Hypothesis ' Biological ' depression ; because sleep fails ?

The melancholy mind has been recognized throughout recorded history. It was given a medical context by the ancient Greeks who claimed for it a relationship with constitution in the form of physique, body chemistry and temperament. It was subject to scholarly analysis by Burton (1927) over three hundred years ago. The disorder has not always been medicalized and some cultures have tended instead to recognize it as a proper and sometimes creative state of mind. It was through the English translation of Kraepelin's writings (1921) that the word 'depression' entered the medical arena. Subsequently Meyer (1934) emphasized the notion that depression was a psychobiological reaction to adverse events. This view has found more recent expression in the writings ofSchmale & Engel (1975) in particular. In this country the debate concerning the nature and sub-classification of depressive illnesses has become a major preoccupation of psychiatry. The longstanding concept of 'endogenous depression' is handicapped by implying aetiological understanding to what is essentially a phenomenological approach. Protagonists of the various views have sometimes seemingly forgotten that in an analysis of such data you only get out what you have put in in terms of patient groups and symptoms. For instance, the large group of depressed people lurking in medical wards and out-patient clinics has seldom been incorporated into studies of other patients attending hospitals and labelled with the diagnosis. Nor has the rich range of feeling states and their disturbances been incorporated into the symptomatology. These have usually been excluded in favour ofapparently hard data such as the presence or otherwise of psychotic phenomena, appetite and weight and sleep changes, all of which can in fact be difficult and elusive features in terms of meaning and measurement. To tap this wide spectrum ofpotentially relevant feeling states and moods one only has to read Burton or Roget's Thesaurus (1953). Paykel (1983) has expressed a measured view about our present state of knowledge in respect of phenomenology and classification. Not much more can be said than that a previous history of a manic episode is probably important prognostically; the presence of anxiety is more common in moderate depressive illness whilst agitation is more common in severe depression. Furthermore, these categorizations may have therapeutic relevance. Meanwhile, there is now a new, elaborate classification DSM III (1980), based strictly on observation and description. Why has the word 'depression' prevailed for so long? As a word borrowed from physics it seems liable to obscure rather than clarify the nature ofthe states of mind in question, perhaps bringing to them a spurious sense of understanding in physical terms. In medicine in connection with brain function we already talk about 'depression of consciousness' and 'CNS depressant drugs' and so it could be muddling also to apply the word to disordered mood. If, however, one turns to the Concise Oxford Dictionary then the definitions there seem possibly to be of some relevance. Depression is a lowering or a sinking, a reduction in vigour, especially of trade, the centre of minimum atmospheric pressure and so on, whilst to depress means to lower, to reduce the activity of or to push down or to pull down. These last two alternative ways of looking at the concept are perhaps amongst the most arresting although some of the other definitions invite psychological parallels. Could the word, for instance, all these years have embodied this compelling and pervasive idea that, in a mentally depressing process, both push and pull can be involved? Could the push derive from avoidance of painful experience and the pull from the potential rewards of helplessness and fulfilled dependency needs? Could the depressed state, or for that matter the long ignored concept of inertia described by Freud and amplified by Schur (1970), comprise either one such process or both processes facilitating each other?