For most of Western history, depression—by which I mean an emotional heaviness that descends without cause and won’t lift—had many minders. The physician attended to it; so did the priest, the philosopher, and the poet. They did not always defer to each other.

In the centuries before the modern clinic, a person sunk in despair might be told that his body was disordered, that he was being tempted, or that he had been marked for a certain kind of depth. Each of these was a whole account of what the condition was, why it was, and how to respond. To name the suffering was to have decided to greet it with purge, prayer, discipline, or even gratitude.

The modern antidepressant is a mid-twentieth-century invention. The first compounds, imipramine and iproniazid, appeared in 1957 and 1958. But the drugs became a fact of life only with selective serotonin reuptake inhibitors, present in American pharmacies since 1988. The first commercial variety, Prozac, is not yet forty. In that time, antidepressants have become one of the most widely prescribed drug classes in the world, taken by roughly one in eight American adults and about one in six in England.

What is distinctive about the present is not that a medical account exists—one always has, at least since the Hippocratics blamed black bile—but that the medical account has become dominant, and that its characteristic remedy comes in a tablet. The pill is the material answer to a question that medicine, philosophy, and theology have wrestled over for two thousand years. The pill does not argue with the monk or the humanist physician but concedes them no jurisdiction.

By setting the neurochemical story beside the ones it has made us forget, we can come to see it as one account among several, and notice that each account belongs to a larger myth of mind. Each of these has a long and serious history—as the temperament of genius, as spiritual trial, as purgative night—that the present paradigm, taken for truth, eclipses.

Saturn’s Children

We begin with a construal so familiar it has hardened into cliché: the Greek concept of the tortured genius, the belief that suffering and brilliance keep company. Today psychiatry regards this notion as a romantic error, a sentimental gloss on what it sees strictly as pathology. But in its origin, the idea was science, not indulgence.

For the Greeks, mind and body were continuous. Temperament was a matter of four humours (blood, phlegm, yellow bile, black bile) corresponding to the elements and seasons of a patterned cosmos. Melancholy was the condition of black bile, melaina cholē, so that to be “melancholic” was to experience a bodily weather with specific powers and liabilities.

The thirtieth book of the pseudo-Aristotelian Problems, a compilation likely from the third century BC, opens with an exaggeration that has echoed ever since. Why is it that all who have become eminent in philosophy, statesmanship, poetry, or the arts are melancholic? As a piece of medical physiology, the text attempts to work out how black bile, through heat and quantity, causes now despondency, now inspiration, here the suicide, and there the sage.

The Renaissance exalted this pairing of melancholy and genius. Marsilio Ficino, fifteenth-century Florentine Neoplatonist and self-described melancholic, wrote in Three Books on Life about how the labour of abstract thought dries and cools the learned mind. In this way, Ficino says, vocation and affliction are two expressions of one way of being. He offers remedies—diet, music, sunlight—but these are meant to make melancholy bearable, not abolish it, since it is bound up with the gift.

The shift of melancholy from humoral disease to brooding temperament of the gifted soul is most famously emblemized in Albrecht Dürer’s Melencolia I. The engraving portrays a winged figure ringed with idle tools of geometry and craft, sunk in a stupor that also seems to be the exhaustion of a mind at the limit of thought. In the melancholic tradition, darkness and depth are not opposites; they are two vantages on one phenomenon.

The Noonday Demon

The desert monks of early Christianity were, meanwhile, drawing an altogether different map. While Christian suffering can always be interpreted as participation in Christ’s redemptive work, the early fathers were more specific about despair. In their writing, the mind is no longer a balance of humours but a soul in motion toward God, exposed on the journey to a traffic of passions and tempting spirits. In that drama, the dark states are not mere corporeal weather but important trials for the soul.

Evagrius of Pontus, a Greek monk who died in 399, catalogued eight afflicting “thoughts,” the logismoi, during his time in the Egyptian desert. Among them he set acedia (akēdia), literally “a failure of care”: a listless, restless state descending at midday, filling him with disgust for cell and work and a longing to be elsewhere—counselling, at last, that the whole enterprise is futile. Evagrius identified acedia with the daemon meridianus of Psalm 91, the “destruction that wastes at noon.” Of this demonic presence he wrote, “First of all, he makes it seem that the sun barely moves, if at all, and that the day is fifty hours long.”

John Cassian, who carried the desert’s teaching into the Latin West a generation later, gave the analysis its fullest treatment in the tenth book of his Institutes. The monks took acedia to be not illness but temptation, and withstanding it was the substance of spiritual progress. The monks drew a line here that the modern clinic has blurred: the feeling of listlessness was not itself a sin but a trial; the sin lay in surrender. Rather than flee the cell, the sufferer was to stay, labour, and, in labouring, be “formed.” The immediate relief of pain was not to be desired, since relief would forfeit the improvement the pain existed to produce.

This logic reached a pitch twelve centuries later in John of the Cross. The sixteenth-century Spanish Carmelite inherited the subject through the scholastic anatomy of the capital sins. The first book of his Dark Night is built explicitly around those sins and treats acedia’s heir, “spiritual sloth,” directly. The desolation in which God seems wholly absent should not be read as a defect or as the sin of sloth, John argues, but as the most intimate operation of grace, weaning the soul from consolations it had mistaken for God. Aridity, abandonment, and withdrawal of sweetness are here severe instruments of purification and union. Darkness is not the absence of the divine but its mysterious presence.

A Hinge

Between these older construals and the clinical present stands Sigmund Freud. The turn he marks is best seen in his essay “Mourning and Melancholia,” published in 1917, which secularizes without yet medicalizing the tradition. Mind, in this theory, is neither humoral body nor pilgrim soul but a dynamic economy of drives and their objects, energy invested and withdrawn, largely below awareness. Melancholia is an event within that economy.

Mourning, in this intermediate view, is the work of detaching desire from a lost object. When it is done, the world is whole again. Melancholia is what happens when loss is taken inward. A lost object is not relinquished but installed in the ego, bringing with it its store of recriminations and lament. “In mourning,” Freud writes, “it is the world which has become poor and empty; in melancholia it is the ego itself.”

Freud’s melancholia is still meaningful and interpretable. It is a condition with an inner history and a hidden logic, even where that logic has gone wrong. This is perhaps the last moment when emotional darkness keeps the dignity of intention, however misdirected. It marks a threshold between two pictures, one where despair retains legitimacy (even if carried too far into the permanent and the pathological), and one where despair has almost no legitimacy—in which, outside a small radius of mourning, it is always a faulty state in want of repair. Much later writing on the subject is in some sense commentary on Freud’s essay.

The Manufacture of Sorrow

The last mental map is the one that now looks like a total frame. In its dominant form, the mind has become the brain, and the brain a chemical system. The popular distortion of this—the “chemical imbalance” righted by topping up serotonin—remains the public’s working picture. The Diagnostic and Statistical Manual of Mental Disorders (DSM) defines depression by a checklist of symptoms counted over two weeks, with little reference to cause. But to say that the neurochemical description of depression took over is to concede that it is contingent—a construct with a history, not simply a discovery of how things are. Two lines of argument underline that contingency without sliding into reflexive anti-psychiatry.

Modern criteria identify depression by counting symptoms bare of context, so that the same symptoms of low mood, poor sleep, and loss of appetite are scored as disorder whether they follow a death or come out of nowhere. For a time, the DSM kept a single exception—the bereavement exclusion, which conceded that grief after a loss was not illness. The exclusion morphed, in 2013, into a note counselling doctors to use judgment. The current criteria erase the distinction that older traditions assumed between sorrow with cause and without, thereby pathologizing a distressingly large range of human response.

The DSM does not specify causation, but it may be a sort of cause in itself. That the diagnostic category is never neutral is the burden of Canadian philosopher Ian Hacking, who argues from the premise that human beings are unlike the kinds studied by the natural sciences. Uranium does not change its behaviour when classified; people do. A category is a way to be—a set of expectations and permissions—and people so classified change in the process.

Expectations are increasingly understood to have a physiological reach, shaping symptom, course, and response through mechanisms that run well past the old notion of placebo. To be told what kind of illness one has is, as it were, to be given a body that behaves accordingly. This dissolves a false choice bedevilling the debate. Depression is neither made up nor a timeless biological reality. It is a category that, once promulgated and inhabited, reshapes the people it names. How we think about it matters.

Taken together, such critiques help us think about how the medical construal tunes out context and may shape what it purports to measure. Of course, the ascendancy of this symptom-based model cannot be explained by evidence or philosophy alone. Even when individual clinicians pull in the opposite direction, diagnostic systems, insurance structures, pharmaceutical marketing, and time-pressed care can incentivize a symptom-focused model.

Which Self, Whose Happiness?

Doubtless, superseded theories of melancholy caused considerable suffering. In the Christian ascetic tradition, giving in to acedia was a sin. Some may have been inspired to rise above; others were punished harshly for what was hardly their fault.

Even more staggering than such suffering is the suffering antidepressants have lifted. There are millions of people for whom prolonged melancholy is not the stigmata of depth, faith, creativity, or conscience; and millions for whom a pill has been life-saving. Past eras likely assigned prestige to despair partly in order to salvage what they could not solve. But this does not diminish the interest of what sufferers sometimes made of their lot. And in the present, much discursive work remains to be done to answer the patient’s question, “What does this mean?”

A person returning from severe despair, or taking the drug for milder moods, might wonder, for example, who this medicated self is. In cases of the drug’s effectiveness—not as the correction of a lesion, which science has never cleanly demonstrated, but as a reliable modifier that returns sufferers to function—this is the question waiting on the far side of efficacy, giving the whole subject a moral charge: If heavy states can be chemically lifted, what becomes of the self that was to undergo them?

In Listening to Prozac, Peter Kramer coined the phrase “cosmetic psychopharmacology” for the prospect of a drug that does not cure illness but improves an ordinary self. He describes patients who become, in his clever phrase, “better than well”—more confident, more fluent than they had ever been unmedicated. Patients in Kramer’s own consulting room who stopped using the drug reported feeling “not themselves,” estranged in the very condition that had preceded all treatment. (Whether this is due to withdrawal is unclear.)

Some moral philosophers regard authenticity as a moral ideal, positing that each person has an original way of being that they are obliged to discover and live. This ideal turns out, under pressure, to be unable to settle the question, since patients cannot agree whether the depressed self or the one chemically altered is the “true” version.

A different wariness has to do not with internal well-being but with mood’s relationship to the external world. A soul that can be brightened irrespective of its objects may lose its tether, its seriousness, the sensitivity to reality that makes its joys and griefs about anything. Beyond Therapy, the 2003 report of the President’s Council on Bioethics, raised as a concern this severing of feeling from warrant. A lone drug addict may frequently feel good, even as his life falls to pieces. On a larger scale, a whole culture may learn to mute the symptoms of disorders it has no intentions of solving.

In Beyond Therapy, we hear echoes of the monk’s intuition that pain is to be faced rather than dissolved, and of Ficino’s that gift and affliction are one. Here, unease is pitched at a culture that has learned to produce contentment unmoored from the conditions to justify it—good feeling without goodness.

The Triumph of the Therapeutic

The therapeutic construal may have taken off partly because it arrived at the right time, amid a rapidly changing ideal of self. In Philip Rieff’s influential formulation, the twentieth century saw the supersession of “religious man” by “psychological man”—the former born to satisfy God, the latter born only to be satisfied. In plain terms, religious man is answerable to an external and universal standard, the latter answerable to himself. The inversion has ramifications for people’s accountability to each other.

The therapeutic ethos is anti-creedal by nature. It does not bind the self into a moral community with obligations and ends but releases it into the management of its own well-being. Once a culture has revised its ideal of the person along these lines, a technology that optimizes individual mood without reference to a shared horizon of meaning is not an intrusion but the culture’s logical extension—the same ethos in chemical form.

The therapeutic self is at risk of being cut off from the web of relations that can absorb some of the individual’s suffering. The drug treats it as such, acting upon one nervous system at a time. What such a shift leaves behind is the ideal of endurance that families, communities, and religions long upheld alongside the physician. The desert fathers’ imperative of remaining in the cell, John of the Cross’s patience under desolation, and even Ficino’s task of making melancholy bearable are what a medicalized order renders obsolete.

The deeper settings of the unhappiness these drugs are asked to cure are ones long named in sociology: the replacement of organic bonds of kin, place, and shared belief with the thin instrumental ties of strangers and the weakened regulation of a society whose old bonds have loosened. Read from this height, the antidepressant is not a neutral repair of a broken part but the chemical instantiation of the therapeutic settlement. It is the device that lets the disembedded individual persist without restoring the embeddedness whose loss was the injury. Distress gets translated into disorder, and chemical management is made the most accessible and socially legible response. A system can be indispensable to those inside it and still reveal a lapse in the world beyond.

The Seam

The classical, patristic, and Renaissance traditions understood pain, sadness, doubt, and despair as the albatross of genius, as demonic trial, as dark night that must be borne since God is behind it. The therapeutic-chemical settlement has displaced these through regulation, diagnostic criteria, insurance codes, and market perception, reducing a vast imaginative territory to a precise checklist of deficits and a blocking agent to be cleared so that a true self can emerge.

This is where science reaches its limit and hands the question back, because whether to accept that verdict cannot be settled by any trial. A randomized study can establish that a drug lifts moods; it cannot establish that moods ought to be lifted or whether darkness is a disposition or a crucible. Those are questions about ends, precisely the questions the scientific method is built to avoid.

Historical reconstruction of this kind need not imply that our approach is wrong and earlier ones were right. But knowing what gave rise to current interventions protects against their drift toward indiscriminate application. Each mode of thought checks the other, helping maintain balance: The chemical account imputes needless suffering to church fathers, while a medieval mystic would see present lives as leached of the grief that puts us in contact with the divine. Neither has the last word on the subject.

Why recover these histories of sorrow? Doing so does not mean we must choose between medieval spiritual terror and modern chemical management. Rather, placing psychopharmacology in historical sequence makes us more grateful for its advances while keeping us sensitive to its encroachment on ordinary feeling. Sadness can be an intuition, the full unfolding of which reveals a novel or poem. Distress can be a signal that we live in a violently unjust world and should find a way to contribute to its restoration. There is danger in numbing those signals too systematically. Examining the humanistic questions that psychopharmacology raises and displaces may, at the very least, give us a clearer view of the compromises we now live with.