1 Boring Old Man

In a former time when the terms endogenous depression and exogenous depression were regularly in our vocabulary, there was a way of thinking about the clinical depressions that was substantively different from what we now hear routinely. Those with endogenous depression were thought to have an illness, generated in some way from within. Their depressions did not bear a relationship to their life situation or events. The depressive symptoms were pervasive and often profound. There was usually a history of previous episodes of depression or mania and a family history of depressions, mood disorders, alcoholism, or suicide. The vegetative symptoms were prominent – appetite changes, insomnia with early awakening, diurnal variability in symptoms. They described their affective experience as unique, unlike any other encountered in life. We grouped these patients by course and used terms like Melancholia, Manic Depressive Illness, Major Depression, etc. While there were no sure-fire biomarkers, these are the patients who often had abnormal dexamethasone suppression or REM latency responses. Classifications within this group varied from author to author, but the overall grouping seemed established in so far as I saw things back then. Like generations of psychiatry trainees before me, I explored the life circumstances of these patients, and that exploration lead nowhere [except to allow the patients more things to look at depressively]. Treatment? Tricyclic antidepressants, ECT, hospitalization [protective], time.

Patients with exogenous depression were everyone else. Their depressive symptoms looked and felt a lot like those of a grieving person. Their depression seemed to fit things going on in their lives. The past/family history was not a major feature. They were not monotonous in that they didn’t all seem similar. They were frequently angry, sometimes very angry. We thought of them as people whose depression had an explanation in their lives, their histories, their mental structure, their personalities. We called it reactive depression in the nineteen fifties and sixties, neurotic depression in the seventies. We might have given them antidepressants, but we weren’t necessarily surprised if they didn’t respond. And the principle approach was psychotherapy of one kind or another. Experienced clinicians made the distinction in minutes. Younger psychiatrists took longer. There were cases in the middle, but not very many. I don’t recall there being much discord among psychiatrists about this distinction. I think most of us thought of them as representing different entities – biological depressions and psychological depressions.

As has been mentioned here and elsewhere, the depression of patients with exogenous depression was a pervasive emotion that was familiar to us, often experienced empathically in an interview – a sadness, a despair, hopelessness. The emotional experience of patients with endogenous depression seems different. As an afflicted person said to me this week, "I’m not really sad, I just hurt. I never feel good. I just want to feel something good!" I’m no better at describing this difference than anyone else, but the difference is qualitative, not quantitative. And the experience of interviewing them is different in equally hard ways to explain.

I would frankly be surprised if many [or any] patients with endogenous depression are included in the studies that come from the Clinical Research Organization run trials. They’re not the kind of people who answer advertisements, nor are they the kind of people physicians or other mental health disciplines would refer for drug studies where they might be given placebos. One feels an urgency to treat them. For many, the term "suicidal" is superfluous in that they often see nothing in life that holds them. So they say things like, "I’m not going to do it because of how my … would feel, but …" Their experience has a timelessness that transcends before or after. And in interviewing them, even if you run across stressors in their lives that you’re tempted to connect to their depression, those things are part of life, and these patients seem so disconnected from life itself that life stresses seem immaterial.

^{A term from the past <Melancholia>, in this manual used to indicate a typically severe form of depression that is particularly responsive to somatic therapy. The clinical features that characterize this syndrome have been referred to as "endogenous." Since the term "endogenous" implies, to many, the absence of precipitating stress, a characteristic not always associated with this syndrome, the term "endogenous" is not used in DSM-III…}

^{"Bottom Line: Major Depression doesn’t exist in Nature. A political process in psychiatry created it…"}