I have used those statistics that come out of sound studies and have been most comfortable with statistics that have been extensively replicated or frequently cited. My finding, in general, is that statistics in this field are inconsistent and that many authors select statistics to make an attractive ensemble in support of preexisting theories. I found one major study, for example, that showed that depressed people who abuse substances nearly always choose stimulants; and another, equally convincing one that demonstrated that depressed people who abuse substances invariably use opiates. Many authors derive a rather nauseous air of invincibility from statistics, as though showing that something occurs 82.37 percent of the time is more palpable and true than showing that something occurs about three out of four times. It is my experience that the hard numbers are the ones that lie. The matters that they describe cannot be defined so clearly. The most accurate statement that can be made on the frequency of depression is that it occurs often and, directly or indirectly, affects the lives of everyone.
It is hard for me to write without bias about the pharmaceutical companies because my father has worked in the pharmaceutical field for most of my adult life. As a consequence of this I have met many people in that industry. It is fashionable at the moment to excoriate the pharmaceutical industry as one that takes advantage of the sick. My experience has been that the people in the industry are both capitalists and idealists—people keen on profit but also optimistic that their work may benefit the world, that they may enable important discoveries that will put specific illnesses into obsolescence. We would not have the selective serotonin reuptake inhibitors (SSRIs), antidepressants that have saved so many lives, without the companies that sponsored the research. I have done my best to write clearly about the industry insofar as this is part of the story of this book. After his experience of my depression, my father extended the reach of his company into the field of antidepressants. His company, Forest Laboratories, is now the U.S. distributor of Celexa. To avoid any explicit conflict of interest, I have not mentioned the product except where its omission would be ostentatious or misleading.
I was frequently asked, as I wrote this book, whether the writing was cathartic. It was not. My experience conforms to that of others who have written in this field. Writing on depression is painful, sad, lonely, and stressful. Nonetheless, the idea that I was doing something that might be useful to others was uplifting; and my increased knowledge has been useful to me. I hope it will be clear that the primary pleasure of this book is a literary pleasure of communication rather than the therapeutic release of self-expression.
I began by writing about my depression; then about the similar depression of others; then about the different depression of others; and finally about depression in completely other contexts. I have included three stories from outside the first world in this book. The narratives of my encounters with people in Cambodia, Senegal, and Greenland are provided in an attempt to counterbalance some of the culturally specific ideas of depression that have circumscribed many studies in the area. My trips into unknown places were adventures tinged with a certain exoticism, and I have not suppressed the fairy-tale quality of those encounters.
Depression, under various names and in various guises, is and has always been ubiquitous for biochemical and social reasons. This book strives to capture the extent of depression’s temporal and geographical reach. If it sometimes seems that depression is the private affliction of the modern Western middle classes, that is because it is in this community that we are suddenly acquiring new sophistication to recognize depression, to name it, to treat it, and to accept it—and not because we have any special rights to the complaint itself. No book can span the reach of human suffering, but I hope that by indicating that reach, I will help to liberate some men and women who suffer from depression. We can never eliminate all unhappiness, and alleviating depression does not assure happiness, but I hope the knowledge contained in this book will help to eliminate some pain for some people.
CHAPTER I
Depression
Depression is the flaw in love. To be creatures who love, we must be creatures who can despair at what we lose, and depression is the mechanism of that despair. When it comes, it degrades one’s self and ultimately eclipses the capacity to give or receive affection. It is the aloneness within us made manifest, and it destroys not only connection to others but also the ability to be peacefully alone with oneself. Love, though it is no prophylactic against depression, is what cushions the mind and protects it from itself. Medications and psychotherapy can renew that protection, making it easier to love and be loved, and that is why they work. In good spirits, some love themselves and some love others and some love work and some love God: any of these passions can furnish that vital sense of purpose that is the opposite of depression. Love forsakes us from time to time, and we forsake love. In depression, the meaninglessness of every enterprise and every emotion, the meaninglessness of life itself, becomes self-evident. The only feeling left in this loveless state is insignificance.
Life is fraught with sorrows: no matter what we do, we will in the end die; we are, each of us, held in the solitude of an autonomous body; time passes, and what has been will never be again. Pain is the first experience of world-helplessness, and it never leaves us. We are angry about being ripped from the comfortable womb, and as soon as that anger fades, distress comes to take its place. Even those people whose faith promises them that this will all be different in the next world cannot help experiencing anguish in this one; Christ himself was the man of sorrows. We live, however, in a time of increasing palliatives; it is easier than ever to decide what to feel and what not to feel. There is less and less unpleasantness that is unavoidable in life, for those with the means to avoid. But despite the enthusiastic claims of pharmaceutical science, depression cannot be wiped out so long as we are creatures conscious of our own selves. It can at best be contained—and containing is all that current treatments for depression aim to do.
Highly politicized rhetoric has blurred the distinction between depression and its consequences—the distinction between how you feel and how you act in response. This is in part a social and medical phenomenon, but it is also the result of linguistic vagary attached to emotional vagary. Perhaps depression can best be described as emotional pain that forces itself on us against our will, and then breaks free of its externals. Depression is not just a lot of pain; but too much pain can compost itself into depression. Grief is depression in proportion to circumstance; depression is grief out of proportion to circumstance. It is tumbleweed distress that thrives on thin air, growing despite its detachment from the nourishing earth. It can be described only in metaphor and allegory. Saint Anthony in the desert, asked how he could differentiate between angels who came to him humble and devils who came in rich disguise, said you could tell by how you felt after they had departed. When an angel left you, you felt strengthened by his presence; when a devil left, you felt horror. Grief is a humble angel who leaves you with strong, clear thoughts and a sense of your own depth. Depression is a demon who leaves you appalled.
Depression has been roughly divided into small (mild or disthymic) and large (major) depression. Mild depression is a gradual and sometimes permanent thing that undermines people the way rust weakens iron. It is too much grief at too slight a cause, pain that takes over from the other emotions and crowds them out. Such depression takes up bodily occupancy in the eyelids and in the muscles that keep the spine erect. It hurts your heart and lungs, making the contraction of involuntary muscles harder than it needs to be. Like physical pain that becomes chronic, it is miserable not so much because it is intolerable in the moment as because it is intolerable to have known it in the moments gone and to look forward only to knowing it in the moments to come. The present tense of mild depression envisages no alleviation because it feels like knowledge.
Virginia Woolf has written about this state with an eerie clarity: “Jacob went to the window and stood with his h
ands in his pockets. There he saw three Greeks in kilts; the masts of ships; idle or busy people of the lower classes strolling or stepping out briskly, or falling into groups and gesticulating with their hands. Their lack of concern for him was not the cause of his gloom; but some more profound conviction—it was not that he himself happened to be lonely, but that all people are.” In the same book, Jacob’s Room, she describes how “There rose in her mind a curious sadness, as if time and eternity showed through skirts and waistcoats, and she saw people passing tragically to destruction. Yet, heaven knows, Julia was no fool.” It is this acute awareness of transience and limitation that constitutes mild depression. Mild depression, for many years simply accommodated, is increasingly subject to treatment as doctors scrabble to address its diversity.
Large depression is the stuff of breakdowns. If one imagines a soul of iron that weathers with grief and rusts with mild depression, then major depression is the startling collapse of a whole structure. There are two models for depression: the dimensional and the categorical. The dimensional posits that depression sits on a continuum with sadness and represents an extreme version of something everyone has felt and known. The categorical describes depression as an illness totally separate from other emotions, much as a stomach virus is totally different from acid indigestion. Both are true. You go along the gradual path or the sudden trigger of emotion and then you get to a place that is genuinely different. It takes time for a rusting iron-framed building to collapse, but the rust is ceaselessly powdering the solid, thinning it, eviscerating it. The collapse, no matter how abrupt it may feel, is the cumulative consequence of decay. It is nonetheless a highly dramatic and visibly different event. It is a long time from the first rain to the point when rust has eaten through an iron girder. Sometimes the rusting is at such key points that the collapse seems total, but more often it is partial: this section collapses, knocks that section, shifts the balances in a dramatic way.
It is not pleasant to experience decay, to find yourself exposed to the ravages of an almost daily rain, and to know that you are turning into something feeble, that more and more of you will blow off with the first strong wind, making you less and less. Some people accumulate more emotional rust than others. Depression starts out insipid, fogs the days into a dull color, weakens ordinary actions until their clear shapes are obscured by the effort they require, leaves you tired and bored and self-obsessed—but you can get through all that. Not happily, perhaps, but you can get through. No one has ever been able to define the collapse point that marks major depression, but when you get there, there’s not much mistaking it.
Major depression is a birth and a death: it is both the new presence of something and the total disappearance of something. Birth and death are gradual, though official documents may try to pinion natural law by creating categories such as “legally dead” and “time born.” Despite nature’s vagaries, there is definitely a point at which a baby who has not been in the world is in it, and a point at which a pensioner who has been in the world is no longer in it. It’s true that at one stage the baby’s head is here and his body not; that until the umbilical cord is severed the child is physically connected to the mother. It’s true that the pensioner may close his eyes for the last time some hours before he dies, and that there is a gap between when he stops breathing and when he is declared “brain-dead.” Depression exists in time. A patient may say that he has spent certain months suffering major depression, but this is a way of imposing a measurement on the immeasurable. All that one can really say for certain is that one has known major depression, and that one does or does not happen to be experiencing it at any given present moment.
The birth and death that constitute depression occur at once. I returned, not long ago, to a wood in which I had played as a child and saw an oak, a hundred years dignified, in whose shade I used to play with my brother. In twenty years, a huge vine had attached itself to this confident tree and had nearly smothered it. It was hard to say where the tree left off and the vine began. The vine had twisted itself so entirely around the scaffolding of tree branches that its leaves seemed from a distance to be the leaves of the tree; only up close could you see how few living oak branches were left, and how a few desperate little budding sticks of oak stuck like a row of thumbs up the massive trunk, their leaves continuing to photosynthesize in the ignorant way of mechanical biology.
Fresh from a major depression in which I had hardly been able to take on board the idea of other people’s problems, I empathized with that tree. My depression had grown on me as that vine had conquered the oak; it had been a sucking thing that had wrapped itself around me, ugly and more alive than I. It had had a life of its own that bit by bit asphyxiated all of my life out of me. At the worst stage of major depression, I had moods that I knew were not my moods: they belonged to the depression, as surely as the leaves on that tree’s high branches belonged to the vine. When I tried to think clearly about this, I felt that my mind was immured, that it couldn’t expand in any direction. I knew that the sun was rising and setting, but little of its light reached me. I felt myself sagging under what was much stronger than I; first I could not use my ankles, and then I could not control my knees, and then my waist began to break under the strain, and then my shoulders turned in, and in the end I was compacted and fetal, depleted by this thing that was crushing me without holding me. Its tendrils threatened to pulverize my mind and my courage and my stomach, and crack my bones and desiccate my body. It went on glutting itself on me when there seemed nothing left to feed it.
I was not strong enough to stop breathing. I knew then that I could never kill this vine of depression, and so all I wanted was for it to let me die. But it had taken from me the energy I would have needed to kill myself, and it would not kill me. If my trunk was rotting, this thing that fed on it was now too strong to let it fall; it had become an alternative support to what it had destroyed. In the tightest corner of my bed, split and racked by this thing no one else seemed to be able to see, I prayed to a God I had never entirely believed in, and I asked for deliverance. I would have been happy to die the most painful death, though I was too dumbly lethargic even to conceptualize suicide. Every second of being alive hurt me. Because this thing had drained all fluid from me, I could not even cry. My mouth was parched as well. I had thought that when you feel your worst your tears flood, but the very worst pain is the arid pain of total violation that comes after the tears are all used up, the pain that stops up every space through which you once metered the world, or the world, you. This is the presence of major depression.
I have said that depression is both a birth and a death. The vine is what is born. The death is one’s own decay, the cracking of the branches that support this misery. The first thing that goes is happiness. You cannot gain pleasure from anything. That’s famously the cardinal symptom of major depression. But soon other emotions follow happiness into oblivion: sadness as you had known it, the sadness that seemed to have led you here; your sense of humor; your belief in and capacity for love. Your mind is leached until you seem dim-witted even to yourself. If your hair has always been thin, it seems thinner; if you have always had bad skin, it gets worse. You smell sour even to yourself. You lose the ability to trust anyone, to be touched, to grieve. Eventually, you are simply absent from yourself.
Maybe what is present usurps what becomes absent, and maybe the absence of obfuscatory things reveals what is present. Either way, you are less than yourself and in the clutches of something alien. Too often, treatments address only half the problem: they focus only on the presence or only on the absence. It is necessary both to cut away that extra thousand pounds of the vines and to relearn a root system and the techniques of photosynthesis. Drug therapy hacks through the vines. You can feel it happening, how the medication seems to be poisoning the parasite so that bit by bit it withers away. You feel the weight going, feel the way that the branches can recover much of their natural bent. Until you have got rid of the vine, you can
not think about what has been lost. But even with the vine gone, you may still have few leaves and shallow roots, and the rebuilding of your self cannot be achieved with any drugs that now exist. With the weight of the vine gone, little leaves scattered along the tree skeleton become viable for essential nourishment. But this is not a good way to be. It is not a strong way to be. Rebuilding of the self in and after depression requires love, insight, work, and, most of all, time.
Diagnosis is as complex as the illness. Patients ask doctors all the time, “Am I depressed?” as though the result were in a definitive blood test. The only way to find out whether you’re depressed is to listen to and watch yourself, to feel your feelings and then think about them. If you feel bad without reason most of the time, you’re depressed. If you feel bad most of the time with reason, you’re also depressed, though changing the reasons may be a better way forward than leaving circumstance alone and attacking the depression. If the depression is disabling to you, then it’s major. If it’s only mildly distracting, it’s not major. Psychiatry’s bible—the Diagnostic and Statistical Manual, fourth edition (DSM-IV)—ineptly defines depression as the presence of five or more on a list of nine symptoms. The problem with the definition is that it’s entirely arbitrary. There’s no particular reason to qualify five symptoms as constituting depression; four symptoms are more or less depression; and five symptoms are less severe than six. Even one symptom is unpleasant. Having slight versions of all the symptoms may be less of a problem than having severe versions of two symptoms. After enduring diagnosis, most people seek causation, despite the fact that knowing why you are sick has no immediate bearing on treating the sickness.
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