Melancholic Mysteries

If I was a young doctor, taking on for half a century ago, melancholy was a rare illness, or at the very least a condition that was seldom diagnosed, which isn’t quite the exact identical thing. In its severe forms it was unmistakable. Patients who would to all looks have everything to live for could twist their faces to the wall, nearly literally when their beds were adjacent to a wall; they might even suffer from Cotard’s syndrome, even the delusional belief they were or had nothing, that their bodies had rotted off, that they were in the last phases of impoverishment even when they had millions in the bank. I recall a patient who told me he was dead and all that remained of him was that the gangrenous tip of his nose. No rational argument could convince him he was confused. Electro-convulsive treatment (ECT) returned him very quickly to his usual condition, a successful and prosperous businessman.
It was impossible not to conceive of him as being sick, pure and easy. But what about lesser forms of melancholy and human misery? When did misery, understandable from the individual’s circumstances, become illness? People who thought there was a bimodal distribution split melancholy into endogenous (that’s to say, originating from the victim’s constitution) and responsive (that’s to say, originating from the individual’s response to his circumstances). The former tended to be, but was not always, more severe, intense and bizarre than the latter; they confessed that circumstances, in some circumstances, could result in acute depression, to a evident disgust with life and even to suicide.
Lately, there was a very similar playful polemic between those who thought that high blood pressure has been bimodally distributed and people who thought it was unimodally distributed. In the bimodal model, there were also a separate group of men and women who suffered from an as yet undiscovered illness that resulted in exceptionally severe high blood pressure, while everyone else had blood pressures that were distributed around a mean.
It is now generally accepted that those who believed in unimodal distributions, both of depressed mood and blood pressure, won the argument. Personally, I believe that is appropriate in the case of blood pressure, but wrong in the example of melancholy. As soon as you have seen melancholia, because it was called, you can’t confuse it for depression of mood, however protracted. But I am quite conservative.
In the last twenty five decades, identification of depression has gotten so prevalent that up to a sixth of adults in western states have been taking antidepressants–or even alleged anti-depressantsas critics might say. The term unhappiness has almost been deducted from the lexicon, and nobody complains of itif they whine at all, it is of melancholy. Deviation from pleasure and contentment, at least for more than two weeks, has become a disorder: the default setting of Man, so to speak, is pleasure.
Certainly, anybody who attends to the history of Rasselas, Prince of Abyssinia will not concur, but a few people do attend it. The issue remains, addressed within this publication without definitive answer (because none can be granted ), as to whether the higher number of individuals diagnosed, or even self-diagnosed, as suffering from depression represents a real gain in the incidence of the illness, better comprehension of a condition that has been always there but dismissed, or perhaps a cultural fashion.
Jonathan Sadowsky’s Empire of melancholy has much to recommend it. It is brief and succinct, that the writer writes obviously without resort to jargon to give his writing a false feeling of profundity, and he’s undogmatic in a field not lacking from dogma and dogmatists. He’s clearly read a terrific deal about the topic, and in general his reasoning is solid. This isn’t to say that I would concur with his judgments, but none of them is indefensible.
By way of instance, I believe he’s way too generous to in general psychoanalysis and Freud particularly. This Freud was frequently acute in his observation of mankind is correct, but were La Rochefoucauld and Lichtenberg (a higher proportion of the time, in fact, plus a great deal more pithily). Even fortune tellers tend to be severe observers of their clients, but such acuteness does not require the vast superstructure of theory that Freud claimed to own erected on the grounds of assumed observations, but actually on these of preconceptions encouraged (as by now has been fairly well-established) by a significant resort to mystification and blatant lies in the outcomes of his therapy. The observation that gloomy adult patients have frequently had mentally deprived childhoods (if accurate ) is just one that may be made with no psychoanalytic theory whatsoever.
One of the issues of melancholy as an object of research is that there are not any clear-cut biological markers to differentiate instances from non-cases. A few endocrinological conditions mimic depression, and a few medications undoubtedly make it. In the terrific majority of instances, but there are no measurable bodily modifications, except those caused from the symptoms : in melancholy, symptoms and disorder are just one, at least in the present condition of knowledge.
The writer is more concerned to avoid false dichotomies: genetic vs environmental, physical versus psychological, social versus person, versus responsive. It is rarely in medication, he says, the causes of a disorder are both necessary and adequate; Koch’s famous postulates are not often fulfilled even in relatively easy circumstances, let alone in something as complicated as melancholy.
Although he says that scorn isn’t beneficial to understanding history, he’s somewhat scornful of the idea that there is a moral dimension to melancholy. At no time does he believe a conscious effort to be resilient, by way of instance, might play a useful part in the prevention of depression: he thinks a willingness to admit and accept psychological vulnerability is an advance. In many cases, it might very well be ; however, it being would be perfectly compatible with a rapid increase in melancholy on a population basis. As a colleague of mine, Dr. Colin Brewer, once placed it, misery increases to satisfy the means available for the alleviation.
The writer does not (in my opinion) sufficiently look at the cultural significance of the replacement of the term unhappiness by melancholy in common parlance. The functional effect is significant. A miserable person should either set up with his urgency, or examine the causes of this and try to modify either himself or his plight. The depressed person is declaring himself sick and putting the responsibility on somebody else to cure him. In present medical circumstances, in which doctors have hardly any time for every individual (and much of the taken up with inputting data, or pseudo-data, on a pc ), a prescription is the most likely result.
The writer suggests that people who espouse or deny the seriousness of melancholy tend to use the expression character flaw to account for its apparently rising incidence. But is there such a thing as character defect?The pills prescribed might or might not assist; if they do, then it might or might not be due to a real antidepressant effect. In many cases, but they do not do the job, even as a placebo (that they may even work as a nocebo, ” a theory that makes no appearance in this book). Luckily for the doctor, perhaps less so for the individual, there are many distinct doses and several distinct pills that may be tried before all pharmacological therapy possibilities have been exhausted. A kind of pas de deux can occur between the doctor and patient lasting several months, by which time the feelings of melancholy may have remitted in almost any instance.
But matters are far from straightforward. It isn’t unusual in medication, at least nowadays, to prescribe medication to a hundred individuals understanding it is going to work in only one of them, but never understanding in which one. This is the explanation for the prescription of both antihypertensive medication and statins, which in almost any human patient are more likely to cause minor side-effects compared to do some good: even if they do well, it is a very good good really. And precisely because melancholy is so protean, so obscure and so ill-understood, it isn’t easy to tell which individual will benefit from which therapy. Is there more rejoicing in heaven over a regained depressive than over ninety-nine depressives given medicine uselessly, or even harmfully? I don’t believe there is, or can be, a definitive answer.
The writer suggests that people who espouse or deny the seriousness of melancholy tend to use the expression character flaw to accounts for its apparently increasing incidence. But is there such a thing as character flaw? If there is not, does that not rather empty all human life of moral significance, just as critics of the over-diagnosis of melancholy says it does? Indeed, the writer almost suggests the use of term character flaw might be considered–a character flaw.
But the situation is complicated. I recall that a patient of minein my early seventies, who for about twenty years had been lacking energy, had loved nothing, and had sat about moping. As in everybody’s life, there were factors that may plausibly explain her misery. No treatment functioned; she remained the same. I was about to write off her as character-defective once I prescribed an monoamine oxidase inhibitor for her, an old-fashioned drug that needs the individual to abjure specific foods to avoid a potentially dangerous reaction. In my surprise and enjoyment, but in addition to my shame at having nearly written off her since character-defective, she regained her joie de vivre, began to play the piano and became vivacious. I found it difficult to believe this was a mere placebo answer: why this kind of response so late in the day? It is not hard to write people off as bad figures, which isn’t to say there are no such folks.
The story I’ve just told would not surprise Professor Sadowsky because he has a complicated and sophisticated rather than a simplistic and primitive view of melancholy. He is fair-minded instead of polemical, however there are omissions. There is surprisingly little mention of suicide from the publication; he does not address the problem of how to differentiate between a plausible and also a genuine cause of a psychological state. After all, everyone has a reason to be miserable but not everyone is miserable, even if his motive to be miserable is very strong.
I am glad to say, but that Professor Sadowski is a worthy director of Hamlet: he does not disdain or hate attempts to explain man’s illness, but does not believe either the core of the puzzle is going to be crawled out.