My patient was a middle-aged woman. She was deeply depressed, immobile, wracked with guilt, and convinced that the food offered to her was poison. It was 1968, I had just started a psychiatry residency, and the supervising physician, a psychoanalyst in his mid-forties, sported—as did I—long brown sideburns and the other orthodoxies of the day. A bit impatiently, as if he shouldn’t have to be telling me anything so elementary, he said: “We know that depression is anger turned inward. You need to get at her anger.”
This anger-turned-inward business comes straight out of Freud’s paper “Mourning and Melancholia.” We took it very seriously back then. We spent countless hours trying to get depressed patients to talk about their anger. Enterprising psychologists and psychiatrists devised schemes to make such patients angry. In one, a depressed patient was instructed to build a tower out of small blocks. As the tower neared completion, the therapist knocked it down. When I first observed this procedure, the patient never gave up and never got angry. He continued to start the tower and seemed unconcerned when the psychiatrist whacked it down. But the anger theory captivated us, and the total lack of evidence that any of these therapies actually worked seemed a trivial matter, barely worth mentioning. So patients endured our attempts to get at their anger until, for whatever reason, their depression lifted.
Although Prozac and its cousins were twenty years away back then, antidepressants, today’s mainstay of psychiatric treatment, had been around for a decade in the form of monoamine oxidase inhibitors and tricyclics. And we used them. They were, however, an adjunct to psychotherapy at best. In fact, debates raged throughout the 1960s and early 1970s over whether or not antidepressants were impeding the progress of psychotherapy.
It’s easy to poke fun at the popular treatments of bygone eras—theriaca, purging, and bloodletting, to name some of the less harmful. And we acknowledge, albeit with a cringe, the certainty with which we not so long ago urged routine tonsillectomies, bland ulcer diets, radical mastectomies, and, yes, psychoanalytic therapy for depression. It’s harder to see the folly of our current theories and treatments.
We no longer try to make depressed patients angry. We scan their brains and revel in the parts that light up and the parts that don’t. We subject the depressed to so-called cognitive therapy, a series of exercises designed to banish the irrational thinking that, according to this theory, causes depression. Most of all we give them antidepressant drugs. The fact that cognitive therapy has yet to be proven more effective than a placebo or an exercise regimen or any of the alternative therapies doesn’t dissuade us. Nor does the uncomfortable statistic that less than half of patients prescribed antidepressants actually benefit from them.
The truth is, we simply don’t know why some people plummet into depression and why others, even in the face of horrendous circumstances, stay clear of it. We’re not short of theories: more than 2,000 years ago, Hippocrates postulated that black bile (melancholia) caused depression, and both before and since innumerable theories have sprouted, died, and, in some instances, been reborn (serotonin is today’s black bile). Some of these claims are more fanciful than others, but all are bereft of supporting data.
As a start, we need to figure out which depressed patients require and benefit from medication and which might benefit from some form of psychotherapy. After all, despite the wide use of new antidepressants, victims of depression continue to murder themselves at a rate about seventy times that of the general population.
Maybe Freud was on to something.
