Night Falls Fast

by Kay Redfield Jamison

  The illnesses most commandingly responsible for suicide are the psychiatric disorders. And nowhere is the danger of suicide more real than in the mood disorders: depression and manic-depression.

  Mood disorders, or mood disorders in combination with alcohol and drug abuse, are by far the most common psychiatric conditions associated with suicide. In fact, some type of depression is almost ubiquitous in those who kill themselves. An estimated 30 to 70 percent of people who kill themselves are victims of mood disorders; the rate is even higher when depression coexists with alcohol or drug abuse.

  In its severe forms, depression paralyzes all of the otherwise vital forces that make us human, leaving instead a bleak, despairing, desperate, and deadened state. It is a barren, fatiguing, and agitated condition; one without hope or capacity; a world that is, as A. Alvarez has put it, “airless and without exits.” Life is bloodless, pulseless, and yet present enough to allow a suffocating horror and pain. All bearings are lost; all things are dark and drained of feeling. The slippage into futility is first gradual, then utter. Thought, which is as pervasively affected by depression as mood, is morbid, confused, and stuporous. It is also vacillating, ruminative, indecisive, and self-castigating. The body is bone-weary; there is no will; nothing is that is not an effort, and nothing at all seems worth it. Sleep is fragmented, elusive, or all-consuming. Like an unstable gas, an irritable exhaustion seeps into every crevice of thought and action.

  Sylvia Plath, five years before her suicide, described the seeping, constricting side of her depression: “I have been and am battling depression,” she wrote in her journal. “I am now flooded with despair, almost hysteria, as if I were smothering. As if a great muscular owl were sitting on my chest, its talons clenching and constricting my heart.” British writer Alan Garner portrayed the cold terror of the beginnings of his manic-depressive breakdown in a different way, but the sense of horror and suffocation is palpable:

  The next thing I remember is that I was standing in the kitchen, the sunlit kitchen, looking over a green valley with brook and trees; and the light was going out. I could see, but as if through a dark filter. And my solar plexus was numb.

  Some contraption, a piece of mechanical junk left by one of the children, told me to pick it up. It was cylindrical and spiky, and had a small crank handle. I turned the handle. It was the guts of a cheap musical box, and it tinkled its few notes over and over again, and I could not stop. With each turn, the light dimmed and the feeling in my solar plexus spread through my body. When it reached my head, I began to cry with terror at the blankness of me, and the blankness of the world.

  A scene from Eisenstein’s “Alexander Nevsky” swamped my brain: the dreadful passage in which Nevsky dupes the Teutonic Knights onto the frozen lake, and the ice breaks, and their faceless armour takes them under. The cloaks float on the water before being pulled down, and the hands clutch at the ice floes, which flip over and seal in the knights.

  All that helplessness, cold and horror comprised me. I was alone in the house, and throughout the afternoon I turned the tinkle tinkle tinkle of the broken toy, which became the sound of the ice. My body was as heavy as the armour and the waterlogged cloaks as I slid beneath the ice.

  When the family came home, I was lying on the kitchen settle, in a foetal position, without moving or speaking, until I went to bed at midnight. Sleep was unconsciousness without rest.…

  I was incapable of emotion except that of being incapable of emotion. I had no worth. I poisoned the planet.

  The horror of profound depression, and the hopelessness that usually accompanies it, are hard to imagine for those who have not experienced them. Because the despair is private, it is resistant to clear and compelling description. Novelist William Styron, however, in recounting his struggle with suicidal depression, captures vividly the heavy, inescapable pain that can lead to suicide:

  What I had begun to discover is that, mysteriously and in ways that are totally remote from normal experience, the gray drizzle of horror induced by depression takes on the quality of physical pain. But it is not an immediately identifiable pain, like that of a broken limb. It may be more accurate to say that despair, owing to some evil trick played upon the sick brain by the inhabiting psyche, comes to resemble the diabolical discomfort of being imprisoned in a fiercely overheated room. And because no breeze stirs this caldron, because there is no escape from this smothering confinement, it is entirely natural that the victim begins to think ceaselessly of oblivion.

  Mania provides a violent contrast to the melancholic states. “The blood,” as Austrian composer Hugo Wolf said, “becomes changed into streams of fire”; thoughts cascade and ideas leapfrog from topic to topic. Mood is exultant but often laced with a savage and agitated irritability. One is, said Robert Lowell, “tireless, madly sanguine, menaced, and menacing.” Thought is expansive, frictionless, and astonishingly quick; talk is fast and unstoppable; and the senses are acute, engaged, and sharply responsive to the world about them.

  The fluidity of thinking in mania is matched by a seductive, often psychotic sense of the cosmic relatedness of ideas and events. (This dazzle and rush of euphoric mania make it hard for many patients to give it up.) Russian poet Velimir Khlebnikov—who was highly eccentric, wildly moody, for a time institutionalized in a mental hospital, and who was described by Mayakovsky as the “Columbus of new poetical continents … one of our masters”—believed that he possessed “equations for the stars, equations for voices, equations for thoughts, equations of birth and death.” The artist of numbers, he was certain, could draw the universe:

  Working with number as his charcoal, he unites all previous human knowledge in his art. A single one of his lines provides an immediate lightninglike connection between a red corpuscle and Earth, a second precipitates into helium, a third shatters upon the unbending heavens and discovers the satellites of Jupiter. Velocity is infused with a new speed, the speed of thought, while the boundaries that separate different areas of knowledge will disappear before the procession of liberated numbers cast like orders into print throughout the whole of Planet Earth.

  Here they are then, these ways of looking at the new form of creativity, which we think is perfectly workable.

  The surface of Planet Earth is 510,051,300 square kilometers; the surface of a red corpuscle—that citizen and star of man’s Milky Way—0.000, 128 square millimeters. These citizens of the sky and the body have concluded a treaty, whose provision is this: the surface of the star Earth divided by the surface of the tiny corpuscular star equals 365 times 10 to the tenth power (365 × 1010). A beautiful concordance of two worlds, one that establishes man’s right to first place on Earth. This is the first article of the treaty between the government of blood cells and the government of heavenly bodies. A living walking Milky Way and his tiny star have concluded a 365-point agreement with the Milky Way in the sky and its great Earth Star. The dead Milky Way and the living one have affixed their signatures to it as two equal and legal entities.

  With mania, there is a vast, restless energy and little desire or need for sleep. Behavior is erratic, impetuous, and frequently violent; drinking, sex, and the spending of money are excessive. When mania is severe, visual and auditory hallucinations, as well as delusions of grandeur or persecution, may occur. Paranoia, explosive rage, and despair not uncommonly lie beneath the expansive manic exterior.

  This weaving together of paranoia and darkness in the midst of mania is clear in the response of one of my patients to the blank card from the Thematic Apperception Test, a psychological test that requires a patient to make up a story about what he sees on the card. The patient, who was twenty-five years old at the time of testing, was hospitalized for acute mania. The story he reeled off, without pause—again, it should be noted, in response to a blank card—is saturated with paranoid overtones, overt psychosis, and a depression that is mixed with hope:

  It’s really clear, except for some spots. There are lots of germs, that’s why I’m not
holding it close to my face. It would look better with some color. There is an absence of all color except there are bits of color. I identified with the hero, afraid of germs. Color of lithium. Shapes of butterflies. Lots of symmetry, counterparts. Candy-colored bullshit. I feel like I’m being held involuntarily in a fog, don’t see much blue. Don’t see any flowers. A guy sees a bunch of black guys and weirdies, he follows the man and they find a civilization, walking like robots until they find it. They escape, find a lot of secrets about the trap. They have a run-in with the police, find a guy who looks like God who is arrested for having sex with his wife, who should have been having a test-tube baby. There is a lot of electrocardiac shock in the fog, a lot of homosexuals and green and gray people who traveled through fog into an insane asylum. They emerged out into the world and found the sun for the first time in a hundred years.

  Earlier in the century, a more exuberant patient described a grandiosity of psychotic proportions, as well as the rapid chase of ideas so characteristic of mania. But underlying the escalating thoughts and feelings were fleeting strands of self-destructiveness:

  The condition of my mind for many months is beyond all description. My thoughts ran with lightning-like rapidity from one subject to another. I had an exaggerated feeling of self importance. All the problems of the universe came crowding into my mind, demanding instant discussion and solution—mental telepathy, hypnotism, wireless telegraphy, Christian science, women’s rights, and all the problems of medical science, religion and politics. I even devised means of discovering the weight of a human soul, and had an apparatus constructed in my room for the purpose of weighing my own soul the minute it departed from my body.…

  Thoughts chased one another through my mind with lightning rapidity. I felt like a person driving a wild horse with a weak rein, who dares not use force, but lets him run his course, following the line of least resistance. Mad impulses would rush through my brain, carrying me first in one direction then in another. To destroy myself or to escape often occurred to me, but my mind could not hold on to one subject long enough to formulate any definite plan.

  Manic-depression—characterized by episodes of mania (which can be severe or mild) in addition to episodes of depression—is less common than depression but nonetheless quite prevalent. One person in a hundred suffers from the more severe form of the illness, and perhaps another two or three have the milder variations. The average age of its onset, eighteen years, is considerably younger than that for major depression, which is about twenty-six. Unlike depression, which is at least twice as common in women as in men, manic-depressive illness strikes men and women evenly. Bipolar illness is generally a more severe disorder than depression alone, recurs more frequently, and has far more of a genetic component. It is also more likely than depression to be accompanied by drug or alcohol abuse (nearly two-thirds of those with manic-depression have a serious drinking or drug problem, compared with one-fourth of those with depression alone).

  Suicide attempts are disproportionately high in both of these mood disorders. At least one person in five with major depression will attempt suicide, and nearly one-half of those with bipolar disorder will try to kill themselves at least once. Individuals with mood disorders tend also to make more serious attempts than those without depressive illnesses, and, despite often using nonviolent methods such as drug or medication overdoses, their attempts usually show more detailed planning and a greater intent to die.

  For those with mood disorders, the risk of suicide is highest if the depression is very severe, hospitalization has been required, or suicide has been attempted at some point. Mild or moderate depressions, while often painful and debilitating, do not carry with them the same high risk of suicide. Swedish researchers psychiatrically assessed an entire rural population and then kept track of their mental health for the next fifteen to twenty-five years. Virtually all the men who committed suicide during the follow-up period had been diagnosed during their initial evaluations as having depressive illness. The suicide rate for men with no psychiatric diagnosis at all was 8.3 per 100,000, but for those with depression it escalated to 650. The direct relationship between the severity of depression and suicide was the most compelling finding, however. No one with mild depression committed suicide (although characterized by the Swedish doctors as “mild,” such depressions were still sufficiently serious to lead to a radically reduced activity level), but the rate went up to 220 per 100,000 for those who had been diagnosed with moderate depression and skyrocketed to 3,900 per 100,000 for those with severe depressive illness (defined by the researchers as depression with impaired reality testing, often of psychotic proportions). The severity of depression—especially when coupled with physical agitation, alcohol or drug use, and profound emotional upheavals, losses, or disappointments in life—is far more predictive of suicide than a diagnosis of depression alone.

  Suicide appears to be slightly more common in major depression than in bipolar illness, although many people who are diagnosed with depression turn out to have mild forms of mania as well; these so-called hypomanias generally are not reported by the patients themselves, nor are they always picked up by their doctors or ascertained through psychological autopsies. Individuals who experience these mild periods of mania—usually characterized by high energy, little sleep, and marked irritability—often have coexisting alcohol or drug problems, have chaotic lifestyles, and do not take their medications as prescribed. When irritability and substance abuse are a part of the prolonged depressive phase of the illness, the volatile elements may prove to be a particularly deadly combination.

  The violent agitation of some suicidally depressed patients is impossible to comprehend unless it is intimately observed or personally experienced. These high-voltage, perturbed, yet morbid conditions are particularly common in bipolar illness during mixed states. Broadly conceptualized as the simultaneous occurrence of both depressive and manic symptoms, mixed states may exist as an independent clinical form (as mania and depression do), or they may occur as transitional conditions, bridging and blending one phase of the illness with another. They are particularly common when depression escalates into mania, mania ratchets down into depression, or depression clears into normal functioning. In the late nineteenth century, psychiatrist Emil Kraepelin captured the violent desperation of many of his manic-depressive patients:

  The patients, therefore, often try to starve themselves, to hang themselves, to cut their arteries; they beg that they may be burned, buried alive, driven out into the woods and there allowed to die.… One of my patients struck his neck so often on the edge of a chisel fixed on the ground that all the soft parts were cut through to the vertebrae.

  Behavior and moods during these periods tend to be volatile and erratic. Any combination of symptoms is possible, but the one most virulent for suicide is the mix of depressed mood, morbid thinking, and a “wired,” agitated level of energy. Paranoia, extreme irascibility, fitful sleep, heavy drinking, and physical lashing out not uncommonly go along with this particular variant of a mixed state. It is singularly and dangerously uncomfortable. Excess energy produces a kind of unhinging agitation, an “almost terrible energy,” as poet Anne Sexton put it:

  I walk from room to room trying to think of something to do—for a while I will do something, make cookies or clean the bathroom—make beds—answer the telephone—but all along I have this almost terrible energy in me and nothing seems to help.… I walk up and down the room—back and forth—and I feel like a caged tiger.

  Edgar Allan Poe, too, described a “fearful agitation,” in a letter written shortly after his suicide attempt:

  I went to bed & wept through a long, long, hideous night of despair—When the day broke, I arose & endeavored to quiet my mind by a rapid walk in the cold, keen air—but all would not do—the demon tormented me still. I CANNOT live … until I subdue this fearful agitation, which if continued, will either destroy my life or, drive me hopelessly mad.

  Mixed states, whether
they occur as depressive manias or agitated depressions, make people who experience them more likely to kill themselves. Mania itself rarely kills—and, when it does, it is usually because a patient has acted on a delusional belief that he or she can fly, walk on water, or attack an armed police officer with impunity. The intention of suicide in such situations is highly questionable.

  Before the availability of modern medications, many patients died during acute mania due to exhaustion, heart attacks, or widespread infections from unnoticed and unattended wounds in their feet that occurred during prolonged, often barefoot walks. Kraepelin described the frenetic behavior of his manic patients:

  The patient cannot sit or lie still for long, jumps out of bed, runs about, hops, dances, mounts on tables and benches, takes down pictures. He forces his way out, takes off his clothes, teases his fellow patients, dives, splashes, spits, chirps and clicks.… [There are] discharges of inner restlessness, shaking of the upper part of the body, waltzing about, waving and flourishing the arms, distorting the limbs, rubbing the head, bouncing up and down, stroking, wiping, twitching, clapping and drumming.… [Death may be caused] by simple exhaustion with heart failure (collapse) in long continuing, violent excitement with disturbance of sleep and insufficient nourishment, by injuries with subsequent blood-poisoning.

  Psychosis, the presence of hallucinations or delusions, is less clearly associated with risk for suicide in mood disorders than is the actual severity per se of depression or mixed states. Some investigators have found an increase in psychotically depressed patients, but this is by no means a consistent finding. Even though severely depressed patients with auditory hallucinations may hear voices commanding them to kill themselves, they do not appear to be more likely to actually commit suicide. Psychotic patients do, however, tend to use more violent and bizarre methods.