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THE TREATMENT OF MELANCHOLIA IN PRIVATE PRACTICE.

By ROBERT THOMFSON.

B Y the treatment of melancholia in private practice I mean the treatment of the disease in all conditions apart from a public or a private mental hospital.

Although there are probably few more difficult or disappointing cases to treat outside the specialised r~gime of a mental hospital, there can be few physicians who have not had to undertake such cases. For example, a mild attack in which the patient is determined to carry on with his work, or a more severe attack when the rela- tions will not countenance the idea of a mental hospital, does not give the physician, willingly or unwillingly, much choice in the matter.

Diagnosis. Although this paper is primarily intended to deal with treatment,

the question of diagnosis might perhaps merit some passing atten- tion. I t is scarcely necessary to remind my readers not to expect the anxious expression, furrowed brow, monosyllabic answers and slow stooping gait of the textbooks. These are to be found only in the established disease as usually seen in a mental hospital. I n the earlier stages and in the milder types of the disease probably none of these symptoms will be present, and the cardinal symptom of all melancholic states--mental or emotional depression--may not even be complained of by the patient, who may actually strive to conceal it or even deny its existence.

The cardinM symptom of melancholia, and the only essential symptom, is mental depression. The depression may be of only slight degree, and the patient may, in fact, be genuinely uncon- scious that he is depressed, attributing in good faith his feeling of ill-health to the supposed affection of some bodily organ. For this reason not infrequently elaborate investigations axe undertaken and sometimes operations carried out upon patients, who usually afterwards reveal the true diagnosis by a suicidal attempt or by the frank development of the disease,.

I f there is only one symptom of melancholia and that symptom frequently denied or concealed, how then, one may ask, is a diagnosis to be made with reasonable accuracy?

Mental depression of almost any degree causes a certain " strained tenseness" which is unmistakable to the practised observer. In the cases I have in mind the patient will talk freely and connectedly and have a full grasp .of all his business and social relationships. There will be no obvious delusion, no mental con- fusion, no loss of memory. Mental depression may not be corn-

MELANCHOLIA IN PRIVATE PRACTICE 627

plained of, and the patient may attribute all his or her symptoms to insomnia, high blood pressure, indigestion, change of life, etc. But even in those cases where depression is neither spontaneously complained of, nor admitted on questioning, the " strained tense- nes s " referred to is never absent. In a long conversation one will miss the normal, fleeting, spontaneous changes of expression, and the most thorough physical examination somehow does not give the expected relief.

The question is sometimes asked: What degree of depression constitutes melancholia? While the term " melancholia" is often reserved for the textbook type of attack--with anxious fears or delusions of unworthiness--there can be no question but that the milder forms, with scarcely noticeable depression, are essentially of the same nature. This was clearly demonstrated by Kraepetin many years ago. The essential fact is not quite so much the degree of depression as its permanency. A passing phase of depression has been experienced by most people, but in those who seek medical advice the depression has, as a rule, become more or less permanent, with perhaps periods of the day when it is not so pronounced.

A pitfall worth remembering is that, however harrowing a patient's history may be, one should not conclude that his mentaI state is the natural sequel to such an experience. A person may normally be sad or " unstrung " following a period of great stress, but melancholia should never be present.

In considering this question of diagnosis, it would be well to consider briefly some of the other mental c~nditions with which melancholia might be confused. I f one calls any of these conditions melancholia there is little harm done, and the error is not nearly so grave as it might be if the mistake were the other way round, but on the other hand a mistaken diagnosis only leads to waste of time and energy.

Dementia pr~ecox sometimes begins with a depressed phase, but apathy or indifference is much more characteristic .of the emotional picture than real depression. A history of eccentric behaviour, bizarre acts, sullen moods, impulsive or violent outbursts, will go far to strengthen the suspicion of a primary dementia. A point that is often immediately helpful is that melancholic patients are usually described by their relations as being most conscientious and reliable before their illness--often the mainstay of the home or business--whereas in the case of dementia pr~ecox the early history is rarely satisfactory, and the subject is described as being unreli- able, moody, sullen, etc. I t is well also to bear in mind that dementia pr~ecox has no monopoly ~)f the adolescent period. I t is in fact relatively more frequent in the late twenties. Melancholia is not at all infrequent in the early adolescent period, from 15 years upwards.

Many conditions, often termed anxiety states, anxiety neuroses, etc., are not fundamentally different from an early stage of melan- cholia. Where a degree of more or less permanent emotional depression is present, it is much safer to adopt the graver dia~osis.

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Functional cases with a large element of hysteria are often puzzling, as they take on so many diverse forms. Generally spealdng, however, where the hysterical element is at all prominent, it will usually be found that the illness is a source of interest to the patient, who often becomes quite animated in disclosing his various symptoms. The suggestion of real suffering so characteristic of melancholia is absent.

Confusional states usually develop with some abruptness. In a fair percentage of these cases a predisposing cause can be found, e.g., alcohol, drugs, febrile toxmmia, etc. Before confusion becomes marked the patient is usually dull and listless, and on close examination is found unable to Eve a really coherent or complete account of himself.

Other conditions such as paranoid states, in which the patient becomes increasingly antagonistic to his surroundings, generally over a number of years, are too rare to be of real difficulty. General paralysis must of course be kept in mind, especially in middle-aged men, and the possible presence of a cerebral tumour should not be entirely forgotten.

With regard to a possible physical cause, one will always, of course, exclude such conditions as tuberculosis, the anaemias, etc., but in actual practice there is usually no trouble in deciding that the mental state has not primarily a physical cause. Even in the presence of a very definite physical cause, the assumption that this is the cause of the mental state, and that the latter will disappear when the former is put right, is fraught with much fallacy and danger. Again, one has to keep in mind the bodily symptoms ordinarily caused by melancholia., such as loss of weight, poor appetite, various digestive troubles and, in young women, amenorrhcea.

Prognosix.

I shall refer only briefly to prognosis in so far as it will affect one's attitude towards the case. In all cases in which the patient, prior to the illness, was a normM, reliable member of society the outlook must be regarded as very favourable. There is also no essential reason why, on complete recovery, the relations should anticipate a second attack or why the patient should not undertitke all his former responsibilities. Consideration, however, will have to be given to the circumstances precipitating the attack, and activities involving needless expenditure of energy should be curtailed. Many of these patients habitually spend themselves, for the benefit of others, seemingly without limit or reserve. I t is advisable to preserve a more cautious outlook in the case of patients over 55 years of age. In many of these patients from this age onwards, and in exceptional cases, below this age, the illness seems to be based upon a cardio-vascular-renal degenerative process, and mental symptoms may precede a complete physical breakdown leading to death--by from six months to three years. In these cases, there-

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fore, a graver view must be taken and, generally speaking, a correspondingly more rigid nursing r~gime adhered to.

Trea~tment-----General C o,nsidera~ions. When faced with an undoubted case of melancholia, whether of

mild or more marked degree, the first question which must immediately occur to one's mind is--what reserve of volitional control has the patient got---or, in plainer language--what is the risk of a suicidal attempt? In very acute cases one assumes, whether or not the patient gives expression to suicidal ideas, that there is no reserve, and one takes the necessary steps to have the patient under continuous nursing supervision night and day. In well marked, though less acute cases, one will again usually endeavour to play for safety; this type of case can frequently be persuaded, often with excellent results, to enter a mental hospital as a voluntary boarder. I t is in the comparatively mild typ~ of case, where perhaps the patient is carrying on fairly competently with his work, in which the greatest difficulty arises.

I a trying to arrive at a decision in these cases one takes into account a number of factors, but in the end the decision is probably arrived at by a kind of intuition. The older psychiatrists used to place great importance upon what they called the degree of " insight " into the illness, by which they meant how far the patient understood his illness. In the cases we are now considering this will not be of much help, as these patients will be able to discuss their illnesses quite rationally and will not give expression to any delusion~ The apparent " depth " of the depression is sometimes of help but must be interpreted cautiously, as there is often considerable variation in the degree of depression and one may be interviewing the patient in one of his better periods. The most helpful consideration is probably the general demeanour of the patient taken in conjunction with his replies to certain ques- tions. One asks such questions as : " What do you feel like in your worst moments? . . . . How bad is the worst depression you have experienced?", etc. I f the patient admits of suicidal thoughts at such times one can further inquire what degree of control he felt he had over such thoughts. I f the patient will make no reference to suicide, it is often (though perhaps not always) advisable to put the matter bluntly and to ask whether suicidal thoughts ever entered his mind, and if so, how far he dwelt upon them. In this discussion of the patient's symptoms and of the question of suicidal thoughts (which, by the way, on~ should explain to the patient are a common accompaniment of all depressed states and nothing to be unduly alarmed about) one forms an estimate of the amount of volitional control present and of the probable reserve in case of emergency.

Upon the other points of treatment, as such will so much depend upon individual factors I do not propose to dwell in detail. Some form of medicinal treatment will probably be advisable, and the

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most generally useful drug in my experience has been ammonium bromide in from 10-15 gr. doses, three times a day. Iron in some form is also very useful to correct the secondary anmmia which is almost invariably present. I t is also advisable to correct any degree of sleeplessness and, if hypnotics are given it is well to give them boldly and to refuse to enter into any discussion with the patient as to their merits or demerits. The patient must be taken in hand firmly at this stage. I f treated as an out-patient it is well to insist on seeing him at least twice a week. In this way one will note any trend for the better or worse and take action accordingly. Forceful suggestion plus a kind of moral support farm the best psychological treatment. I would strongly advise against any form of mental probing or " analysis" or even allowing the patient to dwell in too great detail upon his past history and supposed mis- takes. A stern warning against allowing ideas of suicide to dwell in the mind is sometimes most useful, as is also putting the patient strictly on his honour to report immediately should there be any marked increase in the depression or any feeling of inability to cape with suicidal thoughts. These patients must be under the very definite .control of their doctor, so that changes of air and sea voyages are ruled out.

In the more marked cases when one has decided that treatment in a nursing home is essential it is well to bear several points in mind. One is that, in these cases, recovery is quite exceptional under three months, most common in from four to eight months, relatively common in from nine to 18 months, and not so very uncommon after two, three, or even five years' illness. Apart, therefore, from financial considerations, incarceration in the some- what restricted atmosphere of a nursing home far anything like these periods is usually very badly borne. To put it plMnIy, nursing home treatment should be regarded as only a very temporary expedient. These patients are not physically ill and the outlet in games, recreations, fresh air and congenial company which the patient will ha~e in a well-run mental hospital is altogether missing.

In treating the more severe cases difficulty will again be encountered when the patient begins to recover. Almost invariably the patient will request a relaxation of control, liberties and privileges long before it is advisable to grant them. This con- stitutes a crucial period in the treatment of the disease and demands exceptional care and judgment. In the course of recovery many of these patients pass through this intermediate restless and some- what irritable stage, in which they usually state they are now fully recovered and ask to be sent home or allowed to return to work. One must not of course, unless absolutely driven to it, directly oppose a patient's wishes at this stage. Recovery in melancholia is a tender plant. I t is usually possible, while agreeing with the patient, to suggest a further period to " build up ," and it may be possible to grant small concessions, such as shopping expeditions with a companion, or car drives, which will tide over the difficult

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period. When recovery is complete this phase is usually replaced by an amiable contented phase in which the patient is not at all over-anxious to be granted all his liberties. Other signs of com- plete recovery which it is well to bear in .mind are full n~tural sleep every night, good appetite and increase in weight, natural and spontaneous interest in all his surroundings, disappearance of all tension in manner and speech, spontaneous laugh, and no appearance of depression at any time in the 24 hours. When one is satisfied that a patient has reached this stage, it is frequently a useful plan then to suggest a date of discharge two to four weeks hence. The fixing of the date overcomes the slight disappointment at not being discharged immediately, while the additional few weeks give the patient a chance to consolidate his recovery.

To /ace page 632.

[DR. MAXWELL'S PAPER.]

~IG. 1.

FIG. 2,

[DI~. MAXWELI~'S :PAPER.]

FIG. 3.

Fxc.. 4.

[DR. MAXWELL'S PAPER.]

FIG. 5.

FIG. 6.