Updated: Feb 12, 2021
Depression has befuddled people for centuries. Not just those who suffer from it, but doctors, physicians, psychiatrists, and pharmacists alike. What is now commonly known as depression has over the years hosted a number of different identities. For a very long time the favoured term was melancholia, from the Greek meaning black (μέλαινα) bile (χολή). Melancholia was defined and coined by Hippocrates, ‘the father of medicine’, who was writing in the fourth century BCE. This etymology might seem strange without context. From Hippocrates’s time until around the beginning of the sixteenth century, humoral theory dominated European thought about health. The body was believed to be home to four vital fluids; phlegm, yellow bile, blood, and black bile. A person’s constitution was determined by their particular composition of these four elements. An imbalance of the humours was thought to cause sickness, and a rebalancing was needed for the sick person to recover. Melancholia was believed to be the result of an excess of black bile in the body. Whilst the science can duly be considered medieval, the prescribed treatments are rather more familiar. A balanced diet, routine exercise, massage and long baths were the order of the day. You can almost imagine ‘love yourself’ and ‘you are what you eat’ mosaiced on the wall of an ancient Greek spa.
Another popular treatment, slightly less echoic of the 21st Century, is the practice of bloodletting. Bloodletting was used for a vast array of illnesses (including depression) across different cultures and thousands of years. Earliest usage can be dated back to the Egyptians around 3,000 years ago, and it had its moment with physicians all over the world, playing a major role in western medicine until the 19th century, when it peaked and subsequently died out (for which we are all extremely grateful). During the tenth and eleventh centuries, Persian physicians were pushing the boundaries of medical knowledge. Reconciling different strains of thought from Greek thinkers such as Hippocrates and Aristotle with the growing body of Persian and Sanskrit works, these polymathic physicians nourished the medical community for centuries to come. Amongst the most celebrated are Avicenna (980-1037 AD) and his predecessor Rhazes (865-925 AD). Avicenna’s great scholastic work, The Canon of Medicine, devoted an entire chapter to neurological and psychiatric disorders. His examination of melancholia drew together both physical and psychological concepts of the illness, and acknowledged that a distinction could be made between an early phase and a chronic phase. Treatments included lifestyle modifications and herbal medicines. Amongst the remedies listed in his natural apothecary is saffron. This expensive spice has since been put to the test in RCTs (Randomised Controlled Trials) and its efficacy at alleviating depressive symptoms proven. Although their science was still rooted in an humoral understanding of the body, there is remarkable compatibility between these Medieval models and our current interpretations of depression. Almost a thousand years have passed since Avicenna’s pioneering work, and there have been huge advances in technological tools used to better understand the neuropathology of mental illness. However, many of the treatments used by these extraordinary Medieval physicians still deserve pride of place in the clinics and academic studies of today. Without being able to observe neurological activity through brain-imaging as we are, they were more than capable of acknowledging depression’s cognitive, behavioural and physical manifestations.
Humoral theory began to grow out of fashion in the sixteenth century, when anatomists started cutting open cadavres and finding that, in fact, the body was not composed of these four fluids as previously thought. It may seem strange to a modern reader that there weren’t anatomists performing these dissections before, but there was enormous religious and cultural pushback against such ideas at the time. The publication of Robert Burton’s Anatomy of Melancholy in 1621 is a considerable feat and pulls together threads from the diverse sciences of the day. Still, however, heavily influenced by ancient and medieval thinkers. Fast forward to the nineteenth century, to Vienna, where Sigmund Freud is developing his groundbreaking and much-examined theories on clinical psychology and the unconscious mind. In 1917 the sixty-one year old ‘father of psychoanalysis’ published Mourning and Melancholia. The influence of this text on our understanding of how people react to loss has been huge. So too is the influence of his psychoanalytic method on psychotherapy. Around 900 kilometres away in France, psychologist and pharmacist Emile Coué has been developing a therapeutic method called auto-suggestion. That the words we tell ourselves have the power to heal is a concept enjoying a second heyday today. Positive affirmations and the sexier sounding ‘neuro-linguistic programming’ provide nourishing psychological fodder for millions of people welcoming self-help techniques into their daily lives.
Enter the 1930’s, and with the arrival of ECT (Electroconvulsive Therapy) eyebrows, questions, (and hair) are being raised across the psychiatric community. Whilst ECT may sound like something out of a crime thriller, it is important to consider the first hand accounts of those who were treated with it. Many of whom speak positively about the experience, and appreciate the life-changing help it gave them. In fact, it is still used to treat a number of patients with severe depression today. At the time, it was the lesser of two evils when compared to its predecessor, CCT (Chemical Convulsive Therapy) which quite frankly terrified its patients and was an overall dreadful experience. ECT usage spread rapidly in the 40’s and 50’s, but it wasn’t long before it began to fall into disrepute. Perhaps deservedly so. Grim stereotypes about its questionable ethics were generally founded in truth. A grey cloud was forming over the field of psychiatry. Conditions in mental hospitals were dire, and these gloomy institutions cast a sinister shadow on the therapies used within their walls.
The first antidepressants became available for use in the 1950’s. Like their antecedent therapies, antidepressants were not without their drawbacks and some of the side effects were hard to tolerate. Biochemists worked hard to improve safety risks, and progress was made. Nevertheless, as with most strong medication, some unwanted side effects persist. SSRIs (selective serotonin reuptake inhibitors), which are the most widely prescribed antidepressant today, can deliver unwelcome sexual problems. Reduced desire, discomfort during sex, and an inability to orgasm or get an erection are not uncommonly reported. Changes to libido can have a huge impact on a person, and on their relationships. It is important these potential side effects are talked about so that the patient isn’t left wondering what is wrong with them; adding another notch on their belt of emotional distress. Opponents of antidepressants may criticise the pills for being a ‘quick fix’ which neglect the relationship between mental health and external, social factors. Antidepressants aren’t really a quick fix though. A six month prescription may sound a whole lot less than eight years of Freudian psychoanalysis, but they are no magic happy-pill.
The antidepressant era both fed on and fueled the idea that depression was a biochemical malfunction; the result of a so-called chemical imbalance in the brain. The use of the phrase ‘chemical imbalance’ was nowhere to be found in the psychopharmacological literature, but it soon became a household idiom after drug companies like Pfizer started using it in their marketing. People’s concept of depression consequently changed. This goes to show how public perception of mental illness is tangled up with contemporary treatment methods and the media. Antidepressants like Prozac, and its contemporaries Zoloft and Bupropion, became great success stories and ushered in a new phase in the diagnosis and treatment of depression. Was their success a triumph for the people suffering from mental health issues, or for the pharmaceutical companies? Both, I would argue. Antidepressants provide important, sometimes life-saving, treatment to the people who need them. However, antidepressants are not the only lab-synthesized medication that deserves a seat at the table.
Whilst the language and treatments surrounding depression have changed over time, its symptomatic pool has more or less stayed the same. Looking at the range of treatments our ancestral sufferers of depression have sampled, some stand out as more ethical than others. We can comfortably observe the ethical outrages of the past from the context of our current ethical compass. But we must not rest too comfortably on our laurels. This is not the apex of human scientific discovery and ethical understanding. We can always strive to be more compassionate, and to develop better treatments with fewer side effects. From humoral concepts and bloodletting, to biochemical concepts and antidepressants, medical professionals respond to the prevailing ideas of the time and therapeutic best practice changes accordingly. What are the prevailing mental health ideas in society at this time? How are medical professionals responding?
In the U.K. today, health has become something of a status symbol. Not only in the sense that the distribution of illness in the population more or less mirrors widening wealth inequality in our society, but also in the sense that good health has become fashionable. Unhealthy habits have become hushed-up behaviours, hidden from the sparkling, prying eyes of online social networks. Whilst we appear to be talking about mental illness more than ever, we are simultaneously preaching good vibes only. The right hand bears a sign saying it is okay to be sad, and the left hand a burdensome stack of self-help books with titles like ‘Smarter. Better. Faster’. A suffocating positivity burns hot at the centre of the self-optimisation movement.
The title Smarter. Better. Faster perfectly encapsulates the perilous, pervasive idea that elsewhere, the grass is greener. It doesn’t matter if you are already smart, good, and fast. You can be more of it all. You can have more of it all. From the desire for progress and improvement springs a healthy source of motivation. But people find themselves chasing elusive, outward-manifesting symbols of success, and in the process tread a path devoid of fulfilment. This is not meant to imply that the pursuit of perfection is the sole cause of what some have called an epidemic of mental health in today’s society. Better detection, more awareness, widening wealth inequality, media coverage, and changing social pressures are all factors at play in the U.K’s reported increase in anxiety and depression over the last decade. It is a complex issue, and cannot be explained away by one cause. Are we searching for meaning more than our ancestors did? Do the means of our search make for a paradoxical outcome? These are interesting questions, and hard to answer. In secularised societies, we still yearn for a sense of purpose and we still yearn to belong to a community. Where the Church once provided, gym memberships, yoga influencers and mindfulness retreats now pick up the baton. Their dedicated followers become disciples, devoted to the physical and psychological benefits these practices promise.
The search for meaning is not trivial, nor new. It has plagued and aroused the human mind for millennia. Over the tens (even hundreds) of thousands of years that have occurred since the first whispers of spirituality, humans have gone from stone tools to space stations. But for all the technological innovation, it is the ancient practices we turn to in our modern crisis of meaning. Early roots of yoga can be found in The Vedas, a large body of sacred texts written in India around 1500–1200 BCE. The origins of meditation can be traced back to a similar time and place, although it is likely to have emerged earlier. In the West we call upon these ancient arts to help us breathe deeper and think clearer through our neo-liberal storm. In South Asia, these arts are tightly woven into the fabric of their culture, as they have always been.
The fact is, these practices do help us breathe deeper, think clearer, and feel better. They should be embraced with open arms by the medical and mental health communities. An immensely positive product of this secular search for spiritual enlightenment is the mainstreaming of a more holistic approach to health. These ancient practices address both the physical (somatic) and psychological aspects of wellbeing. Mental health issues are psychosomatic, meaning that symptoms manifest in the mind as well as in the body. Mind and body influence one another. They are, of course, inextricably connected. An holistic approach to mental health helps architect a framework in which to treat mental health issues that acknowledges their composite nature.
This is where certain of today’s most widely prescribed treatments fall short. Whilst a six month course of antidepressants may be successful in altering a patient’s brain chemistry for that period of time, it neglects the other components that feed the illness. Importantly, the patient is able to get through the days in a better mood and more motivated. Whilst it is a beautiful thing to be able to lift the darkness out of someone’s days, what if, instead of simply lifting the darkness you could shower their days in light? One provides a pair of glasses through which they can temporarily view the world. The other changes the world.
Antidepressants work by inhibiting the reuptake of certain neurotransmitters in the brain, so that more of these neurotransmitters stick around. But antidepressants stop here. Psilocybin, the active chemical compound in magic mushrooms, works differently. Psilocybin acts by stimulating receptors in the brain that would otherwise be stimulated by the neurotransmitter serotonin. This may not sound too dissimilar from what antidepressants are doing. Both are altering neuronal activity in the brain. But then with psilocybin, something else happens. Pioneering work by Imperial College London and the Beckley Institute in Oxford revealed that an explosion of novel neuronal pathways is enabled by the hushing of the brain’s otherwise disciplinary Default Mode Network (DMN). Ego dissolution, ecstatic joy, a sense of oneness or the interconnectedness of all things, synesthesia, and dream-like visual and auditory hallucinations all become possible in the sphere of this liberated mind. For many, the experience is profoundly mystical. This ineffable eliciting of the ‘divine within’ is what gives psilocybin its classification as an entheogen (Θεός; god) as well as a psychedelic. Psilocybin harnesses the creative potential of the mind and the mind itself becomes the healer. Clinical trials have shown that patients experience a substantial reduction in psychological symptoms for between 6 - 12 months after their therapeutic dose. In 2016, world-leading institutions Johns Hopkins and New York University conducted sister studies with severely depressed and terminally ill patients. The results of which showed remarkable results, both quantitative and qualitative. Over 70% of patients rated the experience amongst the top five most meaningful in their entire life.
What do these results say about the kind of treatment psychedelics provide when compared to their approved chemical colleague, the antidepressant? What is astonishing about psychedelics is that it is not the chemical stimulation alone that effects change. The memory of the experience serves as an ongoing therapeutic tool. Patients are given a dose on either one or two occasions. Most people taking antidepressants will be advised to take them daily for between six months and a year, but increasingly people are staying on them long-term. Data released under the Freedom of Information Act in 2018 showed that 4.4 million of the 7.3 million people who had been prescribed antidepressants in the U.K. in the year 2017-2018 had also been prescribed antidepressants in the two previous years. Antidepressants are not exclusively prescribed for depression. They can also be used to treat Post Traumatic Stress Disorder and panic disorders, for example. PTSD is another area where psychedelic assisted therapy has shaken the psychiatric community by the shoulders and said ‘wake up!’. Therapists are opening their eyes. More and more sufferers of PTSD, we hope, can wake up to a world free of nightmares, flashbacks and anxiety. For many people, taking antidepressants long-term comes with its own challenges. Whilst the drug is working to make them feel better, rumination on questions of self-identity and fear about coming off the medication are not uncommon. Questions of selfhood are particularly pertinent in young adults on antidepressants. The wrestle with self-discovery is played out in a nebulous arena in which the perceived ‘true’ self tries to distinguish itself from the perceived medicated version. It is a fight that is impossible to call. With psilocybin assisted therapy, autonomy and selfhood are restored to the patient. The unique experience of the drug is theirs and theirs alone; a private, sacred treasure that stays with them for as long as their mind can remember it. An experience so exceptional, so out of the ordinary, leaves no question of which parts are really you. The therapeutic experience of psilocybin shows that chemical treatments for depression have the potential to do more than just mend something that feels broken. More than a fix, psilocybin becomes a tool for prevention, and for transcendance. When psychedelic-entheogens are proven to be effective in treating depression, why are they not widely-used? It has a complex history marred by politicised decision-making.
The chemical structure of Psilocybin is shared by LSD. Whilst psilocybin can be found in nearly two hundred species of mushroom, LSD is made in a lab, by isolating the compound lysergic acid diethylamide from ergot fungi. It was first synthesized in a Swiss lab in 1938 by Albert Hoffman. At the time he was working on a drug to treat circulatory and respiratory illnesses. The effect of these mind-bending fungi can be traced in the history books, from the Eleusinian Mysteries to the Dancing Plague of 1518. Hoffman only discovered LSD’s hallucinogenic properties five years later in 1943, by accident when he himself sampled the drug. His cycle home that day was a memorable one. In the two decades that followed it enjoyed relative clinical success with eminent psychologists keen to explore its potential to treat major depressive symptoms and addiction disorders. In the 60’s it was making headlines as the hippy drug favoured by the peace-loving counterculture movement. Governments perceived a threat in this giggle-inducing compound, and it was criminalised in 1966 in the U.K., and in the U.S. in 1968. The late Terrence McKenna, ethnobiologist and revered myco-prophet, once said “Psychedelics are illegal not because a loving government is concerned that you may jump out of a third story window. Psychedelics are illegal because they dissolve opinion structures and culturally laid down models of behaviour and information processing.” When something is criminalised, it becomes much more difficult to receive funding for research, and so research sadly drew to a close. With no cash flow and controversial stories reaching the media, the medical community pretty much turned their back on psychedelics, and it would be three decades until research picked up again. What is unethical: therapeutic experts giving a patient an illegal treatment that is potentially life-saving; or denying a patient potentially life-saving treatment because it is illegal?
In recent years the therapeutic interest in psychedelics has been reignited with great fervour. The FDA even came forward in 2018 and identified psilocybin as a breakthrough therapy for treatment-resistant depression. Research at the world’s leading universities and research centres continues, and clinical trials show results that are truly worth getting excited about. On the horizon, psychiatry appears to glow with the possibility of entheogenic illumination.