When I started my training in psychiatry at the Maudsley Hospital I was taught that there were two types of depression, reactive and endogenous, the latter being uninfluenced by environmental factors. This distinction has faded into history, partly due to the research of George Brown and Tyrril Harris on life events and depression. Their work was foreshadowed by Holmes and Rahe who studied the relationship between life events and the development of schizophrenia in conscripts to the US Navy. Their measure of the impact of events was insufficiently objective and was superseded by the rigorous work of Brown and Harris, who inquired in detail into the individual circumstances of each person who reported an event. They also classified events as independent of the person’s behaviour or not in an attempt to clarify the issue of causality. They focused on women and found that those who had a supportive partner were much less likely to develop depression than those who lacked an intimate relationship. Their research on depression continued over several decades with increasing sophistication and led to the conclusion that events preceding episodes of depression entailed a major loss, whereas episodes of anxiety were precipitated by events that threatened losses of various kinds. In recent years they addressed the issue of causality by initiating a randomised controlled trial evaluating the efficacy of providing a female befriender for women who lacked a supportive partner. This intervention proved to protect vulnerable women from the impact of life events.
Prior to his work on depression, Brown collaborated with Michael Rutter on developing a measure of the emotional relationship between carers and their relatives with schizophrenia, which they named expressed emotion (EE). This proved to be a remarkably potent predictor of relapse in schizophrenia and also in depression, as shown by Christine Vaughn and myself. After years of focusing on schizophrenia I felt I should return to studying depression, and mounted an intervention trial for depressed patients living with a critical partner. This was a parallel to Brown and Harris’s trial of befriending, but instead of providing a supportive partner, we employed two couple therapists to attempt to improve the relationship between the patient and her/his partner. We found that couple therapy was more effective than antidepressants in treating depression and preventing relapse, and much more acceptable to the clients. Furthermore, the improvements in depression were attributable to reduction in the patient’s exposure to hostility shown by their partner.
If, as is often stated, psychiatry is the Cinderella of medicine, then social psychiatry, with its focus on human relationships, is, in the view of many biological psychiatrists, the Cinderella of psychiatry. It was George Brown who waved the fairy godmother’s wand and transformed this ragged and despised subspecialty into a substantial discipline, capable of developing innovative and efficacious treatments, which equal or even surpass the achievements of biological psychiatry, and in the case of family work for schizophrenia have been incorporated in NICE guidelines.
- Royal College of Psychiatrists