There is a surprisingly relatable description of depression and heartbreak from 3,000 years ago in Mesopotamia, the land between the Euphrates and Tigris rivers that hosted the peoples of Babylon and Assyria:
“If Depression continually falls upon him, he continually sighs, he eats bread and drinks beer but it does not go well for him, then says, ‘Oh, my heart!’ and is dejected, he is sick with Lovesickness; it is the same for a man and a woman.”
Sighing, eating bread, and drinking beer, but not feeling better: These are all recognizable qualities of a low mood or break-up in the 21st century. And yet this text was translated from what’s known as the Diagnostic Handbook— a series of 40 clay tablets that date to the first millennium B.C.E. Portions of copies of the tablets were recovered in what is now Iraq and Syria, and put together to make a complete book.
The tablets were written in the Akkadian language in a writing system called cuneiform, which involved the text being impressed onto wet clay tablets and then dried—not chiseled into hard stone, as it may look.
The clay tablets are almost alien in their appearance—these are strange, geometric grooves imprinted into rock— but they contain a treasure trove of all-too-human experiences that can feel uncannily similar to emotions we feel today.
Though the handbook and other similar texts from this period describe physical conditions including epilepsy, seizure, and skin lesions, Moudhy Al-Rashid, an assyriologist at the University of Oxford, has been especially focused on unearthing the parts that have an emotional or mental component to them, like the depression-like symptoms in this passage from a medical text that describes ailments caused by witchcraft:
“If a man eats (and) drinks, but it does not approach his flesh, he is sometimes pale, sometimes red, sometimes his face becomes darker and darker, he is worried, he is depressed, his heart is not up to speaking.”
A text from around 900 to 600 B.C.E. described people forgetting speech, losing their appetite, having nightmares, struggling to fall asleep, or having low libido: “He has no desire for [bread and] beer, he has no desire to go to a woman, his 'heart' cannot arouse him toward a woman; he babbles, he has repeated cramps, he is depressed, he continually pours out, he says, 'Have mercy on me!'” (A note on the translations: When brackets are used, it means a word missing in the original text, and inferred from other original materials or copies. Parentheses are used to denote words that were added to make the phrases more legible in English.)
Behaviors that suggested confusion— like wandering around without realizing what you’re doing, laughing without reason, or crying out—were recorded. There are, in fact, two phrases referring to crying out—one is just a sound, and the other translates to, “Oh my heart!” or “Oh my insides!”
The Diagnostic Handbook also includes, alongside the main emotional symptoms that Al-Rashid studies, many bodily complaints familiar to those dealing with anxiety or depression: stomach issues like indigestion, vertigo, dizziness, fatigue, sweating, weakness, and restlessness.
These documents are striking for how detailed they are, and also for the resonance a modern reader can find within them. They reveal how what we recognize in the present day as symptoms of mental and emotional distress have long existed in some form, even if they’ve been explained in different ways, depending on historical time and place. Sometimes, emotions are extreme enough that we enlist the help of others—in Mesopotamia that meant intervention from "exorcists" and "healers," while today it’s psychotherapy or medication.
But the interpretation of these cuneiform texts raises an issue that we still struggle with: How best to categorize emotional distress in order to make sense of it. A previous tendency in the field, called “retrospective diagnosis,” is now being resisted by the next generation of interpreters, who do not want scholars to simply assign our contemporary diagnostic categories to translations from the Diagnostic Handbook, like Obsessive Compulsive Disorder (OCD), schizophrenia, or psychopathy.
Looking at the ways mental symptoms were described forces us to reckon with our own meaning-making structures around emotional distress and place them in our specific cultural and historical contexts. It also, though, connects us to a broader legacy: For thousands of years, humans have been trying to make sense of their emotions as they exist in relationship with the world; our distant ancestors struggled with similar agonies we do; and all along, people have sought to treat, be treated for, and understand that distress.
“They, too, were trying to bring some kind of order to the chaos,” Al-Rashid said.
Al-Rashid has had depression sporadically since childhood, and the intricate characterizations of depression-like symptoms resonated with her lived experience. Similarly, I came to this topic through a paper from 2012 presenting what the authors called a description of "OCD" behaviors in Babylon. Because I have OCD, I was curious if the symptoms would be similar.
The paper was written by a pioneer translator of the Diagnostic Handbook, British assyriologist James Kinnier Wilson, in collaboration with the neurologist Edwards Reynolds. They translated the "OCD" behaviors as such:
“He does not not know why he is compelled to take (things), to hide (things)… to step in blood or walk about over a place where blood has been shed…(or why) he has a phobia of meeting an accursed person or of an accursed person meeting him, or of sleeping in the bed, sitting in the chair, eating at the table, or drinking from the cup of an accursed person.”
Kinnier Wilson also translated what he called "phobias": “He does not know why he has a (morbid) fear of beds, chairs, tables, lighted stoves, lamps… of leaving or entering (such and such) city, city gate, or house, or of (such and such) a street, temple, or road.” Other "phobias" included fear of certain days or months, of hunger, or of having the name of a god invoked in his presence.
I have certainly felt anxiety around sharing another person's cup due to intrusive thoughts around contamination, but it’s not accurate to project my experience of OCD into the past to describe what a person was going through, said Chiara Thumiger, a historian of medicine at Kiel University in Germany.
Al-Rashid said that in her opinion, Kinnier Wilson's translations are quite liberal; the original work they are excerpting from is called Shurpu, a collection of incantations to accompany a particular ritual, and it includes lists of potential sins committed by someone who might need to consult that text.
"This list method follows established methods of recording and presenting information in Assyrian and Babylonian scholarly texts where they basically try to be exhaustive by listing possibilities of things," she explained.
Calling these sins "phobias" is at best a metaphor; this could be seen as a case where retrospective diagnosis can distract from the original meaning. “The modern psychiatrist will recognize a remarkably accurate description of an agitated depression with biological features including insomnia, anorexia, weakness (and probably weight loss), impaired concentration and memory,” Kennier Wilson and Reynolds wrote.
While the symptoms may be similar, our languages are different, as is our understanding of the body, science, and medicine. Retrospective diagnosis can obscure what the texts have recorded by trying to map modern illness concepts onto them, Al-Rashid said. It doesn’t tell us the complete story.
Diseases, including what we call mental illness, were understood in Mesopotamia to come from outside the body. Whether it was a seizure, skin lesion, or depression, the cause was usually understood as being supernatural. When a person had a broken heart, it could, people thought, have been caused by a goddess that needed to be appeased. Demons could cause illness, including specific demons which were associated with specific ailments. Gods and goddesses like Ishtar, the godless of love and fertility, were responsible for a wide variety of illnesses. Ghosts could also be responsible, and were often implicated as having caused mental symptoms. Depression was often tied to the figure of the witch, which was not wielded as a personal accusation against specific others, but against a demonic and chaotic unidentified figure.
These supernatural causes weren't thought of as unusual. Our view, and word, for the supernatural implies that it's beyond the natural. But to the Mesopotamians, the supernatural was part of the everyday.
The ašipu—translated as exorcists—who would often be called on to treat the mental symptoms were not shocking horror-movie-like figures. They were part of a regulated office. Calling on them was as normal as calling any kind of other doctor or official.
“I tell my students sometimes you should think of it as if, in America, alongside the IRS, we also had the Department of Exorcism,” said Gina Konstantopoulos, an assistant professor in assyriology and cuneiform studies at the University of California, Los Angeles.”It was part of an administrative and bureaucratic framework, and was a technical profession that someone trained extensively in.”
Elsewhere in the Diagnostic Handbook are detailed descriptions that are very similar to what we understand as stroke or epilepsy—neurological conditions. In a description of what we might call today a focal motor seizure, a text describes how a person’s left eye will move to the side, his lips will pucker, spit will come out from his mouth, and the left side of his body will jerk “like a newly-slaughtered sheep.”
The authors of the text did not share our understanding of the causes of such seizures, but knew they were dangerous, and offered a quantified approach to assessing their effects: “If an epilepsy demon falls many times upon him and on a given day he seven times pursues and possesses him, his life will be spared. If he should fall upon him eight times his life may not be spared.”
Al-Rashid takes a philological approach, which means studying the language in its context and deriving its meaning from when the words are used, when they’re used with other words, and how frequently they appear. This is a lot of work—her dissertation on the context, meaning, and use of just three Akkadian words runs around 400 pages.
One of the phrases that Al-Rashid is working on right now is ḫīp libbi, which means the breaking of the heart—a literal translation. “I think it refers to a type of anxiety in some context,” she said. “But then you read another context and it’s quite clearly a stomachache.”
These complications around retrospective diagnosis don't mean we can't compare ancient texts to modern understandings—we just have to be thoughtful in the interpretations. "What I do think is useful is looking at symptoms, rather than disease or illness, and there is a lot of overlap there with what we experience today," she said.
Al-Rashid is currently looking at the metaphors people use to describe their experiences, and where there are poignant overlaps to the present. For example, there are descriptions in the ancient texts that describe the heart as being low, or the face being downcast.
“I think it’s interesting that the ‘sad is down’ metaphor appears 3000 years ago,” Al-Rashid said. “And we still do that. The word depression literally means a sunken down place.”
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“When is an emotional excess a sign of mental illness?” said Marke Ahonen, a lecturer and researcher at the University of Helsinki. “Is mental illness a thing of the body or a thing of the soul? Can philosophers treat mental illness or is it the prerogative of a medical doctor?”
These are disputes that are still unresolved, and it’s meaningful that the same issues arise in the study of the past. Today, there is ongoing discussion around the validity and application of the Diagnostic and Statistical Manual of Mental Disorders, or DSM, and whether its classifications lead to over diagnosis and the medicalization of normal human emotions.
"You can go on psychiatric Twitter almost any day and find people arguing that depression and anxiety are normal parts of life,” said Jonathan Sadowsky, a historian of psychiatry at Case Western Reserve University, and author of The Empire of Depression.
Sadowsky agreed that sadness and anxiety are typical parts of life, and responses to all sorts of life events and circumstances. But something we gain from looking to the past is an understanding that as long as people felt sad or anxious within an expected everyday range, there have also been chronic and extreme forms of these emotions that people have been trying to understand, and come up with treatments for.
“Many of the people who want to deny depression and anxiety illness status want to focus on how it’s a new construction that came out of modern psychiatry,” Sadowsky said. “And in that sense, I think understanding that these observations of severe mood disorders in medical traditions are common and ancient does have some value.”
“From quite early on, we find the idea that low mood, fear and anxiety can sometimes arise without an adequate cause and are symptoms of an illness rather than ‘normal’ emotional states,” Ahonen said.
Melancholy, as a defined illness, appeared around the 1st century B.C.E to the 1st century A.D. “In melancholy, people experience distress and fear that can be extreme and the condition often involves fanciful delusions,” Ahonen said. “It could even involve lycanthopy, the delusion that one was turned into a wolf or a wild dog. This melancholy resembles modern depression, but is also quite different from it.”
The fact that the Mesopotamian descriptions were found in the Diagnostic Handbook means that “presumably the stuff that makes it into the medical corpus is something that is sufficiently chronic or extreme to be considered not a part of normal expectable response to something,” Al-Rashid said.
But Sadowsky doesn’t think it’s the “oldness” of these emotions that definitively legitimizes depression as an illness. “I think what qualifies something as an illness category is actually a social decision that is made in different contexts,” he said. “It depends on how the culture regards the symptoms, or if they even regard them as symptoms of an illness, and how they treat them.” Depression and anxiety should be under the purview of medicine because there are treatments, Sadowsky said, both pharmacological and non-pharmacological, that can help people.
For depression, one part of the Diagnostic Handbook outlines a treatment for a person who “has frequent nervous breakdowns," "shakes with fear in his bedroom and his limbs have become ‘weak,'” “his limbs often hang limp, and he is sometimes so frightened that he cannot sleep by day or night and constantly sees disturbing dreams,” “has a 'weakness' in his limbs (from) not having enough food and drink,” and “he forgets (cannot find) the word which he is trying to say.” To treat such a condition requires a ritual of creating clay figurines, sacrificing a sheep, and chanting and incantation appealing to the god and goddess that has bestowed these ill wills on them.
“There's an understanding of extreme emotion and there's an understanding of grief and sorrow and certainly rage,” said Konstantopoulos. “But there is also an understanding that these emotions which we would think of, at least at present, as depression and extreme anxiety can be fixed within a system that has treatments and ritual procedures to address them and ritual specialists trained in those procedures.”
The past can provide lessons for the future too; Sadowsky said that looking at how antiquity and other cultures dealt with depression can help us remember that there are forms of social support and ritual that can be helpful outside of treatments like drugs or ECT.
“As to treatment," Ahonen said, "their methods often vary from cruel to ludicrous, but there are also quite sensible approaches: alleviating fear, instilling joy, bringing distraction, correcting erratic thoughts. Physical treatment, [like] drugs or bloodletting, and psychological treatment were often combined, as they still are.”
Mesopotamian treatments were often about a practitioner spending a lot of time with a person. “They would make them these fancy necklaces with shiny, precious stones, putting them on the patient, saying incantations over the patient,” said Willis Monroe, a historian at the University of British Columba who studies astronomy and astrology in cuneiform texts. “You’re probably going to feel better after that to some degree. You walk away with a shiny necklace, a nice smelling sachet, and things seem a little bit brighter.”
In one of the medical texts, Monroe said, it begins by describing all the things a practitioner may see on their way to a sick person’s house. “In our modern conception, we wouldn't think that has anything to do with a patient presenting symptoms,” he said. “But this text is teaching the practitioner to observe on the way to the house and think about what they see. It did train the practitioner to be observant in a way that I think we're learning more to do now as well.”
Another facet of the texts is that physical illnesses aren't privileged over mental illness, Konstantopoulos said. They were equally recognizable problems. And there wasn’t as much moralizing involved in mental symptoms, because they were caused by external forces.
“When we think about the stigmatization against mental illness that is present in the modern world, looking at a system where that isn’t
necessarily present in the diagnostic handbooks in how it's being presented and treated is a helpful thing to look at," she said.
Thumiger, who studies Greco-Roman antiquity, said that there’s also a lack of a sharp separation between mind and body. “Mind and body are really in a continuum and the doctor looks at both things as if they were of equal importance,” Thumiger said.
Al-Rashid believes that the messy, imperfect process of naming is important, both in past and present, because it can help make sense of what we’re experiencing. Monroe said that the fact that these texts exist, that there were practitioners who specialize in these texts, and made a living off their services shows how deep down, humans have long been trying to understand and soothe the anxiety they have about the world.
“People have always been worried about their future and about how they're feeling,” Monroe said. “And there has long been a whole genre of knowledge that has dealt with this issue: what is the future, what's going to happen to you, how can we make you feel better in the moment.”
It can be incredibly soothing to know that people have felt like you did, when you were at your lowest. I still remember vividly the first International OCD Foundation conference I went to, at the start of my OCD treatment, where I listened to panelists describe feelings and challenges that I myself was experiencing. Warm feelings of camaraderie and solidarity—and also hope—washed over me. I was not the only one to feel the way I did, and it was possible to get through it.
To Al-Rashid, one example from the Mesopomtamian texts that also serves that role is the Epic of Gilgamesh, often called the first story in the world. In it, the legendary ruler Gilgamesh grieved the loss of his friend and lover, Enkidu. Gilgamesh’s experience perfectly described what happens when you lose a person you love.
“Gilgamesh’s journey reminds anyone who has ever grieved that they’re not alone—the experience of extreme loss transcends the millennia-long gap between what it meant to be human then and what it means now,” Al-Rashid wrote recently in Psyche.
After the shock of Enkidu’s death and the subsequent funeral, Gilgamesh said, “Sorrow has entered my belly. I became afraid of death and go wandering the wild.”
"Even if the symptoms get organized slightly differently, or the labels are slightly different from one time period or place to the next, I think it’s important to show how old our experiences are,” Al-Rashid said. "There are these common denominators in our experiences of mental distress that have always been there. And a lot of people say it makes them feel less alone."
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