Thursday, May 7, 2009

Yer Blues

I have of late--but wherefore I know not--lost all my mirth, forgone all custom of exercise; and indeed it goes so heavily with my disposition that this goodly frame, the earth, seems to me a sterile promontory. This most excellent canopy the air, look you, this brave o'erhanging, this majestical roof fretted with golden fire--why, it appears no other thing to me than a foul and pestilent congregation of vapours. What a piece of work is a man! How noble in reason, how infinite in faculty, in form and moving how express and admirable, in action how like an angel, in apprehension how like a god--the beauty of the world, the paragon of animals! And yet to me what is this quintessence of dust? Man delights not me--no, nor woman neither, though by your smiling you seem to say so.


I don't know of a more powerful or compact account of depression than these few words from Shakespeare, and William Styron's Darkness Visible sufficiently conveys the essence of a severe melacholic episode and its treatment. But given the perennial shroud of mystery surrounding depression, I suppose additional memoirs couldn't hurt. So Daphne Merkin provides a narrative of her latest depressive episode, in the Times. I recall reading some years ago an article by her in The New Yorker, and this one generates a sense of deja vu. But given that depression tends to be recurrent, that may be fitting.

We speak much of the bottomless nuance of psychiatry, and the infinite individual variations of its maladies, but when it comes to really debilitating depressions, one is struck by their uniformity. The lethargy, the anhedonia, the leaden numbness, the hopelessness, the sense of utter isolation and estrangement from humanity, the inevitable thoughts of self-extinction. Whatever the myriad causes feeding into depression, its symptoms constitute a universal final common pathway.

As Merkin notes, depressives are always encouraged to seek out social contact and support, but they soon encounter the hard truth that most non-depressed people, beyond a few encouraging words, have little understanding of or patience with depression. The depressive essentially must forge a relatively euthymic facade to gain any real foothold in the social world that may eventually help boost his spirits for real. This masquerade of equanimity can feel dishonest.

She describes the peculiarly disheartening quality of the late middle-aged breakdown. The depression of youth may seem more appropriate--life is hard, and one is after all just learning the ropes, right? But several decades in, shouldn't one have gained some mastery? So the kernel of self-doubt germinates.

I relished Merkin's exasperation with her analytically-inclined therapist, who after long questioning the real helpfulness of medications, suddenly switches course and suggests that she have ECT--this is a nice illustration of the throw-up-your-hands-and-throw-in-the-kitchen-sink aspect of treating depression.

Depression, like most mental disorders, is both illness and meta-illness, sickening the body and mind at the same time that it saps the self's capacity to maintain in all respects. It is a bit like AIDS in this formal respect, an assault on the organism's defenses against all kinds of entropy. It wounds and disarms in one stroke.

Merkin's article contains what by now is the stock account of the dismal psychiatric ward experience. The usual players are here: the execrable decor, the mind-numbing routines, the callous and distant staff, and of course the insipid food. Even the antiseptic fluorescent lighting gets a mention. I'm no fan of psychiatric units, but what exactly is expected here, incandescent lighting? As if inpatient wards, in addition to their other crimes against humanity, should generate unnecessary carbon as well?

What is it about ping pong tables and psychiatric units? It is low-maintenance, offers competitive and enjoyable exercise, and unlike billiard balls, its implements cannot cause harm. The perfect pastime for the bored and potentially suicidal (and I mean this quite seriously).

Her episode ends as many, fortunately, do, more with a whimper than with a bang. Just when things seem bleakest and she is considering a return to the hospital for ECT, the gloom lightens subtly, and all of a sudden the notion of writing, of doing anything, no longer seems absurd or insurmountable. She is on Abilify--can we credit the drug, or did the episode simply wind down of its own accord? Neither she nor her psychiatrist can really know. Take what you can get and keep your fingers crossed.


Retriever said...

Interesting article. Poor woman.

It's a good article to put the lie to ideas that depresssion can be cured with prozac and six sessions of CBT. I personally believe that the analytic therapy is enormously valuable, even if it can't cure. For those of us in it for life, depression is easier to manage and work around with more rather than less understanding. Suicidal impulses come and go, but they are in some sense like John Nash's description of his voices. Always there, but over time (and with meds too obviously) he learned how to function despite them. This work is the stuff of therapy and cookbook varieties do not help many except the easily bullied or the stupid.

On psychiatric wards, it's just as well they aren't too luxurious. They are havens when one is truly ill, if half-way decent, but they aren't supposed to be spas or hotels. I think the fluorescent lights, like the mandatory infantilizing activities, serve the valuable purpose of helping one concentrate without distraction on the reasons why one is there. Sort of like the harsh light revealing wrinkles and excess pounds, the barren surroundings keep one from escaping oneself. This is unpleasant, embarassing and sobering of course, but necessary. Retreat houses for the religious do the same thing. Depression afflicts body and spirit, and ascetism to a degree can help.

As far as depression in middle age versus youth? That's easy. It sucks to be middle aged. I personally can't think of a single thing that is anything but worse about my life in middle age as versus in my youth. If one is depressed in middle age it is related to the following real life experiences (as well as the hardwired brain stuff in one's genes):
loss of good looks
developing health problems even so trivial as an old runner's knee preventing one running.
marital problems or boredom or divorce
obnoxious teen or young adult children
NO children
age discrimination preventing one doing anything good job-wise
years of psych meds making one stupid
menopause (or male "difficulties" at the same age)
aging parents to take care of (or lost forever to death)
mindless job (people with chronic depression are generally underemployed)
too little energy to decorate or tidy a nice home, yet negatively affected by messy surroundings
reading about one's college peers who are now nationally famous when one is a nonentity
fears about money
exhausted by years of faking good cheer so's not to alienate people with one's depression.

Whereas the young can realistically hope for:

--better medicine, treatments, and the possibility of cure or at least real remission
--the prospect of romantic love
--interesting work
--the pleasures of good physical health
--looking good and being admired
--still being young enough to change

Just call me Eeyore...Have to go off and find something funny to watch

Anonymous said...

The opening Hamlet quote very nearly drained me of the will to go on...and read the rest of the post (not to mention your comment Retriever - the list! what a list...). And finally that article. I think the terminally happy should read it so that they may die with an inkling of understanding of what it feels like to be dead and still be forced to breathe.

Retriever said...

Sorry, Anon. For a corrective: Life looks 200% better in the morning with extremely strong fresh coffee and a sweet dog nuzzling one. Who cares about feeling old and busted or fame and fortune when the sun is out after a week of rain and theire are amorous squirrels in the back yard to stalk with my Nikon.....Personally, I preferreading Jamison to poor Malkin. Cheerier.

Anonymous said...

Anonymous, over the past 20 plus years I've struggled with depression, I've searched for ways to somewhat adequately describe it--I like "what it feels like to be dead and still be forced to breathe". It reminds me of something I saw awhile back--"The opposite of depression isn't happiness--it's vitality."

Novalis said...

These comments show that you just have to look on the bright side--unless you can't. Simple, right?

Leon's current assignment said...

Agree that Styron does an outstanding job of "representing" but my favorite narrative is Jane Kenyon's wonderful poem "Having it out with Melancholy". I simply must share...(I'd track it back to my blog but I think I've disabled such things, good solipsist that I am ;)

If many remedies are prescribed for an illness, you may be certain that the illness has no cure.-- A. P. Chekov, "The Cherry Orchard"


When I was born, you waited
behind a pile of linen in the nursery,
and when we were alone, you lay down
on top of me, pressing
the bile of desolation into every pore.

And from that day on
everything under the sun and moon
made me sad -- even the yellow
wooden beads that slid and spun
along a spindle on my crib.

You taught me to exist without gratitude.
You ruined my manners toward God:
"We're here simply to wait for death;
the pleasures of earth are overrated."

I only appeared to belong to my mother,
to live among blocks and cotton undershirts
with snaps; among red tin lunch boxes
and report cards in ugly brown slipcases.
I was already yours -- the anti-urge,
the mutilator of souls.


Elavil, Ludiomil, Doxepin,
Norpramin, Prozac, Lithium, Xanax,
Wellbutrin, Parnate, Nardil, Zoloft.
The coated ones smell sweet or have
no smell; the powdery ones smell
like the chemistry lab at school
that made me hold my breath.


You wouldn't be so depressed
if you really believed in God.


Often I go to bed as soon after dinner
as seems adult
(I mean I try to wait for dark)
in order to push away
from the massive pain in sleep's
frail wicker coracle.


Once, in my early thirties, I saw
that I was a speck of light in the great
river of light that undulates through time.

I was floating with the whole
human family. We were all colors -- those
who are living now, those who have died,
those who are not yet born. For a few

moments I floated, completely calm,
and I no longer hated having to exist.

Like a crow who smells hot blood
you came flying to pull me out
of the glowing stream.
"I'll hold you up. I never let my dear
ones drown!" After that, I wept for days.


The dog searches until he finds me
upstairs, lies down with a clatter
of elbows, puts his head on my foot.

Sometimes the sound of his breathing
saves my life -- in and out, in
and out; a pause, a long sigh. . . .


A piece of burned meat
wears my clothes, speaks
in my voice, dispatches obligations
haltingly, or not at all.
It is tired of trying
to be stouthearted, tired
beyond measure.

We move on to the monoamine
oxidase inhibitors. Day and night
I feel as if I had drunk six cups
of coffee, but the pain stops
abruptly. With the wonder
and bitterness of someone pardoned
for a crime she did not commit
I come back to marriage and friends,
to pink fringed hollyhocks; come back
to my desk, books, and chair.


Pharmaceutical wonders are at work
but I believe only in this moment
of well-being. Unholy ghost,
you are certain to come again.

Coarse, mean, you'll put your feet
on the coffee table, lean back,
and turn me into someone who can't
take the trouble to speak; someone
who can't sleep, or who does nothing
but sleep; can't read, or call
for an appointment for help.

There is nothing I can do
against your coming.
When I awake, I am still with thee.


High on Nardil and June light
I wake at four,
waiting greedily for the first
note of the wood thrush. Easeful air
presses through the screen
with the wild, complex song
of the bird, and I am overcome

by ordinary contentment.
What hurt me so terribly
all my life until this moment?
How I love the small, swiftly
beating heart of the bird
singing in the great maples;
its bright, unequivocal eye.

I recall attending a seminar on suicide a few years ago and being astounded at the rates for middle-aged white women, among the highest. Made perfect sense to me...still does.

Regarding CBT, I laughed aloud when reading not-so-distant-research that "CBT clinicians" did not seek out similar therapeutic means when they found themselves in need of individual therapy. No duh. Please.

Thanks for the article link. I'll have to get back to it this weekend.

Anonymous said...

Happiness (or a rough estimation from the perspective of the perennially unhappy):

That micromoment upon awakening from sleep and realising you've actually had 8 hours rest and feel replenished instead of being prematurely and brutally dragged out of oblivion by that savage beast of urgent impatience - time and its evil minion, the alarm.

The first bite.

The first sip.

That flash of insight.

The absence of pain.

The realisation that existence is finite, and so is suffering.

Everything else is a lie.