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MENTAL HEALTH IN HISTORICAL PERSPECTIVE

From Melancholia
to Depression
Disordered Mood in
Nineteenth-Century Psychiatry
Åsa Jansson
 Mental Health in Historical Perspective

Series Editors
Catharine Coleborne
School of Humanities and Social Science
University of Newcastle
Callaghan, NSW, Australia

Matthew Smith
Centre for the Social History of Health and Healthcare
University of Strathclyde
Glasgow, UK
Covering all historical periods and geographical contexts, the series
explores how mental illness has been understood, experienced, diagnosed,
treated and contested. It will publish works that engage actively with
contemporary debates related to mental health and, as such, will be
of interest not only to historians, but also mental health professionals,
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The scope of the series is kept as broad as possible to attract good
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 Åsa Jansson

From Melancholia
to Depression
Disordered Mood in Nineteenth-Century
Psychiatry
Åsa Jansson
Institute for Medical Humanities
Durham University
Durham, UK

Mental Health in Historical Perspective

ISBN 978-3-030-54801-8 ISBN 978-3-030-54802-5 (eBook)
https://doi.org/10.1007/978-3-030-54802-5

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For Annika. Thank you, for everything.
 Preface

This book has been a long time in the making. The seeds were sown in
2009 when I started researching an M.A. dissertation on melancholia and
depressed mood in Wilhelm Griesinger’s work, and quickly realised that
there was a much bigger story to be told about what happened to the
melancholia concept in nineteenth-century psychiatry. This story became
the focus of a Ph.D. thesis on which this book is based.
Melancholia is a topic that has attracted vast attention from writers
across disciplines and genres, spanning a range of perspectives. At the
same time, much existing work on melancholia is underpinned by a
common theme: the belief that melancholy is a timeless human emotion,
a phenomenon that has remained largely constant as our societies have
changed, a shared experience that connects us to our ancestors of past
historical periods. Seen in this way, melancholy is a core feature of
humanity, as is its pathological mutation, melancholia. To understand
melancholia, then, is to understand something about what it means to
be human: to suffer without apparent cause.
As this is the context in which this book is written, and as it will
inevitably be read against the backdrop of a large catalogue of works
on melancholia and melancholy, it is only right that I confess that my
interest in this topic and my original motivation for exploring it are less
ambitious and more mundane than those of many of the writers who
have sought to make sense of this ubiquitous yet elusive feature of the
human condition. My initial interest in mood disorders arose in relation

vii
viii PREFACE

to the politics of the pharmaceutical industry and the medicalisation of

psychological distress that provides a lucrative market for drug companies.
I once offered this explanation in a scholarship interview, and it didn’t go
down very well. It was not, it seemed, how or why one is supposed to
do history. It was, however, the truth, though that original motivation
has since been superseded by a more fundamental desire to understand
how knowledge in the psy disciplines is produced, in particular relating to
psychiatric classification.
But I was never particularly interested in exploring melancholy as
a feeling. In the field of the history of psychiatry, the question that
often looms—usually unspoken—over our heads when we talk about
our research is that of personal experience. Do you write about melan-
cholia because of your own struggles with pathological low mood? The
short answer to that is no. My interest is more broadly in the produc-
tion of psychiatric knowledge about people, how our emotions, thoughts,
and actions become symptoms of psychiatric diagnoses. Depression has
become ubiquitous, more so than any other psychiatric condition—the
WHO considers it to be a leading cause of disability worldwide and the
prescription and consumption of antidepressant medication continue to
rise every year. I wanted to understand how we got to this point. But
when I delved into the world of historical scholarship on depression and
melancholia I soon discovered that a significant piece of the puzzle was
missing.
The more I read, the more evident it became that something funda-
mental occurred in the nineteenth century. Most writers on the topic,
whether they subscribe to a narrative of continuity or one of change,
recognise that today’s Major Depressive Disorder doesn’t correspond to
past conceptions of melancholia. But nineteenth-century melancholia was
not only significantly different from clinical depression as understood
today, it was equally different from the various forms of traditional melan-
choly madness that came before. As German Berrios has noted, a shift
occurred that was about more than just a change in language.1 The recon-
ceptualisation of melancholia in the nineteenth century facilitated the later
emergence of clinical depression in the twentieth, but it also paved the

1 German E. Berrios, “ Melancholia and Depression during the Nineteenth Century: A

Conceptual History,” British Journal of Psychiatry 153 (1988): 298–304.
 PREFACE ix

way for the creation of other affect-based diagnostic categories, such as

bipolar disorder, borderline personality disorder, and anxiety disorders.
The story of how melancholia was reconfigured along biomedical lines
is not, then, only the story of a specific diagnosis, or state of mind, it is
also the story of how the modern concept ‘mood disorder’ was created.
That story didn’t begin on asylum wards, but with the rise of a new
discipline: experimental physiology. The epistemological framework that
was created in the early nineteenth century to explain the internal opera-
tion of emotions and ideas continues to form the basis for how we think
about psychological events today, and consequently informs the direction
of current research into the mind and brain. If we want to understand
how we arrived at this point in history where ‘depression’ is an illness that
can be treated with psychotropic medication and therapeutic strategies
aimed at teaching us to ‘regulate’ our emotions, we must first understand
how the idea of disordered mood as a medical condition became possible
in the first place. And we must also understand the relationship between
statistics and diagnostic practices, another distinctly modern development
that is crucial to mapping the creation not just of mood disorders but of
most modern psychiatric diagnoses.
This book, then, is an attempt to redress a significant gap in the history
of depression and melancholia, and of mood disorders more generally.
It arises from a desire to understand how knowledge that is absolutely
fundamental to the human experience in the twenty-first century was
created and made real. So, I didn’t come to this topic because of an
interest in melancholy as a feeling or a personal experience with depres-
sion. But of course, an interest in psychiatric knowledge is an interest
in knowledge about human distress and suffering, and in this way it
concerns us all. Most if not all of us will experience psychological distress
at some point in our lives (whether or not that distress is pathologised
and diagnosed). And what I found once I immersed myself in the archival
records of Victorian asylums was that while I don’t necessarily relate to
twenty-first-century descriptions of clinical depression, some of the ways
in which nineteenth-century asylum patients diagnosed with melancholia
expressed their distress resonated with me deeply. Many Victorian melan-
cholics appeared to display ‘symptoms’ that are largely consistent with
the key criteria of depression today, but equally common were profound
delusions, and in more severe cases hallucinations were not unusual.
x PREFACE

This led me to start asking questions about our current separation of affec-
tive (mood) and cognitive (schizo) disorders, which began in the nine-
teenth century and was cemented in the twentieth. That story is yet to be
told, and doesn’t form part of this book. But it looms in the background
and illustrates one of the most important differences between nineteenth-
century melancholia and clinical depression, in that delusions and hallu-
cinations are only a secondary and much less talked about feature of the
latter.
Finally, it should be emphasised that there are many ways in which one
can write the history of nineteenth-century melancholia. This book is an
attempt to write it as the history of medical and psychiatric conceptions of
what melancholia was—and became—in this period. In other words, this
book is not a search for answers about what melancholia feels (or felt)
like or why people are apparently afflicted by it. Nor is it an attempt to
right historical wrongs in psychiatry by demonstrating the timelessness of
melancholia as a medical condition. And it is not a critique of the ubiquity
of the clinical depression concept. These are all important issues, which
to various extents form the context for the present story, but they have
been, and are still being, comprehensively discussed elsewhere. This book
is the story of how the first modern mood disorder was created.
Why is this important? There are undoubtedly many reasons, but the
most fundamental is this: ‘knowledge about human beings changes what
people are’.2 An historical perspective on such knowledge is crucial. It
allows us to understand where it comes from, how it emerged, how it
operates, and most importantly how it becomes central to our lives. It
shows us that such knowledge is not permanent or universal. Mood disor-
ders constitute a particular, historically specific way of making sense of
and experiencing emotional distress. What shedding light on this histor-
ical specificity does is show us that the existence of this framework is not
inevitable. It’s very much real today—people are diagnosed with mood
disorders and experience themselves as suffering from these conditions—
but it hasn’t always been. This way of understanding emotional distress
is neither right nor wrong; it can be both helpful and harmful. What is
important is that we are equipped with the tools to think critically about
its place in our lives and the work that it does, and to equally allow for

2 Roger Smith, Being Human: Historical Knowledge and the Creation of Human Nature
(Manchester: Manchester University Press, 2007), 8.
 PREFACE xi

different frameworks and ways of experience. This, in my view, is one of

the most important tasks of history: to remind us of the impermanence of
human nature, and that we have the power to fundamentally change the
way we understand our inner selves and the world around us.

Durham, UK Åsa Jansson

 Acknowledgements

I’m indebted to many people and institutions for their help and support
in the research and writing of this book. Thanks first of all to Molly
Beck at Palgrave Macmillan for her enthusiastic interest in and support
for the book, as well as to Maeve Sinnott for continuous support and
guidance during the writing process. Thanks also to the editors of the
Mental Health in Historical Perspective series, Catharine Coleborne and
Matthew Smith, and to the anonymous peer reviewers for their helpful
comments on the proposal and manuscript.
This book would not have been possible without a generous scholar-
ship from the Wellcome Trust (grant number 092988/Z/10/Z), which
allowed me to research and write the thesis on which the book is based.
I’m also grateful to my colleagues and friends at the University of London
whose feedback at various stages of this project in its early years was instru-
mental in shaping the story that eventually became the present book, in
particular my Ph.D. supervisors Thomas Dixon and Rhodri Hayward, as
well as Sarah Chaney, Chris Millard, Jennifer Wallis, Tom Quick, Stephen
Jacyna, and Sonu Shamdasani. I’m also especially grateful to Felicity
Callard for continuous support and advice over the years.
Thanks also to my colleagues at the Institute for Medical Humani-
ties and Hearing the Voice at Durham University, in particular Angela
Woods, Sarah Atkinson, Victoria Patton, Ben Alderson-Day, Chris Cook,
Charles Fernyhough, Kaja Mitrenga, and Mary Robson. Working in a
collaborative and interdisciplinary context over the last few years has had

xiii
xiv ACKNOWLEDGEMENTS

a profound impact on my approach to history, and has led me to ask

sometimes difficult and uncomfortable questions about the role of histor-
ical research and historical perspective in the medical humanities, and
more fundamentally in our common endeavour to understand and redress
human suffering.
I’m also grateful to the following people for feedback, advice, and/or
fruitful conversations that have provided insight and guidance over the
years since I first began researching this topic: Ingrid Lindstedt, Roger
Smith, Rob Iliffe, Roger Cooter, Rebecca O’Neal, Victoria O’Callaghan,
Yewande Okuleye, and Eric Engstrom, as well as everyone who has
offered questions and comments on seminar and conference talks based
on different aspects of this research.
Finally, my deepest gratitude is due to the people whose unconditional
love and support have kept me (relatively) sane through the various stages
of this journey: Annika, Annelie, Britta, Melek, Becky, Shannon, Anna,
Danny, Sophie, Hanna, and Olly. Thank you.
 Contents

1 Introduction: Disordered Mood as Historical Problem 1

2 The Scientific Foundation of Disordered Mood 35

3 The Classification of Melancholia

in Mid-Nineteenth-Century British Medicine 63

4 Melancholia and the New Biological Psychiatry 89

5 Statistics, Classification, and the Standardisation

of Melancholia 123

6 Diagnosing Melancholia in the Victorian Asylum 173

7 Conclusion: Melancholia, Depression, and the Politics

of Classification 209

Index 229

xv
 CHAPTER 1

Introduction: Disordered Mood as Historical

Problem

If mania and melancholia took on the face that we still recognise today, it is
not because we have learnt to ‘open our eyes’ to their real nature during the
course of the centuries; and it is not because we have purified our perceptive
processes until they became transparent. It is because in the experience of
madness, these concepts were integrated around specific qualitative themes
that have lent them their own unity and given them a significant coherence,
finally rendering them perceptible.1
Michel Foucault, History of Madness (1961)

In the summer of 1874, Moses B., a young doctor, was brought into
Edinburgh Royal Asylum at Morningside. According to his family, he
had become so intent on taking his own life that they saw no other
option but to have him certified as insane and admitted to the hospital.
One of the doctors who examined him in his home had written in the
medical certificate that Moses suffered from severe ‘delusions’, which
had him convinced that ‘his soul is lost, that he ought to die’ and that
‘he is committing great sins’. When Moses arrived at Morningside, the
attending physician noted in the patient journal that the young man’s
‘depression’ was ‘considerable’, and made a note of his ‘suicidal tenden-
cies’, which, based on family testimony, consisted in ‘taking belladonna,
refusing food, &c’. Moses B. was subsequently diagnosed with melan-
cholia, with emphasis given to his pronounced ‘suicidal tendencies’, which
required that he be placed under close observation.

© The Author(s) 2021 1

Å Jansson, From Melancholia to Depression,
Mental Health in Historical Perspective,
https://doi.org/10.1007/978-3-030-54802-5_1
2 Å. JANSSON

For the experienced medical staff at Morningside, diagnosing Moses

was a straightforward matter. Melancholia was, at the time, a common
affliction among patients who arrived in the asylum. Its symptoms were
considered to be clearly recognisable and, according to the institution’s
chief physician, Thomas Clouston, the disease ran ‘a somewhat definite
course, like a fever’.2 But what would a twenty-first-century psychiatrist
or general practitioner make of a patient like Moses Black? Would they
conclude that he suffered from Major Depressive Disorder, prescribe him
a course of antidepressants, and put him on the waiting list for Cogni-
tive Behavioural Therapy? Or would his thoughts and actions—believing
himself to have sinned against God and attempting to poison himself—
appear unfamiliar to today’s clinicians? These questions speak to a more
profound, ontological concern: is clinical depression a timeless condition?
In other words, have people always been depressed?
I will return to this question momentarily. Whether or not depression
has always been a feature of the human condition, if current statistics
are to be believed we are, as a society, becoming more depressed with
each passing year. According to the World Health Organisation, clinical
depression is now the world’s leading cause of disability. When a new
generation of antidepressant drugs, selective serotonin reuptake inhibitors
(SSRIs), flooded the market in the late twentieth century, one scholar
suggested that we had entered an ‘antidepressant era’.3 In the 1990s,
SSRIs became what benzodiazepines were to the sixties—the universal
cure for unwanted negative emotions. A common question in response to
these developments, which has been posed by scholars across the natural
and human sciences, is whether rates of depression have increased, or
whether we have become less tolerant of emotional distress, or simply
more likely to denote it as a medical problem with a chemical solution.
It has been suggested that the apparent rise in depression is primarily
due to a growing tendency to over-diagnose ‘normal sadness’.4 Others
argue that there has been a real increase in the symptoms of genuine
Major Depressive Disorder since the early twentieth century, leading one
observer to conclude that depression is, like obesity and type-II diabetes,
a ‘disease of modernity’ caused by humanity’s collective derailment from
our true evolutionary path, suggesting that ‘humans have dragged a body
with a long hominid history into an overfed, malnourished, sedentary,
sunlight-deficient, sleep-deprived, competitive, inequitable, and socially-
isolating environment with dire consequences’.5
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