The term “depression” was coined in the late 19th century by the great German psychiatrist Emil Kraepelin who spoke of depression as a polar opposite of excited manic states. Before Kraepelin, severe depression was generally known as melancholia and what we today call “bipolar disorder” (with manic and depressive phases) was generally termed “circular insanity”. Kraepelin used the term “manic-depressive insanity” to mean any full-blown mood disorder whether manic, depressive or both. Not everyone diagnosed with “manic-depressive insanity” 100 years ago would be diagnosed as “bipolar” today; some of them simply experienced repeated episodes of depression.
The difference between the diagnostic categories of 1921 and those of today is that today’s clinical depression encompasses a far wider range of severity than manic-depressive insanity ever did. Depressed patients with manic-depressive insanity really were, in the terminology of the day, “insane” ― too sick to work, too sick to cope with the demands of daily life, too ill often to partake in extended conversation and sometimes incapable of speaking at all. In today’s jargon they all had severe depression, and most of them were psychotic, often deluded and experiencing auditory and visual hallucinations.
Symptoms that most people associate with schizophrenia today were relatively common in depression back in the days before antidepressants or antipsychotics or mood stabilizers or ECT. Here’s Dr Kraepelin’s own description from 1913 of some of his most extreme cases (published in English 1920):
Abundant hallucinations appear. The patients see evil spirits, death, heads of animals, smoke in the house, crowds of monsters, lions’ cubs, a grey head with sharp teeth, angels, saints, dead relatives, the Trinity in the firmament, a head rising in the air. Especially at night extraordinary things happen. A dead friend sits on the pillow and tells the patient stories. The patient thinks that he is on a voyage; God stands beside the bed and writes down everything; the devil lies in wait behind the bed; Satan and the Virgin Mary come up out of the floor. God speaks in words of thunder; the devil speaks in church; something is moving in the wall. The patient hears his tortured relatives screaming and lamenting; the birds whistle his name; “Do away with him, do away with him,” “Now she’s coming, now there’ll be blood again,” “Now we’ve caught her nicely,” “You have nothing more,” “You’re going to hell.” A woman is standing at the door and is giving information to the persecutors; there is a voice in his stomach, “You must still wait a long time till you are arrested; you are going to purgatory when the bells ring.” The patient is electrified by the telephone, is illuminated at night by Röntgen-rays, pulled along by his hair; someone is lying in his bed; his food tastes of soapy water or excrement, of corpses and mildew.
Kraepelin, E Manic-Depressive Insanity and Paranoia (1920) Chapter V, p89
Of course milder depressions were recognized 100 years ago, but went by different names: neurasthenia, hypochondria, “psychogenic depression” or simply “moodiness”. Back then many who were tormented by recurrent “moodiness” simply had to get on with life.
People with money tended to visit resort towns to attempt to refresh themselves with mineral springs and mountain air. When the attacks became more chronic or severe they were apt to fall into the hands of quacks who treated them with anything from hot cups to magnets placed on the heart to tinctures of opium, this last treatment of course being highly addictive. But conveniently enough (for the quacks) there was no requirement back in the day to list ingredients of patent medicines, meaning once hooked you could only be assured of relief by purchasing supplies of the same branded mystery medicine, not even knowing it was in fact opium you were addicted to. Then as now, only the worst cases of depression were treated in mental hospitals, often after years of suffering, failures and disappointments.
Nowadays we have antidepressants, so everything’s so much better ― isn’t it? Not necessarily. Since the introduction of SSRI antidepressants in the late 1980s (drugs in the Prozac family) antidepressants have been prescribed in ever larger quantities for ever-milder states of depression. This coincided with widespread publicity about the addictive properties of anti-anxiety medications like Valium, so doctors simply switched from dishing out one kind of pills to another. Between 2007 and 2017 antidepressant prescriptions doubled in the UK, reflecting an increase in popularity worldwide. Nowadays almost anyone who visits the doctor saying they’re feeling down and not sleeping is likely to walk away with an antidepressant prescription.
However antidepressants are not equally suitable for all types of depression, and that includes severe depression. It’s now accepted that in bipolar disorder antidepressants are highly likely to cause a “manic switch” ― either into full-blown mania or a nasty mixed state where manic and depressive symptoms combine. This is a problem, because in the early days of anyone’s mental health “journey” it’s not always clear who is bipolar and who isn’t. It’s common for bipolar patients to experience repeated depressive episodes for many years, sometimes decades before mania ever appears. About half of all people who get recurrent depressions are bipolar to some degree.
On top of this, researchers have noticed that along with the upsurge in antidepressant prescriptions there’s been an upsurge in bipolar rapid cycling. Once considered a relatively rare phenomenon, rapid cycling means bipolar disorder with four or more manic, hypomanic, depressed or mixed episodes per year ― although most rapid cyclers experience far more than that.
So what’s the answer? When a patient is known to be bipolar they are almost never given an antidepressant without a mood stabilizer ― either lithium, carbamazepine, valproate or lamotrigine, sometimes a combination. Many patients are now given antipsychotics as a primary medication because these drugs also have anti-manic properties, can stabilize mood and are said to be valuable treatments for bipolar depression even without other drugs.
For anyone dogged by depression or bipolar disorder, the situation today is brighter than it ever was… there are many treatments but still no cure. For the doctors and the drug companies this is a great thing. It means their multi-millions of mood-disordered patients will be coming back for more pills for many years to come!
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