Depression can sometimes feel like a very modern affliction, but it something that has always been with us. The reported rate of depression varies, with lifetime risk of having a depressive episode ranging from 3% in Japan to 17% in the United States, but falling into the 8-12% range for most countries. Unlike many other diseases, depression has been recognised and described for over 2000 years. Current treatments are usually a mixture of pharmacological and psychological therapies, and Western society’s attitudes to the illness are generally becoming more open, accepting and sympathetic. But what of our ancestors – how might their experiences of depression have been different and what treatments could they have been offered?

Some very early accounts of a condition called ‘melancholia’ survive. While ancient civilisations largely seemed to agree that the cause of this and other mental illness was some form of demonic possession or the work of evil spirits, attitudes to and treatment of it varied. In Ancient Egypt, for example, priests were called upon to perform exorcisms to drive out the demons, and techniques to encourage them to leave their host could involve starving or beating the afflicted person. The Greeks, on the other hand, suggested that some personalities were more prone to depression than others. The physician Hippocrates, who characterised all “fears and despondencies, if they last a long time” as being symptoms of melancholia, argued for a kindly and supportive disposition towards patients, with bloodletting, bathing and exercising encouraged.

As Europe moved into the Middle Ages, the more enlightened person-centred ideas of depression demonstrated by Hippocrates faded away as religious and moral approaches took hold. Demonic or satanic possession, or the influence of witches, were common explanations and it was feared that any form of mental illness could be contagious, leading to avoidance and stigma of the sick. In a crusade against witches that reached its peak in the 17th and 18th centuries, over 100,000 people across Europe were executed as witches, 85% of whom were women. Some historians suggest that at least some of those accused of witchcraft were mentally ill, including those suffering from depression.

Those who weren’t thought afflicted by supernatural means could find themselves increasingly shut away from society, sometimes locked in poorhouses or jails, or in the new private madhouses for those who could afford them. The growth in the number of madhouses over time (in London, for example, this went from 16 in 1774 to 40 by 1819) has been connected to the demands of the growing service economy, which left many families less able to care for their own as they now worked outside the home. The isolation and loss of familial support this caused cannot have helped those who needed care.

Robert Burton’s 1621 book The Anatomy of Melancholy was, then, a masterpiece way ahead of its time in that it considered melancholy to be an illness of both body and mind, and examined both causes and possible cures for it. He suggested it could be brought about by things as diverse as poverty, too little exercise or inadequate sleep, and suggested remedies that were both of the time (trepanation, bloodletting and prayer) and those we would think appropriate today (distraction and exercise). Burton also noted that the best cure was often, “In my judgement, none so present, none so powerful, none so apposite as a cup of strong drink, mirth, music and merry company”.

The 18th and early 19th centuries saw a movement towards seeing depression as an inherited weakness of character and largely something that could not be changed. While patients were no longer feared as contagious or possessed, the lack of moral rigour they seemed to demonstrate saw much continued poor treatment by both society and the medical profession, although the odd enlightened source reminds us that not everyone saw illness in the same way.

We can recognise depression in volume 10 of Denis Diderot’s Encyclopédie (1765), for example, which describes a condition “with insurmountable sadness, a dark mood, misanthropy, and a firm penchant for solitude” caused by “grief, pains of the spirit, passions, as well as all the love and sexual appetites that go unsatisfied”. He recommended dietary treatment, with patients avoiding “melancholic meats” (those which were salted or smoked) and spirits, instead encouraging light meals, summer fruits, and wine as it “fortifies and delights the stomach”.

A more popular 18th century treatment was to employ the water cures that many establishments and spas recommended for a wide range of ailments. Cold water in the form of a douche (shower) or bath was though to rouse the depressed patient, and could be delivered in a variety of imaginative ways, such as bath boxes that enclosed patients in tanks of cold water, dunking devices set over ponds, and systems of ladders, buckets and busy attendants to keep the melancholic regularly doused from above.

Benjamin Rush, often called the father of American psychiatry, took this a step further by introducing the ‘tranquilising chair’ to his Pennsylvania hospital in the early 19th century, which kept patients still while covering their head in what we would now call a sensory-deprivation device. “It binds and confines every part of the body,“ he later wrote, “By keeping the trunk erect, it lessens the impetus of blood toward the brain. By preventing the muscles from acting, it reduces the force and frequency of the pulse, and by the position of the head and feet favors the easy application of cold water or ice to the former and warm water to the latter. Its effects have been truly delightful to me.” Dr Rush also invented a spinning stool for those patients who he thought would better benefit from more circulation being brought to their brain; by creating a sensation of dizziness, it was supposed to drive a vigorous circulation and help realign the mind.

In 1813, Samuel Tuke reported that his combination of medical and moral treatment for depression (warm baths and physical exercise) at the York Retreat had a 65% success rate for the patients in his care. Tuke was a Quaker, and the Retreat – still an operating charitable institution today – became a model for the humane treatment of the mentally ill. The Retreat was established as a direct response to the death in 1790 of Hannah Mills, who had been committed to the York Asylum and died after several weeks of being kept in poor conditions that included debilitating purges and icy cold baths, and being denied access to her family. The 7th Earl of Shaftesbury, a reformer of treatment for the mentally ill, noted in an 1851 diary entry, “madness constitutes a right, as it were, to treat people as vermin”.

Conditions in most asylums fared little better in the United States. In 1887, pioneering investigative reporter Nellie Bly got herself deliberately committed to a New York mental hospital to reveal the poor condition of inmates. She noted “oblivious doctors”, rough orderlies, dirty linen, rotten food, and told of her experience of a cold water treatment that sounds today like a precursor to waterboarding: “My teeth chattered and my limbs were goose-fleshed and blue with cold. Suddenly I got, one after the other, three buckets of water over my head – ice-cold water, too – into my eyes, my ears, my nose and my mouth. I think I experienced the sensation of a drowning person as they dragged me, gasping, shivering and quaking, from the tub.” Her reports not only made her a famous journalist, but also pushed authorities into providing more adequate funding for the institution.

It took until 1895 for depression to be distinguished from schizophrenia, but this distinction laid the foundation for the development of a new sort of treatment – psychoanalysis, the first ‘talking cure’. The most famous proponent of this approach was Sigmund Freud, who in 1917 suggested that many cases of depression could be triggered by loss, either real (such as that caused by grief) or symbolic (the loss of an important relationship or job for example) or by the patient inwardly directing anger towards themselves. This approach was revolutionary, but only available to those who could pay for it privately. It is a technique still used by some therapists today alongside other psychological methods such as cognitive behavioural therapy.

Treatments in the late 19th and early 20th centuries were still often unable to help those with severe depression, who as a result were sometimes referred for desperate measures such as electroconvulsive therapy (ECT) or even lobotomies, where part of the brain’s frontal lobe was removed. Lobotomies were often unsuccessful, sometimes resulting in personality change, inability to make decisions or even death. ECT grew disreputable as it was revealed it was often used to subdue rather than treat patients, as was famously portrayed in the Ken Casey novel One Flew Over the Cuckoo’s Nest.

Over the latter parts of the 20th century, pharmaceutical responses became more widespread. Depression was still considered a shameful weakness by many and was rarely discussed, with GP visits about ‘nerves’ often resulting in prescriptions for tranquilisers such as Valium. 1971 saw the creation of fluoxetine, branded as Prozac, which opened up a whole new avenue of treatment for people with depression. By 2012, 40m prescriptions for antidepressants were being issued annually in the UK alone.

Depression may have always been with us, but the way we have understood and treated it has changed radically over time. While some in the past may have been fortunate enough to benefit from more humane care, many more would have been subject to poor or even cruel treatment. Due to the shame and stigma of mental illness, little survives in the way of first-hand accounts of treatments, but it does not take much imagination to find empathy with those afflicted who had little hope of becoming well again.