The Noonday Demon: An Atlas of Depression

by Andrew Solomon

Prozac, Paxil, Zoloft, Wellbutrin, Klonopin, BuSpar, Valium, Librium, Ativan, and “of course Xanax” and was now on several of these as well as Depakote and Ambien.

“The self-consciousness gets in the way of offering much depth of personality to people—as a result, most friends I’ve made in the past eight or nine years are fairly casual. This grows lonely, and leaves me feeling idiotic. I just called, for example, a very dear (and demanding) friend in West Virginia, who wants an explanation for my not coming to visit her and her new baby. What to say? That I would have loved to make the trip but was busy staying out of mental hospital? It’s so humiliating—so degrading. If I knew I wouldn’t get caught, I’d love to lie about it—invent an acceptable cancer, that recurs and vanishes, that people could understand—that wouldn’t make them frightened and uncomfortable.”

“It’s hard to be honest with him about how I’m feeling because I don’t want to let him down.”

Is it depression when I think how I would prefer to go where they have gone, and to stop the maniacal struggle of staying alive? Or is it just a part of life, to keep living in all the ways we cannot stand?

I find the fact of the past, the reality of time’s passage, incredibly difficult.

When I see friends from college, I try not to talk about college too much because I was so happy then—not necessarily happier than I am now, but with a happiness that was particular and specific in its moods and that will never come again.

past pleasure is much harder to process than past pain.

There is such a thing as post-joy stress too. The worst of depression lies in a present moment that cannot escape the past it idealizes or deplores.

Reconciling the psychosocial and the psychopharmacological understandings of depression is difficult but necessary.

It is striking that patients who recover from depression by means of psychotherapy show the same biological changes—in, for example, sleep electroencephalogram (EEG)—as those who receive medication.

Melvin McGuinness, a psychiatrist at Johns Hopkins Hospital, speaks of “volition, emotion, and cognition” running along in interlocked cycles, almost like biorhythms.

Freudian model, though flawed, is an excellent one. It contains, in Luhrmann’s words, “a sense of human complexity, of depth, an exigent demand to struggle against one’s own refusals, and a respect for the difficulty of human life.”

The psychodynamic therapies that have grown out of psychoanalysis, however, do have a crucial role to play.

“Take notes,” wrote Virginia Woolf in The Years, “and the pain goes away.” That is the underlying process of most psychotherapy.

Most psychodynamic therapies are based on the principle that naming something is a good way to subdue it, and that knowing the source of a problem is useful in solving that problem. Such therapies do not, however, stop with knowledge: they teach strategies for harnessing knowledge to ameliorative use. The doctor may also make nonjudgmental responses that will allow the client sufficient insight to modify his behaviour and so improve the quality of his life.

Luhrmann writes, “Doctors feel that they have been trained to see and understand a grotesque misery, yet all they are allowed to do is hand out a biomedical lollipop to its prisoners and then turn their backs.”

Therapy allows a person to make sense of the new self he has attained on medication, and to accept the loss of self that occurred during a breakdown. You need to be reborn after a severe episode, and you need to learn the behaviours that may protect against relapse. You need to run your life differently from how you ran it before. “It’s so hard to regulate your life, sleep, diet, exercise, under any circumstances,” comments Norman Rosenthal of the NIMH. “Think how hard it is when you’re depressed! You need a therapist as a sort of coach, to keep you at it. Depression is an illness, not a life choice, and you have to be helped through it.”

Most of the good psychiatrists I saw would begin by letting a patient tell his story and would then move briskly on to highly structured interviews in which they looked for particular information. The ability to conduct such an interview well is among a clinician’s most important skills.

“Those who have lived in one place for long periods of time are temporarily homeless for circumstantial reasons but are capable of living well-regulated lives, and they require primarily a social intervention. Those who have moved around constantly, or who have been homeless repeatedly, or who can’t remember where they’ve lived, probably have a severe underlying complaint and require primarily a psychiatric intervention.”

The two kinds of talking therapy that have the best record for the treatment of depression are cognitive-behavioural therapy (CBT) and interpersonal therapy (IPT).

Beck proposes that one’s thoughts about oneself are frequently destructive, and that by forcing the mind to think in certain ways one can actually change one’s reality—it’s a programme that one of his collaborators has called “learned optimism.” He believes depression is the consequence of false logic, and that by correcting negative reasoning one may achieve better mental health. CBT teaches objectivity.

The therapist begins by helping the patient make up a list of “life history data,” the sequence of difficulties that have led him to his current position. The therapist then charts responses to these difficulties and attempts to identify characteristic patterns of overreaction. The patient learns why he finds certain events so depressing and tries to free himself of inappropriate responses. This macroscopic part of CBT is followed by the microscopic, in which the patient learns to neutralize his “automatic thoughts.” Feelings are not direct responses to the world: what happens in the world affects our cognition, and cognition in turn affects feelings. If the patient can alter the cognition, then he can alter the concomitant mood states. A patient might, for example, learn to see her husband’s preoccupation as his reasonable response to the demands of the workplace rather than as a rejection. She might then be able to see how her own automatic thoughts (of being an unlovable jerk) turn into negative emotion (self-reproach) and identify how this negative emotion leads to depression. Once the cycle is broken, the patient can begin to achieve some self-control. The patient learns to distinguish between what actually happens and her ideas about what happens.

Facts and advice are specifically excluded from the therapist’s conversation.

This is how the principle of CBT might be carried to an extreme under extreme circumstances. If you can force your thoughts into certain patterns, that can save you.

IPT focuses on the immediate reality of current day-to-day life. Rather than working out an overarching schema for an entire personal history, it fixes up things in the present.

It assumes that many people who are depressed have had life stressors as the trigger or consequence of their depression, and that these can be cleaned up through well-advised interaction with others. Treatment is in two stages. In the first, the patient is taught to understand his depression as an external affliction and is informed about the prevalence of the disorder. His symptoms are sorted out and named.

Problems are sorted into four categories: grief; differences about role with close friends and family (what you give and what you expect in return, for example); states of stressful transition in personal or professional life (divorce or loss of job, for example); and isolation.

that the therapist was acting in good faith; that the client believed that the therapist understood the technique; that the client liked and respected the therapist; and that the therapist had an ability to form understanding relationships.

“Mind cannot exist without the brain, but mind can have influence on the brain. It’s a pragmatic and metaphysical problem whose biology we do not understand,” says Elliot Valenstein, professor emeritus of psychology and neuroscience at the University of Michigan.

“Psychotherapy changes biology. Behaviour therapy changes the biology of the brain—probably in the same way the medicines do.”

(it is found in a number of foodstuffs, including turkey, bananas, and dates), which raises serotonin levels, that doesn’t help immediately, though there is evidence that reducing dietary tryptophan may exacerbate depression.

Under ordinary circumstances, serotonin is discharged by neurons and then reabsorbed to be discharged again. The SSRIs (selective serotonin reuptake inhibitors) block the reabsorption process, thus increasing the level of free-floating serotonin in the brain.

It helps form scabs, causing the clotting necessary to control bleeding.

The human brain is stupefyingly plastic. Cells can respecialize and change after a trauma; they can “learn” entirely new functions.

“You get the same kind of results from raising serotonin that you get from raising norepinephrine. Do they lead into two different black boxes of function? Do they lead into the same black box? Does one thing lead to the other which leads to a black box?”

Does it matter that most antidepressants suppress REM sleep, or is that an irrelevant side effect? Is it important that antidepressants usually lower brain temperature, which, in depression, tends to go up at night? It has become clear that all the neurotransmitters interact and that each influences the others.

Monkeys separated from their mothers in infancy grow up psychotic; their brains become physiologically different and they develop much lower serotonin levels than do monkeys raised with their mothers.

Repeated maternal separations in a range of animals give them excessive levels of cortisol. Prozac will reverse these effects.

Four classes of antidepressant medication are currently available. The most popular are the SSRIs, which bring about higher brain levels of serotonin. Prozac, Luvox, Paxil, Zoloft, and Celexa are all SSRIs. There are also two older kinds of antidepressants. The tricyclics, named for their chemical structure, affect serotonin and dopamine. Elavil, Anafranil, Norpramin, Tofranil, and Pamelor are all tricyclics. The monoamine oxidase inhibitors (MAOIs) inhibit the breakdown of serotonin, dopamine, and norepinephrine. Nardil and Parnate are both MAOIs. Another category, atypical antidepressants, includes drugs that operate on multiple neurotransmitter systems. Asendin, Wellbutrin, Serzone, and Effexor are all atypical antidepressants.

Anita Clayton, of the University of Virginia, divides sexual experience into four phases: desire, arousal, orgasm, and resolution. Antidepressants affect all four.

It is both important and difficult, as Clayton has observed, to tease out the sexual problems that are characteristic of the underlying psychology that may have made a person depressed; the sexual problems that are a result of the depression (99 percent of people with acute major depression report sexual dysfunction); and the sexual problems that are the result of antidepressant therapy.

Keeping up levels of estrogen improves mood, and sudden declines in estrogen levels can be devastating. The 80 percent drop in estrogen that women experience during menopause has pronounced mood effects.

There are also fast-acting drugs, the benzodiazepines—a category that includes Klonopin, Ativan, Valium, and Xanax.

Xanax made the horror disappear as a magician makes a rabbit vanish. While the antidepressants I have taken were slow as dawn, shedding light bit by bit on my personality and letting it come back into the known and patterned world, Xanax provided extraordinary instant relief from anxiety—“a finger in a dyke at the crucial moment,”

I have been on, in various combinations and at various doses, Zoloft, Paxil, Navane, Effexor, Wellbutrin, Serzone, BuSpar, Zyprexa, Dexedrine, Xanax, Valium, Ambien, and Viagra.

Researchers are working in four directions towards new treatments. The first is to shift as far as possible to preventative therapies: the sooner you catch mental problems of any kind, the better off you are. The second is increased specificity of drugs. The brain has at least fifteen different serotonin receptors. Evidence suggests that the antidepressant effects depend on only a few of these sites, and that many of the nasty side effects of SSRIs probably go with others. The third is faster drugs. The fourth is more specificity to symptom rather than to biological position, so that the experimentation to choose drugs can be abrogated.

If we discover, for example, tags that would allow genetic subtypes of depression to be identified, it might be possible to find treatments specific to those subtypes.

for depression is the least clean and specific one of all. Antidepressants are effective about 50 percent of the time, perhaps a bit more; ECT seems to have some significant impact between 75 and 90 percent of the time. About half of those who have improved on ECT still feel good a year after treatment, though others require repeated rounds of ECT or regular maintenance ECT.

Martha Manning has described her depression and ECT in a beautiful and surprisingly hilarious book called Undercurrents

I just couldn’t care enough, but suddenly I knew that if I did get and use a gun, I would stop that child’s song. I would silence her. And that day, I checked myself in for ECT.