Darkness Visible

“I’d feel the horror, like some poisonous fogbank, roll in upon my mind.” William Styron

For years I have pondered the mystery of my father’s alternating cycles of depression and elation that governed his life. I wondered what was at work to give rise to this strange and sad mix of horrible and wonderful days. I have read countless accounts of the various explanations for what is known now as bipolar disorder and the equally numerous treatments that attempt to alleviate it.

One of them was William Styron’s account in Darkness Visible of his battle with the storms of depression. The other day I noticed it on my bookshelf and decided to read it again. Styron describes his depression as “a disorder of mood, so mysteriously painful and elusive in the way it becomes known to the self—to the mediating intellect—as to verge close to being beyond description”

He begins with an account of a trip to Paris in the winter of 1985 when he realized that the melancholy that had dogged him for months was descending into a “siege” that rendered him practically speechless and socially inept.

After he returned to his home in Connecticut he became bedridden, unable to write, with suicidal thoughts and a degree of suffering that was indescribable. In time he was hospitalized where its seclusion and the support of his family and friends enabled him to recover.

In my father’s case, neither psychoanalytic therapy, the drugs available at that time, electroshock treatment, or the best private "rest homes" gave him any lasting relief. Would the newer drugs and treatments available today have made a difference? Perhaps they might have made it easier for him to manage the furies more effectively or put them at a greater distance.

However, I am not at all sure about this and I remain a skeptic about the current views of the brain mechanisms that may be responsible for bipolar disorder. Yes, he may have had some kind of chemical imbalance, but I saw the world in which he grew up, the way his mother and father treated him, and how he had to spend his working days in the family business. It was never a placid situation. There was no escaping the world he brought with him but neither could he escape the one he had to live through during each and every day of his relatively brief life.

Styron also attributes the source of his depression to his early years where his father battled “the gorgon for much of his lifetime, and was hospitalized …after a spiraling downward that in retrospect I saw perfectly resembled mine.”

After reading Darkness Visible, I asked myself if Styron’s account of his descent into madness helped me to better understand my father’s torments. I confess it didn’t, although many readers wrote to him to say how grateful they were for describing so clearly their own battles with depression.

The only thing that ever helped me was an experience I had as a young man, after having my wisdom teeth removed. He was with me when I was recovering from Sodium Pentothal (so-called truth serum), the anesthetic used then.

Its aftereffects led to a period of uncontrollable crying that I was fully aware of but could do nothing to stop. I said to him then that I finally understood why he couldn’t do anything about the demons that descended upon him.

But that was an atypical experience as Sodium Pentothal is rarely used today. And yet it taught me why it is so difficult to grasp the essence of this illness that plagues so many people today. As Styron notes, “To most of those who have experienced it, the horror of depression is so overwhelming as to be quite beyond expression.“

The Science of Melancholy

Louis Menand is a professor of English at Harvard and “Critic at Large” for the New Yorker. He is also knowledgeable across a wide range of disciplines including psychology and psychiatry. In the March 1st of the New Yorker, he writes about current research on depression, therapy, and antidepressants. His discussion centers around six topics:

Depression
Menand claims there is scarcely any agreement on the causes or most effective treatments for depression. Indeed, it may never be known what the source(s) of depression are, largely because it is almost impossible to distinguish a genuine depressive pathology (if there is one) from a sadness or long-lasting melancholy from naturally occurring events.

Diagnosis
There is also considerable disagreement about the definition of depression and a very low agreement among trained psychiatrists in diagnosing a mental patient who appears to be suffering from depression.

Therapy
Psychotherapy for depression has highly variable results with outcomes that are often not significantly different than no-treatment or placebo conditions. There is also little evidence that “…supplementing antidepressant medication with talk therapy improves outcomes.” Further, patients often get better over the course of time without clinical interventions

Antidepressants
In spite of the advice--“Take the meds.”--of a number of well known individuals (William Styron in Darkness Visible, Andrew Solomon in The Noonday Demon, etc), there is also little evidence that antidepressants lead to enduring recovery or that they are superior to placebos

Drug Companies
While the understanding of depression languishes in uncertainty, the drug companies are thriving. “Between 1988, the year after Prozac was approved by the F.D.A, and 2000, adult use of antidepressants almost tripled. By 2005, one out of every ten Americans had a prescription for an antidepressant.”

Coping
There is a strain of pharmacological and psychotherapeutic Calvinism in this country that underscores the importance of learning how to cope with adversity. “We think that sucking it up and mastering our fears is a sign of character.” Or that we don’t want to be the kind of person who doesn’t experience sorrow or distress. These are questions beyond the scope of research and, for Menand, will forever remain matters for philosophy and literature to grapple with.

If the confusion and disarray among those who study and treat depression wasn’t already clear to you, it surely will be after reading Menand’s review. I believe it gives an accurate account of the current state of depression research and analysis. There is scarcely any certainty about what to do if you become depressed and if you are in some way professionally qualified, how to go about treating it.

As one who has spent much of my life observing and studying depression, as well as spending many long hours thinking about the depressed people I have known and loved, I wonder if we will ever be able to understand and effectively overcome what has become an increasingly common problem for all too many individuals

On Depression

Could depression be an adaptive response to painful life stressors? You might wonder how anyone might think anything as unpleasant could be the least bit adaptive. However, if you think the question makes little sense, consider the fact that 1 in 18 or 14.4 million people in USA are estimated to become seriously depressed during their life.

What possible function could such distress or even mild suffering have? This is the question Jonah Lehrer considers in his article “Depression’s Upside” in this week’s New York Times Magazine. The question emerges within an evolutionary psychology framework that tries to account for human thought and action in terms of natural selection processes.

Darwin himself suffered from periodic bouts of depression that he came to believe allowed him to focus on his work. Lehrer quotes Darwin: “Work is the only thing which makes life endurable to me.” And later sadness “…leads an animal to pursue that course of action which is most beneficial.” “The darkness was a kind of light.”

The light it might shed has been taken up by a psychiatrist, Paul Andrews and an evolutionary psychologist, J. Thomson in their controversial paper “The bright side of being blue: Depression as an adaptation for analyzing complex problems.” According to Lehrer they began by focusing on rumination, one of the dominant thought processes of a depressed person. They wondered what purpose rumination might serve.

Andrews and Thomson claim there are real benefits to be derived from ruminative thinking even though it occurs while a person is suffering. They are the insights gained in thinking analytically about their depression. They call their view the “Analytic Rumination Hypothesis.

“The analytical rumination (AR) hypothesis proposes that depression is an adaptation that evolved as a response to complex problems and whose function is to minimize disruption of rumination and sustain analysis of complex problems.”

Andrews and Thomson respond to the many critics of their view by admitting depression cannot be so easily encapsulated into a single formulation, that it is a highly variable phenomena that takes many forms, often without any discernable benefits and that it has numerous alternative theoretical accounts. “To say that depression can be useful doesn’t mean it’s always going to be useful.”

I am sympathetic to Thomson’s view of the critical test for the AR Hypothesis, namely, “Do these ideas help me in my practice?” To find out he began cutting back on anti-depressive medications in the belief that they were actually making it harder for individuals to resolve their dilemmas. He relates the response of one patient who, when asked if her anti-depressants were working, said, “Yes their working great. I feel much better. But I’m still married to the same alcoholic son of a bitch. It’s just now he’s tolerable.”

Lehrer proceeds to discuss the mounting evidence that anti-depressants do not lead to lasting improvement and that the relapse rates for those on them is as high as 76 percent, whereas for those receiving the increasingly popular cognitive therapy it is 36 percent. In addition, he discusses recent research on the effects of negative moods (a sad video, gray/rainy days, negative performance feedback, etc.) that often lead to better decision-making and improved writing.

In one study he showed that unhappy writers write better than happy ones. This is consistent with the large body of research assembled by Kay Redfield Jamison in Touched with Fire that creative achievement in the arts is often associated with depression or manic-depressive illness.

The relationship between depression and improved writing skills seems like a paradoxical quirk of evolution. In an experiment he conducted on abstract-reasoning Andrews found that, “Depressed affect made people think better.” At least it did for some depressed individuals. A seriously ill depressed psychotic is clearly not going to think better or show any benefit from ruminating about their misery.

Lehrer concludes, “The challenge, of course, is persuading people to accept their misery, to embrace the tonic of despair. To say that depression has a purpose or that sadness makes us smarter says nothing about its awfulness….even if our pain is useful, the urge to escape from the pain remains the most powerful instinct of all.”

Telling someone then to embrace the tonic of their despair is easy. Getting them to do that is another matter. Perhaps one way writers try to escape from their despair is by writing about it. Since that rarely works for very long, is it any wonder our bookshelves are filled with so many unhappy novels and memoirs.

Cycles of Creativity

In describing her episodes of profound depression Daphne Merken comments on their cyclic nature. They seem to come and go in an entirely unpredictable, unexpected manner. She notes how scary that is.

And in her study of manic-depressive psychosis, Kay Redfield writes about the seasonal nature of the illness. She says,

“Two broad peaks are evidence in the seasonal incidence of major depressive episodes: spring (March, April, May) and autumn (September, October, and November. The data on mania are somewhat more scarce, but the peak incidences clearly occur in the summer months, as well as the early fall.” She attributes these variations to changes in light-dark cycle.

What interests me most in her analysis is the relationship between the incidence data and artistic creativity. She suggests that while little work has been done on this relationship, there is a “tendency for artistic productivity to increase during spring and autumn, but there is clearly wide variability across artists and writers.”

Extrapolating from the data Jamison presents suggests some consistency in the patterns of artistic productivity. She has partitioned these data in terms of whether or not the artist sought treatment during the period of their illness.

In British writers and artists with a history of treatment for depression on manic-depression, the most productive periods are in the spring and autumn. This corresponds to the incidence data above. For those who did not seek treatment for either form of the illness, the periods of increased productivity are similarly greatest during the spring and autumn months.

The reason I am dwelling on these trends is my interest in the role of weather on creative achievement. Do writers and painters do their best work when it is warm or are they most productive when it is colder or more moderate in temperature? There is virtually no data on this question, but there are some hints in the data presented by Jamison.

Hot weather, for example, is generally not conducive to creative work. Neither are the extremely cold periods of the late fall and early winter. Instead, creative work seems to be more closely associated periods of moderate temperature that occur in the spring and early autumn.

And yet Jamison produces contradictory data in analyzing the paintings and drawings of Vincent van Gogh. It is clear that his most creative periods occurred during the hot summer months of June and July in the south of France, with a lesser number during the spring and autumn months and the least during the winter months (November through February).

“The summer peak of productivity is consistent with what we know about his own description of his frenzied moods and energy during those months of the year, as well as with a perhaps natural tendency to paint more in the longer, warmer, drier days of summer. Perhaps even more interesting, however, is his pattern of productivity during the winter and late fall. From his letters it appears than van Gough had relatively more “pure” depressive episodes during November and February, and more “mixed” depressive episodes during December and January.”

It is understandable that there are wide variations in the effects of temperature on creativity. The most sensitive analysis of this issue will be revealed in a case-by-case study of individual writers and artists. I recall a comment by the psychiatrist Robert Coles:

“I’m constantly impressed with mystery, and maybe even feel that there are certain things that cannot be understood or clarified through generalizations, that resolve themselves into matters of individuality, and again, are part of the mystery of the world that one celebrates as a writer, rather than tries to solve and undo as a social scientist. …to do research and more research, and yet miss the essential point of things.”

Touched With Fire

We’re never going to survive, unless
We get a little crazy. Seal

Earlier this month David Brooks wrote an Op-Ed piece in the Times on the modern view, as he put it, of genius. It has little to do with intelligence, he says, and far more with hard work. It is hours and hours of deliberate practice that separates geniuses from the rest of us. In this respect he agrees with Malcolm Gladwell’s claim in his recent book, Outliers. Brooks writes, “Mozart played a lot of piano at a very young age, so he got his 10,000 of practice in early and then he built from there.”

A few days later Roger Dobson took a contrary view on creative minds in The Independent. He claims creative people in all areas from poetry, and mathematics to humor, have traits associated in mental illness. He cities evidence that compared to the population at large “the incidence of mood disorder, suicide and institutionalization to be 20 times higher among major British and Irish poets in the 200 years up to 1800.” Dobson reminds us that it was over 2000 years ago that the Roman philosopher Seneca wrote, “There is no great genius without a tincture of madness.”

Well before then in fourth century Athens, Aristotle asked, “Why is it that all men who are outstanding in philosophy, poetry, or the arts are melancholic?” Kay Redfield Jamison, a physician and brilliant writer, examines this issue as thoroughly and as systematically as I’ve ever seen in her book, Touched with Fire: Manic-Depressive Illness and the Artistic Temperament. She goes further in bringing together the biographical and scientific evidence for a “compelling association, not to say actual overlap, between two temperaments—the artistic and the manic–depressive.”

Jamison reviews study after study indicating, “among distinguished artists, the rates of manic depression and major depression are 10 to 30 times as prevalent as in the population at large.” William Styron, Ernest Hemingway, Virginia Woolf, the poet Robert Lowell, and Vincent Van Gough come to mind. Going further, she cites a study by Dr. Arnold Ludwig that looked at the frequency of psychiatric illness among 1,004 eminent men and women in the creative arts and “ten other professions—of the stature of Aldous Huxley, Alexander Graham Bell, Albert Einstein and Henri Matisse.”

According to Ludwig, psychiatric illnesses are far more common among the artists s than among the other professions with the rate of alcoholism 60% among actors and 41% among novelists, but only 3 % among those in the physical sciences and 10% among military officers. “In the case of manic depression, 17 % of the actors and 13 percent of the poets were thought to have had the disorder, while those in the sciences were believed to have suffered from it at the rate of less than 1%, comparable to the incidence in the general population.”

More recent research is turning to the neurobiological basis of this relationship, including the emerging field of neuroimaging. This should be no surprise to readers of this blog.

What is one to make of this compelling relationship? Are we to nurture our bouts of depression, assuming we will then be able to craft the great American novel? Should we take to the bottle to turn ourselves into the Picasso of the 21st Century? Or should we, as Brooks and Gladwell argue, get with it, and practice, practice, practice? Of course, that will take the magic out of creative genius, but with a little help from our wiring who knows what we might be able to achieve if we practiced for 10,000 hours?

“Emily Dickinson was not an alcoholic, she was not abusive, she was not neurotic, she did not commit suicide. Neurotic people or alcoholics who go through life make better copy, and people talk about them, tell anecdotes about them. The quiet people just do their work.” Joyce Carol Oates.

Darkness Visible

For the thing which I had greatly feared is come upon me,
And that which I was afraid of is come unto me.
I was not in safety, neither had I rest, neither was I quiet;
Yet trouble came. Job

For years admired I have admired the essays and articles of Daphne Merkin. Never once did I sense she was engaged in a life-long battle with chronic depression. As she notes in her frank and brutally candid account of her experience in the Sunday Times Magazine, she was good at “adopting the mask of all-rightness that every depressed person learns to wear in order to navigate the world.”

She reports that as early as 5 or 6 she “had begun to be apprehensive about what lay in wait” and by 10 had been hospitalized for frequent bouts of crying. At times she has felt suicidal and at others times simply unable to escape from the darkness and despair that permeated every cell in her body, lying in bed for days at a time, unable to read, eat, or do anything but sleep. Merken confesses she had quite literally ground to a halt.

For over four decades she has been going to psychotherapists and has tried every medication and combinations of medications that have been prescribed since her early 20s. None of the therapists or drugs had done much for her. “What’s more, after a lifetime of talk therapy and medication that never seemed to do more than patch over the holes in myself, I wasn’t sure that I still believed in the concept of professional intervention.”

“In some ways, the quiet terror of severe depression never entirely passes once you’ve experienced it. It hovers behind the scenes, placated temporarily by medication and renewed energy, waiting to slither back in, unnoticed by others. It sits in the space behind your eyes, making its presence felt even in those moments when other, lighter matters are at the forefront of you mind. It tugs at you, keeping you from ever being fully at ease.”

The precipitating events are never clear to her. As she puts it, they include “everything and nothing, as is just about always the case—some combination of vulnerable genetics and several less-than-optimal pieces of fate.” About her most recent return to a psychiatric hospital, she writes, “I wanted to die, but at the same time, I didn’t want to, not completely. Suicide could wait my sister said.”

She says the first night was the hardest, but then later says they never got any better. The lack of a reading lamp added to her panic. She writes, “the absence of a light source by which to read after dark represented the end of civilization as I had know it.”

Throughout this time (3 weeks) the major issue for Merken was whether she would undergo ECT, a treatment with a checkered history that currently finds some favor and was recommended by her psychiatrist to pull her out of her “neurovegetative” condition. Merkin resists. And then one day she says, “something shifted ever so slightly in my mind.” She had replaced one of her medications with a new one but really had no idea what led to the change. She speculates, “Maybe it was the fear of ECT, or perhaps the tweaked medication had kicked in, or maybe the depression had finally taken its course and was beginning to lift…”

Merken began to feel a little better, better at least to leave the hospital and try to reenter her life. “I had things I wanted to say” and new books to read and films to see. Still she said everything felt fragile and while her depression had taken a time out, she knew full well it could return at any time without warning. This is the underlying terror of chronic depression.

I have known people who have journeyed through life with this affliction, people who I have lived with and loved. And what I have observed is that there is no escaping the internal “dungeon” through which they must travel. Nothing they try works. Not the drugs, the new and the old, and their limitless combinations. Not the year after year of therapeutic treatments or the hospitalizations, regardless of how long or short or where they are located. And not the ECT no matter how often it is administered or how it is tweaked.

Chronic depression appears to come and go on its own. Merken writes, “Worst of all it honors no season and respects no calendar; it arrives precisely when it feels like it.”