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Early Depression Treatments: Ancient Greece, Exorcism and Sigmund Freud

This blog post marks the beginning of a 5-blog series on depression where I will be looking at the history of how we understood depression, treated it, and what are the newest and most exciting developments in the field of depression research. I will start by telling you about the ancient history of depression treatment leading up to the dawn of the modern pharmacological and psychotherapeutic era of antidepressant treatments. Without further ado, let's look into the history of depression!

Depression is one of the oldest emotional and psychological illnesses known to man. The earliest mention of depression ("melancholia" at the time) was in ancient Mesopotamia. The early Babylonian, Chinese and Egyptian civilizations viewed mental illness as a manifestation of demonic possession. Naturally, the demonic affliction that depression was viewed as was treated using various exorcism techniques - beatings, restraints, and starvation. The idea behind such treatment was that harsh treatment was supposed to drive out demons from the afflicted person's body. So, the first historical understanding of depression was that of a spiritual (or mental) illness rather than a physical one.


The early Roman and Greek doctors had a differing opinion on depression - it was both a biological and psychological disease. According to Roman and several greek physicians, depression was caused by grief or blood and bile imbalances. Hippocrates, the famous Greek physician, suggested that the mind and the body are connected through the balance or imbalances of body fluids called humors. There were 4 humors: yellow bile, black bile, phlegm, and blood. Proponents of the humor school of thought classified mental illnesses based on the relative presence of specific humors. For example, depression was supposedly caused by too much black bile in the spleen. An "antidepressant" remedy to the humor imbalance was bloodletting to restore the "balance" of blood. Interestingly, the Greeks and Romans also acknowledged the value of gymnastics, baths, music, and a good diet as potential therapies. A healthy body meant a healthy mind.


*The four temperaments clockwise from top left (sanguine; phlegmatic; melancholic; choleric) according to an ancient theory of mental states.


The middle ages and Renaissance brought with it Catholic moral conservatism that permeated their explanations of mental illnesses. The belief that mentally ill people were possessed by demons, the devil, or witches lead to incredibly barbaric treatments such as drowning and burning. Moreover, the general public started to believe that mental illnesses are contagious. The latter lead to the locking away of depressed individuals in lunatic asylums where they were segregated from the rest of the society.


Throughout the dark times of the middle ages and Renaissance there always existed an alternative, enlightened school of thought that was trying to approach the treatment of depression from a methodological standpoint rather than a moralistic one. A notable progressive thinker here is Robert Burton. Robert Burton lived in the 16th century and was an English writer who was also a fellow at Oxford University. In 1621, Robert Burton published his most famous work - an encyclopedic book titled "Anatomy of Melancholy". This book was a synthesis of previous medical thinkers on depression, but also an innovative work that suggested that the roots of depression are not only psychological but also social. These social causes could have been things like poverty, fear, and solitude that derailed a person's psyche. Burton's prescribed antidepressant treatment quite closely reminded that of the Ancient Greeks and Romans - diet, exercise, bloodletting, and even music therapy.


Still, the dominant narrative in the public's perception of depression was moralistic. This mindset extended to the Enlightenment era (18th, and early 19th century). However, the religious explanations of mental illnesses were replaced by pseudo-scientific rationalizations. Depression was now believed to be an inherited and unchangeable weakness of temperament. As a consequence of this, the solution to depression was that of shunning and locking depressed people up. Most people with mental illnesses would become homeless and poor while some would be kept in pseudo-psychiatric institutions for the rest of their lives.


Psychiatric innovation did not stop though. The scientific revolutions driven by mechanical and electrical developments in the sciences inspired the idea that depression could be a manifestation of slowed brain circulation and depleted energy. Therapies such as immersion therapy, spinning stools, lobotomies, and electroshock therapy (ECT) were all invented at this time. The application of these techniques was often sloppy. Lobotomies (targeted removal of connections in the prefrontal cortex) often left patients comatose or even killed. In ECT, inexperienced doctors often used too high of a voltage which permanently damaged the brains of the patients. Interestingly though, some of these practices (e.g. ECT) are making a resurgence in the 21st century of psychiatry when done under stringent safety protocols and in specific psychiatric cases.

*A picture of a lobotomy.


At this point, depression is starting to be treated as having a biological foundation by some members of the medical community. At about the same time, Sigmund Freud, the father of psychoanalysis, created one of the first psychotherapies for depression. In his 1917 paper "Mourning and Melancholia", Freud theorized that objective loss, such as losing a loved one to some accident, results in a subjective loss as well. The Freudian concept of "ego" is important here to understand that "subjective loss". Freudian "Ego" should be understood as the organizing, calculating self that expresses your inner feelings (Freudian "id") in a respectable manner in the real world. The idea of "subjective loss" happens when the "ego" has identified itself with the object of affection and is then compromised when that object of affection is lost. The resulting "maimed" ego manifested itself in a complete loss of interest in the surrounding world and apathy. Freud was one of the first psychologists of the modern era who developed a form of talk therapy for the depressed patient. The idea here was that talking and exposing the trauma that caused the subjective loss to the "ego" could help solve the root cause of

depression.


This brings us to the beginning of the 20th century where depression started to be seen as a biopsychosocial model that looks at the biological, psychological, social factors that play a role in depression. Curiously, in the 1950s, some psychiatrists noticed that a tuberculosis drug was quite effective in depression treatment, This discovery sparked a new era of antidepressant psychopharmacology and the depression monoamine hypothesis. The next blogpost will be about this particular story - which I believe is one of the most fascinating stories in modern psychopharmacology.



The article was prepared by Matas Vitkauskas on behalf of INA

Sources: https://en.wikipedia.org/wiki/Humorism.

https://academic.oup.com/jhmas/article/38/3/298/751355

https://www.verywellmind.com/who-discovered-depression-1066770

https://www.mentalhelp.net/depression/historical-understandings/

https://pulsetms.com/resources/depression-history/

Image sources: https://en.wikipedia.org/wiki/Humorism https://nihrecord.nih.gov/2019/11/01/when-faces-made-case-lobotomy