Why does ECT work? We don’t know. It seems to have a strong enhancing effect on dopamine and affects all the other neurotransmitters as well. It can also affect metabolism in the frontal cortex. High-frequency electricity seems to raise the metabolic level; low-frequency electricity can lower the metabolic level. Of course, it is not clear whether depression is one of many symptoms of hypometabolism, agitated depression a symptom of hypermetabolism, or whether both depression and these alterations of metabolism are functions of some other change in the brain. ECT temporarily lowers the blood-brain barrier. The effects of ECT are not limited to the frontal cortex; even the brain-stem functions are temporarily affected by the electric charge.
I’ve decided not to go off my medications. I’m not sure that I’m addicted, but I am dependent: without the drugs I would run the risk of emerging symptoms of illness. It’s a fine line. I have gained an unbecoming amount of weight. I get weird hives for no apparent reason. I sweat more. My memory, never very good, is mildly impaired: I frequently forget what I am saying in the middle of a sentence. I get headaches a lot. I get occasional muscular cramps. My sex drive comes and goes and my sexual function is erratic: an orgasm is a special occasion nowadays. It’s not ideal, but it seems to have put up a real wall between me and depression. The last two years are without question my best in a decade. Slowly, I will now catch up. When two friends died not long ago, both in freak accidents, I felt terribly sad, but I did not feel my self slipping out of my hands, and to feel just grief was almost (I know this sounds terrible, but in some selfish way it is true) a kind of satisfaction.
The question of what functions depression serves in the world we inhabit is not quite the same as the question of what function antidepressants are coming to serve. James Ballenger, anxiety expert, says, “We’re eight inches taller than we were before the Second World War, and much healthier, and we’re living longer. No one complains about the change. When you remove a disability, people go out in life and find more, both good and bad.” And that, I think, is really the response to the question that I was asked by almost everyone to whom I mentioned this book. “Don’t these drugs blank out your life?” No. What they do is to allow you to have your pain in more important places, in better places, for richer reasons.
“You’ve got twelve billion neurons,” says Robert Post, chief of the Biological Psychiatry Branch of the National Institute of Mental Health. “Each one’s got between one thousand and ten thousand synapses, all changing at rapid speed. Getting them all to run just right so that people are wonderfully happy all the time—we’re a long, long way from that.” James Ballenger says, “It’s not been my impression that the suffering level in the universe has gone down much, with all our improvements, and I don’t think we’ll reach a tolerable level anytime soon. Mind control need not occupy us at present.”
Normal is a word that haunts depressives. Is depression normal? I read of normal groups and depressive groups in studies; of medication that could “normalize” depression; of “normal” and “atypical” clusters of symptoms. One of the people I met during this research said to me, “At first when these symptoms began, I thought I was going crazy. It was a big relief to find out that it was just a clinical depression and that it was basically normal.” It was, of course, basically the normal way to go crazy; depression is a mental illness, and when you are in its throes, you’re crazy as a loon, a bit balmy, a few sandwiches short of a picnic, bats in the belfry.
At a cocktail party in London, I saw an acquaintance and mentioned that I was writing this book. “I had terrible depression,” she said. I asked her what she had done about it. “I didn’t like the idea of medication,” she said. “I realized that my problem was stress-related. So I decided to eliminate all the causes of stress in my life.” She counted off on her fingers: “I quit my job. I broke up with my boyfriend and never really looked for another one. I gave up my roommate and now I live alone. I stopped going to parties that run late. I moved to a smaller place. I dropped most of my friends. I gave up, pretty much, on makeup and clothes.” I was looking at her with horror. “It sounds bad, but I’m really much happier, and much less afraid than before.” And she looked proud. “And I did it without pills.”
Someone who was standing in our group grabbed her by the arm. “That’s completely crazy. That’s the craziest thing I’ve ever heard. You must be crazy to be doing that to your life,” he said. Is it crazy to avoid the behaviors that make you crazy? Or is it crazy to medicate so that you can sustain a life that makes you crazy? I could downgrade my life and do fewer things, travel less, know fewer people, and avoid writing books on depression—and perhaps if I made all those changes, I would not need medications. I might live my life within the bounds of what I can tolerate. It is not what I have opted primarily to do, but it is certainly a reasonable option. Living with depression is like trying to keep your balance while you dance with a goat—it is perfectly sane to prefer a partner with a better sense of balance. And yet the life I lead, full of adventure and complexity, affords me such enormous satisfaction that I would hate giving it up. I would hate that more than almost anything. I would sooner triple the number of pills I take than cut my circle of friends in half. The Unabomber—whose techniques of communicating his Luddite sensibilities were disastrous but whose insights into the perils of technology are sound—wrote in his manifesto, “Imagine a society that subjects people to conditions that make them terribly unhappy, then gives them the drugs to take away their unhappiness. Science fiction? It is already happening. . . . In effect, antidepressants are a means of modifying an individual’s internal state in such a way as to enable him to tolerate social conditions that he would otherwise find intolerable.”
The first time I ever saw clinical depression, I didn’t recognize it; in fact, I didn’t really even notice it. It was the summer after my freshman year in college, and a group of us were at a house where my family spends summers. My good friend Maggie Robbins was there, charming Maggie, always so lustrous with energy. Maggie had had a psychotic manic breakdown in the spring and had been in the hospital for two weeks. Now she seemed to have recovered from that. She was no longer saying crazy things about finding secret information in the basement of the library and about having to stow away on a train to Ottawa, so we all presumed mental health; her long silences that summer weekend seemed ponderous and deep, as though she had learned to weigh the value of her words. It was strange that she hadn’t brought a bathing suit—not until years later did she tell me she had felt that she couldn’t be so naked and vulnerable and exposed as she would have been without all her clothes on. We were all splashing merrily, giddy and sophomoric. Maggie sat in a long-sleeved cotton dress on the diving board and watched the merriment and pulled her knees up under her chin. Seven of us were there, and the sun beat down, and only my mother said (in an aside to me) that Maggie seemed awfully withdrawn. I had no idea how hard Maggie was trying, not the slightest inkling of what she was pushing herself through. I didn’t notice the dark circles she must have had under her eyes, the ones I have since learned to check for. I do remember that we all kept teasing her about not swimming, about missing the fun, until finally she stood up at the end of the diving board and took a dive, dress and all. I remember that leaden clothing clinging to her as she swam one length of the pool, then trudged damply back to the house to put on dry clothes, the water dripping off into the grass. It was a few hours before I found her inside, napping again. When she didn’t eat much at dinner, I thought she didn’t like steak or was watching her waistline. Curiously enough, I remember that as a happy weekend, and I was shocked when Maggie reported her experience as illness.
Fifteen years later, Maggie suffered the worst depression I have ever seen. With stunning incompetence, her doctor had told her that after fifteen years of doing well she might want to try going off lithium, as though curing had happened and her severe bipolar illness were rinsed out of her body. She had slowly lowered her dose. She had felt grea
t. She had lost weight, and her hands had finally stopped shaking, and she had recovered some of that old Maggie energy, the energy she had had when she’d first told me that her lifelong goal was to be the most famous actress in the world. Then she began to feel inexplicably great all the time. We all asked her whether she wasn’t worried that she was getting a teeny bit manic, but she assured us she had not felt so well in years. That should have told us all we needed to know: feeling so well was not a good thing. She was not so well. She was not so well at all. Within three months, she had concluded that God was directing her and she was on a mission to save the world. A friend took her in hand and, when he couldn’t reach her psychiatrist, found another and got her back on medications. During the months that followed, she crashed into depression. The next autumn, she went to graduate school. “Graduate school gave me a lot; for one thing, it gave me the time and space and loans to have two more episodes,” she joked. During her second term, she had a mild hypomania, then had a mild depression; at the end of her fourth term she skyrocketed into total mania, and then plunged into a depression so deep it seemed boundless. I remember Maggie at a friend’s loft, curled up on the couch in a tight ball, wincing as though someone were putting slivers of bamboo under her fingernails. We didn’t know what to do. She seemed to have lost speech altogether; when we finally got a few words out of her, they were barely audible. Fortunately, her parents had learned all about bipolar illness over the years, and that night we helped her move into their apartment. That was the last any of us was to see of her for two months as she lay in a corner there, not stirring for days at a time. I had been through depression, and I wanted to help, but she could not talk on the phone and she did not want visitors, and her parents knew enough to give her leeway for silence. I have felt more closely in touch with the dead. “I will never go through that ever again,” she has said. “I know that I would do anything that I had to do to avoid that, that I absolutely refuse.”
Now Maggie is doing well on Depakote and lithium and Wellbutrin, and though she keeps Xanax on hand, she has not needed it in a long time. She is off the Klonopin and Paxil she took at the beginning. She will be on medication permanently. “I needed to develop the humility to say, ‘Wow, maybe some of the people who decided to go on medications are just like me and never meant to ever, ever, ever go on medications in their whole life for any reason. And then they did, and it has helped them.” She writes and makes art; she works a day job as a copyeditor at a magazine. She doesn’t want a more high-powered day job. She wants some security and some health insurance and a place where she needn’t be brilliant all the time. When she gets pensive—or angry—she writes poetry about an alter ego she has created for herself, whom she calls Suzy. Some of her poetry is about being manic. Some of it is about being depressed:
Someone’s standing in the bathroom,
staring into Suzy’s eyes.
Someone with the look of voices
Suzy doesn’t recognize.
Someone living in the mirror
Some fat face that cries and cries.
Suzy’s skull is packed and pounding.
Suzy’s teeth are shaking loose.
Suzy’s hands are slow and tremble
covering the glass with mousse.
Suzy studied knots one summer.
Suzy doesn’t know a noose.
Suzy feels a veil get lifted.
Suzy hears a veil get torn.
Then the truth lies, pinned, before her—
stark and struggling, woken, worn.
Hunger pangs are all that’s certain,
All we’re given when we’re born.
“I decided when I was eight years old,” she told me, “that I was Maggie. I remember doing this in school, in a hallway, saying, ‘You know, I’m Maggie. And I’m just always going to be me. This is the me, right now, that I’m going to be. I’ve been different because I can’t even remember some of my life, but from right now on, it’s going to be just me.’ And it has been. And that’s been my sense of identity. I’m that same person. I can look back and say, ‘Oh, God, I can’t believe I did that dumb thing when I was seventeen.’ But it was me doing it. I don’t have any discontinuity of self.”
To have an immutable sense of self through the outrage of manic-depressive illness attests to a great strength. Maggie has reached stages of wanting to be released from this coherent self. In that horrifying, almost catatonic depression, she says, “I would lie in bed singing ‘Where Have All the Flowers Gone’ over and over to occupy my mind. I realize now that I could have had some other drugs, or that I could have asked someone to come and sleep in my room, but I was just too sick to think of that. I couldn’t say what scared me so much, but I thought I would explode from the anxiety. I just went down and down and down and down. We kept changing medications and I just kept going further down. I believed my doctors; I always accepted that I would eventually come back to normal. But I couldn’t wait; I couldn’t even do the next minute. I was singing to blot out the things my mind said, which were: ‘You are—you don’t even deserve to live. You are worthless. You are never going to be anything. You’re nobody.’ And that was when I really started thinking about killing myself. I’d considered it before, but now I was really planning it. I had an almost constant imagining of my own funeral. While I was staying with my parents, I had this whole image of myself going up to the roof and over the edge in a nightgown. There was an alarm on the door to the roof and I would set off the alarm, but it wouldn’t matter; I’d be over the edge before anyone else could get up there. I couldn’t take any risk of it not working. I picked out what nightgown I would wear. And then some vestige of my self-esteem kicked in and reminded me of how many people would be sad if I did that, and I couldn’t bear the responsibility of causing that many man-hours of sadness. I had to acknowledge to myself the aggression of suicide against others.
“I think that I repressed a lot of the memory of it. I can’t get at it; it’s impossible to remember because it doesn’t make sense. But I can remember certain parts of the apartment, and how bad I felt there. And I can remember the stage that came next, when I thought about money all the time. I would start to fall asleep and then wake up worried; I couldn’t shake that. It wasn’t very rational—I wasn’t in trouble financially at the time. I’d think, what if I don’t have very much money ten years from now? There’s no relation whatsoever between feelings of fear and anxiety in my normal life and the kind of fear or anxiety I was having at that time. It’s of a completely different quality, not just quantity. Man, those were terrible times. I finally had the good sense to switch doctors. And then I got the Xanax. I’d take a half milligram or so and I felt as if the heel of a giant hand came and settled itself on my hip and the rest of the hand pressed my side, the fingers on my shoulder. That whole hand just pushed me about two inches down into the bed. And then I would finally fall asleep. I was terrified that I’d get addicted, but the doctor assured me that I wouldn’t—I wasn’t taking anywhere near enough for that—and said that even if I did, he would get me off it when I was better able to handle life. So I thought, okay, I’m not going to think about it; I’m just going to do it.
“You don’t think in depression that you’ve put on a grey veil and are seeing the world through the haze of a bad mood. You think that the veil has been taken away, the veil of happiness, and that now you’re seeing truly. You try to pin the truth down and take it apart, and you think that truth is a fixed thing, but the truth is alive and it runs around. You can exorcise the demons of schizophrenics who perceive that there’s something foreign inside them. But it’s much harder with depressed people because we believe we are seeing the truth. But the truth lies. I look at myself and I think, ‘I’m divorced,’ and it seems like that is the most terrible thing. While I could be thinking, ‘I’m divorced!’ and feel great and free about it. Only one remark was really helpful through all of this. A friend said, ‘It won’t always be like this. See if you can just remembe
r that. It’s like this right now, and it won’t always be like this.’ The other thing she said, which also helped, was, ‘That’s the depression talking. It’s talking through you.’ ”
Therapy and medication are the most accessible treatments for depression, but another system has helped many people to cope with their illness, and that is faith. Human consciousness may be seen bound by the sides of a triangle: the theological, the psychological, and the biological. It is enormously difficult to write about faith because it trades in the unknowable and the indescribable. Further, faith in the modern world tends to be highly personal. Nonetheless, religious belief is one of the primary ways that people accommodate depression. Religion provides answers to unanswerable questions. It cannot usually pull people out of depression; indeed, even the most religious people find that their faith thins or vanishes during the depths of depression. It can, however, defend against the complaint, and it can help people to survive depressive episodes. It gives reasons to live. Much religion allows us to see suffering as laudable. It grants us dignity and purpose in our helplessness. Many of the goals of cognitive and psychoanalytic therapy are accomplished by the systems of belief that underlie the world’s primary religions—the refocusing of energy outside the self, the discovery of self-regard, the patience, the breadth of understanding. Faith is a great gift. It provides many of the advantages of intimacy without being contingent on the whim of a person, though God too is, of course, famous for his whims. There is a divinity that rough-hews our ends, shape them though we will. Hope is a great prophylactic, and faith in its essence offers hope.
You survive depression through a faith in life that is as abstract as any religious belief system. Depression is the most cynical thing in the world, but it is also the origin of a kind of belief. To endure it and emerge as yourself is to find that what you did not have the courage to hope may yet prove true. The discourse of faith, like that of romantic love, has the disadvantage that it carries the potential for disillusionment: depression is for many people an experience of being cast out by God or abandoned by Him, and many who have been depressed say they are unable to believe in a God who inflicts such cruelty so uselessly on the members of His flock. For most of the faithful, however, this rage against God lifts as the depression does. If belief is your norm, you return to it as you do to any other norm. Formal systems of religion lie outside my upbringing and experience, but I find it hard to stave off the sense of intervention that characterizes one’s decline and one’s rise. It is a matter too deeply felt to be a godless act.
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