War and Peace was written at a time when the term ‘depression’ was not used, although the symptoms were recognised and referred to as ‘melancholy’. It is believed that Tolstoy himself had suffered from depression, and in this work he is able to powerfully convey its symptoms through Natasha Rostova. Interestingly, her father develops depression later in the book, reflecting the frequent presence of a family history.

When Natasha is well, she is charming, lively and spontaneous, and enjoys singing. She is attractive and has many suitors, becoming engaged to Prince Andrew. When Prince Andrew leaves to go travelling, womaniser Anatole seduces Natasha. She makes plans to elope with him but her family foil these and shame Natasha for her actions. Her initial reaction is one within the normal range for someone suffering an adverse life event: she does not move from the sofa, sobbing that everyone despises her, and does not sleep that night. Following the news that Anatole is in fact already married, Natasha feels foolish and humiliated. She attempts suicide by poisoning herself with arsenic, but she quickly becomes frightened and wakes her cousin, who administers an antidote. Again, we sometimes see suicide attempts in adolescents with love life troubles that they soon regret and seek help for.

Natasha's condition worsens over the following months. She is permanently low in spirits, cannot eat or sleep and grows thinner. She avoids any activities that previously brought her pleasure, such as balls and concerts as well as singing and laughing, as these feel like ‘blasphemy in face of her sorrow’. She rarely leaves the house and only feels comfortable with her brother Petya and slight happiness if close friend Pierre visits. Natasha feels that there is no future for her and no joy in life; she continues to feel guilty. She thus meets ICD and DSM criteria for depression, with five depressive symptoms lasting longer than 2 weeks and associated functional impairment. Anger from her family is replaced by them medicalising her problems and paying doctors to try to treat her ‘illness’. In 1812, when events described in the book take place, depression was not an identified illness and there were no effective treatments. Doctors tried several medications in order to appear to be helping and although Natasha knows they will not work, she seems to appreciate the effort. Her family recognising her as being ill and not apportioning blame, but trying to treat her, seem like helpful and supportive reactions.

Natasha recovers when a friend encourages her to attend church regularly. Praying for forgiveness satisfies her spiritual discomfort after doing wrong. She is also given a sense of routine and purpose, the basis of activity scheduling therapy for depression. Natasha obtains peace and happiness through her sense of forgiveness from and closeness to God, but the doctors think that their treatments have made her get better.

As 21st-century doctors, we must not assume it is always our treatments that lead to our patients' recovery – like for Natasha, this may in fact be due to changes in their social situation or their spiritual needs being met. This also illustrates the importance of thinking about our patients holistically. We teach students and trainees the importance of considering (and trying to address) physical, psychological and social aetiology factors. We should also think about spiritual issues that may be contributing to illness and encourage our patients to seek expert help, as addressing these problems may be crucial for recovery.