The Noonday Demon (10 page)

There has been relatively little written about the fact that breakdowns are preposterous; seeking dignity, and seeking to dignify the sufferings of others, one can easily overlook this fact. It is, however, real and true, and obvious when you are depressed. Depression minutes are like dog years, based on some artificial notion of time. I can remember lying frozen in
bed, crying because I was too frightened to take a shower, and at the same time knowing that showers are not scary. I kept running through the individual steps in my mind: you turn and put your feet on the floor; you stand; you walk from here to the bathroom; you open the bathroom door; you walk to the edge of the tub; you turn on the water; you step under the water; you rub yourself with soap; you rinse; you step out; you dry yourself; you walk back to the bed. Twelve steps, which sounded to me then as onerous as a tour through the stations of the cross. But I knew, logically, that showers were easy, that for years I had taken a shower
every day
and that I had done it so quickly and so matter-of-factly that it had not even warranted comment. I knew that those twelve steps were really quite manageable. I knew that I could even get someone else to help me with some of them. I would have a few seconds of relief contemplating that thought. Someone else could open the bathroom door. I knew I could probably manage two or three steps, so with all the force in my body I would sit up; I would turn and put my feet on the floor; and then I would feel so incapacitated and so frightened that I would roll over and lie facedown, my feet still on the floor. I would sometimes start to cry again, weeping not only because of what I could not do, but because the fact that I could not do it seemed so idiotic to me. All over the world people were taking showers. Why, oh why, could I not be one of them? And then I would reflect that those people also had families and jobs and bank accounts and passports and dinner plans and problems, real problems, cancer and hunger and the death of their children and isolating loneliness and failure; and I had so few problems by comparison, except that I couldn’t turn over again, until a few hours later, when my father or a friend would come in and help to hoist my feet back up onto the bed. By then, the idea of a shower would have come to seem foolish and unrealistic, and I would be relieved to have been able to get my feet back up, and I would lie in the safety of the bed and feel ridiculous. And sometimes in some quiet part of me there was a little bit of laughter at that ridiculousness, and my ability to see that, is, I think, what got me through. Always at the back of my mind there was a voice, calm and clear, that said, don’t be so maudlin; don’t do anything melodramatic. Take off your clothes, put on your pajamas, go to bed; in the morning, get up, get dressed, and do whatever it is that you’re supposed to do. I heard that voice all the time, that voice like my mother’s. There was a sadness and a terrible loneliness as I contemplated what was lost. “Did anyone—not just the red-hot cultural center, but anyone, even my dentist—care that I had withdrawn from the fray?” Daphne Merkin wrote in a confessional essay on her own depression. “Would people mourn me if I never returned, never took up my place again?”

By the time evening came around, I was able to get out of bed. Most depression is circadian, improving during the day and then descending again by morning. At dinner, I would feel unable to eat, but I could get up and sit in the dining room with my father, who canceled all other plans to be with me. I could also speak by then. I tried to explain what it was like. My father nodded, implacably assured me that it would pass, and tried to make me eat. He cut up my food. I told him not to feed me, that I wasn’t five, but when I was defeated by the difficulty of getting a piece of lamb chop onto my fork, he would do it for me. All the while, he would remember feeding me when I was a tiny child, and he would make me promise, jesting, to cut up his lamb chops when he was old and had lost his teeth. He had been in touch with some of my friends, and some of my friends had called me anyway, and after dinner I would feel well enough to call some of them back. Sometimes, one would even come over after dinner. Against the odds, I could usually even have a shower before bed! And no drink after crossing the desert was ever lovelier than that triumph and the cleanliness. Before bed, Xanaxed out but not yet asleep, I would joke with my father and with friends about it, and that rare intimacy that surrounds illness would make itself felt in the room, and sometimes I would feel too much and begin to cry again, and then it was time to turn off the lights, so that I could go back to sleep. Sometimes close friends would sit with me until I drifted off. One friend used to hold my hand while she sang lullabies. Some evenings, my father read to me from the books he had read me when I was a child. I would stop him. “Two weeks ago, I was publishing my novel,” I would say. “I used to work twelve hours and then go to four parties in an evening, some days. What’s happened?” My father would assure me, sunnily, that I would be able to do it all again, soon. He could as well have told me that I would soon be able to build myself a helicopter out of cookie dough and fly on it to Neptune, so clear did it seem to me that my real life, the one I had lived before, was now definitively over. From time to time, the panic would lift for a little while. Then came the calm despair. The inexplicability of it all defied logic. It was hellishly embarrassing to tell people I was depressed, when my life seemed to have so much good and love and material comfort in it; for all but my close friends, I developed an “obscure tropical virus” that I “must have picked up last summer, traveling.” The lamb-chop question became emblematic to me. A poet friend, Elizabeth Prince, wrote:

Later, I read in Leonard Woolf’s diary his description of Virginia’s depressions: “If left to herself, she would have eaten nothing at all and would have gradually starved to death. It was extraordinarily difficult ever to get her to eat enough to keep her strong and well. Pervading her insanity generally there was always a sense of some guilt, the origin and exact nature of which I could never discover; but it was attached in some peculiar way particularly to food and eating. In the early acute, suicidal stage of the depression, she would sit for hours overwhelmed with hopeless melancholia, silent, making no response to anything said to her. When the time for a meal came, she would pay no attention whatsoever to the plate of food put before her. I could usually induce her to eat a certain amount, but it was a terrible process. Every meal took an hour or two; I had to sit by her side, put a spoon or fork in her hand, and every now and again ask her very quietly to eat and at the same time touch her arm or hand. Every five minutes or so she might automatically eat a spoonful.”

You are constantly told in depression that your judgment is compromised, but part of depression is that it touches cognition. That you are having a breakdown does not mean that your life isn’t a mess. If there are issues you have successfully skirted or avoided for years, they come cropping back up and stare you full in the face, and one aspect of depression is a deep knowledge that the comforting doctors who assure you that your judgment is bad are wrong. You are in touch with the real terribleness of your life. You can accept rationally that later, after the medication sets in, you will be better able to deal with the terribleness, but you will not be free of it. When you are depressed, the past and future are absorbed entirely by the present moment, as in the world of a three-year-old. You cannot remember a time when you felt better, at least not clearly; and you certainly cannot imagine a future time when you will feel better. Being upset, even profoundly upset, is a temporal experience, while depression is atemporal. Breakdowns leave you with no point of view.

There’s a lot going on during a depressive episode. There are changes in neurotransmitter function; changes in synaptic function; increased or decreased excitability between neurons; alterations of gene expression; hypometabolism in the frontal cortex (usually) or hypermetabolism in the same area; raised levels of thyroid releasing hormone (TRH); disruption of function in the amygdala and possibly the hypothalamus (areas within the brain); altered levels of melatonin (a hormone that the pineal gland makes from serotonin); increased prolactin (increased lactate in anxiety-
prone individuals will bring on panic attacks); flattening of twenty-four-hour body temperature; distortion of twenty-four-hour cortisol secretion; disruption of the circuit that links the thalamus, basal ganglia, and frontal lobes (again, centers in the brain); increased blood flow to the frontal lobe of the dominant hemisphere; decreased blood flow to the occipital lobe (which controls vision); lowering of gastric secretions. It is difficult to know what to make of all of these phenomena. Which are causes of depression; which are symptoms; which are merely coincidental? You might think that the raised levels of TRH mean that TRH causes bad feelings, but in fact administering high doses of TRH may be a temporarily useful treatment of depression. As it turns out, the body begins producing TRH during depression for its antidepressant capacities. And TRH, which is not generally an antidepressant, can be utilized as an antidepressant immediately after a major depressive episode because the brain, though it is having a lot of problems in a depression, also becomes supersensitive to the things that can help to solve those problems. Brain cells change their functions readily, and during an episode, the ratio between the pathological changes (which cause depression) and the adaptive ones (which fight it) determines whether you stay sick or get better. If you have medications that exploit or aid the adaptive factors enough to put down the pathological ones once and for all, then you break free of the cycle and your brain can get on with its usual routines.

The more episodes you have, the more likely you are to have more episodes, and in general the episodes, over a lifetime, get worse and closer together. This acceleration is a clue to how the disease works. The initial onset of depression is usually connected either to kindling events or to tragedy; people with a genetic predisposition to develop depression are, as Kay Jamison—a charismatic psychologist whose texts, academic and popular, have done a great deal to change thinking about mood disorders—has observed, “like dry and brittle pyres, unshielded against the inevitable sparks thrown off by living.” The recurrences at some point break free of circumstance. If you stimulate seizures in an animal every day, the seizures eventually become automatic; the animal will go on having them once a day even if you withdraw the stimulation. In much the same way, the brain that has gone into depression a few times will continue to return to depression over and over. This suggests that depression, even if it is occasioned by external tragedy, ultimately changes the structure, as well as the biochemistry, of the brain. “So it’s not as benign an illness as we used to suppose,” explains Robert Post, chief of the Biological Psychiatry Branch of the National Institute of Mental Health (NIMH). “It tends to be recurrent; it tends to run downhill; and so one should in the face of several episodes consider long-term preventative
treatment to avoid all the horrible consequences.” Kay Jamison thumps the table when she gets going on this subject. “It’s not like depression’s an innocuous thing. You know, in addition to being a miserable, awful, nonconstructive state, for the most part, it also kills people. Not only through suicide, but also through higher heart disease, lowered immune response, and so on.” Frequently, patients who are medication-responsive cease to be responsive if they keep cycling on and off the medications; with each episode, there is an increased 10 percent risk that the depression will become chronic and inescapable. “It’s sort of like a primary cancer that’s very drug-responsive, but then once it metastasizes, it doesn’t respond at all,” Post explains. “If you have too many episodes, it changes your biochemistry for the bad, possibly permanently. At that point, many therapists are still looking in completely the wrong direction. If the episode now occurs on automatic, what good is it to worry about the stressor that kicked off the original process? It’s just too late for that.” That which is mended is but patched and can never be whole again.

Three separate events—decrease in serotonin receptors; rise in cortisol, a stress hormone; and depression—are coincident. Their sequence is unknown: it’s a sort of chicken and chick and egg mystery. If you lesion the serotonin system in an animal brain, the levels of cortisol go up. If you raise levels of cortisol, serotonin seems to go down. If you stress a person, corticotropin releasing factor (CRF) goes up and causes the level of cortisol to go up. If you depress a person, levels of serotonin go down. What does this mean? The substance of the decade has been serotonin, and the treatments most frequently used for depression in the United States are ones that raise the functional level of serotonin in the brain. Every time you affect serotonin, you also modify the stress systems and change the level of cortisol in the brain. “I wouldn’t say that cortisol causes depression,” says Elizabeth Young, who works on this field at the University of Michigan, “but it may well exacerbate a minor condition and create a real syndrome.” Cortisol, once it is produced, binds to glucocorticoid receptors in the brain. Antidepressants increase the number of these glucocorticoid receptors—which then absorb the excess cortisol that is floating around up there. This is extremely important for overall body regulation. The glucocorticoid receptors actually turn on and off some genes, and when you have relatively few receptors being swamped with a lot of cortisol, the system goes into overdrive. “It’s like having a heating system,” Young says. “If the temperature sensor for the thermostat is in a spot that’s become drafty, the heat will never turn off even though the room is scalding. If you add a few more sensors located around the room, you can get the system back under control.”