Depression has been around for ever – it just had different names, says historian Jonathan Sadowsky in this extract from his new book on melancholy

Theory of the humours: If you have been alive any time starting in the 1980s, you have likely heard that depression is caused by a “chemical imbalance”. This phrase was not a nuanced rendering of what the science showed, but it was widespread in popular press and TV commercials for drugs. The substances have changed, but this was the idea behind the humoural theory of medicine [of ancient times]. Sickness was caused by imbalance. In the case of melancholia, the imbalance was too much black bile, the humour associated with dryness and cold. Purging, in hope of expelling the excess substance, was a common treatment. Not all pre-modern observers of melancholy were humouralists, but it was the most influential paradigm for centuries, particularly from the time of Galen in the second century onwards.

Each of the humours had a natural purpose in the body. Ill-health was caused when they were out of their correct proportion. Each of the four humours corresponded to a temperament: yellow bile with the choleric, blood with the sanguine, phlegm with the phlegmatic, and black bile with the melancholic. Each was also associated with one of the four seasons, one of the four elements, and one of the four stages of life. In each person, a humour could be dominant because of inborn constitution, or acquired because of habits and environment. The physician’s job was to put the humours back in balance.

Sadness as a sin: In the Christian Middle Ages, melancholic symptoms were called “acedia” and were associated with sloth. Sloth, of course, is a sin, and a deadly one. Melancholy also violated the Christian command to be cheerful, though St Paul thought some sadness was good if it led to penance. The humoural and physical basis of the sickness was still assumed. Observers began to wonder more, though, about what blame the sick had for their suffering. That question has survived, often in subtle ways, into the modern era of depression.

Acedia was a temptation, according to a father of Egyptian monasticism named Evagrius Ponticus. Late in the third century of the common era, he settled in deserts southwest of Alexandria, and spent the next 17 years with hermit colonies. Acedia, he said, was a demon, the most oppressive demon of all. It would attack a monk’s soul between the fourth and eighth hours, and would make the sun “appear sluggish and immobile, as if the day had fifty hours”. The demon’s force could be strong enough to drive him away from the monk’s life. One influential monk, John Cassian, connected acedia especially to sloth. Despondency was also a feature, though. Cassian described acedia as a “weariness or distress of the heart” and “akin to dejection”.

In the Middle Ages, lists of sins proliferated, and they included acedia. The sin was also considered an affliction. Confession was a form of healing, and penance a medicine for the soul.

St Hildegard of Bingen, a visionary of the 11th century, wrote a lot about medical matters, and provided a theory about how sin and the humours were related. The bile was changed by the sins in Eden, which turned it to darkness. The “black bile… first originated from Adam’s semen through the breath of the serpent, since Adam heeded its counsel in taking food”. Black bile is in everyone, and a reason for humanity’s sorrow and wickedness, our inability to find joy in this life, or even hope for the next one.

As a humouralist, Hildegard did not think everyone had the same problem with this forlorn substance. Some were innately melancholy, men whose brains are fatty. Both the membranes encasing the brain and their blood vessels are turbid. The colour of their faces is dark; even their eyes are firelike and viperlike. They have hard, strong blood vessels containing black, dense blood.

Her descriptions of such men were filled with animal imagery: “With women they are without restraint like asses”, their embrace of women is “hateful, and deadly, like that of ravaging wolves”. Others shun the female sex “but in their hearts they are as violent as lions and they behave in the manner of bears”. The melancholic were lustful and sex could relieve the malady.

Misery in the Renaissance: “For if the heart is troubled and sad, physical weakness follows too… Diseases of the soul are real diseases” – Martin Luther

The early modern period, between the Middle Ages and the modern industrial era, saw many social changes – the growth of mercantile capitalism, the renewed interest in writers of antiquity in the Renaissance, the Protestant reformation, and a new willingness to question authoritative texts. The treatment of madness, though, did not change much. Most early modern writers fused their spiritual or psychological explorations of melancholia with humoural assumptions about the workings of the human body.

By the end of the 16th century, melancholia was becoming a signature sickness of the time, prompting several learned books, the most famous by Robert Burton. In England, Elizabethan and early Stuart literature was filled with melancholy characters.

Many writers on both melancholia and depression have been people with the illnesses. Marsilio Ficino, a Catholic priest of the 15th century, who was an important figure in the Italian Renaissance, was an example. He thought melancholia was a condition of the soul, seated in the body, with astrological influences creating a temperament that life habits could ease or worsen. Ficino was a humouralist, but his work shows that humouralism was a flexible set of ideas. Those (like him) born under Saturn, were born prone to melancholia. But scholars were especially prone. Saturn and Mercury were cold and dry, and pulled people towards scholarship. But coldness and dryness were also brought on by the scholar’s lifestyle. Philosophers were at special risk.

Food was a problem. Anyone frustrated by the long list of foods modern nutritional science tells us to avoid will also want to avoid Ficino’s dietary advice for melancholics. Black bile, he said, was worsened by rich, dry, or hard foods that cooled the blood, as well as by too much food and wine. Melancholics should avoid salted food, bitter or stale food, burned food, roasted or fried food, rabbit, beef, old cheese, pickled fish, beans, lentils, cabbage, mustard, radishes, garlic, onions, leeks, blackberries, and carrots. Fortunately, some foods could relieve melancholy, such as fruits and other sweets.

Ficino also warned against anything else that cools or tires a person. But things that warmed were also a problem, because they could dry you out. He warned against dark emotions: anger, fear, misery, and sorrow. Also, literal darkness. And anything that dries the body, including lack of sleep, worry, purging, urinating, physical exertion, fasting, cold dry air, and frequent sex.

Sixteenth-century German views of madness, including melancholia, can be seen through comparison of two famous figures, Martin Luther and Paracelsus. Luther was fascinated with madness. He used charges of madness against theological opponents (who returned the favour) and had a lot to say about melancholia. Luther thought melancholia caused inattentiveness. This helped make sense of strange stories in the Hebrew bible. Lot absent-mindedly had sex with his own daughters. Isaac bestowed his birthright blessing on the smooth-skinned Jacob instead of the hairier Esau, while Jacob was wearing some lambskin in order to deceive their father. How could these things happen? For Luther, Isaac’s poor eyesight did not explain enough. He thought both Lot and Isaac must have been melancholic.

For Luther, melancholia mingled the physical and the spiritual. He called it an “essentially physical disorder”. But physical problems could have spiritual causes, and their cures a spiritual basis. Luther did not think melancholia was entirely bad, though. He mistrusted the spiritually content. Inner conflict was a mark of mental vitality and wisdom. Low spirits showed that one knew the deeply wrong state of the world and humanity, and sadness showed conscience. Perhaps he felt consolation in this, as he often felt attacks of doubt and deep sorrow.

Paracelsus was a Renaissance physician and philosopher who was proud to have broken with Galenic humouralism. In his early work, he emphasised reason and materialism, but he turned to a more Christian, biblical outlook later in life. He grouped madness into five principal kinds, including melancholia. Like the humouralists, he thought that melancholia came from both inborn temperament and life changes. His sensibility differed from Luther’s, but they shared certain beliefs about melancholia. Both believed, for example, that it could be the result of demonic possession. They also shared an ambiguous view of the moral aspects. They thought sin was a disease, but they also thought that disease could be a punishment for sin. And they both thought that mind and body were meshed. Neither could be changed without changing the other.

Intending to comfort a friend, clergyman and physician Timothy Bright published a popular book about melancholy in 1586. Bright wanted to sever any connection between melancholy and sin. Melancholia had physical, psychological, or even Satanic sources, but was not the result of divine judgment. He recommended good diet, exercise, grooming, rest and sleep as antidotes.

Burton was motivated to write by his own melancholy, and found writing therapeutic. The Anatomy Of Melancholy was a popular book, going through six editions in Burton’s lifetime. The Anatomy was a bookish book. Burton read everything he could find on the subject. Symptoms of melancholy for Burton included anxiety, fearfulness, sadness, gloom, restlessness, dissatisfaction, emotional instability, suspicion, weeping, complaining, aggressive behavior, social withdrawal, lethargy, an inability to experience pleasure, insomnia, suicidal tendencies, delusions and hallucinations.

When looking at Burton’s views of the causes of melancholy, his mimicry of earlier writers needs to be kept in mind. He lists a lot of causes, because he probably listed every one anyone had ever proposed.

Like Hildegard, Burton rooted human misery, including melancholy, in the sins of Eden and saw some melancholy as a part of being human that no one could avoid. Causes also included God’s intervention, or the supernatural acts of other beings, such as angels, saints, witches, and magicians. But Burton was a humouralist too. Lots of things caused the imbalance – the planets, the climate, other illnesses, too much study, social isolation, old age and autumn, for example. Burton thought that men more often got melancholy, but that women would be more deeply affected – think of the contrast between Hamlet and Ophelia.

Then, the foods. Burton had a long list of dangerous ones. And with food, Burton was only getting started on causes. Bad air, cold air, thick air, foggy air, misty air, air from fens. In an anticipation of our modern seasonal affective disorder, too much darkness: cloudy days, night, underground vaults. Exercise was good, but only if moderate.

Burton said that the label of melancholic sickness should be restricted to cases where it seemed unwarranted by life circumstances. Yet he was paradoxically mindful of life situations that could lead to the malady. Idleness and solitude. Insults and slanders. Loss of liberty, servitude, imprisonment. Poverty. Loss of friends. Bad marriage. Disgraces. Infirmities.

Activities and lifestyle mattered. Life should not be too hedonistic or too ascetic. Extreme love of gaming and too much sensual pleasure were worrisome. He followed Ficino in warning against too much study. He knew from experience.

Remedies were plentiful too. They included prayer, changes in diet, changes in air, exercise, music and cheerful company. But Burton did not think melancholy could be cured. He thought it could be relieved, but relapses were likely. He urged melancholics to maintain constant vigilance over their health. He also believed, as so many modern therapists have said, that the patient must want to improve.

The Anatomy Of Melancholy was the fullest flowering of the humoural view of melancholy. Soon after, humouralism slowly lost ground. William Harvey’s discovery of the circulation of the blood (seven years after the first edition of The Anatomy), and growing conceptions of the universe and the body as governed by mathematical and mechanical laws undercut much of humoural theory. For mental illness, the brain attracted growing focus.

Excerpt from The Empire of Depression: A New History by Jonathan Sadowsky (Cambridge: Polity, 2020), reprinted with kind permission from Polity. Copyright © Jonathan Sadowsky 2020