The Noonday Demon

by Andrew Solomon

major depression, I had moods that I knew were not my moods: they belonged to the depression, as surely as the leaves on that tree’s high branches belonged to the vine. When I tried to think clearly about this, I felt that my mind was immured, that it couldn’t expand in any direction. I knew that the sun was rising and setting, but little of its light reached me. I felt myself sagging under what was much stronger than I; first I could not use my ankles, and then I could not control my knees, and then my waist began to break under the strain, and then my shoulders turned in, and in the end I was compacted and fetal, depleted by this thing that was crushing me without holding me. Its tendrils threatened to pulverize my mind and my courage and my stomach, and crack my bones and desiccate my body. It went on glutting itself on me when there seemed nothing left to feed it. I was not strong enough to stop breathing. I knew then that I could never kill this

Anyone who has taken high school science classes knows that human beings are made of chemicals and that the study of those chemicals and the structures in which they are configured is called biology. Everything that happens in the brain has chemical manifestations and sources. If you close your eyes and think hard about polar bears, that has a chemical effect on your brain. If you stick to a policy of opposing tax breaks for capital gains, that has a chemical effect on your brain. When you remember some episode from your past, you do so through the complex chemistry of memory. Childhood trauma and subsequent difficulty can alter brain chemistry. Thousands of chemical reactions are involved in deciding to read this book, picking it up with your hands, looking at the shapes of the letters on the page, extracting meaning from those shapes, and having intellectual and emotional responses to what they convey. If time lets you cycle out of a depression and

as we have a drug for violence, violence will be an illness.

Depression has gone too far when, despite a wide margin of safety, you cannot balance anymore. In depression, all that is happening in the present is the anticipation of pain in the future, and the present qua present no longer exists at all.

Listen to the people who love you. Believe that they are worth living for even when you don’t believe it. Seek out the memories depression takes away and project them into the future. Be brave; be strong; take your pills. Exercise because it’s good for you even if every step weighs a thousand pounds. Eat when food itself disgusts you. Reason with yourself when you have lost your reason. These fortune-cookie admonitions sound pat, but the surest way out of depression is to dislike it and not to let yourself grow accustomed to it. Block out the terrible thoughts that invade your mind.

Neither depression nor skin cancer is a creation of the twenty-first century. Like skin cancer, depression is a bodily affliction that has escalated in recent times for fairly specific reasons. Let us not stand too long ignoring the clear message of burgeoning problems. Vulnerabilities that in a previous era would have remained undetectable now blossom into full-blown clinical illness. We must not only avail ourselves of the immediate solutions to

I have for the moment managed to contain the disablement that depression causes, but the depression itself lives forever in the cipher of my brain. It is part of me. To wage war on depression is to fight against oneself, and it is important to know that in advance of the battles. I believe that depression can be eliminated only by undermining the emotional mechanisms that make us human.

“I know nothing,” the painter Gerhard Richter once wrote. “I can do nothing. I understand nothing. I know nothing. Nothing. And all this misery does not even make me particularly unhappy.”

Being upset, even profoundly upset, is a temporal experience, while depression is atemporal. Breakdowns leave you with no point of view.

According to studies done in Pittsburgh, the first episode of major depression is usually closely tied to life events; the second, somewhat less; and by the fourth and fifth episodes life events seem to play no part at all. Brown agrees that beyond a certain point, depression “takes off on its own steam” and becomes random and endogenous, dissociated from life events.

The wish for a more visible illness was, I would later learn, a commonplace among depressives, who often engage in forms of self-mutilation to bring the physical state in line with the mental.

When you’re hugely self-conscious, it’s hard to be fully happy. I love baseball. And when I see other guys at the stadium, swilling beer, seeming so unconscious of themselves and their relation to the world, I envy that. God, wouldn’t it be great to be like that?

I believe that if I had gone on medication before my first breakdown had swept me all the way into the abyss, I would have been able to bring my first depression to heel before it got out of control, and that I might have avoided real breakdowns altogether. If I had not gone off the medication that helped me through that breakdown, I might never have had a second one. By the time I started heading for a third one, I was determined not to make a stupid mistake again.

“Giving attention to others is the simplest way to get attention from others. It is also the simplest way to keep a sense of perspective about yourself. I have a need to share my self-obsession. I am so aware of it in my life right now I wince every time I hit the ‘I’ key. (Ouch. Ouch.) The whole day thus far has been an exercise in FORCING myself to do the tiniest things and trying to evaluate how serious my situation is—Am I really depressed? Am I just lazy? Is this anxiety from too much coffee or from too much antidepressant? The self-assessment process itself made me start to weep. What bothers everyone is that they can’t DO anything to help other than be present. I rely on E-mail to keep me sane! Exclamation points are little lies.”

The conflict between psychodynamic therapy and medication is ultimately a conflict on moral grounds; we tend categorically to assume that if the problem is responsive to psychotherapeutic dialogue, it is a problem you should be able to overcome with simple rigor, while a problem responsive to the ingestion of chemicals is not your fault and requires no rigor of you. It is true both that very little depression is entirely the fault of the sufferer, and that almost all depression can be ameliorated with rigor. Antidepressants help those who help themselves. If you push yourself too hard, you will make yourself worse, but you must push hard enough if you really want to get out. Medication and therapy are tools to be used as necessary. Neither blame nor indulge yourself. Melvin McInnis, a psychiatrist at Johns Hopkins Hospital, speaks of “volition, emotion, and cognition” running along in interlocked cycles, almost like biorhythms. Your emotion affects volition and cognition, but it doesn’t take them over.

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 behaviors that may protect against relapse. You need to run your life differently from how you ran it before.

In the low part of her depression, she says, “I hate the mistakes of myself, of course, and as I lose tolerance, I lose generosity and hate the world and the mistakes of those around me and end up wanting to scream because there are spills and stains and fallen leaves, parking fines and people who are late or don’t return calls. None of this is good. Pretty soon the children will be crying, and if I ignore that, they’ll end up very quiet and obedient, which is worse because the tears are now inside. Fear is in their eyes and they go silent. I stop hearing their secret hurts that are so easy to right when things are good. I hate myself like that. Depression takes me down and down.”

David Grand, a trained psychoanalytic therapist who now uses EMDR with all his patients, says, “EMDR can help a person to do in six to twelve months what couldn’t be done in five years of ordinary treatment. I’m not comparing in the abstract: I’m comparing my work with EMDR to my work without it. The activation bypasses the ego and activates deeply, quickly, and directly. EMDR is not an approach, like the cognitive or the psychoanalytic; it’s a tool. You can’t just be a generic EMDR therapist. You have to be a good therapist first and then figure out how to integrate EMDR. The oddity of it is a turnoff, but I have been doing it for eight years, and I could not go back to doing therapy without EMDR knowing what I know now. It would be such a regression, such a return to the primitive.” I always came out of my EMDR therapist’s office reeling (in a good way); and the things I learned have stayed with me and enriched my conscious mind. It’s a powerful process. I recommend it.

During the Second World War, many British soldiers had to spend extended periods adrift in the Atlantic after their ships had suffered disabling attacks. The soldiers who had the best rate of survival were not the most young and able but the most experienced, who often had a toughness of spirit that transcended the limits of their bodies. The educator Kurt Hahn observed that such toughness had to be learned, and he founded Outward Bound, which is now a large confederation of associations scattered around the globe. Through structured encounters with the wild, Outward Bound attempts to keep to Hahn’s objectives: “I regard it as the foremost task of education to ensure survival of these qualities: an enterprising curiosity; an undefeatable spirit; tenacity in pursuit; readiness for sensible self-denial; and, above all, compassion.”

Claudia has had a lifetime of insight into and discipline concerning her depressions. “I have a lot of trouble remembering positive things when I’m depressed. I go over and over the negative things that people did to me, for which I have an elephant’s memory, and times when I was wronged or shamed or embarrassed, and they escalate and become worse than they were in real life, I’m sure. And once I think of one of those things, I can think of ten and that leads to twenty more. In an alternative-spirituality group to which I belong, I was asked to write down negative things that have hindered my life, which I did for twenty pages; and then I was asked to write down positive things. I couldn’t think of anything positive to say about myself. I also get fascinated with dark subjects, with Auschwitz or with a plane crash, and I can’t stop imagining dying in such situations. My practitioner can usually figure out what to prescribe to alleviate my obsessive fear of disasters.

Eventually, she gave up the medications, so that she could reawaken sexual feeling, and began on the homeopathic remedies she was taking when I first got to know her. The homeopathic remedies seemed to work for quite a while; she feels they are effective at keeping her stable, but when circumstances drove her into a new depression, they could not bring her up out of it. There were some tough times, but she stuck out homeopathy through a long winter. When, once a month, she panicked that her depression was returning, she’d realize that it was just PMS. “I’m always so glad when I start bleeding; and I’d think, ‘Oh! Well, that was that!’ ” Though the lack of medication did not cause any major regression, she did have a harder time with hard things. The overall treatment program seemed to be inconsistent for her physical ailments, the tension-related ailments in particular; her eczema got so bad at one point that her breasts bled through her shirt. At about this time she gave up talking therapy and began writing what Julia Cameron calls “morning pages,” twenty-minute written exercises in matinal stream of consciousness. She says that they help her to clarify her life; she has not missed a day in three years now. She also keeps on her bedroom wall a list of things to do when she is beginning to feel down or bored—a list that begins, “Read five kids’ poems. Make a collage. Look at photographs. Eat some chocolate.”

Depression is not the be-all and end-all of my life. You know, I’m not going to lie on my bed for the rest of my life and suffer. The people who succeed despite depression do three things. First, they seek an understanding of what’s happening. Then they accept that this is a permanent situation. And then they have to somehow transcend their experience and grow from it and put themselves out into the world of real people.

Dana was too depressed to talk tonight. She pulled her knees up under her chin and promised she’d try to talk later. Anne hadn’t been to MDSG in a while. She’d had a bad time: took Effexor for depression and it helped a lot. Then when her dose was raised, she’d gone paranoid, “flipped out.” Believed the Mafia was out to get her and barricaded herself in her apartment. Eventually got hospitalized and had “every medication, every single one” and then when none of them helped, she got ECT. Couldn’t remember much from that time; the ECT had wiped out a lot of the memories. She used to be an executive, white-collar. Now she fed people’s cats for a living. Today she’d lost two clients, and rejection was tough. And humiliation.

That basic feeling at the support group—I have my mind today, do you have yours?—spoke volumes, and almost in spite of myself, I began to relax into it.

be intuited only by others who know. “If I were on crutches, they wouldn’t ask me to dance,” said one woman about her family’s relentless efforts to get her to go out and have fun.

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.”

The idea that women are depressed because of the patriarchal conspiracy has some validity; the idea that we make women feel bad about their depression as part of the patriarchal conspiracy ignores women’s own assertions of their experience of depression.

Depressed mothers are usually not great mothers, though high-functioning depressives can sometimes mask their illness and fulfill their parenting roles. While some depressed mothers are easily upset by their children and behave erratically as a consequence, many depressed mothers simply fail to respond to their children: they are unaffectionate and withdrawn. They tend not to establish clear control or rules or boundaries. They have little love or nurturance to give. They feel helpless in the face of their children’s demands. Their behavior is unregulated; they become angry for no apparent reason and then, in paroxysms of guilt, express extravagant affection for equally indistinct reasons.

Dièry and I met through his wife, who is an old school friend of mine. We have been friends for about a decade and, in part because of our mutual experience of depression, have become extremely close. I am not good at exercising on my own, and for some time Dièry has also been my trainer—a position that breeds an intimacy in many ways as great as that, I experience with my psychiatrist. In addition to structuring an exercise program, he gets me up and keeps me going. Because he constantly tests my limits, he knows what those limits are. He knows when it makes sense to push me to my physical edge and when it is necessary to pull back short of my emotional one. He is one of the first people I call when I begin to dissolve—in part because I know that stepping up my exercise regimen will have a positive effect on my mood, and in part because he has a singular sweetness; in part because he knows whereof I speak, and in part because introspection has given him a capacity for genuine insight. I have had to trust him, and I do. He is the one who came to my house and helped me to shower and get dressed when I was at my lowest. He is among the heroes of my own depression story. And he is authentically generous, someone who chose his work because he believes he can make other people feel good, someone who can be gratified by his own kindness; he has turned the aggression of his self-torture into a productive discipline. This is a rare quality indeed in a world full of people who feel...

Inuit families are large. For months on end, families of perhaps twelve people stay unremittingly inside in their house, usually gathered in one room. It is simply too cold and too dark for anyone to go out except the father, who goes hunting or ice fishing once or twice a month to supplement the stock of dried fish from the summer. There are no trees in Greenland, so no jolly fires are burning inside; traditionally, in fact, there would have been only a small lamp burning seal fat inside an igloo where, as one Greenlander I met put it, “we all sat around together for months on end watching the walls melt.” In these circumstances of enforced intimacy, there is no place for complaining or for talking about problems or for anger and accusations. The Inuit simply have a taboo against complaining. They are silent and brooding or they are storytellers given to laughter, or they talk about the conditions outside and the hunt, but they almost never speak of themselves. Depressiveness, with concomitant hysteria and paranoia, is the price paid for the intense communality of Inuit lives.

For the Inuit, depression is so minor in the scale of things and so evident a part of everyone’s life that, except in severe cases of vegetative illness, they simply ignore it. Between their silence and our intensely verbalized self-awareness lie a multitude of ways of speaking of psychic pain, of knowing that pain. Context, race, gender, tradition, nation—all conspire to determine what is to be said and what is to be left unsaid—and to some extent they thereby determine what is to be alleviated, what exacerbated, what endured, what forsworn. The depression—its urgency, its symptoms, and the ways out of it—is all determined by forces quite outside of our individual biochemistry, by who we are, where we were born, what we believe, and how we live.

The decision to take Prozac instead of cocaine is a version of the strategy of deferred gratification, and the decision to take cocaine instead of antidepressants is predicated on a yearning for immediate gratification.

Most depressed substance abusers have two linked illnesses running concurrently, each of which requires treatment and each of which exacerbates the other. These illnesses interact within the dopamine system. The popular idea that you have to get a person off substances before you pay attention to his depression is faintly ludicrous: you are asking someone who tamps down his misery to let that misery blossom before you do anything about it. The idea that you can ignore addiction and treat depression as the primary illness, helping someone feel so good that he won’t want substances anymore, overlooks the reality of physical dependence. “If there’s anything we’ve learned in the addiction field,” says Herbert Kleber, who was for some years deputy drug czar for the United States and who now heads Columbia University’s Center for Addiction and Substance Abuse, “it’s that once you get addicted—it doesn’t matter how you got there—you have a disease with a life of its own. If you treat a depressed alcoholic with an antidepressant, you produce a nondepressed alcoholic.” Taking away the original motivation for abusing substances does not free someone who has developed a pattern of substance abuse.

It takes many months for the body to achieve optimal recovery from long-term substance abuse; some brain alteration “appears to be permanent,” according to Kleber, and some has a life of at least a year or two. Positron-emission tomography (PET) scans show the effects of various substances of abuse on the brain, and they show limited recovery even at the three-month point. There are persisting lesions, and chronic abusers of substances often suffer permanent memory damage.

R. E. Meyer has proposed five possible relationships between substance abuse and depression. Depression may be the cause of substance abuse; depression may be the result of substance abuse; depression may alter or exaggerate substance abuse; depression may coexist with substance abuse without affecting it; depression and substance abuse may be two symptoms of a single problem.

And yet do we have choice? If one knows that there is ready relief for immediate pain, what does it mean to deny oneself? T. S. Eliot wrote in “Gerontion,” “After such knowledge, what forgiveness?” In the dark night of the soul, is it best not to know what cocaine can do for you?

William Potter, who formerly ran the psychopharmacological division of the NIMH, comments, “We’ve made a judgment that drugs that prevent you from experiencing appropriate emotional response are not acceptable. That’s why cocaine is illegal. There are too many problems when you cease to detect warning signs and threats. You pay a price for an excessive high. That’s not moralizing; that’s just my observation.” In contrast, “No one gets an intense Zoloft craving,” says Steven Hyman. “No one would ever kill to get a Zoloft.” They also do not produce either euphoria or supersize relaxation. One does not speak of a diabetic as being addicted to insulin. Perhaps our society’s emphasis on deferred gratification is so intense that we simply prefer those drugs that make you feel bad (side effects) and then good (mood effects) to drugs that make you feel good (high) and then bad (hungover)?

Oh, the anxiety! Anxiety in depression is this feeling like you have a terrible secret, and everyone’s going to find out, and you don’t even know what the secret is.”

Why should you say no when no will lead you only to more intolerable misery?

T. S. Eliot wrote in “Gerontion,” “After such knowledge, what forgiveness?”

Thomas Szasz, an influential critic of the mental health establishment who has favored limiting the power of psychiatrists, says, “Suicide is a fundamental human right. This does not mean that it is desirable. It only means that society does not have the moral right to interfere, by force, with a person’s decision to commit this act.” Szasz believes that by intervening forcibly with the suicidal, one deprives them of the legitimacy of their selves and actions. “The result is a far-reaching infantilization and dehumanization of the suicidal person.” A Harvard study gave doctors edited case histories of suicides and asked them for diagnoses; while the doctors diagnosed mental illness in only 22 percent of the group if they were not told that the patients had committed suicide, the figure was 90 percent when the suicide was included in the patient profile. Clearly, suicidality creates a smooth diagnosis, and it is likely that some degree of infantilization—or at least paternalism—occurs.

Suicide is often the manifestation of the depressive end of a manic-depressive mood spectrum, and this is the reason usually given for the high rate of suicide among people who are highly successful. It is also the case that people who are successful tend to set high standards for themselves and are often disappointed even in their greatest achievements. Self-examination and rumination may lead to suicide, which occurs frequently among artists and other creative people. But the rate is also high among successful businessmen: it would appear that some of the qualities that make for success also make for suicidality. Scientists, composers, and high-level businessmen are five times more likely to kill themselves than the general population; writers, especially poets, have an even higher rate of suicide.

If I had been fresh from a conference on cardiology and were sitting next to a three-hundred-pound man who was smoking like a chimney and eating sticks of butter, and who complained of chest pain that radiated down his left arm, I might have felt that it was appropriate to warn him that he was in real and current danger. To tell someone that he is at risk for suicide is much more difficult. I hinted around the subject, advised my new friend to go back on medications, told him it was good to be in touch with a psychiatrist just in case he ever had a recurrence. Some sense of social convention made it impossible for me to say, “You may feel fine right now, but you’re heading toward suicide and must immediately take preventative measures.” • • •

I know when things are getting worse because the kinds of suicide I imagine become more various and to some extent more violent. My fantasies leave behind the pills in my medicine chest and even the gun in my safe and extend to figuring out whether the blades of a Gillette sensor razor could be used to slit my wrists, or whether I would be better off using an X-Acto knife. I have gone so far as to try a beam just to see if it would be strong enough to support a noose. I have worked on figuring out timing: when I would be alone in the house, at what hour I could carry things through.

It gives a sense of control to your situation.

A. Alvarez writes, “A suicide’s excuses are mostly by the way. At best they assuage the guilt of the survivors, soothe the tidy-minded, and encourage the sociologists in their endless search for convincing categories and theories. They are like a trivial border incident which triggers a major war. The real motives which impel a man to take his own life are elsewhere; they belong to the internal world, devious, contradictory, labyrinthine, and mostly out of sight.”

That, in essence, is the catastrophe of suicide for those who survive: not only the loss of someone, but the loss of the chance to persuade that person to act differently, the loss of the chance to connect. There is no one to whom one so yearns to connect as a person who has committed suicide. “If we had only known” is the plea of the parents of a suicide, people who rack their minds trying to figure out what failing of their love could have allowed such a thing to come and surprise them, trying to think what they should have said.

And must I then, indeed, Pain, live with you All through my life?—sharing my fire, my bed, Sharing—oh, worst of all things!—the same head?— And, when I feed myself, feeding you, too?

Suicide is really more of an anxiety response than a depression solution: it is not the action of a null mind but of a tortured one. The physical symptoms of anxiety are so acute that they seem to demand a physical response: not simply the mental suicide of silence and sleep, but the physical one of self-slaughter.

The question of suicide as control has not been sufficiently well explored. An attachment to control motivated my mother’s death, and that motivation exists for many people who kill themselves under very different circumstances. Alvarez writes, “Suicide is, after all, the result of a choice. However impulsive the action and confused the motives, at the moment when a man finally decides to take his own life he achieves a certain temporary clarity. Suicide may be a declaration of bankruptcy which passes judgment on a life as one long history of failure. But it is a decision which, by its very finality, is not wholly a failure. There is, I believe, a whole class of suicides who take their own lives not in order to die but to escape confusion, to clear their heads. They deliberately use suicide to create an unencumbered reality for themselves or to break through the patterns of obsession and necessity which they have unwittingly imposed on their lives.”