Paradigm Shift

Kraepelin’s influence in renaming melancholia “depression” was enormous. But that alone would not suffice to explain why, an ocean away and a hundred years later, everybody became depressed. Mediators were needed to carry the doctrine of depression to the discipline of psychiatry, and then to individual patients. Those mediators were the American psychoanalysts, many of them distinguished migrants from Europe, and they gave pride of place to neurotic depression. Other mediators extracted depression and anxiety from the pool of nerves and yoked them together, making mixed depression-anxiety the favored disorder. To gain some perspective: In the first third of the twentieth century, in a great paradigm shift that transferred behavioral disorders from neurology to psychiatry, the spotlight shift ed from nerves, a diagnosis that implicated the whole body, to mood, a diagnosis that implicated mainly the mind. Mental illness triumphed over nervous illness, and depression became the main mood diagnosis. In 1908, Oswald Bumke, a psychiatrist then at the university psychiatric hospital in Freiburg, Germany (later to become professor of psychiatry in Munich), scolded the family physicians who never suspected depression in their wealthy patients whom they sent from spa to spa and sanatorium to sanatorium for the treatment of nondisease (symptoms without organic causes). The family doctors, who doubtlessly suspected the symptoms were of psychological origin, focused on the symptoms themselves; Bumke, more interested in mental than in physical symptoms, focused on what he believed the underlying cause to be: “depression,” as manifest in symptoms such as tiredness or an anxious preoccupation with their bodily health. For clinicians of Bumke’s generation, depression was a familiar concept. In understanding the rise of depression there are two questions that have to be sorted out: Why the depression diagnosis becomes so common and why depressive symptoms become divorced from the nervous syndrome and take on a life of their own as an affective disorder. Because events on both tracks happen around the same time, the narratives interblend, but they are separate stories. To foreshadow, it was American psychoanalysis that first put depression in the spotlight.