“The most important theme in my work is redemption,” Bill Stein says. “I still don’t know my role in things. I’m drawn to stories of saints and martyrs. I don’t think I could endure what they have gone through. I’m not ready to set up a hospice in India, but depression put me on the right course. I meet people and I know that they don’t have the level of experience that I have. The fact that I got through such a catastrophic illness has permanently changed my interior landscape. I was always drawn to faith and goodness, but I wouldn’t have had the drive, the moral purpose, without the breakdowns.”
“We walked through hell to find paradise,” Tina Sonego says. “My reward is very simple. I am now able to understand things that I just could not understand before; and the things I don’t understand now, I will in time, if they matter. Depression is responsible for making me who I am today. What we gain is so quiet but so loud.”
“Our needs are our greatest assets,” Maggie Robbins says. If it is through our needs that we come to know ourselves, that we open ourselves up to others, then neediness can breed intimacy. “I am able to just be there with people because of the stuff I’ve needed from people. I guess I’ve learned to give all the things I need.”
“Mood is—another frontier, like deep ocean or deep space,” Claudia Weaver says. “Having so much low mood gives you mettle; I think I deal with difficult losses better than most other people because I have so much experience of the feelings they entail. Depression isn’t an obstacle in my path; it’s a sort of part of me that I carry along down the path, and I believe that it’s supposed to help me at various points. How? That I don’t know. But I believe in my depression, in its redemptive power, nonetheless. I’m a very strong woman, and that’s partly because of the depression.”
And Laura Anderson wrote, “Depression has given me kindness and forgiveness where other people don’t know enough to extend it—I am drawn toward people who might put off others with a wrong move or a misplaced barb or an overtly nonsensical judgment. I had an argument about the death penalty tonight with someone, and I was trying to explain, without being too self-referential, that one can understand horrifying actions—understand the terrible links between mood and job and relationships and the rest of everything. I would never want depression to be a public or political excuse, but I think that once you have gone through it, you get a greater and more immediate understanding of the temporary absence of judgment that makes people behave so badly—you learn even, perhaps, how to tolerate the evil in the world.”
On the happy day when we lose depression, we will lose a great deal with it. If the earth could feed itself and us without rain, and if we conquered the weather and declared permanent sun, would we not miss grey days and summer storms? As the sun seems brighter and more clear when it comes on a rare day of English summer after ten months of dismal skies than it can ever seem in the tropics, so recent happiness feels enormous and embracing and beyond anything I have ever imagined. Curiously enough, I love my depression. I do not love experiencing my depression, but I love the depression itself. I love who I am in the wake of it. Schopenhauer said, “Man is [content] according to how dull and insensitive he is”; Tennessee Williams, asked for the definition of happiness, replied “insensitivity.” I do not agree with them. Since I have been to the Gulag and survived it, I know that if I have to go to the Gulag again, I could survive that also; I’m more confident in some odd way than I’ve ever imagined being. This almost (but not quite) makes the depression seem worth it. I do not think that I will ever again try to kill myself; nor do I think that I would give up my life readily if I found myself in war, or if my plane crashed into a desert. I would struggle tooth and nail to survive. It’s as though my life and I, having sat in opposition to each other, hating each other, wanting to escape each other, have now bonded forever and at the hip.
The opposite of depression is not happiness but vitality, and my life, as I write this, is vital, even when sad. I may wake up sometime next year without my mind again; it is not likely to stick around all the time. Meanwhile, however, I have discovered what I would have to call a soul, a part of myself I could never have imagined until one day, seven years ago, when hell came to pay me a surprise visit. It’s a precious discovery. Almost every day I feel momentary flashes of hopelessness and wonder every time whether I am slipping. For a petrifying instant here and there, a lightning-quick flash, I want a car to run me over and I have to grit my teeth to stay on the sidewalk until the light turns green; or I imagine how easily I might cut my wrists; or I taste hungrily the metal tip of a gun in my mouth; or I picture going to sleep and never waking up again. I hate those feelings, but I know that they have driven me to look deeper at life, to find and cling to reasons for living. I cannot find it in me to regret entirely the course my life has taken. Every day, I choose, sometimes gamely and sometimes against the moment’s reason, to be alive. Is that not a rare joy?
Notes
Many excellent general books on depression have influenced this book. Among these, I would particularly commend Peter Whybrow’s dignified and accessible A Mood Apart, Kay Redfield Jamison’s moving An Unquiet Mind and Night Falls Fast, Julia Kristeva’s impenetrable but episodically brilliant Black Sun, Rudolph and Margot Wittkower’s Born Under Saturn, and Stanley Jackson’s rigorous Melancholia and Depression. I have identified all direct quotations from printed sources. All other quotations are from personal interviews conducted between 1995 and 2000.
9 The epigraph is from the closing paragraph of Mikhail Bulgakov’s The White Guard, page 302.
A NOTE ON METHOD
11 The New Yorker article appeared as “Anatomy of Melancholy” in the issue of January 12, 1998.
12 The quotation from Graham Greene comes from his Ways of Escape, page 285.
13 My father’s company is Forest Laboratories. The company was not involved in the development of Celexa, though they have worked on producing its enantiomer.
13 The novel to which I allude is A Stone Boat.
13 Kay Redfield Jamison, Martha Manning, and Meri Danquah are among the authors who have discussed the toxicity of this subject matter.
CHAPTER I: DEPRESSION
15 The words depression and melancholy are grossly general and, despite the efforts of some authors to distinguish between them, are synonymous. The term major depression, however, refers to the psychiatric condition defined under the rubric “Major Depressive Disorder” in DSM-IV, pages 339–45.
16 I have taken the story of Saint Anthony in the desert from a lecture by Elaine Pagels.
16 The first quotation from Jacob’s Room is on pages 140–41. The second is on page 168.
17 For a discussion of “legally dead,” see Sherwin Nuland’s How We Die, page 123.
19 Anhedonia is “the inability to experience pleasure,” as defined by Francis Mondimore in Depression: The Mood Disease, page 22.
21 The depression formula comes from the 1989 edition of the Comprehensive Textbook of Psychiatry, page 870.
24 Both quotations come from Schopenhauer’s Essays and Aphorisms: the first is on pages 42–43; the second is on page 43.
25 The number 19 million comes from the NIMH’s Web site at www.nimh.nih.gov/depression/index1.htm. That approximately 2.5 million children suffer depression may be adduced through the compilation of a number of statistics. “The MECA Study,” by D. Shaffer et al., in the Journal of the American Academy of Child and Adolescent Psychiatry 35, no. 7 (1996), found that approximately 6.2 percent of children age nine to seventeen had a mood disorder within a six-month period, and that 4.9 percent suffered a major depressive disorder. This latter percentage, applied to 1990 census statistics for children age five to seventeen (roughly 45 million) equals a rough estimate of 2.5 million. I thank Faith Bitterolf and the Sewickley Academy Library for their help with this matter.
25 The number 2.3 million comes from the NIMH’s Web site at www.nimh.nih.gov/publicat/manic.cfm.
25 That unipolar depression is t
he leading cause of disability in the United States and worldwide for persons age five and up is taken from the NIMH Web site at www.nimh.nih.gov/publicat/invisible.cfm. The statistic ranking major depression as second in magnitude of disease burden in the developed world also comes from the NIMH at www.nimh.nih.gov/publicat/burden.cfm.
25 That depression claims more years than war, cancer, and HIV/AIDS put together is taken from the World Health Organization’s World Health Report 2000, which can be viewed on-line at www.who.int/whr/2000/index.htm. The information is taken from Annex Table 4, and is valid for lung cancer and skin cancer, in some mortality strata in the Americas and Eastern Mediterranean, and in all mortality strata in Europe, Southeast Asia, and the Western Pacific. For Annex Table 4 specifically, see www.who.int/whr/2000/en/statistics.htm.
25 The idea that somatic illness masks depression is a commonplace. Jeffrey De Wester, in his article “Recognizing and Treating the Patient with Somatic Manifestations of Depression,” Journal of Family Practice 43, suppl. 6 (1996), writes that while “it has been estimated that 77 percent of all mental health visits in the United States occur in a primary care physician’s office . . . less than 20 percent of these patients complain of psychological symptoms or distress,” page S4. Elizabeth McCauley et al., in “The Role of Somatic Complaints in the Diagnosis of Depression in Children and Adolescents,” Journal of the American Academy of Child and Adolescent Psychiatry 30, no. 4 (1991), write that “somatization has been well documented as one way in which depression presents itself, especially in those individuals and/or cultures in which acknowledgment and expression of affect states is not acceptable,” page 631. For more, see also Remi Cadoret et al., “Somatic Complaints,” Journal of Affective Disorders 2 (1980).
25 The percentages given here may be found in D. A. Regier et al., “The de facto mental and addictive disorders service system. Epidemiologic Catchment Area prospective 1-year prevalence rates of disorders and services,” Archives of General Psychiatry 50, no. 2 (1993). The study states, “Those with Major Unipolar Depression had an intermediate rate of mental health service use, in which almost half (49%) had some professional care, with 27.8% using the [specialty mental health/addictive] sector and 25.3% [general medical] sector care,” page 91.
25 That over 95 percent of the general population suffering from depression are treated by general practitioners is stated in Jogin Thakore and David John, “Prescriptions of Antidepressants by General Practitioners: Recommendations by FHSAs and Health Boards,” British Journal of General Practice 46 (1996).
25 That depression is recognized only 40 percent of the time for adults, and only 20 percent of the time for children was set out by Steven Hyman, the director of the National Institute of Mental Health (NIMH), in an oral interview on January 29, 1997.
25 The estimated number of people on Prozac and on the other SSRIs is taken from Joseph Glenmullen’s Prozac Backlash, page 15.
25 The mortality rates for depression have been studied extensively and the results are not fully consistent. The figure of 15 percent was originally established by S. B. Guze and E. Robbins, “Suicide and affective disorders,” British Journal of Psychiatry 117 (1970), and was confirmed by Frederick Goodwin and Kay Jamison in a comprehensive review of thirty studies included in their book Manic-Depressive Illness (see the chart on pages 152–53). The lower rates are based on the work of G. W. Blair-West, G. W. Mellsop, and M. L. Eyeson-Annan, “Down-rating lifetime suicide risk in major depression,” Acta Psychiatrica Scandinavica 95 (1997). This study demonstrated that taking current estimates of depression levels and applying the 15 percent figure would give an overall number of suicides at least four times as high as is currently documented. Some recent researchers have proposed a figure of 6 percent, but this is based on a population sample that seems to contain a deceptively high number of people treated as inpatients (see H. M. Inskip, E. Clare Harris, and Brian Barraclough, “Lifetime risk of suicide for affective disorder, alcoholism, and schizophrenia,” British Journal of Psychiatry 172 (1998). The most recent work is by J. M. Bostwick and S. Pancratz, “Affective disorders and suicide risk: a re-examination,” American Journal of Psychiatry (in press). This work establishes a rate of 6 percent for those who have been hospitalized for depression, 4.1 percent for those who have had inpatient treatment, and 2 percent for those who have had no inpatient treatment. It should be emphasized that the statistical problems involved in these calculations are extremely complicated, and that different methods of calculating proportionate mortality have given varying rates, mostly higher than those established by Bostwick and Pancratz.
25 The comparative rates of cumulative depression were taken from the Cross-National Collaborative Group, “The Changing Rate of Major Depression,” Journal of the American Medical Association 268, no. 21 (1992); see Figure 1, page 3100.
26 The notion that depression is occurring in a younger population is taken from D. A. Regier et al., “Comparing age at onset of major depression and other psychiatric disorders by birth cohorts in five U.S. community populations,” Archives of General Psychiatry 48, no. 9 (1991).
26 For a particularly eloquent exegesis on the supermodel’s negative effects on women, see The Beauty Myth by Naomi R. Wolf.
27 Herman Spitz’s The Raising of Intelligence states, “On the Wechsler Intelligence Scales mild retardation is encompassed by IQs of 55 to 69, and on the Stanford-Binet Intelligence Scale by IQs of 52–67,” page 4.
30 The pills I see in these colors are BuSpar and Zyprexa (white); Effexor immediate release (pink); Effexor sustained release (dark red); and Wellbutrin (turquoise).
31 That skin cancer rates are rising is indicated by numerous studies. H. Irene Ball et al., “Update on the incidence and mortality from melanoma in the United States,” published in the Journal of the American Academy of Dermatology 40 (1999), states, “Over the past few decades, melanoma has become much more common; its increase in both incidence and mortality rates have been among the largest of any cancer,” page 35.
31 Hippocrates’ views on depression are discussed at length in chapter 8.
33 The horrors of the Khmer Rouge are extensively documented. For a vivid reenaction of the atrocities, I would commend the film The Killing Fields.
38 The quotation from Ovid I have taken from Kay Jamison’s Night Falls Fast, page 66.
CHAPTER II: BREAKDOWNS
44 The story of my life with the Russians is told in my first book, The Irony Tower, and in these subsequent articles for The New York Times Magazine: “Three Days in August,” published September 29, 1991; “Artist of the Soviet Wreckage,” published September 20, 1992; and “Young Russia’s Defiant Decadence,” published July 18, 1993.
44 The rock band in question was Middle Russian Elevation.
45 The quotation from Gerhard Richter may be found in his poetical diary, published as The Daily Practice of Painting, on page 122.
47 The article I was closing during my kidney stones was published in the August 28, 1994, edition of The New York Times Magazine as “Defiantly Deaf.”
48 The idea of hypothalamic and cortical function coinciding has been put forward on many occasions and is explicated in Peter Whybrow’s A Mood Apart, pages 153–65.
48 The percentages are based, in my view, on difficult and still uncertain science and therefore show wide discrepancies. I have, nonetheless, taken these statistics, which reflect the general consensus, from Eric Fombonne’s essay “Depressive Disorders: Time Trends and Possible Explanatory Mechanisms,” published in Michael Rutter and David J. Smith’s Psychosocial Disorders in Young People, page 576.
48 I have not treated manic-depressive illness at great length; it is a topic that warrants books of its own. For a scholarly examination of the specifics of the disease, see Fred Goodwin and Kay Jamison’s Manic-Depressive Illness.
52 The remarks by Julia Kristeva are from Black Sun and occur on page 53.
52 The Emily Dickinson poem, which is among my favorite poems ever in
the whole history of the world, is in The Complete Poems of Emily Dickinson, pages 128–29.
53 The quotation from Daphne Merkin appeared in The New Yorker, January 8, 2001, page 37.
54 The Elizabeth Prince poem is unpublished.
55 The quotation from Leonard Woolf may be found in his book Beginning Again, on pages 163–64.
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