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Solving the Riddle of Melancholia

Edward Shorter is the Jason A. Hannah Professor of the History of Medicine endowed chair at the University of Toronto School of Medicine as well as a Professor of Psychiatry.  Max Fink has exensively contributed to the psychiatric community’s understanding of electroconvulsive therapy (ECT), pharmaco-electroencephalography (pharmaco-EEG), cannabis and the psychopathologies of catatonia, melancholia and mania.  Together they wrote, Endocrine Psychiatry: Solving the Riddle of Melancholia, which traces the enthusiasm of biological efforts to solve the mystery of melancholia and proposes that a useful, and a potentially life-saving, connection between medicine and psychiatry has been lost.  Below we have excerpted the preface which explains why endocrine psychiatry deserves a second look.

In the past hundred years, medicine has tried to acquire a scientific basis.  Age-old prejudices and pointless procedures have been discarded in controlled study after study.  Today, we take it for granted that the practice of medicine is evidence-based.

Yet in psychiatry the penetration of science has been imperfect.  The discipline has swung wildly from fashion to fashion – from asylum care to psychoanalysis to lobotomy to psychopharmacology -without having an underlying scientific rationale for doing so.  More than any other medical field, psychiatry has been guided by cultural preferences and political persuasions.  We vaguely dislike the notion of “locking up” people or of shooting volts of electricity through their brains; we have a natural enlightened tropism toward psychotherapy and the enhancement of human reason and against the madness of unreason.  None of these prejudices and preferences is in itself reprehensible, and all flow from a praiseworthy humanism.  But prejudices and beliefs are not science.  In a great disjunction, science and psychiatry have passed each other like two ships in the night.

Yet psychiatry cries out for science.  To be sure, we can gauge the neurochemistry of the brain and assess its structures with the devices of neuroimaging.  But the questions of clinical psychiatry are more complex than fluctuations in neurotransmitters or glucose uptake in the basal ganglia, where the brain gives up a few of its secrets.  Is there no other way to gain a window to the brain and gauge is activity in psychiatric illness?  Yes, there is.  Another system, the endocrine system, sets the biological rhythms of the brain and body.  Psychiatry was once fascinated with the endocrine system.  Today, the adrenal and pituitary glands, and the hypothalamus within the brain, have lost their charm and arouse little interest.

Simultaneously, psychiatry also said adieu to another familiar historical concept, melancholia, as a diagnosis of severe depression.  After the introduction of a new system of disease classification in 1980, the diagnosis of “major depression” – a heterogeneous assortment of varied illness entities and unhappiness states – swept in the field.  This is very interesting: At the same time that psychiatric interest in neurotransmitters such as serotonin quickened, the discipline embraced such new illnesses as “major depression” and “bipolar disorder.”  In understanding the seat of illness, there was a shift from the endocrine periphery to the neurotransmitter central, and in classification, there was a shift from such sturdy historical concepts as “melancholia” to the more faddish notions of “major depression” and “bipolar disorder.”  These two shifts are related.  In both, the profession of psychiatry walked away from solid, well-verified knowledge into a botanical maze of fashion, commerce, and politics.

Melancholia is a serious illness.  It involves the slowing of thought and mood, the absence of joy or pleasure in life, and profound changes in the body’s daily rhythms.  Max Fink and Michael Alan Taylor have defined it as “a recurrent, debilitating, pervasive brain disorder that alters mood, motor functions, thinking, cognition, perception and many basic physiological processes.”  This book makes the point that melancholia has a biology of its own that is heavily entwined with the endocrine system.  In coming to grips with the riddle of melancholia, psychiatry has this endocrine knowledge to draw upon, yet seldom does.  This is a failure of science and of clinical practice.

How did this failure happen?  Endocrine thinking in psychiatry rode a wave of great excitement in the 1970s and 1980s, and then it seeped away.  Few clinicians today are curious about cortisol or thyroid-releasing hormone, two hormones with intimate relationships to behavior.  While physicians might include assays of thyroid hormones when requesting laboratory tests, they are often incurious about the results unless a blood measure is wildly out of balance.  As for the complex interrelationships among hypothalamus, pituitary, adrenal gland, and the rest of it, that material is learned once during medical school and rarely considered again thereafter.

There is a price to be paid for this endocrine distaste, just as there is a price for the profession’s reluctance to contemplate convulsive therapy.  Melancholic illness, among the most serious of all psychiatric disorders, remains often imperfectly diagnosed and inadequately treated.  We try to deliver the best possible care of patients, yet patient care suffers when important guides to understanding illness and meliorating symptoms are left fallow.

This endocrine indifference is typical of a wider pattern.  A trail of discarded therapies and paradigms litters the history of psychiatry.  Some, such as lobotomy and pouring cold water on women with “hysteria,” will probably not again see the light of day.  Others, such as electroconvulsive treatment and using the brain’s electrical rhythms to study drug effects, have been prematurely cast aside – and urgently deserve a rebirth.  Our interest today in neurotransmitter levels and multicolor images of neuron-neuron interaction, on serotonin and dopamine, but cortisol may well offer a better marker of patients’ woes than the principle neurotransmitters.  This loss is particularly serious if the patients are melancholic.  In mood disorders, there are important markers that have unjustly fallen into desuetude.

…Endocrine psychiatry deserves a second look.