Medical Mystery: What caused Lincoln's severe bouts of depression?

In 1833, the 24-year-old Abraham Lincoln met the love of his life when he was a boarder at her father's tavern. Ann Rutledge, 18, was a beautiful girl with expressive blue eyes, fair complexion, and sandy hair, according to a local schoolmaster.

The two were engaged, but soon after, Ann became severely ill and died of "fever" of unknown origin. Typhoid may have been spreading through the community.

Lincoln's law partner, William H. Herndon, later wrote that during Ann's illness, Lincoln "neither ate nor slept and his mind wandered from its throne." Lincoln visited his fiancee on her deathbed and Herndon noted: "his heart, sad and broken, was buried in her grave." Lincoln sadly told a friend: "I did honestly and truly love the girl and think often of her now." Still, her death sent him into a nervous breakdown, and friends even said he spoke of suicide.

It took him years to recover from Ann Rutledge's death. In December 1839, he met Mary Todd, daughter of a wealthy Lexington, Ky., slave-holding family. Their wedding was canceled when a deeply conflicted Lincoln broke off their engagement.

That event precipitated Lincoln's next severe bout with depression, or melancholia as it then was called, in the winter of 1840-41. He again took to his bed and talked of death.

Seemingly recovered, Lincoln later met Mary Todd again and the couple decided to get married on Nov. 4, 1842, in the Springfield mansion of Mary's sister.

But before the ceremony, Lincoln walked out of the house. When asked where he was going, he replied, "To hell, I suppose." Still, he went through the wedding.

The standard treatment of the day for melancholia was aggressive purging of the body, drawing of blood, swallowing mercury, and other toxic substances to induce vomiting and diarrhea plus starving the patient. We know that Lincoln endured a "treatment" that consisted of immersion in ice cold water up to his neck.

What kind of diagnosis would Lincoln receive, were he alive today? How would his emotional state affect the rest of his life and his presidency?

Today, psychologists and grief counselors recognize that bereavement can cue the onset of depressive symptoms that can last for years. Lincoln certainly fits this description, given the many losses he suffered.

Life had almost never been without grief and loss for the young man who would become our 16th president.

Lincoln was just 9 when his mother suddenly died. By the time he was 20, he had also buried an aunt, uncle, sister, and a newborn brother. He never had a good relationship with his father, who rented out young Abe for odd jobs such as splitting logs and rails. As a young politician, he was sometimes called the "Rail Splitter."

A cousin, John Hanks, said Lincoln described his situation more harshly, saying, "I was a slave." 

Also, bereavement disorder can become chronic in individuals with a personal history or family history of depression, which was the case for Lincoln.

Joshua Wolf Shenk, author of Lincoln's Melancholy: How Depression Challenged a President and Fueled His Greatness notes that Lincoln was in his mid-20s when he had his first breakdown (after Ann Rutledge's death), suffering what we today would call unipolar depression. 

But whether one regards his depression as situational, biological, or both, it's certain that he would face terrible challenges in both his personal and political life until his assassination in 1865.

Three of the four boys born to the Lincolns died before they were 19; both parents experienced depression following these devastating losses. Only Robert, their first-born child, lived to adulthood.

Even on the campaign trail, Lincoln was hardly the smiling politician Americans have come to expect. 

In February 1860, he gave an address at Cooper Union in New York that by all accounts was a triumph - though not apparently to Lincoln.

"No man in all New York appeared that night more simple, more unassuming, more modest, more unpretentious, more conscious of his own defects," said Republican Charles Nott, who saw Lincoln as a "sad and lonely man."But far from a character issue and a political liability, many historians believe Lincoln's personal suffering helped make him the president who kept the union together. 

They argue that his own experiences gave him greater empathy for the slaves, influencing him to issue the Emancipation Proclamation and urge approval of the Thirteenth Amendment. They also point out that as Robert E. Lee surrendered at Appomattox, Lincoln ordered General Ulysses S. Grant to make sure that the surrendering soldiers had provisions to return home. 

As Shenk wrote: "Lincoln didn't do great work because he solved the problem of his melancholy; the problem of his melancholy was all the more fuel for the fire of his great work."

Allan B. Schwartz, M.D., is a professor of medicine in the Division of Nephrology & Hypertension at Drexel University College of Medicine.

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