Frank’s surgery, in combination with Zyprexa, has been a success. During the year that followed, he had a few blips but was not hospitalized once. During this time he wrote to me about his progress and described being able to stay up all night to celebrate a friend’s wedding. “Before,” he wrote, “I couldn’t do that because I was always afraid I’d affect my precarious mood.” He was accepted in a graduate program at Johns Hopkins to learn science writing. With great trepidation, he decided to attend. He had a girlfriend with whom he was for the moment happy. “I’m kind of amazed when someone wants to tangle with the obvious problems that accompany me, but I’m really excited to have both companionship and romance. My girlfriend is something to look forward to.”
He successfully completed his graduate work and got a job working for an Internet start-up. He wrote me in early 2000 about Christmas. “My dad gave me two presents: first, a motorized CD rack from The Sharper Image—it’s totally unnecessary and extravagant but my dad knew I’d get a kick out of it. I opened this huge box and saw something I didn’t need at all and knew my dad was celebrating the fact that I’m living on my own, have a job I seem to love, and can pay my own bills. The other present was a photo of my grandmother, who committed suicide. As I opened the present, I began to cry. She was beautiful. She is in profile, looking downward. Dad said it was probably from the early thirties: it’s a black-and-white that he gave a soft blue matte and silver frame. My mom came over to the chair and asked if I was crying because of all the relatives I never knew and I said, ‘She had the same disease I have.’ I’m crying now—it’s not that I’m so sad—I just get overwhelmed. Maybe it’s that I could have killed myself but didn’t because those around me convinced me to keep going—and I had the surgery. I’m alive and grateful to my parents and some doctors. We live in the right time, even if it doesn’t always seem like it.”
People travel from all over West Africa, some from even farther, for the mystic ndeup ceremonies for mental illness that are practiced by the Lebou (and some Sérèr) people of Senegal. I set off for Africa to explore. The head of the primary mental hospital in Dakar, Dr. Dou-dou Saar, who practices Western-style psychiatry, said that he believes that all of his patients have sought out traditional treatments. “They are sometimes embarrassed to tell me about these activities,” he said. “But I believe that the traditional and modern healing, though they should be kept separate, must coexist; if I myself had a problem and foreign medicines did not cure me, I would go for traditional help.” Even at his establishment, the Senegalese customs prevail. To enroll there, the one who is sick must come with a caretaker family member so that they can both stay at the hospital; the caretaker is given instruction and learns some basic psychiatric principles so that he can ensure the continuing mental health of the person who is being treated. The hospital itself is rather basic—private rooms are $9 per day, semiprivate $5, and large rooms with rows of beds $1.75. The whole place stinks, and those who have been declared dangerously insane are locked up behind iron doors; you can hear their wailing and banging at all times. But there is a pleasant garden where residents grow vegetables, and the presence of the many caretakers somewhat mitigates the aura of frightening weirdness that makes many Western hospitals so grim.
The ndeup is an animist ritual that probably antedates voodoo. Senegal is a Muslim country, but the local brand of Islam turns a blind eye to these ancient practices, which take place at once publicly and somewhat secretly; you may have an ndeup and everyone will congregate around you for it, but you do not speak about it much. The mother of a friend of the girlfriend of a friend who moved to Dakar some years ago knew a healer who could conduct the ceremony, and through this elaborate connection I arranged to undergo an ndeup. Late on a Saturday afternoon, some Senegalese friends and I took a taxi from Dakar to the town of Rufisque, through tiny alleyways and run-down houses, collecting people who would be involved, until at last we reached the house of Mareme Diouf, the old woman who would perform the ceremony. Mareme Diouf’s grandmother had conducted the ndeup in this place and had taught Mareme; Mareme’s grandmother had learned from her grandmother, and Mareme said the family lore and this chain went back as far as memory. Mareme Diouf came to meet us, barefoot, wearing a headdress and a long robe that was batiked with rather frightening images of eyes and trimmed in pea-green lace. She took us to the area behind her hut, where, under the spreading branches of a baobab, there were about twenty large clay pots and as many phallic wooden posts. She explained that the spirits she brought out of people were placed in the earth beneath, and that she fed them through these pots, which were all filled with water and roots. If those people who had been through the ndeup found themselves in trouble, they came to bathe in or drink the water.
After we had seen all this, we followed her into a small, rather dark room. Some considerable discussion about what to do ensued, and she said that it all depended on what the spirits wanted. She took my hand and looked at it closely, as though it had writing on it. Then she blew on my hand and had me place it on my forehead, and she began to feel around my skull. She asked me about my sleeping habits and wondered whether I had headaches, and then she declared that we would appease the spirits with one white chicken, one red cockerel, and one white ram. Then began the haggling about the price of the ndeup; we lowered the price (to about $150) by agreeing to acquire ourselves the ingredients she would require: seven kilos of millet, five kilos of sugar, one kilo of cola nuts, one calabash, seven meters of white cloth, two large pots, one reed mat, one threshing basket, one heavy club, the two chickens, and the ram. She told me that some of my spirits (in Senegal, one has spirits everywhere, some necessary to you, some neutral, some harmful—a little bit like microbes) were jealous of my sexual relations with my living partners and that this was the reason for my depression. “We must make a sacrifice,” she declared, “to placate them, and then they will be quiet, and you will not suffer from this heaviness of depression. Your full appetites will be with you and you will sleep in peace without nightmares and the bad fear will be gone.”
We made our second trip to Rufisque at dawn on Monday. Just outside the town we saw a shepherd and stopped to buy a ram. We had some difficulty getting it into the trunk of the taxi, where it made plaintive noises and relieved itself copiously; we drove another ten minutes and once more entered the labyrinth of little streets in the sprawl of Rufisque. We left the ram with Mareme and went to the market to get the other items, which one of my friends piled up on her head like the Tower of Pisa; then we returned by horse-drawn cart to the house of Mareme Diouf.
I was instructed to remove my shoes, and then I was taken to the place where the pots reside. Fresh sand had been spread, and five women had gathered, all in loose-fitting robes with huge necklaces of agate and belts made of cloth pouches like sausages (stuffed with iconic objects and prayers). One, in her late seventies, sported a pair of enormous Jackie Onassis sunglasses. I was made to sit on a mat with my legs straight out and my palms upturned for the divination. The women took quantities of millet and poured them into the threshing basket, then added an assortment of shamanistic power objects—short, fat sticks, someone’s horn, a claw, a small bag tied up with a great deal of thread, a sort of round object made of red cloth with cowrie shells sewn onto it and a plume of horsehair. Then they put a white cloth over me and placed the threshing basket six times on my head, six times on each arm, and so on over my whole body. I was given the sticks to hold and let fall, and the women talked and consulted about the patterns. I did this six times with my hands and then six times with my feet. Several eagles came and perched in the baobab above us; this appeared to augur well. Then the women removed my shirt and put a string of agates around my neck. They rubbed my chest and back with the millet. They asked me to stand up and to remove my jeans and put on a loincloth, and they rubbed my arms and legs with the millet. Finally they collected the millet that had fallen all around and wrapped it up in a piece of newspaper and told me that I
should sleep with it under my pillow for one night and give it to a beggar with good hearing and no deformities the next day. Because Africa is a continent of incongruities, the radio was playing the theme music from Chariots of Fire during this entire procedure.
Five drummers arrived about then and began to play the tama drums. About a dozen people had already been hanging around, and as the sound of the drums spread, more and more began to gather until there were perhaps two hundred, all come for the ndeup. They formed a circle around a grass mat. The ram’s legs had been bound and he lay on his side, looking rather bemused by events. I was told that I must lie down behind him and hold him to me, as though we were spooning in bed. I was covered with a sheet, and then with perhaps two dozen blankets, so that I and the ram (which I had to hold down by the horns) were in total darkness and stifling heat. One of the blankets, which I saw afterward, had the words Je t’aime embroidered on it. The drums got louder and louder and the rhythms more inexorable, and I could hear the voices of the five women singing. Periodically, apparently at the end of a song, the drumming would stop; then one voice would begin and the drums would join and the other four voices would join and sometimes the voices of the hundreds of onlookers would also join. All the while the women were dancing around me in a tight circle, and I was embracing the ram, and they kept hitting us all over with what I later discovered was the red cockerel. I could hardly breathe and the smell of the ram was powerful (he had relieved himself again in our little bed), and the ground was shaking with the movement of the crowd and I could barely hold down the ram, which was squirming with increasing desperation.
At last the blankets were lifted and I was raised and led to dance to the drums, which kept increasing in pace. Mareme led the dancing, and everyone clapped as I imitated her stomping gestures and her swipes toward the drummers. Each of the other women in turn stepped forward and I had to imitate them, and then one at a time various women came from the crowd and I had to dance with them too. I was dizzy, and Mareme held out her arms to me and I nearly collapsed into them. One woman was suddenly possessed and danced hysterically, leaping about as though the ground were on fire, and then collapsed completely. I later learned that she had had her ndeup just a year earlier. When I was completely out of breath, the drums abruptly stopped, and I was told to remove my underwear as I would be wearing just the loincloth now. The ram was lying down and I had to step over him seven times from right to left and seven times from left to right, and then as I stood with one leg to each side of him, one of the men who had been drumming came and placed the ram’s head over a metal basin and slit the ram’s throat. He wiped one side of his knife on my forehead and the other on the back of my neck. The blood poured out and soon it had half-filled the bowl. I was instructed to bathe my hands in the blood and to break apart the lumps as they began to congeal. Still dizzy, I did as I was told, as the man beheaded the cockerel and mixed its blood with the blood of the ram.
Then we left the crowd for the area near the pots, the place where I had been earlier that morning. There the women covered me with the blood. It had to be placed on every inch of my body; they rubbed it through my hair and across my face and over my genitals and on the bottoms of my feet. They rubbed it all over me, and it was warm and the semicoagulated parts smushed over me, and the experience was peculiarly pleasurable. When I was fully covered, one of them said it was midday and offered me a Coke, which I gladly took. She let me wash some of the blood off my hand and my mouth so that I could drink. Someone else brought me some bread. Someone with a wristwatch said we might as well relax until three o’clock. A sudden lightness entered into the proceedings, and one of the women tried to teach me the songs they had been singing around me during the morning when I lay under the blankets. My loincloth was soaked through, and thousands of flies began to settle all over me, drawn by the smell of the blood. The ram, meanwhile, had been hung in the baobab, and one of the men was skinning and butchering it. Another man had taken a long knife and was slowly digging three perfectly circular holes, each about eighteen inches deep, near the pots of water from previous ndeups. I stood around trying to keep the flies out of my eyes and ears. At last when the holes were completed and it was three o’clock, I was told to sit down again, and the women fastened my arms and legs and chest with the intestines of the ram. I was told to drive seven sticks deep into each hole, making a prayer or wish with each one. Then we divided the ram’s head into three parts and put one in each of the holes; they added some herbs and a small part of each section of the animal, then small pieces of the cockerel. Mareme and I took turns putting seven cakes of millet and sugar into each of the holes. Then she took out bags of seven different powders made from leaves and bark, and she sprinkled something from each one in each hole. Then we divided and poured the rest of the blood; I was untied; the intestines went into the holes; and Mareme put fresh leaves over everything and she and the man (who kept trying to pinch her bottom) filled the holes; and then I had to stamp on each one three times with my right foot. Then I repeated these words to my spirits: “Leave me be; give me peace; and let me do the work of my life. I will never forget you.” Something about that incantation was particularly appealing to me. “I will never forget you”—as though one had to address the pride of the spirits, as though one wanted them to feel good about having been exorcised.
One of the women had glazed a clay pot with blood, and it was placed over the area we had just filled in. A club was driven into the ground, and a mixture of millet and milk and water was poured over all the inverted bowls from previous ceremonies and onto the top of the phallic clubs. Our bowl was filled with water and various herbal powders were added to it. By this time the blood on me had hardened and it was like being covered with an enormous scab, my skin utterly constricted. I was told that it was time for me to be washed. Laughing merrily, the women began peeling the blood off me. I stood up and they took mouthfuls of water and spit them over me, and in this fashion and with much rubbing the blood came off. At the end, I had to drink a pint or so of water full of the same leaf powders that Mareme had used earlier. When I was completely clean, and in a fresh white loincloth, the drumming began again and the crowd returned. This time the dancing was celebratory. “You are free of your spirits, they have left you,” one of the women told me. She gave me a bottle of water mixed with leaf powder and told me to bathe myself with this curative potion if the spirits ever troubled me again. The drummers playfully increased rhythms and I had a sportive competition with one of them, who played more and more aggressively while I jumped higher and higher—and then he conceded that it was a match. Then everyone got a few cakes and a piece of the ram (we took a leg to barbecue that evening), and Mareme told me that now I was free. It was after six in the evening. The crowd followed our taxi as long as they could and then stood waving, and we came home with the buoyant feeling of having done something festive.
The ndeup impressed me more than many forms of group therapy currently practiced in the United States. It provided a way of thinking about the affliction of depression—as a thing external to and separate from the person who suffers. It jolted the system, which could certainly throw one’s brain chemistry into overdrive—a kind of unplugged ECT. It entailed an intimate experience of community. It included close physical contact with others. It put one in mind of death and at the same time affirmed that one was oneself alive and warm and pulsating. It forced a great deal of physical movement on the sufferer. It introduced the comfort of a specific procedure to follow in the event of a recurrence. And it was bracingly energetic—an absolute tour de force of movement and sound. Finally, it was a ritual, and the effect of any ritual—being covered in the mixed blood of a ram and a cockerel or telling a professional what your mother did when you were small—is not to be underestimated. The mix of mystery and specificity is always enormously powerful.
How is one to choose among depression’s thousand therapies? What is the optimum way to treat depression? And how can one comb
ine these unorthodox treatments with more traditional ones? “I can tell you the answer that was correct in 1985,” says Dorothy Arnsten, an interpersonal therapist who has studied myriad treatment systems. “I can tell you the answer that was correct in 1992; I can tell you the one that was correct in 1997; and I can tell you the one that’s correct right now. But is there any point doing it? I can’t tell you the one that will be correct in 2004, but I can tell you that it will definitely be different from the one that’s correct right now.” Psychiatry is as much subject to trend as is any other science, and one year’s revelation is the next year’s folly.
It is hard to know exactly what the future holds. We have made but small advances in our understanding of depression at the same time that we have made enormous advances in our treatment of depression. Whether treatment can continue to outstrip insight is hard to say, since that kind of development depends to some large extent on luck; and it will take a long time for knowledge to catch up with what we can already do. Of the drugs in late-stage trials now, the most promising is reboxetine, a selective norepinephrine reuptake inhibitor. Norepinephrine, which is boosted by tricyclic antidepressants, is implicated in depression along with serotonin and dopamine, and it seems likely that a norepinephrine booster might work well with SSRIs and perhaps with Wellbutrin, a combination that would attack all the neurotransmitters. Early studies show reboxetine as a good product for raising patients’ energy and improving their social functioning, though it also seems to cause dry mouth, constipation, insomnia, increased perspiration, and accelerated heartbeat. Reboxetine is being produced by Pharmacia and Upjohn. In the meanwhile, Merck has been working on products targeted at another substance in the brain, substance P, which is involved in the pain response and which they believe is implicated in depression. The first substance P antagonist they have developed does not appear to be particularly successful in the treatment of depression, but they are investigating others.
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