Connor Mulligan is an undergraduate Chemistry Major at Grinnell College who has an interest in psychiatric medicine.
In an era of evidence-based medical practice, psychiatry is falling behind. Treatment options and the theories behind them have retained a few common threads for the last two hundred years, but most have varied widely. Other medical specialties have built and furthered their practices through scientific advances based upon older, but sound, theories and information. In contrast, Edward Shorter, a psychiatric historian, claims that psychiatry has not moved much farther past the days of Aristotle and Galen’s humors.[1]
While such assertions may be a bit harsh, psychiatrists’ understanding of many mental illnesses is still not complete. Psychiatry is currently mired in a battle between the biochemical and more social, context-based explanations of mental illness. The biochemical approach argues that all mental illness have a concrete biological basis which can be treated to cure the disease. The context-based approach, on the other hand, focuses on more social and environmental factors as the cause of mental illness. The modern social approach has attempted to distance itself from Freudian theories which have largely been rejected, however, and relies more on current psychological theories such as learned helplessness and cognitive error, which can be treated with cognitive behavioral therapy, or CBT.[2] While many claim the biochemical and social theories are not mutually exclusive and should be used to understand and treat mental illness together, the lack of a cohesive theory has made it difficult for scientists and practitioners to do this effectively.
The lack of a cohesive, concrete theory especially impacts treatments for the most common mental illnesses such as depression. Prozac, a selective serotonin reuptake inhibitor (SSRI), is one of the most commonly prescribed antidepressants in the world. Much controversy and misinformation surrounds the use of Prozac and other antidepressants. Psychiatrists and chemists themselves still do not exactly understand how they treat depression. From the biochemical standpoint, depression is most likely related to varying neurotransmitter levels, with a focus on serotonin and epinephrine. Additionally, over half of those diagnosed with depression demonstrate high levels of cortisol, a hormone which is produced as a stress response and can influence the levels of the aforementioned neurotransmitters in the brain.[3] While some may argue that the relationship between depression and such neurotransmitters is clear, the data does not necessarily support their claims. Not everyone diagnosed with depression exhibits similar low levels of serotonin and epinephrine, which may indicate that what is now known as depression is in fact a multitude of illnesses. In addition, medications that both increase and decrease serotonin levels have been shown to effectively treat depression. While such data does not rule out the potentially causal relationship between the neurotransmitters’ relative levels and depression, much more research is necessary to fully understand such processes.
In contrast, depression’s social theories argue that the illness is primarily a response to external factors. Aaron T. Beck, a professor of Psychiatry at the University of Pennsylvania, argues that depression is a direct result of cognitive error, or ways of thinking and processing information which can be corrected. According to Beck, depression is caused by a perceived loss not processed in a healthy manner. The depressed person understands the loss as a reflection of their own self-worth and internalizes this pessimistic attitude.[4] Such an interpretation of depression differed from previous Freudian analysis because it was not bound by the common mother-child dyad. Additionally, the patient defines the loss him/herself; the therapist does not “discover” it through psychoanalysis, which in turn gives the patient more influence over their experiences and treatment. The more personal explanations of depression also draw from behavioral studies on other species. Another expert in the field, Martin Seligman, derived his theory of depression from “learned helplessness” experiments completed on laboratory animals. He proposed that humans, like other animals, can become passive if they believe they have no control over their lives.[5] While such comparisons between humans and other animals must be taken lightly due to their neurological differences, the resulting theories are useful in that they can lead to management of depression thorough treatment options such as cognitive behavioral therapy instead of antidepressant drugs.
Connections can be drawn between the biochemical and social theories of depression, but the current paradigm often prevents them from working in tandem. Psychiatrists do employ both viewpoints, but in order for psychiatry to advance as a scientific medical field it must weave them together into one cohesive theory. Preventing such a revolutionary change is a lack of understanding of depression and a long history of competing viewpoints on depression both from the medical field and society as a whole.
Depression was not a word often used until the 19th century. Instead, both physicians and the general public often referred to depressive symptoms as “melancholia.” These symptoms’ descriptions were not always identical, but accounts of melancholia’s “darkness” in Aristotle’s time could be recognized even today. Aristotle and Galen, two influential philosophers and scientists, view melancholia as an imbalance of humors.[6] In their view, either too much or burnt “black bile” would result in a melancholic, depressive state. Stimulation was also common remedy at the time so that depressive thoughts would not become overwhelming. Edward Shorter, a historian of psychiatry, calls this time period the “first biological era” in psychiatry. Scientists believed that melancholia had physical, internal causes that affected disposition. While Galen and Aristotle had similar ideas on melancholia’s origins, they differed in how they described the experience of depression.[7] Aristotle and those who followed in his footsteps often held a romanticized view of melancholia. Consequently, academics were often seen as melancholic due to their penchant for solitude and, surprisingly many even took pride in the designation. Melancholia had become a marker of education and genius. In contrast, Galen viewed it as a hardship which put those suffering from it into a dark world of misery.[8] Melancholia was not something to be celebrated, but instead should be managed by activity and rebalancing of the humors.
Both perspectives were maintained until well into the Victorian era. While the basis behind melancholia evolved from unbalanced humors to disorders of the nerves and blood flow, the biological understanding of mental illness remained. Melancholia became more romanticized, as popular literature contained numerous depictions of melancholic love and heroism. In addition, disadvantaged and minority groups, especially women, diagnosed themselves as melancholic to justify their more educated and literary leanings which were previously restricted to upper-class men.[9] Interestingly, melancholia had become a desired mental “illness” and was not often associated with the suffering that Galen described.
At the same time, the field of psychiatry was beginning to gain more influence. As the numerous biological theories of nervousness, blood flow, hysteria, and neurasthenia competed for society’s understanding of melancholia, mental asylums started to become more commonplace. Mental illnesses began to be diagnosed and recognized more often, and families were seeking help in caring for those who suffered from them.[10] Before mental asylums were commonplace, the care of the mentally infirm was placed in the hands of their family. This practice put a huge strain on middle or lower class families especially, as they could not spare much extra time or food on them. In response to the strains put on working-class families by those suffering from mental illnesses, many European countries in addition to the United States began to construct mental asylums. The primarily goal was not treatment for most patients, but mainly housing and care. Psychiatrists rarely treated patients held in such institutions, but were rather their caretakers and simply managed the patients and their symptoms.[11] The initial emergence of mental asylums furthered the field of psychiatry and excited experts in the field, but eventually their prestige became stagnant as they simply remained the caretakers of often overflowing mental asylums.
While previously explanations of depression or melancholia had retained a biological basis, new emerging theories began to exhibit a more social approach. Psychiatrists such as Sigmund Freud began to posit more context-based psychological explanations for depressive symptoms which required intense psychotherapy to treat. Such therapies required much more time spent individually with trained psychiatrists, and therefore could only be accessed by those in the upper class. Like neurasthenia, depression and melancholia began to be a diagnosis primarily of the upper class who could pay for such psychotherapeutic treatments. Psychiatrists, previously stuck in their mental asylums, jumped at these new theories. Treating mental illness, especially depression, was starting to become an office-based endeavor with a stable income.
While some psychiatrists were busy treating the upper class for depression with psychotherapy, many were still stuck in mental asylums. Patients in such asylums often suffered from more severe forms of mental illness which were not treatable through psychotherapy.[12] Psychiatrists were still looking for methods to treat such patients so that they could be released from the mental asylums. Consequently, psychiatrists began to try new, experimental techniques. One such method was electroconvulsive therapy, which is still used today to treat patients with depression. In addition, such experimentation ushered in the first wave of psychiatric drugs. Many of these drugs were barbiturates and amphetamines, both highly addictive.[13] These drugs were not illness-specific and were used to treat depression as well as many other mental illnesses. Such drugs revolutionized the field of psychiatry and brought even more psychiatric practice into the office setting.
These advancements resulted in even more research into psychiatric drugs, eventually leading to today’s selective serotonin reuptake inhibitors. The more Freudian psychotherapy theories still mar the field of psychiatry, however. Patients, instead of simply receiving a pill, often fondly recall the large amounts of time psychiatrists spent with them during psychotherapy. They desire a more personalized approach to psychiatric care while psychiatry has become more generalized after the advent of psychotherapeutic drugs. In addition, the science behind such drugs is often not completely understood. Serotonin may in fact not play a large part in depression at all. While both the social and biological theories could be used in tandem to more fully treat depression, the long history surrounding the mental illness has created numerous barriers to such unification, both at a professional and societal level.
[1] Shorter, Edward. Before Prozac: The Troubled History of Mood Disorders in Psychiatry. Oxford: Oxford University Press, 2009.
[2] Wolpert, Lewis. Malignant Sadness: The Anatomy of Depression. New York: The Free Press, 1999.
[3] Ibid.
[4] Lawlor, Clark. From Melancholia to Prozac: A History of Depression. Oxford; New York: Oxford University Press, 2012.
[5] Ibid.
[6] Ibid.
[7] Shorter, Before Prozac.
[8] Lawlor, From Melancholia to Prozac.
[9] Ibid.
[10] Shorter, Edward. A History of Psychiatry: From the Era of the Asylum to the Age of Prozac. New York: John Wiley & Sons, 1997.
[11] Ibid.
[12] Shorter, History of Psychiatry.
[13] Shorter, Before Prozac.
For Further Reading:
Lawlor, Clark. From Melancholia to Prozac: A History of Depression. Oxford; New York: Oxford University Press, 2012.
Shorter, Edward. A History of Psychiatry: From the Era of the Asylum to the Age of Prozac. New York: John Wiley & Sons, 1997.
Wolpert, Lewis. Malignant Sadness: The Anatomy of Depression. New York: The Free Press, 1999.
