very common. Yet it is not melancholia.

Historically, plenty of people have suffered from low moods. Today, few of us can stay in our beds because we have to earn a living. Yet it was once common for middle-class women, in households that had servants, to take to their beds when feeling down. In 1917, London literary figure Virginia Woolf, age 36, noted in her diary for October 25: “Owing to the usual circumstances, I had to spend the day recumbent.” She meant that she was having her period, and always had to lie down. Still, menstruation was not the only reason she went recumbent. Late in 1918 she had a tooth out and spent two weeks in bed, “and being tired enough to get a headache—a long dreary affair, that receded and advanced much like a mist on a January day.” “Here is a whole nervous breakdown in miniature,” she recorded in July 1926. “Sank into a chair, could scarcely rise; everything insipid; tasteless, colourless. Enormous desire to rest.” In November 1931 she was assailed by “a perpetual headache,” and “so took a month lying down.” On October 5, 1932, she said, “I spent yesterday in bed; headache; infinite weariness up my back: clouds forming in my neck; half asleep.”
³
So this is the kind of nervous behavior that was congruent with people of her social class at that place and time.

But there are deeper, more alarming notes. On September 28, 1926, “Intense depression: I have to confess that this has overcome me several times since September 6th . . . It is so strange to me that I cannot get it right—the depression, I mean, which does not come from something definite, but from nothing.” (Indeed, melancholia often comes out of the blue.) In June 1929, “And so I pitched into my great lake of melancholy. Lord how deep it is! What a born melancholic I am! The only way I keep afloat is by working.”
⁴
The metaphor is interesting. She ultimately commits suicide in 1941 by drowning.

“ There is a loss of light in the eyes. They become like fish eyes. And when the patients are treated successfully, the light comes back.”
Gordon Parker, 2012
⁵

There are two different kinds of depression, as different as tuberculosis and mumps; it makes no sense to lump both of them together under the general term “depression.” The first kind of depression concerns the mood disturbances that occur in the context of nervous disease, and we have already reviewed them. They are nonmelancholic and nonpsychotic, heavily admixed with anxiety and fatigue, laced with obsessive thinking, and often overshadowed by somatic complaints—almost to the point of being invisible. Virginia Woolf had some variety of this, even though she alludes occasionally to things such as “my present fit of melancholy.”
⁶

The second kind of depressive disorder is melancholia. It is an independent and unmistakable disease entity, often not combined with anything, and fearsome in a far different way than nervousness, for it may lead to despair, hopelessness, a complete lack of pleasure in one’s life, and suicide. By the late nineteenth century, the differences between these two depressions lay clear in view and observers often distinguished between them. Subsequently, both swim out of focus; nervous disease is broken up, and what we have emerged with today as “depression” bears little resemblance to these historic ancestors.

Serious depression is a real and terrible illness. William Sargant, professor of psychiatry at St. Thomas’s Hospital in London, recalled the back wards in the 1930s and 1940s: “My memory of those days is of patients with melancholia dying of agitated exhaustion after months or years in mental hospitals, and of the rows of depressed patients who had to be kept on special suicidal precautions in mental hospitals and psychiatric clinics alike. Even in the more neurotic types of depression, and despite all the psychotherapy given, suicides were frequent, and patients often took months or years to get well no matter what one tried to do to help them.”
⁷
So in melancholia we are dealing with one of the most terrible afflictions in medicine.

What is melancholia? Like nerves, melancholia too is a disease of the entire body. The endocrine system is intimately involved, and the blackness of affect reaches into the adrenal gland. In melancholia, affect is profoundly down, and stupor and dejection may alternate with periods of agitation and hand-wringing. Oswald Bumke, among the most thoughtful of the German academic psychiatrists of his generation (at a time when Germany was the epicenter of world psychiatry), said in 1908, “The essential characteristic of melancholia is a sadness of mood that is not founded in external circumstances, a strongly depressive affect, from which a gloomy assessment of one’s own situation arises, as well as ideas of having deeply sinned in the past and anxious fears about the future.”
⁸
(Bumke was writing as a time when people were still preoccupied with sin; today, melancholic patients often imagine that they have committed some other unpardonable deed.)

But we have to modify Bumke’s judgment slightly. It is not so much sadness of the weepy variety as pain that the patients complain of. Melancholia is a disorder of pain. “I can’t stand the pain any longer,” Edith La Tour, 30 years old, said in a note she left behind in 1934 after she jumped from a twelfth floor room at the Barbizon Hotel for Women in New York. She was said to have suffered a nervous breakdown.
⁹
( Just to clarify, the term nervous breakdown was the patient term for melancholia; nervous breakdown was never a medical diagnosis.)

Another piece of evidence: In the early 1960s, the young French-born psychologist Rachel Gittelman helped conduct a clinical trial of the antidepressant drug imipramine with Max Fink and Donald Klein at Hillside Hospital (see below). “These were patients whom I will never forget,” she later said in an interview. “Severely depressed individuals with retarded or agitated depression. People I wanted to run from because they were in such pain, causing me pain.”
¹⁰
Yet 6 weeks after medication, “They walked into my office and they were well. I get chills even now thinking about them.” They were not sad; they were in pain.

So this is point one: melancholia means a dejection that appears to observers as sadness but that the patients themselves often interpret as pain. When people look at these patients, they see sadness, though that may not be what the patients themselves are primarily experiencing. “The classical melancholic oozes depression, so that the observer feels depressed himself,” said one English physician in 1957.
¹¹
Indeed, Jane S, a domestic servant from Bradford admitted to the West Riding Asylum in Yorkshire in 1872, was the very image of dejection. She had given birth out of wedlock. Said James Crichton-Browne, director of the asylum, “Her fall from virtue had preyed much upon her mind during her pregnancy; and the depression of spirits thus occasioned deepened considerably at the time of her confinement, when she was in poor lodgings . . . and passed into morbid despondency three days after delivery, when the unexpected announcement of her father’s death reached her. She at once formed the idea that her father (who was a very aged man, and really died in the course of nature) had been killed by the shame of her misfortune. She sank into a state of inconsolable grief, wept incessantly, was sleepless, and twice attempted to put an end to her existence and sorrow by jumping through the window. After this she refused all food, complained of insupportable misery and weakness, and repeatedly threatened suicide.” Thereupon, she was admitted to the asylum. What is really of interest was her appearance. Crichton-Browne described, “ . . . a thin, pale, careworn-looking woman . . . seated in the day-room, with her head bowed down, and her hands crossed upon her lap, in an attitude of listless dejection. Her features were fixed in an expression of mental suffering, the angles of the mouth being drawn down, and the corrugators of the upper eyebrows being firmly contracted [this is the Omega sign]. When I spoke to her, she answered slowly and with evident reluctance, turning away from me, as if shrinking from observation and seeking solitude.”
¹²
(This is described as psychomotor slowing.) Was Jane S mainly sad or was she dejected from psychic pain? She had a weepy period, but by the time she reached the asylum her chief complaint seems to have been pain.

Many observers echo this theme. Jean Delay, who was about to become professor of psychiatry in Paris, said of “melancholic mood” in 1946: “Mood is this fundamental affective disposition, rich in all layers of emotionality and instinctuality, that gives to each of our inner lives an agreeable or disagreeable tonality, oscillating between the two extreme poles of pleasure and pain.”
¹³

The emphasis here is on pain and energy, not necessarily mood and sadness. In melancholia, Delay correctly observed, the mood slides down not necessarily to sadness but to pain. For that reason, patients may land in the hands of the internist rather than the psychiatrist. Said Vienna psychiatry professor Peter Berner in 1972 during a symposium at St. Moritz, Switzerland: “In depressions that present with inhibition, a disturbance of the élan vital [core energy] is very pronounced while the affect may be little depressed. Very frequently, these patients consult the internist or the general practitioner.”
¹⁴

Today, this note of pain is profound. A psychiatrist in Coral Springs, Florida, writes in 2007 that “Most of my patients suffering from major depression have described their malady as the worst pain they have had to beat.”
¹⁵
Price at Northwick Park talked of his hospitalized depressed patients’ pain: “If one tries to get such a patient to titrate other pains against the pain of his depression one tends to end up with a description that would raise eyebrows even in a mediaeval torture chamber. Naturally, many of these patients commit suicide. They may not hope to get to heaven but they know they are leaving hell.”
¹⁶

Melancholic patients often look dejected. There is a characteristic posture, a slump with its dejected shoulders, a facies with its empty eyes and frozen features, that has been familiar across the ages and explains why melancholia is often diagnosable at a glance. Here is Dr. Thomas Robertson, testifying in New York in 1894 at the probation of the will of his patient Frederick Lovecraft, a theater manager who had committed suicide the year before.

“He seemed to be in a very depressed condition,” said Dr. Robertson. “He took no interest apparently in anything that was transpiring, when spoken to, he answered in monosyllables, He was exceedingly pale, and complained of insomnia and nervousness. He said he was hardly able to attend to his business.” Dr Robertson said that Lovecraft was “suffering from melancholia, following delusions.”

“What was the condition of his eyes?” asked a lawyer. “Were they vacant or full of life as in ordinary men?”
“I couldn’t tell. I could hardly induce him to look up. He kept his head bowed down. Everything indicated acute melancholia.”
¹⁷
Additionally, melancholia patients suffer psychomotor retardation, meaning slowed thought and movement. Bumke: “All movements are conducted slowly, any change of bodily position is avoided, the speech is soft, halting and limited to what is absolutely necessary.” As for thought, “the patients have to recollect at length what they want to say, and they complain that nothing at all occurs to them any more.” Yet occasionally this slowness gives way to bursts of agitation, and often to extreme anxious excitement. Bumke articulated a point many observers of melancholia had long known,
¹⁸
and that Gordon Parker, professor of psychiatry in Sydney and leader of the Black Dog Institute, emphasized in 1996 when he revived the melancholia diagnosis: Psychomotor change, either slowed or accelerated, was a prime characteristic of melancholia.
¹⁹
What else? Suicide. The melancholic at risk of suicide was devilishly difficult to assess because melancholic patients often complain of everything but their mental pain and negation. As neurologist George Riddoch at the National Hospital at Queen Square told the Royal Society of Medicine in 1930 (it was, again, neurologists more than psychiatrists who saw psychiatric outpatients): “The manic-depressive patient, in a state of depression, may come complaining of anything but his depression. The symptoms which he first describes may, for example, be headache, abdominal discomfort, constipation, sleeplessness, or pain in the chest, and the underlying depression may only be admitted after some time, and then with reluctance. It is kept back, perhaps, because the associated suicidal ideas have become intense.”
²⁰
Admitting depression would cause others to thwart your desire for suicide.
Bumke said the newspapers in Germany in the 1920s were daily filled with reports of individuals who had made themselves away despite family supervision that “never let them out of sight.” “In practice, usually the simple question, how is the patient supervised when going to the bathroom, suffices to evaluate the family’s reassurance that he is ‘constantly watched.’”
²¹
That is precisely what happened to Dr. C. J. Miller of Uniontown, Pennsylvania, who was admitted to the St. Francis Hospital in Pittsburg in 1911 “suffering from a complete nervous breakdown.” He had requested to be shaved one afternoon and then concealed the razor in his pajamas. “He asked the male nurse, . . . to accompany him to a bathroom and then sent the man on an errand. A few minutes later a physician saw a stream of blood running on the marble floor from under the door . . . Dr Miller was found with his throat cut from ear to ear.”
²²
There is one other characteristic of melancholia that Oswald Bumke did not know about in 1908: A biological marker exists for it. Melancholia is one of the few illnesses in psychiatry for which there is a blood test: the dexamethasone suppression test. We have already met Bernard Carroll in the preface, the Melbourne-born psychiatrist and endocrinologist whom everyone calls Barney. In 1968 Carroll discovered that administering a synthetic steroid drug called dexamethasone to melancholic patients uncovered an unsuspected dysfunction of their endocrine system: It keeps their cortisol levels high. Cortisol is the stress hormone. Unlike normal subjects, if you gave them dexamethasone at midnight, their systems did not experience the normal late-night-early-morning reduction of cortisol; this nonreduction correlated with the severity of the illness, and it disappeared after patients were successfully treated for their depression.
²³
Later studies found that the endocrine systems of patients with most other psychiatric diagnoses showed normal suppression in response to dexamethasone. Thus, melancholic patients had a distinctive dysfunction of the hypothalamus-pituitary-adrenal axis called “DST nonsuppression.” (The hypothalamus is the brain region that directs the endocrine system via the pituitary glad; the thyroid and adrenal glands are among the endocrine organs that lie at the far end of the neuroendocrine axes. In melancholia, the adrenal axis, and, to a lesser extent, the thyroid axis, does not respond properly to endocrine signals.) The marker of cortisol nonsuppression is not biologically unique to melancholia: it occurs in severe physical illness and in some psychiatric disorders that are unlikely to be confused with melancholia, such as anorexia nervosa and dementia. Yet the dexamethasone suppression test, or “DST,” has about the same ability to diagnose melancholia properly, without too many “false negatives” and “false positives,” that the interictal (between seizures) electroencephalogram has in epilepsy: useful but not perfect.
²⁴
The DST provides evidence that most melancholic patients, whether unipolar or bipolar, have an underlying biochemical homogeneity that is entirely lacking in other psychiatric disorders.
²⁵
(The DST enjoyed a brief popularity in psychiatry as a “screening test for depression”—which it is not—in the 1970s and early 1980s, then lapsed into oblivion, leaving only a few feathers floating on the surface.
²⁶
This abandonment of a promising lead is not a tremendous accolade for clinical psychiatry.)
What was melancholia for physicians was nerves or a nervous breakdown for patients. As we shall see, nervous breakdown was not a doctors’ phrase, but for patients, it was a medical calamity. In April 1921 Annette Rankine, wife of William Birch Rankine who developed electric power at Niagara Falls, disappeared. With a history of melancholia, she had probably committed suicide. She had said earlier to her nurse, “If I thought I would never recover from this nervous feeling, I would rather be dead.”
²⁷
Melancholia is such a serious illness that in the past it would automatically qualify as a breakdown. For the headline writers of the New York Times, melancholia and nervous breakdown were almost interchangeable: One day melancholia would be assigned as the apparent cause of a suicide and the next day nervous breakdown blazoned as the cause of another. The term melancholia appeared in Times headlines three times (the first mention in 1868) before we reach the first headline about melancholic suicide in 1884: “A Brooklyn Suicide: Driven to Kill Himself by Repeated Attacks of Melancholia.”
²⁸
Thereafter the drumbeat of suicides attributed by headline writers to melancholia is pretty steady at several per year. (The pace of melancholia mentions then falls off dramatically in the mid-1930s and the last clinical mention in a headline occurred in 1951: “Passenger Lost at Sea: Doctor Says Baltimore Man Was Victim of Melancholia.”
²⁹
)
In these years, nerves were giving way to affect. Depression would soon inspire the headline writers. In medicine, what everybody recognized before 1920 as the nervous syndrome began to yield slowly in the interwar years to disorders of mood and affect. Mood and affect are mental conditions. Nerves is a whole body condition. The distinction is fundamental. Affect means emotion. The passage from nerves to depression is a major chapter in the history of psychiatry and in our culture’s encounters with mood and body feeling.