Last week, British psychologist Viren Swami published an interesting research article about how we perceive depression in women and men.
He took 1200 people and had them read a extensive description of a person with formal (DSM-IV) symptoms of depression. Here, I’ll cite only the first lines:
“For the past two weeks, Kate/Jack has been feeling really down. S/he wakes up in the morning with a flat, heavy feeling that sticks with her/him all day. S/he isn’t enjoying things the way s/he normally would. In fact, nothing gives her/him pleasure.” (… more in the original)
All people in the experiment got this same description, with only one difference. 600 people got a Kate, she, her version, about a woman. The other 600 people got the Jack, he, his version: exactly the same text, describing exactly the same symptoms, but now about a man. Everyone was asked to answer some questions about the condition of this “Kate” or of the identical “Jack”.
The results of this experiment were remarkable in several ways. I’ll name only the two most striking things here.
In the first place, people who had read the “Kate” text evaluated the person’s psychical condition as more serious than the people who had read the identical “Jack” text. Only 10% of the “Kate” readers concluded that “Kate” had no really serious problems, while 21% of the “Jack” readers concluded that “Jack” (with the very same symptoms) had no really serious problems. People were also much more inclined to say “Kate” should seek help, than in the identical case of “Jack”.
Secondly, there also were similar differences between the female and the male readers of both texts. Male readers would less often call “Jack” depressed than female readers would. Male readers rated the “Kate” situation as worse (and deserving more sympathy) than the identical situation of “Jack”.
In the end the researcher (Swami) concludes that clearly, gender stereotypes do still play an important role in how we view, judge, qualify symptoms of depression. A quote from Swami’s conclusions:
“To the extent that mental illness is inconsistent with notions of hegemonic masculinity that stress toughness and strength, respondents may be less likely to view men with symptoms of depression as suffering from a mental health disorder and, consequently, may adopt less positive attitudes toward such persons. The ways in which men relate to dominant forms of masculinity thus appear to impact on their mental health-related conceptions and attitudes.”
What Swami in fact concludes is that, due to gender bias and role stereotypes, people may more often fail to recognize a major depression in a man than in a woman. And that males may more often fail to recognize it in themselves. And that one of the results may be that men will be less inclined to seek help when in fact they do need it.
My own comment: as so often, this academic research only confirms what many of us may already have guessed. But I still find it interesting to see that instinctive feeling confirmed by a research experiment.
• tip: There is no actual lesson to be drawn here, except perhaps that from time to time we should remind ourselves that depression in a man can be just as bad as depression in a woman… In other words, that a major depression should not be dismissed as “unmanly behavior”.
• footnote 1: This post was about the research article Mental Health Literacy of Depression: Gender Differences and Attitudinal Antecedents in a Representative British Sample by Viren Swami (Department of Psychology, University of Westminster, London), published November 2012 in the online peer-reviewed journal PloS ONE.
Full text of the research article: PloS ONE: Mental Health Literacy of Depression.
Most of us will make a few terrible mistakes during our lives, huge mistakes that we may regret for a long time or maybe forever. A few times we just make the wrong decision, with important consequences that in hindsight will keep haunting us: if only we had… Fateful decisions like optimistically investing your savings in a high-risk financial scheme, or impulsively rejecting that one job offer that would have been perfect for you, or sacrificing your stable supportive relationship for a short-lived romantic fling with someone else – you name your own.
I’m talking about big mistakes here, with consequences that can be hard to undo or correct. Destructive choices; missed opportunities; doors slammed close. Undeniable mistakes that in due course will generate serious feelings of regret: the kind of fretting that can contribute to (or even cause) depression.
The older you get, the more difficult it becomes to handle this kind of regret. When you’re still young enough to have an entire life before you, chances are you’ll eventually find a way – and have enough time – to repair some of the fatal consequences of your wrong decision. But when you get older, when most of your life already lies behind you, those consequences will more likely look irreversible: you cannot go back in time to change things, and your options for the future appear more limited.
Regret and Depression: Some Research
Can depression be related to the way we handle our feelings of regret? A group of German researchers tried to find out, and a few months ago they published an interesting research article in Science about this (see footnote).
They did some experiments (involving risk games, brain scans, and more) with three groups of people: (1) healthy young people, (2) mentally healthy older people, and (3) older people suffering from depression. The researchers especially tried to find out how each of these groups reacted in situations where the participants became aware they had missed important opportunities: in other words, when they felt regret.
To cut short a long story, they found that group 2 (the mentally healthy older people) reacted less emotionally and in a more controlled way to regret, while both groups 1 and 3 (the healthy youngsters and the depressed older people) appeared to experience feelings of regret in a more intense, more emotional, less controlled way.
What this suggested is that (1) when you are younger you will feel regret more intensely, perhaps because this can still help you to learn from wrong decisions and to avoid such mistakes in the future; while (2) when you get older, normally some mitigating mechanisms begin to work to prevent you from suffering from regret that will be at that stage of life more pointless anyway; but that (3) when you are older and depressed, this mitigation mechanism somehow fails to kick in, causing you to react in the same emotional way as young people do, suffering more from regret which in your case is fairly pointless.
Of course much can be said about this – for example, in the last group, did their already-present depression cause their regret to be more intense, or is it the other way around? Did their more intense way of handling regret cause their depression to be more acute? Or would this perhaps be just some kind of chicken-or-egg question?
What matters to me here is not the point of different age groups, but the more general point of regret related to futility. I think we can safely assume that the less actual chance we have to correct the outcome of past fatal decisions, the more futile, negative and destructive our feelings of regret will be. This may apply to older people more often, but it will just as well apply to someone young who made an important mistake with fundamentally irreversible consequences. It is this irreversibility that can make regret into something poisonous, into a component of depression.
So what is the best way to handle that kind of regret? The German researchers didn’t answer that question; they only noted that not-depressed older people appeared to feel their regret less intensely. But if I were to simply advise you “so try to feel your regret less intensely”, you would rightly complain that’s a hollow, meaningless advice: I could just as well advise “try to be less depressed”…
My personal view is that a really rational, detached, analytical approach is the best strategy here. If you are haunted and depressed by recurring feelings of intense regret about your failures in the past, sit down for a moment and do the following:
The Five Steps
1. Define for yourself as clearly as you can, in a few brief words, what exactly (and I mean: exactly) it is what you feel regret about. No general terms like “I failed” please: name your worst mistake specifically. 2. Next, ask yourself if there is anything you can actually do in the next days or weeks to change or correct or mitigate this particular thing you regret so deeply. Consider all possibilities. Whether it is saying sorry to someone or going to a lawyer or quitting your job or whatever. Is it a real possibility? Might it help? Is there something you could still try to do? – If yes, then all you should do is make an specific, scheduled, feasible action plan right away! Skip step 3 and 4, and jump right to 5. – If no, then the next step should be: 3. Look back carefully at your fatally wrong decision one more time. Tell yourself very consciously that this is your past, and that you’ll have to accept that it’s now too late to change or undo it. And that therefore, any further regret is in fact pointless, futile, negative, and should be barred from your thoughts. 4. Now concentrate no longer on the past, and not on the distant future either: concentrate on the here and now. Think of some unrelated, small activity that is within your scope. Be realistic. Pick something that might be distracting and rewarding, even if only a little, to take up right now. 5. Get up from your seat, and start doing it. Focus fully on what you’ve decided to do.
Will this completely and definitively liberate you from those recurring, nagging, depressing feelings of regret? Of course not. But what it may do is help you (a little) to keep those feelings within reasonable bounds, to defuse them, to make them somewhat better manageable, to prevent them from growing into a full-fledged bout of depression, and perhaps even to put them out of your head for a brief while.
If another day your feelings of regret would come down on you again with their full weight, just sit down again and start all over with those same Five Steps.
To summarize, this strategy can help you achieve two things: (a) to positively confront and defuse your regret instead of trying to run away and still getting overwhelmed by it, and (b) to focus on your actual possibilities instead on what might have been.
For this is what is always at the core of regret: it makes you focus negatively on what, if you hadn’t made that fatal mistake, might have been. To visualize this, here is the Doodle again I drew at the top of this post, this time with a little explanation:
Good. If regret keeps poisoning your life, then I hope this is of some use to you.
I think you can guess what song I’ll include here. There’s one, really only one that qualifies: the famous 1960 chanson Non, je ne regrette rien by the French singer Edith Piaf. Later, this song was covered by countless other artists all over the world.
But did you know that Piaf herself did also sing it in English? She already used to bring the original in a rather dramatic way… and in this English version, her heavy French accent adds an extra dimension to that.
• footnote 2: Yes yes yes, you don’t need to tell me. I do know that the “Chicken Or Egg?” picture in this post does show a rooster, while of course the egg should have been coupled to a hen. My mistake. But quite frankly, this is not the worst mistake I’m regretting today. ;-)
Most of us will be aware that the idea that there is one main cause of depression is overly simplistic. In some corners of the internet you’ll still find websites where this primitive idea lingers on, probably based on the hope that by just pinpointing the one essential cause, we can also indicate the one and only universal cure. But today, this is mainly the position of quacks who try to make a fast buck by selling false hope to the gullible.
Still, even in professional psychiatry and psychology, researchers and therapists sometimes tend to keep searching for causes in one specific direction: brain functions, chemical or hormonal balances, genetic inheritance, environmental factors, food or sleep or daily-behavior patterns, or some other part of the puzzle (see for example my post on “Steampunk Psychiatry”).
In an interesting research article (footnote at bottom) Denny Borsboom and four of his colleagues, psychologists at the University of Amsterdam, have now tried to outline a different and more nuanced approach – one that also leaves room for acknowledging more individual variation in the ways mental health problems can develop and grow worse over time.
Basically, they view depression (and other forms of psychiatric illness) not as one single problem but as a cluster of interconnected problems: as a complex, dynamic network of symptoms.
Put even more basically, we can say that their approach starts from something that resembles the well-known metaphor of the domino effect: the chain of reactions where in a row of standing domino stones, each falling one causes the next one to fall.
In the context of depression a typical “domino” sequence can be, for example, that you experienced a loss, consequently start brooding about it, consequently loose sleep, consequently function less well socially, consequently start feeling guilty: all these consequential symptoms re-triggering and reinforcing each other.
Two things are notable here. In the first place, the Amsterdam researchers tried to identify possible domino stones and their relations. They collected all kinds of recognized symptoms from the authoritative DSM-IV handbook and grouped them by diagnosis. In that way they were able to construct various (but partially overlapping) clusters of interconnected symptoms.
Secondly, the researchers did not assume one fixed, standard domino sequence. They also did not just suppose that the tendency-to-fall of any domino stone can differ for individual people (which they think might have to do with complex genetic connections). In their view, for different people, different domino stones can play a role, and can fall in a different sequence: even if the overall end result (what we call “depression”, the name for a cluster of those symptoms) looks more or less the same.
They visualized this schematically for two different cases:
The picture shows how within the “network” of one’s personal depression, for two people the actual connections may be very different. Each dot stands for a specific depression-related symptom: for an explanation, I must refer you to page 2 of the actual paper. The red dot at the top stands for some external life event that triggers the whole (the first domino stone, we might say).
This, in my own view, is a shortcoming here: it looks like the researchers assume, without much discussion, that there usually is some external event that initially triggers the whole cascade of symptomatic effects. I wonder if that can always said to be true. Couldn’t the process begin just as well with one random symptom, all by itself, internally, so to speak?
But I must say I find the approach of these researchers very refreshing and interesting. They also come up with original suggestions I cannot go into here in detail, such as the option of trying to define not just symptoms but also anti-symptoms in a kind of reverse-DSM list – in the domino metaphor perspective, that would be domino stones that are sturdy and stable enough to keep standing and to prevent other elements from falling.
I must warn you that their paper is, as was to be expected, a rather technical read. Sometimes it is abstract to the point of becoming hard to comprehend for ordinary mortals like you and me. The researchers clearly aim at first building some kind of theoretical framework here, some kind of basis for discussion and further research. So you should not expect much in the line of concrete, directly applicable suggestions. Still I found it original and thought-inspiring. Try taking a look!
And at least one clear lesson can be drawn. Do I need to remember you how not to fight a cascade of falling domino stones?
No, what you see here is not the wisest strategy. Many of us may futilely keep trying to resist in such a way: keep trying to change everything for the better again, all at once. But in the middle of a deep depression, this simply may mean you’re asking too much from yourself.
Instead, a much better strategy to counteract such a chain reaction is to just remove some links from the chain: to quickly pull one or two domino stones out of the row. Then even if the first ones begin to fall, all the rest – past the gap – will remain standing.
Which leaves us with a strategy tip that is in fact not new at all.
• tip: If you have many symptoms of depression (suicidal thoughts, sleep problems, feelings of guilt, eating problems, and so on) then maybe it’s a good idea to concentrate on one specific, small, single thing for a while: why not try to pull that one little domino stone out of the row?
For example, if one of the problems is you don’t have the energy to take a daily walk anymore, focus on that one thing only and try forcing yourself to take that walk anyway. It may help to interrupt the ongoing cascade.
• note: This post was about The Small World of Psychopathology by Denny Borsboom, Angélique Cramer, Verena Schmittmann, Sacha Epskamp and Lourens Waldorp from the University of Amsterdam, published November 2011 in the online peer-reviewed journal PloS ONE.
Full text of the article: PloS ONE: The Small World of Psychopathology. Next to the text you’ll also find a link for downloading the 11-page PDF version (I recommend that one, because of the diagrams and graphs).
• update: In a reaction to this post, author Denny Borsboom emphasized that they did not intend to suggest one-sidedly that a depression “cascade” usually needs some external event (such as the loss of a loved one) to be triggered. They also assume the possibility of internal physical triggers (such as chronic pain). And in line with general system theory, they also assume that in some cases one’s internal “network” can just be inherently unstable.
Last week there’s been a lot of hubbub about the background and contents of the upcoming DSM-V, the successor to the DSM-IV, the formal American Diagnostic and Statistical Manual of Mental Disorders that will be published by APA (the American Psychiatric Association) next year. I already commented about this here.
The new DSM is being prepared by several topical Work Groups, each of about 10 to 15 experts in the field. These groups are already at work since 2008, but for some reason the background of these experts is beginning to get a lot of attention now. I saw several critical news items about it; four days ago it even made a headline in the Dutch Volkskrant newspaper (one of my daily reads).
What is the reason for all this attention? The already known fact (it never was really a secret) that most of the experts who compile the new DSM are, in one way or another, on the payroll of the pharmaceutic industry.
Now first let me make clear I’m not one of those rigorous pharmaceutic-industry-bashers who think that all antidepressants, and the companies that make them, are Just Plain Evil. I think that some of us, sometimes, can really be helped by pills and by the commercial development of new medication. At some points in my life, antidepressants may have helped me too. I just think that too many people are taking those pills for no good reason, and without being aware enough of possible side effects. OK, now you know where I stand.
Today I found that blogger ALT on her ALT-MENTALITIES blog has done some fascinating research on the actual background of the experts in those DSM Work Groups. How many of these people do have direct financial ties to the pharmaceutical industry, in other words, are getting paid directly by that industries for various of their services? Like writing or just co-signing articles for them, etcetera?
Some examples: for the Psychotic Disorders Work Group this is 80% (8 out of 10); for the Mood Disorders Work Group and the Anxiety Disorders Work Group this is 56% (for both, 5 out of 9). All major pharmaceutical companies, such as Abbot Laboratories, Astra-Zeneca, Avera, Bristol-Myers Squibb, Forest, GlaxoSmithKline, GSK, Janssen-Cilag, JDS Pharmaceuticals, Johnson & Johnson, Lilly, Novartis, Pfizer, Wyeth, are paying several of these people.
ALT gives much more detailed info in her post, with striking examples of DSM Work Group experts who collect grants and payments from pharmaceuticals like so many leaves on a tree: it turns out one member of the DSM Mood Disorders Work Group has no less than 46 reported ties to pharmaceutical companies! For all this information by ALT, please read her full post: “For the DSM-V Task Force, being greasy never been so easy!”
My own comment? Look at it like this.
Suppose your city has installed an Urban Transportation Work Group of experts tasked with writing new guidelines and directives for the city’s traffic and transportation policy for the next ten years. Now suppose that most members of this Urban Transportation Work Group have direct financial ties with Ford, GM, Chrysler, BMW, Mercedes, Audi, VW, Toyota, Nissan, Honda and also with major road building companies. Would you be surprised if your city will adopt a policy of planning just more new highways and parking lots, instead of giving public transport alternatives a fair consideration too?
The amazing thing here is not the role of the pharmaceutical industry, but the role of the APA. That the industry is trying to use every possible way to influence policies and push its products, is a natural aspect of our free market society. What is amazing, is that the APA apparently does nothing to safeguard its own objectivity by keeping such influences out of the door. How can a diagnostic handbook be taken seriously if so many of its contributors have direct financial ties with commercial parties? Don’t they see that these blatant conflicts of interest completely undermine its own authority and credibility?
I am convinced that if the APA keeps allowing people who get payments from the pharmaceutical industry to contribute to their DSM, eventually the DSM will lose most of its present status and validity. And rightly so.
A background problem here is of course that it’s not just the DSM that gets ever more tainted. The same goes for psychiatry as an academic, scientific research discipline. At today’s universities, this academic work gets ever more tainted as well. When ever more researchers sacrifice their scientific objectivity and independence by accepting direct (personal) grants from industrial and other involved commercial parties, psychiatry as a serious discipline will in the end lose much of its credibility, too.
My view is that governments and universities themselves should enforce a much more strict legal line here. Either you work as researcher for a company (nothing wrong with that, in itself) or you work as an independent academic researcher for a university. In the latter case, you simply should not be allowed to accept direct commercial grants. The two positions ought to be kept strictly separated. Not combined and mixed up in the shady, non-transparent way that is contaminating much of today’s psychiatric research.
Yes, I never thought I would take the position of an idealist here… To return to the topic of the DSM, I’m not even sure if we really do need one unified authoritative diagnostic handbook. But if we do, then evidently it should by compiled by independent academic psychiatric experts. Not by people who are in any way on the payroll of Lilly or Pfizer.
If the APA remains blind to this obvious requirement, then the only solution would be for a group of truly independent academic researchers in psychiatry to get together and take the initiative themselves: to develop (in a more responsible way) an alternative diagnostic handbook, based on insights and research that can be trusted to be objective. Without any reason for bias. A handbook that deserves the respect and authority that the DSM has thrown overboard. Maybe we could get a philanthropically inclined, not directly involved company such as Google to subsidize such an effort? In the interest of us all?
I know. I already said I never thought I would take the position of an idealist here. But maybe we should not give up all hope.
Sometimes, the narrow outlook of what I’ll call “brain-focused psychiatry” exasperates me. Is depression just a matter of a few loose wires in the computer within our head? Do our feelings really got stuck just because of some faulty connection, some clog in the brain?
Sure, I won’t deny something like that can play a role, sometimes. In specific cases, a kind of malfunction in our head – something with synapses, hormones, chemicals, whatever – might be one part of a wider, complex set of problems. But there are still psychiatrists who entirely limit themselves to frantically trying to reconnect the wires, to locate that one special little button that will reboot the brain as if it were just a crashed computer.
They remind me of medieval alchemists – you know, those bearded eccentrics who stubbornly kept searching for the one magic formula that would turn stone into gold.
They also remind me of the old philosophers who, in the tradition of 17th century philosopher René Descartes (above), tried to understand and analyze and chart the human body and brain as some kind of complicated machine, with virtual cogs and wheels. Most philosophers have since long abandoned such a limited view, but some psychiatrists still seem to adhere to it.
They keep searching for that one broken cog, for that one loose wire that needs to be repaired. Maybe we should mint a new name for this kind of old-fashioned, narrow-minded psychiatry. Maybe we should call it “Steampunk Psychiatry” (if you don’t know what Steampunk is, see this Wikipedia page).
The most extreme example of Steampunk Psychiatry is of course ECT (electroshock therapy). What this amounts to, it is like taking your grandfather’s broken old pocket watch, and shaking it violently in the hope it will start running again. Actually this can work in a few cases. When I got ECT myself several years ago, perhaps it did help me a little. But it may cause only more damage just as well. (Let me prevent misunderstandings: this image here does not show ECT. It’s more Steampunk…)
Two things got me thinking about Steampunk Psychiatry today.
The first one is a research paper in the March 2012 issue of the British Journal of Psychiatry, about an experiment by Australian psychiatrists trying to treat depression with tDCS, Transcranial Direct Current Stimulation. For a readable review of the experiment, see here.
This tDCS can be considered a milder, more modern form of ECT. Unlike ECT, it is not based on the effect of electricity-induced convulsions: rather, it uses the effects of electricity itself. It involves stimulating specific parts of the brain with currents that are weak enough to make anesthesia unnecessary. As you can see here, tDCS equipment almost looks like iPod earplugs put in the wrong places. This is Steampunk Psychiatry taken to a new level of hi-tech.
According to the researchers, after a six weeks trial with 64 patients (where some got fake treatment to see the difference) they established that tDCS “is a safe and effective treatment for depression”. I’ll be no judge of that. But if ECT was like violently shaking your grandfather’s watch, we might say this is more like carefully poking into the broken watch with a tiny screwdriver. Perhaps it can indeed help some of us. What bothers me, is the complete lack of any wider perspective on the causes and nature of depression. Would an electric “screwdriver” really be the first thing we need?
This brings me to my second reason for thinking about Steampunk Psychiatry. My personal reason. Over the last weeks, my own depression has become much worse again. I won’t bother you with the nasty details. I know that I’ve been vulnerable to depression relapses for the last fifteen years anyway: I cannot pinpoint exactly why I’ve been so badly depressed several times. But I do also know that this time, clearly some external factors contribute to my depression.
To mention a few. My present network of friends may be too small for my emotional needs. I also face unexpected financial problems (an old mortgage loan I’m saddled with, has suddenly changed into a burden). For practical reasons, I’m also not happy with the place where I live today. And exactly because I had been getting better last year, I’ve now begun to miss the rewarding challenges of the university job I had to give up because of my depressions eight years ago. Also, I’ve still not been able to cut short my smoking habit, even though I know very well (cough, cough) that I really ought to quit smoking. Need I go on?
In short, my life is not what I would like it to be, I’m not at all happy with myself. And although I do of course try changing things, it’s unlikely that I can change everything to the better right now. Taken together, all these things add considerable weight to my already present (possibly innate) depression tendencies.
Would poking around in my brain, in the Steampunk way, be a solution here? Even if it might help a little, I doubt this would be a full and definitive solution. Any psychiatrist who would want to help me, would need to look at my life in a wider perspective: taking into account my inclinations, my habits, my practical problems, my mood swings, my family background, my activities, my environment and so on.
This does perhaps not apply to each of us, but I do think it applies to many of us.
The problem with Steampunk psychiatrists is not what they do. Maybe some of it can turn out useful. The problem with Steampunk psychiatrists is what they don’t do. Their narrow idea of depression is to just look into it as some kind of mechanical failure, and they forget too easily about all the rest.
Other psychiatrists, all those who have locked up themselves in different theoretical cages, often from their own perspectives make the same kind of mistake. The mistake of limitedness. The mistake of not looking beyond their own walls-of-theory, the cells that happen to confine them. This makes them too partial, too one-sided. Seeking the definitive solution in changing external circumstances. Or in adjusting the patient’s habits. In reprogramming emotional reactions. In furthering self-insight. You name it.
Those well-meaning therapists who think they can cure serious depression with the right pills, or with a long series of probing analytical talks, or with a program of healthy walks and a natural diet, or with some form of daily-life counseling, or with some form of meditative self-relaxation, are in fact all trying to give us their own kind of short-sighted Steampunk Psychiatry.
What I would like, is for psychiatrists to come out of their limited theoretical cells and for once take a look at the rest of the world. I would like them to stop viewing their otherwise oriented colleagues as marginal idiots, and to finally begin to work all together – systematically – to create a more integrated perspective on fighting depression. To recognize that each one of them, from the Steampunk tinkerer to the Freudian listener to the Socio-counselor to the Mindful type, may be a little bit right. And, sometimes, a little bit wrong.
Now if you’ll excuse me, I need to go. I need to do some urgent repairs. No I’m not thinking of my brain right now, that’s been taken care of already. If you want to know, I was thinking more of my heart. Who can tell me what’s broken in there?
Author: Henk van Setten
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Today In History:
May 22, 1859 –
Birth date of Arthur Conan Doyle, the Scottish physician and writer who in his popular stories (from 1887 to 1927) created the best known detective ever: the sharply observing and deducing Sherlock Holmes.
Doyle profiled Sherlock Holmes as an obvious bipolar character, with both manic-active and depressed-lethargic episodes. In the stories, Holmes keeps trying to overcome his periodic depressions by playing the violin (sometimes), smoking (frequently) and using cocaine (as a real addict).
Portrayed in this way, Doyle's Sherlock Holmes probably was the first popular fiction character suffering from frequent depressions.