Table Of ContentTo my Teachers and Students
Depression
and its Treatment
John Pollitt, MD MRCP DPM
Physician in Psychological Medicine
St. Thomas's Hospital, London
William Heinemann Medical Books
London
First published 1965
© John Pollitt 1965
Printed in Great Britain by The Whitefriars Press Ltd
London and Tonbridge
Preface
In planning this book for clinicians important decisions had to be
made. Much of current terminology is out-dated, there is no satisfactory
classification, and existing theories do not cover the breadth of know
ledge which has recently accumulated. There is no proper framework in
which to place important discoveries or on which to plan basic research.
The choice lay between a brief review of hypotheses and the use of
accepted, but inadequate terminology, or suggestions for a new physio
logical theory with a concordant classification. I decided to pursue the
latter boldly and simply, while including as many useful facts as
possible.
I am indebted to Dr Raymond Greene and Dr William Sargant for
their help and encouragement, and I would like to thank my teachers
and all those, including many friends at Harvard, who by their helpful
criticism have brought my ideas into better perspective. I am particu
larly grateful to Dr Marjery Moncrieff and Dr Harry Buckland for their
help in reading and moulding the manuscript.
J. P.
Introduction
The subject of depressive illness is of prime importance not only to
psychiatrists, but to general practitioners, medical students and special
ists in other fields. It is important because of its high incidence, the
large morbidity rate, its world-wide distribution and disrupting effects
upon work, social activities and family life. For these reasons alone, it
is probably true that to know depressive illness is to understand three-
quarters of psychiatry.
Depression is the commonest reaction seen by psychiatrists. It is
common at all ages in adult life, and it afflicts mostly those who are
reliable, capable and conscientious. Although frequently deceptive in its
clinical manifestations, the various guises in which the reaction presents
can be penetrated; straightforward methods of treatment will be found
effective in a large number of apparently difficult cases. Almost all
depressive illnesses are potentially dangerous, because, whether patho
logical or not, most suicides are associated with them; suicides in this
country numbering over 5000, and in the United States 18,000, per year.
From this point of view, untreated depression has the worst prognosis of
any psychiatric illness. An equally serious aspect is that if the illness is
left untreated, or treated improperly, there is a danger of psychosis.
Both the development of psychosis and the possibility of suicide may
lead to hospital admission, time off work, loss of income and dis
organisation of important social relationships.
Methods of treatment for depression have been developing over the
last twenty years. Present methods include those of the simplest kind
such as drugs to be taken by mouth, and range to electro-convulsive
therapy, the technique of which has been improved enormously. In
addition, ways of preventing complications which were commonly seen
thirty years ago, are readily available. Research into mental illness,
particularly depression, is advancing more rapidly than ever before.
Investigation of clinical and social aspects, brain physiology, bio
chemistry of the nervous system, cybernetics, psychopharmacology, and
psychotherapy have progresssed at a rate which has brought the problem
into much better focus.
Diagnosis is particularly important because early treatment can often
resolve the illness before any degree of incapacity has occurred. How
ever severe its manifestations, it is almost always reversible. Good
therapeutic results can be achieved rapidly, and once the depressive
process has cleared, the patient's mental integrity is unimpaired and
there is no resulting personality change, thus its identification and
treatment can be one of the most rewarding processes in medicine for
both patient and doctor.
Several fallacies about depression are still held; one is that depression
÷ Introduction
is commoner among those who are unfortunate in their social and
economic status. Depression does not spare class, station or soul, and
it is not surprising that a number of eminent men have suffered from it.
Occasionally it has ended or interrupted their creative lives long before
their talents have been expended by age. Mozart's depression at the age
of thirty-four, and Edgar Allen Poe's recurrent attacks of depression
which so coloured his writings, consisted of patterns of reaction similar
to those seen throughout the world today. Although the content of
symptoms and their form of expression by the patient vary widely and
challenge the art of medicine, depression remains a constant pattern of
mental disturbance.
This book is concerned with depression in all its forms. The first aim
is to present a physiological basis for physical symptoms, possible
mechanisms for the purely psychological features and a new classifica
tion. The varieties of depression, including deceptive pictures, are des
cribed as the clinician sees them. Common errors of judgement in
depressives are emphasised as a knowledge of these is helpful in pre
venting the implementation of irremediable decisions which the patient
regrets as soon as he is well. The relevant chemistry of the nervous
system, the chemical changes occurring in depression, and the ways of
correcting and modifying these by modern methods are reviewed.
The second aim of the book is to give the principles and details of
the techniques used in treatment. The indications for use of older
methods and the ways of using the more recent anti-depressant drugs
are given. Particular attention is paid to ways of helping the patient
with chronic illness in which all usual methods of treatment have been
tried without result. Although much less common nowadays, the
physical complications, and ways of avoiding them, are described.
The greater interest shown in mental disorder by parliament and
public, and the increasing use of mass media to educate all in the
mechanisms and treatment of mental disorder, demand that the medical
profession as a whole should be well acquainted with one of the chief
illnesses for which now, there can be so much help. There is no branch
of clinical medicine in which depressive illness does not play some part;
and with this in mind, an attempt has been made to give a comprehen
sive account of depression for all engaged in clinical practice. So much
knowledge has been gained only during the past decade that inevitably
the majority of doctors have had no opportunity, during their early
clinical training, to learn this at the bedside or in the lecture theatre. It
is hoped that they, particularly, will find it helpful in focusing those
principles which it is believed will always govern and influence treatment.
Chapter I
Concept and Classification of Depression
"Tell us pray, what devil this melancholy is, which
can transform Men into monsters."
John Ford 1629
In everyday conversation the word depression refers to misery, sadness,
hopelessness or unhappiness, and it is implied that the emotion is justi
fied by the circumstances in which the individual concerned finds him
self. In clinical psychiatry the term depression means much more than
this, for not only do patients suffer from prolonged or severe emotional
reactions justified by unpleasant or traumatic circumstances, but they
more commonly present with a specific disease entity affecting both
body and mind which is not easily understood in terms of a simple
emotional reaction. The latter may be precipitated by physical as well
as psychological stress and occasionally appears in the absence of a
detectable cause. These two types of depression have different natural
histories, prognoses and complications, and require different forms of
treatment. Both involve functional changes, probably biochemical, but
not organic lesions in the brain (some brain lesions may produce
depressive symptoms in addition to neurological changes, but these are
not under review).
There are many clinical types of depression, and as feelings of depres
sion are occasionally absent, even in the severe states, it is more explicit
to refer to depressive "illness" or "reaction" and to reserve "depressive
mood" for the feeling of misery which is but one symptom. Depressive
illness is classified as an affective emotional disorder, because in most
examples depressive mood is the presenting complaint. Mania and
hypomania form the other category of affective disorder, and demon
strate changes of mental and physical kinds opposite to those seen in the
depressive reactions, the presenting features (rarely a complaint) being
of high spirits and elation.
Classification of depressive illnesses
Depression, whatever its type, is always a result of changes in the
internal or external environment on the nervous system of the sufferer.
Certain bodily changes or external events, or both, precipitate depres
sion, the clinical state produced being dependent on the constitution,
personality, physical state and upbringing of the individual affected.
Current classifications of depression, mainly descriptive, but partly
etiological, do not embrace all varieties of the illness; they overlap and
bear no relation to treatment or changes in the nervous system. In view
1
2 Depression and its Treatment
of these deficiencies, a new, simple classification is given. In some
instances terms have been applied in the currently accepted sense. New
terms have been introduced only when old ones could not be used in
a comprehensive classification. A critique of the old terminology and
the relationship of new concepts to older descriptions is given in
Appendix 1.
The present classification attempts to relate terminology with treat
ment methods available at the present time, and to present a rational
approach to the many types of depressive illness. The importance of
classification lies in the need to identify the different types of depression
in order to apply appropriate variations in treatment. There is no
universal formula, and only by careful identification can the method of
treatment most likely to help the patient be selected.
Depressive illness can be roughly divided into two main groups,
which for reasons to be given later, may be labelled as "psychological"
and "physiological".
Psychological depression
The phrase "psychological" depression applies to the development of
feelings of sadness, depression, hopelessness or despondency which are
entirely related to, and justified by, adverse external circumstances in
which the patient finds himself and of which he is fully aware. The
environmental conditions may be overwhelming, or the individual's
personality may be inadequate to deal with current problems, however
mild they seem to others. The patient has full insight into his difficulties
and, secondarily to his complaint of misery, he confesses inadequacy to
deal with his present life situation. The subjective mood is similar in
quality to normal feelings of depression arising from disappointments,
but the reaction is heightened or prolonged beyond normal expectation.
The mental state is, at least from the patient's point of view, justified
and the symptoms and complaints are limited to the psychological or
mental level. For brevity, "psychological" depression will be referred
to occasionally as Type /(justified). No delusions or hallucinations, and
none of the physiological changes to be described as part of "physio
logical" depression are found.
Physiological depression
"Physiological" depression is distinguished by symptoms and signs
of characteristic bodily changes dependent on persisting altered function
in the central nervous system. The pathognomonic features are somatic
manifestations, and it is therefore referred to as Type S.
The nervous and bodily changes have been collectively termed the
"depressive functional shift" (Pollitt (28)), and the explanation of this
phrase and its scientific justification are outlined below. The chief
clinical features are early morning waking and inability to fall asleep
Concept and Classification of Depression 3
again, feeling worse in the early part of the day and better as the day
wears on, loss of appetite, loss of weight, loss of sexual desire, secondary
impotence or frigidity, constipation, pallor, poor emotional expression
in the face, inability to cry, dry mouth, coldness of the extremities and
dryness of the skin. These symptoms and signs, listed in order of their
frequency and importance, indicate that the illness is of pathological
degree regardless of the depth of depressive mood accompanying it.
They indicate also that the illness is not solely related to the circum
stances, however traumatic, which precipitated it. In addition to the
physiological changes, mental phenomena take on a characteristic
pattern in that feelings of guilt, unworthiness, inferiority and inadequacy
develop. In more severe examples these ideas reach delusional strength.
Whereas almost all these features will be found in severe cases, it is
common to find only a few represented in the majority of milder ill
nesses. The group of symptoms exhibited depends largely on the
constitution, family history, personality and age of the patient. Thus
several patients with entirely different clinical pictures may be suffering
from the same illness and require similar treatment. While mental
retardation, anxiety, agitation and paranoid ideas are very commonly
seen in "physiological" depression, the distinction from Type J depres
sion can be made in their absence.
At this stage a direct tabular comparison between the major types
may be helpful in emphasising the main differences.
Psychological Physiological
Depression (Type J) Depression (Type S)
PHYSIOLOGICAL SYMPTOMS
Early waking Absent Present
Feeling worse in the mornings Absent Present
Appetite change Absent Present
Weight change Absent Present
Sexual desire changes Absent Present
PSYCHOLOGICAL SYMPTOMS
Depression Present Usually present
Retardation Absent Often present
Feelings of unworthiness Absent Often present
guilt Absent Often present
„ inadequacy Absent Often present
Delusions Absent Occasionally present
Concern about current life situation Always Frequently
AETIOLOGY
Environmental stresses Always in some degree Frequently
Physical stresses Absent Frequently
PERSONALITY
Inadequacies Frequently present Occasionally present
Having determined the main type of depressive illness, further
identification is necessary, but before discussing this, a scheme to show
4 Depression and its Treatment
the place of the two types of depression in a general classification of
mental disorder may be helpful.
DISORDERS OF CHARACTER Psychopathy
NEUROSES Anxiety states
Obsessional neuroses
Hysteria
Depression Type J
Depression Type S (mild)
PSYCHOSES Depression Type S (severe)
Mania
Schizophrenia
ORGANIC MENTAL REACTIONS Acute, e.g. Toxic confusional states
Chronic, e.g. Dementia
PSYCHOSOMATIC REACTIONS e.g. Psychogenic asthma
Type S depression is classified both as a neurosis and as a psychosis
according to severity. In advanced states the patient lacks insight and
becomes psychotic, whereas in milder cases full insight is common.
Psychological depression (Type J)
This type of depression may be broadly described as follows:
Acuteness: 1. Acute, e.g. acute grief reaction.
2. Chronic, e.g. chronic domestic difficulties.
Type of situation: As the situations likely to cause unhappiness are
legion, and as each set of circumstances must be studied in detail
in psychological depression, nothing is gained by a rigid classifica
tion. Nevertheless, to aid the search for important factors when
examining a patient, the following groups may be helpful: Social,
marital, sexual, domestic, bereavement, occupational, physical
incapacity.
Personality: 1. Good, well adjusted prior to development of traumatic
situation.
2. Specific inadequacy in relation to current situation.
3. Chronic and general inadequacy as shown by frequent
past depressive reactions to similar, or less severe stresses.
The importance of personality structure will be discussed later; at
this stage only broad groups are reviewed.
Physiological depression (Type S)
Having, with reference to the depressive functional shift, determined
that the depressive reaction is of this type, further subdivision provides
more precise clinical information. In describing these, some well known
descriptive terms will be used where they are of value. These terms are
not derived from a unitary classification, they are not mutually ex-
