November 3, 2006
“Depakote really works.” Feels a little subdued but okay.
November 17, 2006
First week on Depakote, the spells stopped. Second week dropped back into deep depression—now back to agitation. First week the explosion episodes stopped. Felt normal. When depressed in the past, wasn’t agitated. But now wakes with sense of dread. Bipolar depression? Off BuSpar. Add Seroquel 25 mg to 50 mg to 100 mg to 200 mg. Continue Depakote and Valium. Contingency—DHMC [i.e., Inpatient Psych Unit/Dartmouth-Hitchcock Medical Center].
December 1, 2006
Seroquel stopped the worst of the symptoms … the madness. At 200 mg he dreams again. Wakes once but back to sleep. Side effects: dry mouth, felt odd, eyes jittery and unsteady. “Don’t feel like myself.” No more Valium. Can stay engaged when busy during the day. Depression’s there but no tears. Still 1250 mg Depakote and no side effects. Tired and can’t sleep during the day.
December 26, 2006
“I’m better—not amazingly so but better.” A.M.s still not great. He’s tried going down on Seroquel. 200 mg works but 150 mg has fewer side effects. Seroquel “gets me through the night.” We’ll go up to 1500 mg Depakote.
February 8, 2007
On 1500 mg Depakote he got more shaky. Went down to 1250 mg. No change in shakiness. We’ll back to 1000 mg Depakote and follow. Tremor may mean the agitated and manic state is continuing in which case would have to go up on Depakote/Seroquel again. He’s down, blunted, sad today.
March 8, 2007
Feels better on 1000 mg Depakote and 50 mg Seroquel. Then thought maybe go down further and start with an antidepressant. But still wakes up anxious. Used Wellbutrin and Celexa before. Lexapro didn’t work for him. We’ll use Seroquel as needed for sleep. Try Effexor for depression/anxiety. If doesn’t work revisit 2-week Inpatient at DHMC.
March 13, 2007
Phone: Really agitated on 37.5 mg Effexor. Lorazepam 1 mg 3x/day.
March 21, 2007
[Full Review] 54y mwm w/ long history of confusing symptoms of mood vacillation, depression, seeming ADHD, etc., throughout life with never really having sustained remission of symptoms. Predominant symptoms is melancholic depression w/hypomanic episodes complicated by alcohol self medication. Feather away Depakote and benzodiazepams over time. Also address alcohol.
Cymbalta: go 10 mg to 15 mg to 30 mg. as tolerated. Lamictal 25 mg. Continue Depakote ER 500 mg 2x/day. [There’s a “Starter Pack” for the transition from Lamictal to Depakote.] Stop Seroquel and Lorazepam and Effexor. Switch to Clonazepam 1 mg.
March 28, 2007
First A.M. after Lamictal w/Cymbalta was first time he felt good waking. Good eye contact, brighter affect, calmer, relaxed. Responded well and tolerated meds. Positive response to bipolar depression approach.
April 11, 2007
The symptoms haven’t really changed in terms of start of day. “I look forward to the end of the day … most of the day I’m sort of flat.” His journal notes: “No interest in getting up regardless of bedtime, exercise, whether I drink, food. If I get up and walk, I just cry on the walk. I’m driven and drowsy.” Hard exercise helps but can lead to dry heaves like last summer. Evening closest to “good mood.”
Good eye contact. Calmer still. Slowly stabilizing and accepting the gradual change offered by meds. Needing a lot of psych-ease and reassurance.
April 25, 2007
“People really do notice improvement.” Told him it takes time to turn the Titanic around. Focus on best times, when noticeable. Had 4-5 pretty good days. Stopped drinking since last visit. Takes a little Clonazepam at night and once in a while a nibble during the day. Mornings are tough. Good eye contact and calmer. Very good response to cross-taper Depakote to Lamictal. Continue.
May 18, 2007
A lot better. Significantly better. Two weeks ago it really kicked in. Went for bike ride and had experience of putting things in perspective. “It was such a relief, it was huge.” Working, writing, muse is back. Sleep is fine, just a little nibble of Clonazepam to sleep. Lamictal 100 mg just right. Very positive response to regime. Continue.
June 20, 2007
He says things were blissful … then settled down … then he started to feel Cymbalta wasn’t doing anything. Then he had one incident with low blood pressure. But only one classic attack; lasted a day … it was after he tried to do without Clonazepam. Didn’t notice side effects with Lamictal … Residual melancholy periodically. Slow incremental change.
July 18, 2007
“Good, good … if I had any crying it was only ½ hour … writing is easier … able to sit still and read just regular stuff.” Still a little tentative about doing things where might not be in control. Side effect curling hair. Good eye contact. Calm, clear. More enthusiasm, relaxed. Humor. Try bumping up Lamictal to 200 mg/day. Try feathering away Clonazepam.
September 14, 2007
Came with wife. “I went up to Cape Breton alone … big deal for me … a lot of that clearing away stuff.” Has some moderate dips that he manages. “I have my brain back.” Infrequent episodes vs. ongoing. “I have a lot of fun now.” Low key. Continue regime and monitor. Coach, support.
November 15, 2007
“I’m like a poster child for Lamictal.” Side effects: a little word finding. “I’m throwing nouns around with abandon.” No problem … sleep is fine. Rarely takes Clonazepam. Doesn’t oversleep as much. Much freer with writing. Happy and relieved. Looks incredibly relaxed and enthusiastic.
Annotations, References, and Random Notes
Dante and Me
I am not a Dante scholar. While I’ve probably read most every canto at one time or another, I’ve never done so sequentially. Still, I’ve thought about him a lot. More as a mythic character than a historical one; a kind of superhuman Scribe who—like Homer before him and Shakespeare after him—appears every once in a while to gather up all the human knowledge that can be held in one brain and write it down, in order to help humanity get its bearings … establish where we are in our evolution.
I’m as interested in how these writers might see the world now as I am in how they saw the world then. As if their understanding, rather than being static, has continued to evolve, following a kind of metaphysical trajectory up to and beyond our present day. To put it simply, the living Dante is not the same as the dead Dante.
At one point, I had a theory that The Divine Comedy was not the book that Dante had actually written. That rather, it was the “public” book, an expurgated version that he created for the contemporary church and state. Perhaps, I thought, there was a “secret text” of the book, hidden in some monastery or castle somewhere, that would, like an Egyptian papyrus, eventually see the light of day.
While that would make a great plot for a novel, I no longer think that’s what happened. The book we read was the book he wrote, just not the book he really wanted to write. He didn’t quite dare to reach as far as he had wanted to in terms of presenting a complete picture of human experience. It was not the church that had censored him … he had subconsciously censored himself. Or, rather, been inexorably censored by his time and place.
Fortunately, whether advertently or not, he left a clue that the journey wasn’t complete: Beatrice told him he had to go back and tell all us temporal humans what he’d seen.
Think of what that means. He goes back. Tells people what he saw in Hell, and Purgatory, and Heaven. And then what? Well, if he sticks to his plot … he goes back again. To witness again and tell again. In the meantime, the people who were in Hell are still in Hell, those in Purgatory are still in Purgatory, and those in Paradise are still Paradise. If we follow this logic … we are all in the Hell of eternal repetition.
Say what you will about history repeating itself, when you finish writing a book you want to start a new one. I see Dante, looking at his elegant script on all those ancient sheaves of parchment shaking his head and smiling affectionately at that “young” Dante. Because by now h
e realizes that as long as he keeps leaving us in Hell, he’s stuck there too. It’s time for a new story.
Even though I’ve always had this almost metaphysical affinity for Dante’s eternal journey, to invoke his name for a book like this seemed a bit contrived. While I could feel the parallels on multiple levels, on the surface our only resemblances are that we’re both Gemini writers with aquiline noses.
At first I thought, well, I’ll include some academic-type essays about Dante to try to obfuscate the apparent tenuousness of the connection. But as I began to immerse myself more deeply into both The Divine Comedy and my own writing, the parallels began to click into place in ways that felt increasingly seamless.
Eventually, I accepted that I doth protest too much. For while, as countless books have attested, The Divine Comedy is the journey of one man, it is also the journey of everyman. Indeed, my journey through Hell (and hopefully not back), was and is every bit as important to humanity as Dante’s. And so is yours. And yours. And yours.
The Dark Wood—yes, we all have been there. Limbo, we’ve been there, too. Hell and Purgatory, we’ve tasted them. And a Paradise that’s beyond the forms of this earth? Beyond contentment? Beyond bliss? Well, those who know don’t say and those who say don’t know. Me? All I can do is say I don’t know.
Translations
Not only am I not a Dante scholar, I don’t even understand Italian. Fortunately, there are many English translations of Dante’s work. At various times, I consulted ones by Henry Wadsworth Longfellow, Mark Musa, H.F. Cary, A.S. Kline, and others. The Dante quotations in this book are the result of my mixing and matching these translations, and then putting them into a vernacular that made sense to me. Heresy, perhaps. But I’m in good company.
References
Growing up in my academic household, you were only supposed to use primary sources. Looking things up in encyclopedias was a capital offense. And summaries like Cliff Notes were beneath contempt. Nevertheless, Wikipedia deserves my thanks and even a bit of my money for saving me an extraordinary amount of time when I was trying to remember for the 20TH time what year Dante was exiled or which behaviors dopamine affects. The ever-expanding website Shmoop was similarly helpful as were the Cummings Study Guides (http://www.cummingsstudyguides.net/). In all cases, you need to cross-check your facts, but sites like this sure make things easier when you encounter a factual block in the middle of a paragraph.
No matter how much cross-checking you do however, there are many things about Dante that are still subject to debate … in particular, when he started and completed each of the three books, and where he traveled while in exile. Sources disagree on the former by years and the latter by miles. Paris? Likely. England? Maybe. And then there’s the stuff of pure legend. Which son found how many remaining cantos? Where? How many months after he died? In this regard, my favorite source for the confusion about his travels while in exile is a review of the book Dante the Wayfarer which was published in The New York Times on December 2, 1905 (http://www.unz.org/Pub/BookmanUK-1905nov-00074).
After reading the introductions to various translations and roaming around the Internet, I pretty much settled on http://www.worldofdante.org/timeline.html for the basic chronology, because it was easy to follow and was developed by the University of Virginia’s Institute for Advanced Technology in the Humanities. Advanced technology? Humanities? I hear a little cognitive dissonance there. But is it all so different from Dante’s insistence on writing in the vernacular? The medium changes. The message evolves.
Beyond that, I intentionally didn’t read too much about Dante while writing this book, because, as I’ve said, my goal wasn’t to write about him so much as have a relationship with him. Since this led me to make some assertions and projections that could raise the eyes, if not ire, of Dante scholars, it’s probably best if we call those those sections “historical fiction” and leave it at that.
One biography I do need to acknowledge is Dante in Love by Harriet Rubin (2004). When I discovered this book, I felt I had met a kindred spirit because she, like me, was more interested in the living Dante than the dead one. Also her book was the one that brought to my attention the important fact that the poet called his book “The Vision of Hell, Purgatory, and Heaven.” Anyone who likes my apparently speculative sections about Dante in this book will likely enjoy Rubin’s.
Depression
There are two authors in this field that I—and most other people interested in depression—consider required reading: Kay Jamison and Peter Kramer. I was informed, illuminated, and inspired by An Unquiet Mind (1995) Jamison’s groundbreaking book about manic-depression (including her own first-hand experience); her Touched with Fire (1993) about manic-depression and creativity; and her Night Falls Fast (1999) about suicide.
I also read Peter Kramer’s Listening to Prozac (1993) and Against Depression (2005), both of which have been major forces for bringing depression “out of the closet,” as an illness that can be treated with medication, and the implications of that for understanding who we “really” are. The latter book also raises the intriguing question of what human life and creativity would look like without depression.
Whenever we read a book about some kind of suffering, we experience a kind of simultaneous relief and envy. There is, however, a place in the middle, where the emotional lives of the writer, reader, patient, caregiver, and innocent bystander all have their place and are equally deserving of acceptance and respect. While there are many memoirs of depression, bipolar, and schizophrenia, William Styron’s Darkness Visible (1990) still sets the standard. By being equally intimate and informative, he lets you into the experience without forcing you to stare or to turn away. To get a bigger picture of his experience and what it was like to live with him through it, read his daughter Alexandra Styron’s new book Reading My Father (2012).
Neuropsychiatry and Pharmacology
While I tried to make most technical terms self-explanatory in the text, I’ve included a Glossary for easier reference. It includes a chart of trade and generic names that professionals tend to use interchangeably.
The only medical text I referred to was DSM IV: Diagnostic and Statistical Manual of Mental Illness, which is published by the American Psychiatric Association. As of this writing, DSM V is about to be released. Many libraries have copies, and there are several websites that give general overviews of the various diagnoses, including http://allpsych.com/disorders/dsm.html and http://www.dr-bob.com
I tend to triangulate between a lot of different resources in order to understand the who, what, when, where, how, and why of technical topics. After a while, however, I began to rely on certain ones. The following are my major Internet resources for understanding neurotransmitters, diagnoses, and medications:
Burke, Dr. Brian: Abnormal Psychology: http://faculty.fortlewis.edu/burke_b/Abnormal/Abnormalmultiaxial.htm
Culbertson, Fred: Phobia List: http://phobialist.com/ (Not to be missed.)
Dewey, Russell A., PhD: Psychology: An Introduction. http://www.intro-psych.com/ch12_abnormal/five_axes_of_dsm-iv.html
Drugs.com: http://www.drugs.com/
EMC Publishing:/Most Commonly Prescribed Drugs: http://www.emcp.com/college_resource_centers/resourcelist.php?GroupID=7237
eMedExpert: http://www.emedexpert.com/compare/ssris.shtml
Enchanted Learning: http://www.enchantedlearning.com/subjects/anatomy/brain/Neuron.shtml (As with all complex topics, children’s books and websites are the best place to start your research … and often to end it.)
Hart, Carol: Secrets of Serotonin: http://www.nasw.org/users/twoharts/serotonin.html (My favorite comprehensive explanation of serotonin.)
Livestrong: http://www.livestrong.com/
McManamy, John: McMan’s Depression and Bipolar Web: http://www.mcmanweb.com/neurotransmitters.html (A comprehensive blog that combines really good information with memoir.)
Pharmacology Corner: http://pharmacologycorner.com/ (Some very helpful short video lectu
res.)
Poore, Jerod: Crazy Meds: (http://www.crazymeds.us/pmwiki/pmwiki.php/Main/HomePage) (The essential layperson’s guide to prescription drugs.)
Prescorn, Sheldon: Applied Clinical Psychopharmacology: http://www.preskorn.com/books/ssri_s1.html (Clarifies the history of SSRIs)
Psychresidentonline.com: http://www.psychresidentonline.com/
WebMD: http://www.webmd.com/depression/features/the-dalai-lama-and-depression-treatment
Chapter Notes
NB: Dante Alighieri was born in Florence in 1265 and died in Ravenna in 1321.
THE DARK WOOD
Words Fail
• Epigraph: From Book 5 of Marcus Aurelius’s Meditations. This 2nd century Roman emperor—as famous for his mastership of Stoicism as his military skills—is the kind of guy who gives brooding melancholic insight a good name. He spent many nights encamped with his troops in the far northern territories of the Roman Empire, writing down his reflections on what it means to be a whole human being … in terms of how you think, feel, and behave. I highly recommend a few passages next time you have to take a deep breath and accept that it really is what it is. Even when it’s not.
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