The Noonday Demon

by Solomon, Andrew

  Depression is often a precursor state to severe impairment of the mind. It appears to predict, to some degree, senility and Alzheimer’s disease; those diseases in turn may coexist with or kindle depression. Alzheimer’s appears to lower serotonin rates even further than does aging. We have severely limited capacities to alter the confusion and cognitive decay that are the essence of senility or Alzheimer’s, but we can alleviate the acute psychic pain that often accompanies those complaints. Many people are disoriented without being frightened or deeply sad, and this is, for the moment, a state we can achieve with these populations—but usually don’t. Some experimentation has been done to gauge whether lowered levels of serotonin may be responsible for senility, but it seems more likely that dementia follows up on damage to various brain areas, including those responsible for serotonin synthesis. In other words, the senility and the lowered serotonin are separate consequences of a single cause. It appears that SSRIs do not have much influence on motor skills or intellectual skills that are damaged by senility; but better mood frequently allows older people to make better use of the capacities that are still organically present in them, and so there may be in practical terms a certain degree of cognitive improvement. Alzheimer’s patients and other depressed elders also seem to respond to atypical medications such as trazodone, which are not usual first-line treatments for depression. They may also respond to benzodiazepines, but these tend to make them overly sedated. They respond well to ECT. The fact that they are incoherent need not consign them to misery. Among the patients who show sexual aggressivity in Alzheimer’s—a not uncommon situation—hormone therapies may help; but this seems to me to be rather inhumane unless the sexual feelings are causing misery to those who experience them. Patients with dementia are not usually responsive to talking therapies.

  Depression is also often a result of stroke. People in the first year after stroke are twice as likely to develop depression as are others. This may be the result of physiological damage to particular parts of the brain, and some research has suggested that strokes in the left frontal lobe are particularly likely to disregulate emotion. After initial recovery, many older people who have had strokes are given to terribly intense bouts of crying at slight matters negative or positive. One patient after a stroke burst into tears between twenty-five and a hundred times a day, each bout lasting between one and ten minutes, and this left him so exhausted he could hardly function. Treatment with an SSRI rapidly brought these crying fits under control; as soon as the patient went off the drug, however, the crying returned, and he is now permanently on medication. Another man who had had to give up work entirely for ten years because of depression that followed a stroke was given to fits of tears; treatment with an SSRI got him up and running again, and in his late sixties he returned to work. There is no question that strokes in certain areas of the brain have emotionally devastating consequences, but it appears that, in many instances, those consequences can be controlled.

  Unlike gender or age in depression, ethnicity does not appear to harbor biological determinants. Cultural expectations around people do, however, cause them to manifest their illnesses in particular ways. In his remarkable book Mad Travelers, Ian Hacking describes a syndrome (physical travel while unconscious) that affected many people in the late nineteenth century and that disappeared after a few decades. No one now has the problem of making physical voyages without knowing he is doing so. Certain historical periods and social sectors have clearly been afflicted by certain mental symptoms. “By a ‘transient mental illness,’ ” Hacking explains, “I mean an illness that appears at a time, in a place, and later fades away. It may be selective for social class or gender, preferring poor women or rich men. I do not mean that it comes and goes in this or that patient, but that this type of madness exists only at certain times and in certain places.” Hacking expounds the theory set forth by Edward Shorter that the same person who would in the eighteenth century have suffered from fainting spells and convulsive cries, who would in the nineteenth century have had hysterical paralysis or contracture, is now likely to suffer depression, chronic fatigue, or anorexia.

  The connections among ethnicity, education, and class, even among depressed Americans, are too tangled to catalog. Nonetheless, some broad generalities can be drawn. Juan López, of the University of Michigan, is a jolly fellow with a nice sense of humor and a warm, irreverent quality. “I’m a Cuban married to a Puerto Rican and we have a Mexican godchild,” he says, “and I lived in Spain for a while. So for Latin culture, I’ve got the bases pretty well covered.” López has worked extensively with the Michigan population of Hispanic migrant workers and with the priests who are their primary caretakers, and he has taken it upon himself to minister to their psychological needs. “The wonderful thing about the United States,” he says, “is that you can have so many different cultural backgrounds interacting with the same disease.” López has observed that Latin people are more likely to somaticize than to register their psychological problems. “You get these women, and I’m related to several of them, who come in saying, oh, my back hurts and my belly aches and my legs feel strange and so on. What I still want to know and can’t find out is whether they just say this to avoid admitting to their psychological problems, or whether they are experiencing depression this way, without feeling the usual symptoms. If they get better, as many of them do, by listening to Walter Mercado, this Puerto Rican mystic who is like a cross between Jerry Falwell and Jeanne Dixon, then what has actually happened biologically inside of them?” Depression among more educated Latin populations is probably more closely akin to depression in a general population.

  A Dominican friend of mine who is in his early forties had a surprising, sudden, overpowering breakdown when he and his second wife agreed to split up. She moved out, and he had increasing difficulty functioning in his job as a building superintendent. He was overwhelmed by simple tasks; he stopped eating; his sleep became irregular. He fell out of touch with his friends and even with his children. “I didn’t think of it as depression,” he later told me. “I thought I was probably dying and that maybe I had a physical disease. I guess I knew I was upset, but I didn’t know what that had to do with anything. As a Dominican, I am very emotional but also I guess pretty macho, and so I have a lot of feelings but I don’t feel that easy expressing them, and I wouldn’t let myself cry.” After spending two months sitting all day and night in the basement of the building where he worked—“I don’t know how I kept my job, but fortunately no one’s apartment had a serious leak or anything”—he finally took a trip home to the Dominican Republic, where he had lived for the first ten years of his life and where he still had a lot of family. “I was drinking. I sat on the plane and I got so drunk because I was so afraid of everything, of going home even. And I started crying on the plane and I cried all the length of the flight, and I stood there crying in the airport and I was still crying when I saw my uncle, who’d come to pick me up. That was bad. I was embarrassed and upset and scared. But at least I was out of that goddamned basement. Then at the beach a few days later I met this woman, this girlfriend, this pretty girl, who thought it was really glamorous that I came from the U.S. And somehow I got to seeing myself through her eyes and I began to feel better. I kept drinking, but I stopped crying because I couldn’t cry in front of her, and maybe that was good for me. You know, for me as a Dominican, especially, the attention of women is a real necessity. Without it, who am I?” A few months later, he and his wife got back together, and though his feeling of sadness lingered, his anxiety evaporated. When I mentioned medications, he shook his head. “You know, it’s not me,” he said, “taking pills for feelings.”

  Depression among African-Americans comes with its own special set of difficulties. In her beautifully poignant book Willow Weep for Me, Meri Danquah describes the trouble: “Clinical depression simply did not exist within the realm of my possibilities, or, for that matter, in the realm of possibilities for any of the black women in my worl
d. The illusion of strength has been and continues to be of major significance to me as a black woman. The one myth that I have had to endure my entire life is that of my supposed birthright to strength. Black women are supposed to be strong—caretakers, nurturers, healers of other people—any of the twelve dozen variations on Mammy. Emotional hardship is supposed to be built into the structure of our lives. It went along with the territory of being both black and female.” Meri Danquah is, ordinarily, anything but depressed: a beautiful, stylish, dramatic woman with an aura of regal authority. Her stories of lost weeks and months from her life are shattering. She never forgets her blackness. “I am so glad,” she said to me one day, “that I have a daughter and not a son. I hate to think about what life is like for black men these days, and what it would be like for a child with a family history of depression. I hate to think I might end up having that child grow up and go behind bars in the prison system. There’s not much place for black women who get depressed, but there’s no place for black men.”

  There is no typical story of black depression. Internalizing racism—self-doubt predicated on dominant social attitudes—often plays a strong role. Several of the people whose stories are included in this book are African-American; I have chosen not to identify people by race except where it seems particularly relevant to the details of their suffering. Among the many untypical stories I heard, I became especially intimate with the tale of Dièry Prudent, an African-American man of Haitian extraction, whose experiences of depression seem to have toughened his spirit and softened his interactions with other people, and who is deeply aware of the ways in which his blackness affects his emotional life. The youngest of nine children, he grew up in the impoverished Bedford-Stuyvesant area of Brooklyn and then in Ft. Lauderdale when his parents retired there. His mother worked part-time as a home health aide, his father as a carpenter. Both parents were sternly religious Seventh-Day Adventists who set high standards of comportment and rectitude, and Dièry had to reconcile these with some of the world’s toughest streets. He made himself strong, physically and mentally, to survive the tension between his family’s expectations and the daily challenges and battles imposed on him by the outside world. “I always had such a sense, even when I was a kid, of being an outsider, of being singled out for punishment and humiliation. There weren’t many other Haitians in our neighborhood when I was growing up, and we were certainly the only Seventh-Day Adventists for miles around. I was teased for being different; the kids on my block called me ‘coconut head.’ We were one of the few families who weren’t on welfare. And I was the darkest-skinned kid around, and I got singled out for that. In my family, somewhere between the cultural expectation that children be unquestioningly obedient and the religious doctrine of ‘Honor thy father and thy mother,’ I learned that it wasn’t okay to be angry—or at least to show it. I learned early to keep a stone face and keep my feelings well hidden. In contrast, there was a lot of anger on the streets, a lot of violence in our neighborhood, and when I got attacked and picked on, I turned the other cheek like our church taught us to do, and people laughed at me. I lived in a state of fear. I developed a speech impediment for a while.

  “Then when I was about twelve, I got tired of being slapped around, robbed, and beat up by bigger, tougher, more streetwise kids. I started working out and practicing martial arts. It felt good to endure the most punishing and grueling regimens I could make up. I had to make myself physically tough, but there was an emotional toughness too that I was looking for. I would have to fight my way through school, endure racism and police brutality—I’d started reading my brother’s Black Panther magazines—avoid getting drugged out or locked up. Nine years younger than my next sibling, I knew I was going to end up attending a lot of funerals—starting with my parents, who were already old when I was born. I didn’t think I had much to look forward to. My fear was combined with a deep hopelessness; I often felt sad, though I tried not to let it show. There was no release valve for the rage, so I worked out, took scaldingly hot baths for hours, read constantly to get away from my own feelings. By the time I was sixteen, my anger began bubbling to the surface. I cultivated this mystique of the kamikaze: ‘You can do whatever you want to me, but if you fuck with me, I’m going to kill you.’ The fighting became addictive, an adrenaline rush, and I felt like if I learn how to suffer, then no one can hurt me. I was trying so hard to cover up my feeling of helplessness.”

  Dièry survived the physical and the psychological pain of his adolescence and left the ghetto to attend the University of Massachusetts, where he majored in French literature. During a term abroad in Paris, he met the woman who is now his wife and decided to stay on an extra year. “Even though I was still a student,” he recalls, “I had a life that appeared glamorous. I was modeling for ad campaigns and runway shows, hanging out in the jazz scene, traveling around Europe. But I wasn’t prepared for the blatant racism of the French police.” After being stopped, frisked, and detained in about a dozen random police checks in a year, he was publicly beaten and arrested for disorderly conduct when he objected to a particularly egregious incident with the Paris cops. Dièry’s hidden rage blossomed into symptoms of acute depression. He continued to function, but there was “a heavy weight on me.”

  Dièry came back to the United States to finish his degree and in 1990 moved to New York to find a career. He landed a sequence of corporate public-relations jobs. But after five years, “I felt my professional options were very limited. I felt a lot of people I was associating with were more successful than I; others seemed to advance more quickly and have better prospects. Most importantly, I felt something was missing for me and my depression deepened.”

  In 1995, Dièry founded Prudent Fitness, his own boutique personal-training company, which has been very successful. It is with a sense of the redemptive power of exercise that he addresses his clients now, some of whom come for their sessions to the renovated Brooklyn brownstone where he lives with his wife and daughter. His treatment is holistic in spirit though disciplined in execution. His ability to bear difficulty becomes an inspiration to his clients. “I choose to engage with people at a pretty profound level, and I think my particular skill as a trainer is that I can take the most recalcitrant, resistant client and find a way to motivate him. It requires a lot of empathy, sensitivity, an adaptable style of communication. This work permits me to use all the best parts of myself to help other people, and I feel very good about that. I met a woman recently who is a social worker and who wants to combine fitness training with social work to empower the individual. I think it’s a fabulous idea. You see, this work is about gaining control over the thing you can control: your own body.”

  Dièry suffers the difficulties of both the poorer world he comes from and the wealthier world where he lives. His gracefulness, which he wears in the most casual fashion, is hard-won, and he can hold his gravitas well because he turns a sharp eye on himself in a world that is constantly ready to turn a sharp eye on him. Dièry has had a hard time making his depression known to all the members of his family. He’s not sure they would all be able to understand the disease from his perspective, even though his father and various other family members have exhibited its symptoms. It has been difficult at times for him to maintain the demeanor of the cheery younger brother, and he has not always been able to keep up the front. Fortunately, one of his sisters, a Ph.D. clinical psychologist with a private practice in Boston, helped him find a way forward when he first sought help. His wife was immediately sympathetic and was to be a staunch supporter, but for her too it was initially difficult to reconcile the masculinity and self-assurance of her husband with what she knew of depression.

  Since his first therapy in Paris, he has been in talking treatment and intermittently on antidepressant medications much of the time. His most recent work has been a five-year therapy with a woman who “has given me a kind of validation. I came to realize how much difficulty I had processing anger. I was afraid of getting angry at any
one for fear that I would just explode and destroy them. Now I am free of that fear. Through my therapy, I’ve developed a whole set of new skills. I feel more balanced. I feel more self-aware. I have an easier time identifying my feelings instead of simply reacting with them.” First his happy marriage and then the birth of his daughter have softened him. “My daughter’s vulnerability is one of the most powerful things she has. It’s her most powerful tool. It’s changed the way I feel about vulnerability and fragility.” Nonetheless, the depression returns. The fragility surfaces. The medication needs to be adjusted. “Suddenly one day a few bad things happen and I feel like I’m out of my depth in my own life. If I didn’t have the love of my wife and daughter to help me ride it out, I’d have given up a long time ago. Through therapy, I’m learning to understand what triggers the depression. With the right care and support, I’m beginning to define the disease instead of letting it define me.”