Depressive Disorders
Depressive Disorders
Depression as a normal emotion
Depression as an abnormal emotion
Clinical pictures of depressions
Psychodynamic mechanisms of depression
Sociocultural factors in depressions
The term “depressive disorders” refers to a large group of psychiatric conditions whose main characteristic is an abnormal feeling of depression. This classification is broad as well as vague; it implies a definition of depression and of abnormal depression. Moreover, the word “depression” refers sometimes to an ordinary emotion, at other times to a symptom, and still at other times to a given clinical entity.
This article will discuss depression as a normal and as an abnormal emotion, clinical pictures of depressions, psychodynamic and sociocultural aspects of depression, and treatment.
Depression as a normal emotion
Depression is a common emotion, second only to anxiety in psychiatric concern and study. Often depression is referred to by such terms as sadness, melancholy, despondency, dejection, low spirit, and anguish. Although practically all human beings have at some time experienced depression, this emotional state is among the most difficult to describe and to analyze. It is a pervading feeling of unpleasantness accompanied by such somatic conditions as numbness, paresthesias of the skin, alterations of muscle tone, and decreases in respiration, pulsation, and perspiration. The head of the depressed person has the tendency to bend; the legs flex; the trunk tilts forward. The face assumes a special expression because of increased wrinkles and decreased mimic play. There is also retardation of movements, rigidity in thinking, and a general feeling of weakness.
It is, however, at the mental rather than the somatic level that depression has more specific characteristics. Whereas anxiety is characterized by an expectancy of danger, depression is accompanied by a feeling that the dangerous event has already occurred, that the loss has already been sustained. For instance, the loved person has already died, the good position has been lost, the business venture has failed, a self-concept or an ideal can no longer be maintained. There is also a more or less marked sense of despair, of unpleasant finality, as the lost object is considered irreplaceable. The loss is deemed to have repercussions on the present as well as the future. From these examples it is evident that, at least in conditions considered normal, depression seems to be a reaction to psychological processes, such as evaluations and appraisals, that have occurred at a cognitive level. The person who becomes depressed must have been able to understand and to assess the significance of certain events. Thus, cognitive and, as we shall see later in detail, social factors (inasmuch as the latter enter into complicated cognitive processes) are very important in the engendering of depression.
Such considerations would make depression a uniquely human emotion, different from more primitive emotions such as fear, rage, and some forms of anxiety that occur also in much lower animals. This point, of course, is debatable. Inasmuch as animals cannot verbalize their feelings, it is an open question whether or not the belief that animals become depressed is an anthropomorphization. A dog, for instance, may appear depressed when his master is away, but it is doubtful that this is either a feeling involving the future or a sense of loss that transcends the immediate discomfort. A feeling of deprivation rather than despair seems to be involved here. On the other hand, these uncomfortable feelings of deprivation, which even infrahuman animals are capable of experiencing, may be the precursors of human depression.
According to Arieti (1959a), depression may have functional significance. If depression had negative survival value, species capable of experiencing it probably would not have procreated themselves in the course of evolution. Other emotions have survival value; anxiety, for instance, is a warning of forthcoming danger. As with other unpleasant sensations and emotions, the function of depression is to urge the person who experiences it to alter his behavior, so that the factor engendering depression will disappear or be removed.
For example, an individual hears the news of the unexpected death of a person he loved. After he has understood and almost instantaneously evaluated what that death means to him, he experiences shock, then sadness. For a few days all thoughts connected with the deceased person will bring about a painful, almost unbearable feeling. Any group of thoughts even remotely connected with the dead person will elicit depression. The individual cannot adjust to the idea that the loved person does not live any more. And, since that person was so important to him, many of his thoughts or actions will be directly or indirectly connected with the dead person and therefore will elicit sad reactions.
Nevertheless, after a certain period of time, that individual adjusts to the idea that the person is dead. By being unpleasant, the depression seems to have a function—its own elimination. It will be removed only if the individual is forced to reorganize his thinking, to search for new ideas so that he can rearrange his life. He must rearrange especially those ideas that are connected with the departed, so that the departed will no longer be considered indispensable.
Depression as an abnormal emotion
Depression is deemed abnormal when it is excessive relative to the antecedent event or events that have elicited it; when it is inappropriate in relation to its known cause or precipitating factor; when it is a substitution for a more appropriate emotion, for instance, when it takes the place of hostility or anxiety; or, when it does not seem to have been caused by any antecedent factor of which the person is aware.
Both constitutional and psychological factors have been postulated to explain the occurrence of abnormal depressions. The constitutional factors have been studied particularly in connection with the depression that occurs in the course of manicdepressive psychosis. Slater (1936), for instance, believes that the inheritance of manic-depressive psychosis depends on a single dominant autosomal gene. To explain why the incidence of the psychosis is lower than would be expected from his hypothesis, he states that the dominant gene is a rare one. Kraines (1957) believes that the depression, as well as the manic state of manic-depressive psychosis, is due to a dysfunction (either increased or decreased function) of the diencephalon. Accordingly, the experience of depression is a “psychic response” to this diencephalic dysfunction. Elevated values for adrenal and thyroid functions, blood pressure, and pulse rate are reported frequently in depressed patients (Reiss 1954).
Arieti (1959a) has described what happens when the process of reorganizing ideas concomitant with normal depression fails. In such cases, depression, rather than forcing a reorganization of ideas, slows the thought processes that are carriers of mental pain. There appears to be a teleological or adaptational mechanism that seemingly acts with the goal of decreasing the quantity of thoughts in order to decrease the quantity of suffering. At times, the attempt to slow thought processes succeeds so well (as in the state called “stupor”) that only a few thoughts of a general and vague nature remain. These are accompanied by an overpowering feeling of melancholy. Thus, the slowing down of thought processes that have an unpleasant emotional tone is a self-defeating mechanism and, in a vicious circle, aggravates the situation instead of alleviating it.
Often, abnormal depression defensively replaces seemingly more appropriate emotions, generally anxiety or hostility. The patient appears to be more capable of coping with a feeling of depression than with anxiety or hostility.
Clinical pictures of depressions
Depressive disorders have been known since ancient times. Some of the great physicians of antiquity, like Hippocrates and Aretaeus, wrote about the conditions that are now called “psychotic depressions.” In spite of this long record in the history of medicine, no agreement has been reached about the various classifications of depressions or the nature of the various types. Following is a brief account of the different clinical pictures that have been recognized.
Reactive or psychoneurotic depression
Reactive or psychoneurotic depressions are characterized by relatively mild feelings of despondency, guilt, and self-depreciation; mild retardation and reduction of spontaneity; and the absence of hypochondrial preoccupations. These depressions seem to occur subsequent to, or as a reaction to, an unpleasant or tragic event in the life of the patient. The patient is aware of this connection. Some authors emphasize the fact that reactive depressions are not endogenous, that is, are not engendered by internal factors, such as organic or hereditary predispositions, but are consequent to external factors. In addition, the patient does not accept the depression as a way of living and, like all other psychoneurotic patients, would like to be relieved of his depressed condition.
Depressed type of manic–depressive psychosis
The depressive aspect of manic–depressive psychosis has generally received the most consideration. Although it was already recognized by Aretaeus, it was described more fully and clarified in some aspects by Kraepelin in the sixth edition of his Psychiatrie: Lehrbuch für Studierende und Ärzte, published in 1899 (see Kraepelin 1883).
This type of depression is characterized by a triad of symptoms: a pervading feeling of melancholia, disordered thought processes characterized by retardation and unusual content, and psycho-motor retardation. In addition, there are, less typically and less frequently, some somatic dysfunctions.
This type of depression occurs much more frequently in women than in men. In the majority of cases it is periodic, not permanent. Attacks of depression are separated by normal intervals.
Feeling of melancholia. The onset of the pervading feeling of melancholia is sometimes quite acute and dramatic, at other times slow and insidious. At times, it is misunderstood or unrecognized at first. When an unpleasant event, such as the death of a close relative, has occurred, a certain amount of depression is justified. However, when a certain period of time has elapsed and the depression normally should have subsided, it becomes instead more intense. The patient has an unhappy, sad appearance. He looks older than his age, his forehead is wrinkled, and his face, although undergoing very little mimic play, reveals a despondent mood. In some cases the main fold of the upper eyelid at the edge of its inner third is contracted upward and a little backward (sign of Veraguth).
The patient is often unable to describe his feeling of intense unhappiness. He may say that “his eyes have consumed all the tears” and “his life is a torment.” He experiences a desire to punish himself by destroying himself and, at the same time, to end his suffering. Suicidal ideas occur in about 75 per cent of patients, and actual suicide attempts are made by at least 10 to 15 per cent.
Disordered thought processes. The second important symptom concerns the content and type of thinking. Gloomy, morbid ideas leave little room for other thoughts. The patient convinces himself that he is hopeless; he has lost or will lose all his money, his family is in extreme poverty, he is incapable of working or even taking care of himself. There is no great variety in his thoughts. He gives the impression of selecting thoughts that have an unpleasant content so that his melancholic mood is retained. Quasi-delusional ideas or definite delusions may occur, often representing distortions of the body-image and hypochondriasis. The patient thinks, for example, that he has a tumor, syphilis, or tuberculosis, that he has lost his bowels, or that his brain is melting. The patient is often self-accusatory, in a delusional form. He believes that he has committed many crimes or that some crimes which have been committed by others are, indirectly, his responsibility. Especially in some Western subcultures that are permeated by intense religiosity, the ideas of guilt, sin, self-condemnation, and eternal damnation are prevalent. Hallucinations are rare in this condition and occur almost exclusively at night.
Psychomotor retardation. The third important sign of depression is retarded hypoactivity. The actions of the patient are reduced in number and are carried out at a slow pace. Talking is reduced to a minimum. Employment and household responsibilities are ignored, and appearances are neglected. When depression reaches a state of stupor, the patient cannot talk or move at all and may be mistaken for a catatonic patient.
Somatic dysfunctions. Frequent accessory symptoms are reduction in sleep, decrease in appetite, loss in weight, marked decrease in sexual desire, dryness of the mouth caused by decreased secretion of the parotid glands. A frequent subvariety of this condition, called “agitated depression,” is characterized by motor restlessness rather than hypoactivity.
Manic episodes. Kraepelin emphasized that in many patients attacks of depression alternate with, or occasionally are followed by, other attacks that seem to have contrasting characteristics. These are the manic attacks, characterized by a state of elation or euphoria, a disorder of thought processes distinguished by flight of ideas and pleasant content, and an increased mobility. Kraepelin thought that when the illness manifests itself in a complete form, both the depressed and manic attacks occur, although in different sequences. Thus he conceived both forms of attack as part of a specific clinical entity, to which he gave the name “manic–depressive psychosis.”
It was soon noticed that the manic attacks are much less frequent than the depressive ones. Perhaps the difference in frequency is not as marked as it seems. It could be, in fact, that mild attacks of mania are better tolerated or unrecognized by the patient or his relatives.
The intensity of the depression is not the only characteristic differentiating between psychotic and reactive depression. In a psychotic depression the patient accepts his depression as his way of life and feels justified in feeling as he does.
Psychotic depressions
Many depressions, even of psychotic proportions, are never preceded or followed by manic attacks. Many authors are reluctant to include such depressions in the manic–depressive syndrome. They feel that these depressions probably should have a classification unrelated to the Kraepelinian psychosis.
Except for the fact that it is not followed by manic attacks, psychotic depression is no different from the depression of the manic–depressive psychosis.
Involutional melancholia
Involutional melancholia (involutional psychosis, melancholic type) occurs in women at least three times as frequently as in men and is characterized by an intense feeling of depression that occurs around the “involutional” age. In women this age generally coincides with the menopause. However, involutional melancholia may precede or follow the menopause even by an interval of four to five years.
Involutional melancholia presents the same characteristics as the depression of the manic–depressive psychosis, with the following exceptions: (1) agitation and restlessness often substitute for, or are superimposed on, the hypoactivity, and (2) the prepsychotic personality differs from that of the manic–depressive. The patient is described as a quiet, retiring, worrisome, frugal, and rigid individual.
Kraepelin, who had originally excluded involutional melancholia from the manic–depressive category, reconsidered his views and finally included it in that group. Kraepelin thought that involutional melancholia had an unfavorable prognosis. However, as some of his contemporaries showed, this is not so. Electric shock treatment, devised by Ugo Cerletti and Lucio Bini in 1938 (Cerletti 1950), seems to be able to cure practically all cases, if by cure we mean a return to the prepsychotic level of adjustment, whatever it was.
Other types of depression
Depressions may also occur as parts of other syndromes or conditions. A depression occurring in old age is often referred to as “senile depression,” and one occurring in schizophrenia as “schizophrenic depression.” When a combination of schizophrenic and manic–depressive features occurs, the syndrome is often called “schizo–affective psychosis.”
A type of depression that is often described in the French and Italian literatures is the one called “Cotard’s syndrome,” after the neurologist J. Cotard, who first described it. Cotard’s syndrome is characterized by a depression accompanied by a delusional state of negation. Nothing exists; the world has disappeared. After the cosmic reality is denied, the physical reality of the patient himself is denied.
Spitz (1946) has described what he calls “anaclitical depression” in infants who have been separated from their mothers between the sixth and eighth months for an approximate period of three months. This type of depression seems more similar to a state or sense of deprivation, as it occurs in infrahuman animals, than to an emotional state that includes a sense of finality and despair.
Psychodynamic mechanisms of depression
Many authors feel that even if constitutional-hereditary facts are important in the etiology of depressive disorders, some experiential factors oc-curing in the early life of the patient have started psychodynamic patterns that have finally determined these conditions. Psychoanalytic studies have contributed greatly to the psychodynamic understanding of depressions. These psychodynamic mechanisms apply primarily to the depressions labeled as the depressed type of manic–depressive psychosis, psychotic depression, and involutional melancholia. It was Freud’s pupil Abraham (1912), not Freud, who introduced manic–depressive psychosis to psychoanalytic conceptions through a comparison of abnormal depression with normal grief. Both conditions are at times elicited by a loss that the person has suffered; but, whereas the normal mourner is concerned about the lost person, the depressed patient is disturbed by guilt feelings. The unconscious hostility that he had for the lost object is now directed toward himself. Abraham also assumed a regression to an ambivalent pregenital stage of object-relationship, that is, a return to an anal-sadistic stage.
Freud (1917) accepted Abraham’s idea that there is a relation between mourning and melancholia and pointed out that whereas in mourning the object was lost because of death, in melancholia there was an internal loss because the lost person had been incorporated (or introjected). The sadism present in the ambivalent relationship is then directed against the incorporated love-object.
Radó (1928) suggested that melancholia represents a desperate search for love. The ego tries to punish itself in order to prevent parental punishment.
According to Melanie Klein (1948), a “depressive position” is a normal event in the life of every child, generally at the time of weaning, that is, around the age of six months. The mother who before was seen by the child as two persons (one good and one bad), according to Klein, is at this time seen as one person; the mother continues, however, to be internalized as a good or bad object. The child is afraid that his instinctual aggressive impulses will destroy the good object, and he interprets the loss of his mother’s breast and milk at the time of weaning as the result of the destructive impulses. The inability to solve adequately this “depressive position” may, according to Klein, lead later to a pathological depression.
Arieti (1959a) found the following mechanisms in the cases that came under his attention. Very early in the life of people who are prone to become psychotically depressed there is a period of intense gratification of needs. The mother or mother-substitute is motivated by a sense of duty to be as lavish as possible in her care and affection. This attitude predisposes the child to be very receptive to others, to introject the others, and later to be an extrovert and a conformist.
At a later period but still in early childhood, generally during the second or third year of life, although in some cases even much earlier, the family situation undergoes a drastic change. The mother now takes care of the child considerably less than before and makes many demands on him. This change in the mother’s attitude may be due to the fact that in the meantime another sibling has been born, and the mother is now lavishing her care on the newborn with the same duty-bound generosity that she previously had for the patient. More often, however, the reason for the change is to be found in the personality of the mother, who believes that when a child is an infant, he has to be fully taken care of, but as soon as he shows the first signs of an independent personality, he should start to be given increasing responsibilities, a sense of duty, of obligation, and the like. No transitional stages are allowed. The child who experiences a drastic change from an atmosphere of receptivity from the others to an atmosphere of expectation by the others may undergo a trauma. He tries to find solutions or pseudosolutions. Generally he adopts one of the two following mechanisms, which he will repeat throughout his adult life. The first is an attempt to make himself even more babyish, more dependent, and aggressively dependent, so that the mother, or the important adult who later takes her place symbolically, will be forced to re-establish an atmosphere of babyhood and of early bliss. Another mechanism consists in trying to live up to the expectations of the mother, no matter how high the price, how heavy the burden. Love or the early bliss will be recaptured only by complying and working hard. If love is not obtained, the patient is at fault; he must atone or work harder.
The patient finds out later in life that these mechanisms do not work. No matter how aggressively dependent the individual becomes, he does not recapture the early bliss. No matter how compliant and hard working he is, he does not obtain what he wants. This realization brings about the depressed feeling. The actual manifest symptomatology of depression occurs when a symbolic reproduction of the early trauma takes place later in life. A loss has been sustained and the patient feels that his way of living has caused such a loss. The loss may be the death of a person important to the patient, the realization by the patient that an important interpersonal relationship has failed (generally with the spouse), or a severe disappointment in a relationship to an institution or work to which the patient has devoted his whole life. At times the loss is more difficult to evaluate; it may concern such abstract concepts as ideals, re-evaluation of the meaning of one’s life, and personal significance.
Claiming and self-blaming depression
The psychological symptomatology of psychotic depressions has been divided by Arieti (1962) into two main types: the claiming depression and the self-blaming depression.
In the claiming depression, which has recently become more common at least in the United States, the symptomatology, although fundamentally one of depression, seems to be a gigantic claim. All the symptoms seem to have a message: “Help me; pity me. It is in your power to relieve me. If I suffer, it is because you don’t relieve me of this suffering.”
In the self-blaming type of depression the main emphasis is on self-accusation and self-depreciation. The patient feels he does not deserve help from others.
When the prepsychotic personality is of the aggressive–dependent type, the psychosis tends to be the claiming type of depression. When the prepsychotic personality is of the duty-bound, hard-worker type, the psychosis tends to be the self-blaming type.
The suicide attempt (often successful) made by patients affected by a psychotic depression has been the object of various psychodynamic interpretations. Several possibilities must be considered. (1) The suicide attempt may actually be a cry for help. The patient wants to convey this message to an important person in his life: “You have the power to prevent my death, if you wish to.” (2) The patient wants relief from suffering. (3) The patient wants to punish himself, since he feels guilt-ridden and deserving of drastic punishment. (4) The patient does not really want to kill himself but the detested person whom he has incorporated. The last explanation is the one originally proposed by Freud (1917) and the one still accepted by the orthodox psychoanalytic school. It is actually based on little clinical evidence and is not unanimously accepted by other schools.
Sociocultural factors in depressions
Sociological and cultural factors may be important in facilitating those conditions which predispose to depression, especially those of the manic–depressive type. Some psychiatrists (Bellak et al. 1952; Arieti 1959b) have noted a decline in incidence of this psychosis. For instance, in a period of 20 years (from 1928 to 1947), the percentage of first admissions to hospitals of manic–depressive psychosis in New York State was reduced from 13.5 per cent of all admissions to 3.8 per cent. Relevant information has been gathered in other parts of the world. Gold (1951) has found a relatively higher incidence of manic–depressive than of schizophrenic psychoses in the lands of the Mediterranean Basin, as well as in Ireland. He reports that in Oriental countries, especially where Hinduism and Buddhism prevail, manic–depressive psychosis is less common, but in Fiji manic–depressive patients are numerous. Gold writes further that whereas in India the incidence of manic–depressive psychosis is low and that of schizophrenia higher, the reverse is true for the Indians who have immigrated to Fiji.
Recently, however, psychiatrists have noticed, at least in the United States, an increase in the number of depressive disorders. This increase has not yet been subjected to statistical study and seems to involve depressions not typically of the manic–depressive category.
In his attempts to understand the decline of manic–depressive psychosis Arieti (1959a; 1959b) drew upon the concepts of the sociologist Riesman (1950). Manic–depressive psychosis occurs more frequently in those cultures which Riesman has called “inner-directed” and tends to disappear where this orientation is also disappearing. It is thus possible to formulate the hypothesis that an inner-directed culture evokes or increases the manic–depressive propensity.
Inner-directed society
In the inner-directed society the mother feels duty-bound and therefore at the time of the birth of the child is very much concerned with his care, permitting the child to develop strong introjective tendencies. Soon, however, the mother will start to burden the child with responsibilities and with a sense of duty and guilt. This is often made necessary by the fact that the mother now has to devote herself to another child. The bliss of paradise is lost, and life becomes a purgatory. An inner-directed personality develops in the sense that this orientation is implanted early in life by the direct and definite influence of the significant adults. Family-life and child-rearing practices are established that seem to correspond to those found in the families of manic–depressive patients.
This hypothesis, suggesting the influence of inner-directed society upon manic–depressive psychosis, receives some validation from the research of Eaton and Weil (1955) on the mental health of the Hutterites. The Hutterites are a group of people of German ancestry who have settled in the Dakotas, Montana, and the prairie provinces of Canada. The Hutterite society seems to be an inner–directed one. In a population of 8,542 people, Eaton and Weil found only 9 persons who sometime in their lives suffered from schizophrenia and 39 with mianic-depressive psychosis; that is, among the Hutterites manic—depressive psychosis occurred 4.33 times more frequently than schizophrenia, whereas in the general population of the United States the incidence of schizophrenia by far exceeds that of manic–depressive psychosis.
Treatment of depressions
Depressive disorders are generally treated with three types of therapy. (1) Psychotherapy (generally psychoanalytically oriented in the United States; in Europe, often existentially oriented) is generally administered to patients suffering from the reactive depressions, the various types of psychotic depressions provided they are of moderate intensity, and patients who are experiencing a symptom-free interval between psychotic attacks. (2) Drug therapy is employed in the treatment of moderately severe depressions. “Psychoanaleptic drugs,” such as imipramine hydrochloride, and the large group of monoamine oxidase inhibitors are among those used. (3) Electric shock therapy, commonly used prior to the advent of drug therapy, is now reserved for the most recalcitrant and stuporous cases. It is still the most frequently used treatment in involutional melancholia.
Silvano Arieti
[Other relevant material may be found inElectro-convulsive shock; Mental disorders; Mental disorders, treatment of; Psychoanalysis; Psychosis; and the biographies ofAbraham; Freud; Klein; Kraepelin.]
BIBLIOGRAPHY
Abraham, Karl (1912) 1953 Notes on the Psychoanalytical Investigation and Treatment of Manic–Depressive Insanity and Allied Conditions. Pages 137–156 in Karl Abraham, Selected Papers. Volume 1: Selected Papers on Psychoanalysis. New York: Basic Books. ? First published in German.
Arieti, Silvano 1959a Manic–Depressive Psychosis. Volume 1, pages 419–454 in American Handbook of Psychiatry. Edited by Silvano Arieti. New York: Basic Books.
Arieti, Silvano 1959b Some Socio-cultural Aspects of Manic–Depressive Psychosis and Schizophrenia. Volume 4, pages 140–152 in Jacob Moreno and Jules Masserman (editors), Progress in Psychotherapy. New York: Grune.
Arieti, Silvano 1962 The Psychotherapeutic Approach to Depression. American Journal of Psychotherapy 16: 397–406.
Bellak, Leopold et al. 1952 Manic–Depressive Psychosis and Allied Conditions. New York: Grune.
Cerletti, Ugo 1950 Old and New Information About Electroshock. American Journal of Psychiatry 107: 87–94.
Eaton, Joseph W.; and Weil, Robert J. 1955 The Mental Health of the Hutterites. Pages 223–239 in Arnold M. Rose (editor), Mental Health and Mental Disorder: A Sociological Approach. Prepared for a committee of the Society for the Study of Social Problems. New York: Norton.
Freud, Sigmund (1917) 1959 Mourning and Melancholia. Volume 4, pages 152–170 in Sigmund Freud, Collected Papers, International Psycho-analytic Library, No. 10. New York: Basic Books; London: Hogarth. ? Authorized translation from the German.
Gold, Henry R. 1951 Observations on Cultural Psychiatry During a World Tour of Mental Hospitals. American Journal of Psychiatry 108:462–468.
Klein, Melanie 1948 Contributions to Psycho-analysis: 1921–1945. International Psycho-analytic Library, No. 34. London: Hogarth.
Kraepelin, Emil (1883) 1921 Manic–Depressive Insanity and Paranoia. Edited by George M. Robertson. Edinburgh: Livingstone. ? Translated from Volumes 3 and 4 of the eighth German edition of Psychiatrie.
Kraines, Samuel H. 1957 Mental Depressions and Their Treatment. New York: Macmillan.
RadÓ, SÁndor 1928 The Problem of Melancholia. International Journal of Psycho-analysis 9:420–438.
Rseiss, Max 1954 Investigations of Hormone Equilibria During Depression. Pages 69–82 in American Psycho-pathological Association, Forty-second Annual Meeting, New York, June 1952, Depression. Edited by Paul H. Hoch and Joseph Zubin. New York: Grune.
Riesman, David 1950 The Lonely Crowd: A Study of the Changing American Character. New Haven: Yale Univ. Press. ? An abridged paperback edition was published in 1960.
Slater, Eliot 1936 The Inheritance of Manic–Depressive Insanity and Its Relation to Mental Defect. Journal of Mental Science 82:626–634.
Spitz, RenÉ A. 1946 Anaclitical Depression. Psychoanalytic Study of the Child 2:313–342.