Depression. Aaron T. Beck, M.D.

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      Adapted from Kessler et al. 2005.

      Age of onset and lifetime prevalence rates (the likelihood of experiencing a mood disorder at some time in one’s lifetime) are presented in Tables 1-4 and 1-5.⁹

Descriptive Concepts of Depression

      The condition that today we label depression has been described by a number of ancient writers under the classification of “melancholia.” The first clinical description of melancholia was made by Hippocrates in the fourth century B.C. He also referred to swings similar to mania and depression.¹⁰

      Aretaeus, a physician living in the second century A.D., described the melancholic patient as “sad, dismayed, sleepless. . . . They become thin by their agitation and loss of refreshing sleep. . . . At a more advanced stage, they complain of a thousand futilities and desire death.” It is noteworthy that Aretaeus specifically delineated the manic-depressive cycle. Some authorities believe that he anticipated the Kraepelinian synthesis of manic-depressive psychosis, but Jelliffe discounts this hypothesis.

      Plutarch, in the second century A.D., presented a particularly vivid and detailed account of melancholia:

      He looks on himself as a man whom the Gods hate and pursue with their anger. A far worse lot is before him; he dares not employ any means of averting or of remedying the evil, lest he be found fighting against the gods. The physician, the consoling friend, are driven away. ‘Leave me,’ says the wretched man, ‘me, the impious, the accursed, hated of the gods, to suffer my punishment.’ He sits out of doors, wrapped in sackcloth or in filthy rags. Ever and anon he rolls himself, naked, in the dirt confessing about this and that sin. He has eaten or drunk something wrong. He has gone some way or other which the Divine Being did not approve of. The festivals in honor of the gods give no pleasure to him but fill him rather with fear or a fright. (quoted in Zilboorg¹¹)

      Pinel at the beginning of the nineteenth century described melancholia as follows:

      The symptoms generally comprehended by the term melancholia are taciturnity, a thoughtful pensive air, gloomy suspicions, and a love of solitude. Those traits, indeed, appear to distinguish the characters of some men otherwise in good health, and frequently in prosperous circumstances. Nothing, however, can be more hideous than the figure of a melancholic brooding over his imaginary misfortunes. If moreover possessed of power, and endowed with a perverse disposition and a sanguinary heart, the image is rendered still more repulsive.

      These accounts bear a striking similarity to modern textbook descriptions of depression; they are also similar to contemporary autobiographical accounts such as that by Clifford W. Beers.¹² The cardinal signs and symptoms used today in diagnosing depression are found in the ancient descriptions: disturbed mood (sad, dismayed, futile); self-castigations (“the accursed, hatred of the gods”); self-debasing behavior (“wrapped in sackcloth or dirty rags . . . he rolls himself, naked, in the dirt”); wish to die; physical and vegetative symptoms (agitation, loss of appetite and weight, sleeplessness); and delusions of having committed unpardonable sins.

      The foregoing descriptions of depression include the typical characteristics of this condition. There are few psychiatric syndromes whose clinical descriptions are so constant through successive eras of history (For descriptions of depression through the ages, see Burton.¹³) It is noteworthy that the historical descriptions of depression indicate that its manifestations are observable in all aspects of behavior, including the traditional psychological divisions of affection, cognition, and conation.

      Because the disturbed feelings are generally a striking feature of depression, it has become customary to regard this condition as a “primary mood disorder” or as an “affective disorder.” The central importance ascribed to the feeling component of depression is exemplified by the practice of utilizing affective adjective checklists to define and measure depression. The representation of depression as an affective disorder is as misleading as it would be to designate scarlet fever as a “disorder of the skin” or as a “primary febrile disorder.” There are many components of depression other than mood deviation. In a significant proportion of the cases, no mood abnormality at all is elicited from the patient. In our present state of knowledge, we do not know which component of the clinical picture of depression is primary, or whether they are all simply external manifestations of some unknown pathological process.

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