How Everyone Became Depressed (18 page)

Abraham’s essay remained widely unknown. Somewhat bizarrely, the figure who planted the diagnosis neurotic depression firmly in the medical imagination was the senior London neurologist Farquhar Buzzard, at a conference in 1930. Buzzard did not care a fig for psychoanalysis, but needed a term to differentiate psychotic depression from other, less serious depressions, and so he chose neurotic depression. “ … There is no evidence,” he said, “that features which distinguish neurotic from psychotic forms of depression have received due recognition.” And what might those features be? He proposed one: “Am I right in thinking that the neurotic throws the responsibility for his troubles on others while the psychotic is ready to shoulder it himself ?” Buzzard mentioned other differentiating features as well, asserting that “psychotic depression is always associated with physical disturbances,” whereas neurotic depression is not. In psychotic depression, by which he meant melancholia, not formal psychosis, there was a much heavier family history of illness, and so forth.
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Neurotic depression as a diagnosis took off from here.

There the Anglo-European story rested. The next chapter in the neurotic depression story would be written in the United States, by émigré European analysts. One keeps in mind that the depression of psychoanalysis was a neurosis, not a mood disorder.

It was owing to the great prestige of the émigré s that neurotic depression as a diagnosis took off in the United States in the 1930s and 1940s, at a time when Europe was convulsed by war and the Holocaust. In 1927, Sandor Rado, a Budapest analyst then at the Berlin Psychoanalytic Institute, took up again, at the Tenth Psychoanalytic Congress in Innsbruck, the question of neurotic depression, in contrast to melancholia, to which he devoted most of his disquisition. “Neurotic depression is a kind of partial melancholia of the (neurotic) ego,” he said.
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This brief squib might perhaps have had little impact had Rado not, in 1931, been summoned by New York’s Abraham Brill (who was Austrian) to lead the newly established New York Psychoanalytic Institute, the very epicenter of psychoanalytic influence in the New World. Rado became immensely influential in the United States and in 1944 was appointed professor of psychiatry at Columbia University. In 1951 he had another go at depression, this time a more extensive treatment, calling it “a desperate cry for love, precipitated by an actual or imagined loss which the patient feels endangers his emotional (and material) security.”
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Rado is generally seen as having imported the study of depression, of any variety, to American psychiatry.

But as for specifically neurotic depression it was Otto Fenichel who became the major figure. Born in Vienna in 1897, Fenichel graduated there in medicine in 1921, joined the Vienna Psychoanalytic Society, then in 1922 moved to Berlin and began a training analysis with Rado at the Berlin Society. Just before emigrating from Germany to Norway in 1933, Fenichel completed his Outline of Clinical Psychoanalysis, which was translated into English and published in 1934 in New York—in a measure of the prestige Freud’s doctrines were acquiring in the United States—by a major trade publisher, W.W. Norton. Here Fenichel had a good deal to say about neurotic depression: “Neurotic depressions occur in all varieties of neuroses,” he wrote. “The mildest cases need no special technique: the solution of the basic infantile sexual conflicts in the course of the analysis of the main neurosis automatically brings about a concomitant harmony with the super-ego.”
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Fenichel moved from Europe to Los Angeles in 1938, and in 1945 brought out a revised and expanded edition of his 1934 text under another title; in this edition the discussion of neurotic depression acquired still greater amplitude. “Neurotic depressions are desperate attempts to force an object to give the vitally necessary [narcissistic] supplies, whereas in the psychotic depressions the actual complete loss has really taken place and regulatory attempts are aimed exclusively at the superego.” Furthermore: “In the phenomenology of depression, a greater or lesser loss of self-esteem is in the foreground.” In neurotic depressions, “The patients try to influence the persons around them to return their lost self-esteem.”
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By this time, neurotic depression had gone from almost 0 in Europe to 60 in the United States. During World War II, psychoanalysis received a major boost by capturing the psychiatric services of the United States Army, with analyst William Menninger as chief military consultant; the classification of psychiatric disorders that the Army issued in October 1945 bore witness to this influence. Here is what the Army, guided by a committee Menninger had convened, had to say about the “neurotic depressive reaction”: “The anxiety in this reaction is allayed and hence partially relieved by self-depreciation through mental mechanism [ sic] of introjection … Dynamically the depression is usually related to a repressed (unconscious) aggression.”
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Thus, if any of the troops developed a neurotic depression after demobilization, Dr. Menninger had laid out what they could look forward to.

This Army document, “Bulletin 203” as it became known, provided the basis for the first edition in 1952 of the famous DSM series of the American Psychiatric Association. Neurotic depression had by now become a concept with great momentum.

The DSM series became, for better or worse, the distinctive U.S. contribution to world psychiatry. Begun in 1952 as an offshoot of the diagnostic school of the Swiss émigré Adolf Meyer, professor of psychiatry at Johns Hopkins University, the series accelerated in size and in impact over the years, becoming by the end of the twentieth century the cardinal international guide to psychiatric diagnosis. At present, as a revised version, DSM-5, lies in the wings, even the daily newspapers are filled with accounts of what the next edition may or may not contain—and why it is so vitally important for the average citizen. It therefore was a sign that a diagnosis such as neurotic depression had acquired a key to the temple, that DSM-I in 1952 dilated upon the psychodynamics of it all: The Manual said of the “psychoneurotic disorders” in general, “The chief characteristic of these diagnoses is ‘anxiety’ … controlled by the utilization of various psychological defense mechanisms.” Of “depressive reaction” in particular it was stipulated, “The anxiety in this reaction is allayed, and hence partially relieved, by depression and self-depreciation,” which was largely the language of the Army bulletin for neurotic depression.
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DSM-II , which appeared in 1968, was even more explicit about the neurotic part, and said of “Depressive neurosis: This condition is manifested by an excessive reaction of depression due to an internal conflict or to an identifiable event such as the loss of a love object or cherished possession.”
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This was really Psychoanalysis 101, and even if neurotic depression was not the commonest depressive diagnosis in the United States (see below), it was the most prestigious: People who received psychoanalytic diagnoses were a cut or two above the run of the mill and could afford to see analysts, or at least to consult psychoanalytically oriented psychiatrists (who were the majority).

When Silvano Arieti’s three-volume textbook of psychiatry appeared in 1966—almost entirely delivered into the hands of the psychoanalysts— the big chapter on “The Psychodynamics of Neurotic Depression” by New York analyst Walter Bonime represented a kind of apex of the diagnosis in American psychiatry: It really does not get any better than this. “The depressive is an extremely manipulative individual who, by helplessness, sadness, seductiveness, and other means, maneuvers people toward the fulfillment of demands for various forms of emotionally comforting response.”
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(It was under the influence of this doctrine that analyst Gregory Zilboorg decided that the physical complaints of his patient George Gershwin were owing to neurotic depression—rather than to the brain tumor that ultimately killed him—and instructed the family to ignore behavior such as putting his fork in his ear at a dinner party, “apparently unable to locate his mouth”; these gestures should remain without comment, Zilboorg advised, in order to deny him the attention he was obviously seeking.
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To understand why depression became such a huge diagnosis, we thus have the role of psychoanalysis, the thread that begins with Karl Abraham and passes through the émigré analysts, to make depth psychology such a popular conveyor belt for neurotic depression. It is almost unimaginable to us today that psychoanalysis once represented the very heart and soul of psychiatry. Robert Cancro, chair of the department of psychiatry at New York University, said in 2002, looking back, “While this may sound facetious, it is not. The belief that repressed, unconscious conflicts were the basis of all psychopathology was held with near-religious zeal.”
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Nowhere was this zeal hedged more ardently than in the offices of the fashionable psychiatrists on the Upper East Side of Manhattan or Westwood in Los Angeles. Nathan Kline, who floated back and forth between high-end psychotherapy and the budding discipline of psychopharmacology, had a private practice in Manhattan located in one of the “mental blocks” on streets such as Park Avenue, so-called, as Kline said in 1973, “because there are so many psychiatrists located there.”
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This was the world of neurotic depression.

Was psychoanalysis really all that important in U.S. psychiatry in those days? Yes, it was. In 1955 the pro-psychoanalytic Group for the Advancement of Psychiatry surveyed departments of psychiatry in U.S. medical schools about their programs for educating budding psychiatrists. Of 26 training programs contacted, the 14 that replied “all indicate that their training program is based on psychodynamic theory.” Of the teaching staff in these programs, 56% were psychoanalytically trained “and another eleven percent had a personal analysis without formal psychoanalytic training.”
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Psychoanalysis was pervasive in U.S. psychiatry, and in American society, in those years. Why did everybody become depressed? Psychiatry had something to do with it.

Mo tto: “The arguments for supposing that anxiety and depression share a common cause are persuasive.”
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David Goldberg, Institute of Psychiatry,

After neurotic depression, the second mood diagnosis to emerge from the ruins of the nervous syndrome was mixed anxiety-depression. From the 1920s on, it surged in popularity, not being dependent on exotic theoretical schemes that assigned the ills of humankind to anomalies in early childhood sexual development. And empirically it was obvious that most depressions were accompanied by anxiety—and vice versa.

Mixed anxiety-depression was the true inheritor of nerves; today, it is by far the commonest presentation of either anxiety or depression. In a nationwide poll in Great Britain in 2000, over 10% of women and 6% of men suffered from “mixed anxiety and depressive disorder,” the most frequent of the neurotic disorders, followed at a distance by generalized anxiety disorder, depressive episode, and then, way down, obsessive-compulsive disorder, phobias, and panic.
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In 1981 psychologist John Overall, one of the pioneers of psychopharmacology, told a committee of the FDA’s Early Clinical Drug Evaluation Units, an entity that sponsored many trials and had a databank of 2700 depressed patients, “I would assure you that 90 percent or more of the patients had mixed anxiety and depression along with other symptoms. It is very difficult to find depressed patients who do not have anxiety.”
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We are talking here much more about the anxiety accompanying nonmelancholic depression than that of melancholy (although melancholics can be anxious too). Alan Schatzberg, another leading figure in psychopharmacology, then at McLean Hospital, a psychiatric facility in Belmont, Massachusetts, associated with Harvard University, said in 1990 that “63 percent of depressed patients met criteria for a lifetime DSM-III-R anxiety disorder and 52 percent met criteria for a current diagnosis.”
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But it was not just the more seriously depressed hospital patients who were anxious. Those individuals in the community who never came within shouting distance of psychiatric care for their symptoms also had mixed anxiety-depression, as David Goldberg and Peter Huxley at the University of Manchester discovered in 1980, in a classic study of mental illness in the community, identified in a sample of primary care patients (They did a transatlantic study, but these particular data are from Philadelphia.) “Minor affective disorders—that is to say, anxiety states, minor depressive illnesses, and states of both anxiety and depression—account for the vast majority of illnesses seen in a primary care setting … Anxiety and worry is the most widely distributed symptom, depression and fatigue follow closely behind. The idea that depression represents a more differentiated form of disorder contained within the population of patients with anxiety states, is not borne out by the data.” What the authors described was the nervous syndrome: 82% of the patients had anxiety and worry, 71% had despondency, sadness, and fatigue, 52% had somatic symptoms, and 50% had disturbed sleep.
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(I do not want to get ahead of the story, but I cannot resist pointing out that Goldberg, a leading epidemiologist later at the Institute of Psychiatry in London, went on to ridicule the “comorbidity” concept, because, after depression and anxiety were separated in DSM-III in 1980, they were considered comorbid when they occurred together: “Comorbidity has some meaning if we are referring to combinations of diabetes and schizophrenia, or even of depression and alcohol dependence, but it is surely stretching the concept to absurdity to allow one or two symptoms from correlated domains to produce the phenomenon.”
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The polarity of the depression, whether bipolar or unipolar (today “major depression”), does not seem to make much difference to the presence of anxiety. The depression of bipolar disorder is melancholia, just as a portion of the unipolar patients with “major depression” are melancholic.
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There is no difference between the melancholias of either unipolar or bipolar disorder. And the polarity does not seem to matter in terms of anxiety: In a study of patients with both kinds of depression, Paula Clayton at the University of Minnesota found that around 75% of all depression patients were worried, 60% or more reported psychic anxiety, around 30% reported panic attacks, and so forth. There were no important differences between those with major depression and those with the depression of bipolar disorder..
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