From Melancholia to Prozac: A History of Depression by Clark Lawlor (review)

Fifty years ago, the number of people diagnosed with depression was relatively modest. At present, by contrast, the Centers for Disease Control and Prevention estimates that no less than one in ten Americans suffer from this condition, or well over thirty million. What is responsible for such a far reaching transformation? Was there a failure or an inability to identify depression? Have social and economic pressures become so complex that many individuals lack coping skills and as a result become depressed? Or have the parameters and meaning of the diagnosis so expanded—particularly, since the publication of DSM-III (American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. Washington, DC: American Psychiatric Association, 1980)—as to include people who in the past would not have been identified as depressed? Such basic questions are often ignored, if only because diagnostic categories at any given time assume a legitimacy that precludes doubts about their validity.

In From Melancholia to Prozac, Clark Lawlor has attempted to provide a brief history of changing interpretations of the diagnosis from the Greeks to the present. The book commences with a chapter on the depression of Dr. Samuel Johnson, editor of the classic Dictionary of the English Language (1755), essayist, poet, literary critic, and biographer. He lived at a time when a religious and prescientific world was being undermined by secular and scientific modes of thinking. This change was embodied when the classic category of melancholia was replaced by the modern diagnosis of depression. James Boswell's famous biography touched upon the many ways—psychological, physical—that characterized Johnson's inner struggles and the conflicting ways in which he gave them meaning. His inner tribulations, alongside his literary achievements, embodied themes that would resonate in the future, including the alleged relationship between genius and mental disorder.

In succeeding chapters, Lawlor traces the changing faces of depression. In classical writings, depression was not called depression. Rather it was called melancholia, which denoted a causeless sadness that derived from an excess of black bile. Although the illness had a physical basis—an imbalance of the humors—powerful emotional stimuli could also intensify the imbalance. In the Renaissance, the understanding of melancholy shifted "between the religious, magical, mystical, alchemical, demonological, and the more naturalistic explanations" associated with Galenic thought (44). In the late seventeenth century, melancholy was redefined, and terms such as hypochondria, spleen, hysteria, and vapors now denoted the disorder. This change reflected the new scientific attempt to investigate nature rather than uncritically accepting the wisdom of the Ancients.

In the late eighteenth and nineteenth centuries, melancholy was slowly replaced by the modern concept of depression, which became less a disorder of the intellect and more of a mood or affective disorder. Knowledge about brain and nerve anatomy and the emergence of psychiatry and psychology played critical roles. The transition was by no means smooth, as the popularity of the concept of neurasthenia—a mixed category that merged nervous exhaustion and depression—suggested. Emil Kraepelen's manic depression insanity, which profoundly influenced twentieth-century psychiatry, set the stage for the emergence of the contemporary diagnosis of depression. His ideas were momentarily submerged by Freud's emphasis on unconscious drives and conflicts within the psyche as well as Adolf Meyer's preoccupation with "reaction types" (a failure on the part of the individual to adjust to circumstances). Since the 1970s, however, the distinction between endogenous and reactive depressions disappeared. The publication of DSM-III in 1980 avoided any discussion about the etiology of depression; instead, it relied only on symptoms. That it increased reliability—the ability of psychiatrists to agree on a diagnosis—was clear. It was equally evident that DSM-III ignored the question of the validity of a system based solely on descriptions of symptoms. Above all, by blurring the traditional distinction between normal and pathological sadness, it set the stage for an enormous expansion of...