My patient was a middle-aged woman. She was deeply depressed, immobile, wracked with guilt, and convinced that the food offered to her was poison. It was 1968, I had just started a psychiatry residency, and the supervising physician, a psychoanalyst in his mid-forties, sported—as did I—long brown sideburns and the other orthodoxies of the day. A bit impatiently, as if he shouldn’t have to be telling me anything so elementary, he said: “We know that depression is anger turned inward. You need to get at her anger.”

This anger-turned-inward business comes straight out of Freud’s paper “Mourning and Melancholia.” We took it very seriously back then. We spent countless hours trying to get depressed patients to talk about their anger. Enterprising psychologists and psychiatrists devised schemes to make such patients angry. In one, a depressed patient was instructed to build a tower out of small blocks. As the tower neared completion, the therapist knocked it down. When I first observed this procedure, the patient never gave up and never got angry. He continued to start the tower and seemed unconcerned when the psychiatrist whacked it down. But the anger theory captivated us, and the total lack of evidence that any of these therapies actually worked seemed a trivial matter, barely worth mentioning. So patients endured our attempts to get at their anger until, for whatever reason, their depression lifted.

Although Prozac and its cousins were twenty years away back then, antidepressants, today’s mainstay of psychiatric treatment, had been around for a decade in the form of monoamine oxidase inhibitors and tricyclics. And we used them. They were, however, an adjunct to psychotherapy at best. In fact, debates raged throughout the 1960s and early 1970s over whether or not antidepressants were impeding the progress of psychotherapy.

It’s easy to poke fun at the popular treatments of bygone eras—theriaca, purging, and bloodletting, to name some of the less harmful. And we acknowledge, albeit with a cringe, the certainty with which we not so long ago urged routine tonsillectomies, bland ulcer diets, radical mastectomies, and, yes, psychoanalytic therapy for depression. It’s harder to see the folly of our current theories and treatments.

We no longer try to make depressed patients angry. We scan their brains and revel in the parts that light up and the parts that don’t. We subject the depressed to so-called cognitive therapy, a series of exercises designed to banish the irrational thinking that, according to this theory, causes depression. Most of all we give them antidepressant drugs. The fact that cognitive therapy has yet to be proven more effective than a placebo or an exercise regimen or any of the alternative therapies doesn’t dissuade us. Nor does the uncomfortable statistic that less than half of patients prescribed antidepressants actually benefit from them. 

The truth is, we simply don’t know why some people plummet into depression and why others, even in the face of horrendous circumstances, stay clear of it. We’re not short of theories: more than 2,000 years ago, Hippocrates postulated that black bile (melancholia) caused depression, and both before and since innumerable theories have sprouted, died, and, in some instances, been reborn (serotonin is today’s black bile). Some of these claims are more fanciful than others, but all are bereft of supporting data. 

As a start, we need to figure out which depressed patients require and benefit from medication and which might benefit from some form of psychotherapy. After all, despite the wide use of new antidepressants, victims of depression continue to murder themselves at a rate about seventy times that of the general population. 

Maybe Freud was on to something.

Comments (4)
Being one with clinical depression I have searched out every area I could in trying to discover the causes of my sickness, in a desperate hope of stopping it. I have yet to solve that riddle, however I will never give up. 
I did have an violent, abusive and sexually warped childhood. Yes, I am very angry about it to this day. I do not express my anger openly though, in fact, I'm considered a mild mannered person to those I know. I can't change my past and I can't forgive my abuser either, so if Freud is right I may be screwed. (I will look into this though) 
I have found a few times in my past where the depression almost went away or was significantly lower.  
In high school I started taking testosterone injections (not legally)and doing sports cause I found that the unending energy & endurance the test gave me just begged to be used. (like a race horse stomping & snorting at the race gate) 
I have nothing but good to say of my time on test and I only quit cause of my poverty. It was about 4-6 months till the depression returned. I have never been so happy or felt so healthy since. 
I never took the HUGE doses that many of my buddies took. I searched out medical knowledge and just took (at most) the max dose suggested by the literature I found. 
Over the years I have noticed that if I'm really interested in a subject, that I can let my OCD run free and just dive into what I'm doing. Keeping very very busy tends to keep me above those very deep and dangerous low spots in my depression. (where I start obsessing about suicide 24/7) 
Today, I take 120mg of Cymbalta a day (the only med that ever had much effect on me. it does help 75% of the time) I'm obese, cause I eat like mad when miserable and I'm miserable often. I get stuck in a feedback loop of depression and self hate, so the pattern feeds itself. It is very much like the OCD itself in that if you turn off the stove & you know you did, but you will never get to sleep till you get up & go check the blasted thing AGAIN. Well, stopping the pull into the depression loop is much like that. The harder I try to resist dwelling on it, the more anxiety it brings me till I just give in. just like the checking the stove thing. 
Maybe it is a learned thing & we at some point chose to be miserable? (I have considered this before) Then again, maybe it is a genetic self destruct for a model of human evolution that is no longer needed, (so the stimuli that would normally keep me struggling to survive & busy like 700 years ago, isn't there, so some form of suicidal self destruct occurs) Like natures way of clearing the path for other models.--since a huge number of people with depression at least consider suicide. (just an idea) 
Well, I wish someone could find out how to give the good effects from taking test, but without the bad results that are said to happen. 
I would try ANY treatment in the world for my depression and as for taking test again. I would if I could afford it, even if it had a 90% chance of killing me. A 10% chance at happiness is acceptable to a person who's body is alive, but soul is long since dead. 
wasted life
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As a psychiatric patient for over 23 years, I can tell you some of the things psychiactric staff people do to enrage their patients. They administer pills jokingly saying, "that's a birth control pill." They say things such as, "We know all about the sex you are having." and "We know how much sex you are having" they also say, "We ahve records on you." and "once mentally ill, always mentally ill." "mental patients don't need affection and love, they need pills." "Their is alot of stgma in the medicine." The list goes on and on. A psychiatrist told my mother he likes to make his patients angry. 
When patient go off their medication and kill people, lack of medication is always blamed, but how psychiatric staff members deliberately make patients angry doesn't come up. The enraging of mental patients by psychiatry professions is a threat to us all, especially psych patients. Psych professionals also do alot to frighten their patients too. 
But please don't just take my word alone for this. I am certain if you deeply privately interview 100 long-term psych patients as to whether they were deliberately tempted into anger or fear by psych professionals, 100 of them would say it's worse than you think. The enraging psych professional do, creates living hostile advertizements to help them sell pills. Psych patients are deliberately being treated bad, attempting to make them angry, in an attempt to justify treatments by promoting violence in mental patients. People are really dying because of this, by murder and heart disease and strokes.
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I didn't go to Brown, but this article and the comments made me respond. Because of deaths of a brother and a son as well as a dysfunctional family while I was growing up, I descended into deep depression for seven years. Through psychological means, I discovered that I was angry at family members, others who had mistreated me, and at God for allowing my losses. 
At a mental hospital, I began to have it out with God for allowing my losses. I railed at him as he came close to me for 8 1/2 months. After 7 1/2 months, he took my depression away, and after another month, he gave me his peace described in the Bible. All my anger about the first 44 years of my life was gone. 
Now, every time my anger builds and I get tired, I ask God what I'm getting depressed or angry about. Then, a thought comes to me, and I have it out with him. Then, my anger and depression about that loss or stressful situation leave. 
You can read about my psychological breakthroughs and prayers in my first book, Doubtbusters! God Is My Shrink! available at Amazon. I hope my experiences help many people.
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Freud was right, depressed patients are so angry and so afraid of their anger they fear killing the person they are angry with or expressing it to some one and losing control. it is better to give them an impossible job and encourage anger at the job rather than the therapist. suck as counting a bag of red beans and being told the count is always wrong till thjey refuse to count more, or clean an impossible ashtray with a tooth brush, or even clean a toilet with a rag till they ask for a brush. when they ask for a brush they start to feel they deserve better and their depression is lifting.