How Everyone Became Depressed

The rise and fall of the nervous breakdown

The Suicide of Robin Williams

We can learn from this tragic story

In Williams’ tragic death, there has been little informed discussion of the disorder that he probably had, and of the highly effective treatments for it that he apparently was denied, a result of the kid-glove approach that many clinicians take to stars.

What he probably had was an acute recurrence of a melancholic depression that had dogged him throughout life. The key word here is not “depression,” which has become a meaningless phrase, but “melancholia,” a time-honored term for a severe kind of mood disorder that has little in common with non-melancholia.

The suicide rate in the US has been increasing, and as we struggle to come to grips with it, the concept of melancholia is now urgently requesting a seat at the banquet – because it’s what many people who commit suicide have.

Of course we can’t know for sure what Williams had. But he seems to have been deeply sad; he was losing weight; he had problems with sleep; and he evidently had Parkinson’s, a neurological illness in which melancholia is not uncommon. In a moment of despair he was driven to commit suicide.

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Now, consider what the main symptoms of melancholia are: (1) deep sadness; (2) complete anhedonia, or inability to derive pleasure from anything in life; (3) slowed thought and movement; (4) changes in bodily functions, such as appetite and sleep patterns. We don’t – or at least I don’t – know if his physical movements and his thinking were slowed. But he had the rest of the melancholia package.

Now, melancholia has good news and bad news. The bad news is that one is constantly at risk of suicide. A lack of any kind of pleasure or joy, or indeed an inability to feel anything, lead readily to self-destruction. That’s the ugly part, the “showstopper,” as psychiatrist Mickey Nardo at Emery University, and originator of the marvelous blog 1 Boring Old Man, calls it. Williams succumbed to the bad-news part.

But the good news about melancholia is that it’s readily treatable! There is a kind of rule in psychiatry that says, the sicker you are, the more easily you respond to treatment. And melancholic illness does respond well to an older class of psychoactive medications called the tricyclic antidepressants (imipramine, brand-named Tofranil, was the first on the US market, in 1959, and it remains the most effective antidepressant today, despite many psychiatrists’ unfamiliarity with it).

But melancholia responds even better to electroconvulsive therapy (ECT), and this is a subject that has been little mentioned in the enormous media discussion of Williams’ death. It hasn’t been mentioned because ECT remains a tabooed subject in the media. Journalists simply do not want to get into it because readers would dismiss it as outlandish.

If Williams had received ECT, he’d be alive today.

Over 80 percent of patients with severe depression respond to it. They don’t just get better: Their depression lifts. Of course they have to maintain their wellness with medication or with further periodic ECT treatments, to avoid relapse. But that’s true of pharmacotherapy as well. There is no psychoactive medication to which 80 percent of seriously depressed patients respond.

I’m going to let Dr Bernard Carroll jump in here, because on the 1 Boring Old Man blog post of August 18, he has an interesting comment to offer: “On the matter of suicides that come as a surprise . . . it isn’t that patients make a reasoned decision to kill themselves. It isn’t that they act in an existentially noble manner. It isn’t even that they want to kill themselves. My sense of it is that their executive inhibitory mechanisms lose control over what has become a prepotent aversive internal stimulus. It is in part loss of cognitive flexibility (which would be compounded by Parkinson’s disease) and in part increased mood lability in the severe depression. The patient with malignant melancholia doesn’t ‘choose’ to kill himself any more than the patient with crippling obsessive-compulsive disorder chooses to be paralyzed by doubt and rituals. “

Carroll didn’t mention ECT in this post but what he did say was that Williams should have been hospitalized, for his protection. Well-run psychiatric facilities have long experience in preventing patients from killing themselves.

Why Williams was not hospitalized, why he didn’t receive ECT, is a mystery. Stars often receive suboptimal care because their doctors, awed by their patients’ celebrity, are reluctant to suggest treatments the patients might find unusual. They end up prescribing what their famous patients think best. (The death of Michael Jackson is a textbook example of this.)

The death of a star extinguishes a life, but the circumstances may illuminate the world. Let’s learn from this tragic story!

 

Edward Shorter, Ph.D., is the Jason A. Hannah Professor in the History of Medicine at the University of Toronto.

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