Book Excerpt: Noonday Demon
— -- Maybe what is present usurps what becomes absent, and maybe the absence of obfuscatory things reveals what is present. Either way, you are less than yourself and in the clutches of something alien. Too often, treatments address only half the problem: they focus only on the presence or only on the absence. It is necessary both to cut away that extra thousand pounds of the vines and to relearn a root system and the techniques of photosynthesis. Drug therapy hacks through the vines. You can feel it happening, how the medication seems to be poisoning the parasite so that bit by bit it withers away. You feel the weight going, feel the way that the branches can recover much of their natural bent. Until you have got rid of the vine, you cannot think about what has been lost. But even with the vine gone, you may still have few leaves and shallow roots, and the rebuilding of your self cannot be achieved with any drugs that now exist. With the weight of the vine gone, little leaves scattered along the tree skeleton become viable for essential nourishment. But this is not a good way to be. It is not a strong way to be. Rebuilding of the self in and after depression requires love, insight, work, and, most of all, time.
Diagnosis is as complex as the illness. Patients ask doctors all the time, "Am I depressed?" as though the result were in a definitive blood test. The only way to find out whether you're depressed is to listen to and watch yourself, to feel your feelings and then think about them. If you feel bad without reason most of the time, you're depressed. If you feel bad most of the time with reason, you're also depressed, though changing the reasons may be a better way forward than leaving circumstance alone and attacking the depression. If the depression is disabling to you, then it's major. If it's only mildly distracting, it's not major. Psychiatry's bible — the Diagnostic and Statistical Manual, fourth edition (DSM-IV) — ineptly defines depression as the presence of five or more on a list of nine symptoms. The problem with the definition is that it's entirely arbitrary. There's no particular reason to qualify five symptoms as constituting depression; four symptoms are more or less depression; and five symptoms are less severe than six. Even one symptom is unpleasant. Having slight versions of all the symptoms may be less of a problem than having severe versions of two symptoms. After enduring diagnosis, most people seek causation, despite the fact that knowing why you are sick has no immediate bearing on treating the sickness.
Illness of the mind is real illness. It can have severe effects on the body. People who show up at the offices of their doctors complaining about stomach cramps are frequently told, "Why, there's nothing wrong with you except that you're depressed!" Depression, if it is sufficiently severe to cause stomach cramps, is actually a really bad thing to have wrong with you, and it requires treatment. If you show up complaining that your breathing is troubled, no one says to you, "Why, there's nothing wrong with you except that you have emphysema!" To the person who is experiencing them, psychosomatic complaints are as real as the stomach cramps of someone with food poisoning. They exist in the unconscious brain, and often enough the brain is sending inappropriate messages to the stomach, so they exist there as well. The diagnosis — whether something is rotten in your stomach or your appendix or your brain — matters in determining treatment and is not trivial. As organs go, the brain is quite an important one, and its malfunctions should be addressed accordingly.
Chemistry is often called on to heal the rift between body and soul. The relief people express when a doctor says their depression is "chemical" is predicated on a belief that there is an integral self that exists across time, and on a fictional divide between the fully occasioned sorrow and the utterly random one. The word chemical seems to assuage the feelings of responsibility people have for the stressed-out discontent of not liking their jobs, worrying about getting old, failing at love, hating their families. There is a pleasant freedom from guilt that has been attached to chemical. If your brain is predisposed to depression, you need not blame yourself for it. Well, blame yourself or evolution, but remember that blame itself can be understood as a chemical process, and that happiness, too, is chemical. Chemistry and biology are not matters that impinge on the "real" self; depression cannot be separated from the person it affects. Treatment does not alleviate a disruption of identity, bringing you back to some kind of normality; it readjusts a multifarious identity, changing in some small degree who you are.
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 feel better, the chemical changes are no less particular and complex than the ones that are brought about by taking antidepressants. The external determines the internal as much as the internal invents the external. What is so unattractive is the idea that in addition to all other lines being blurred, the boundaries of what makes us ourselves are blurry. There is no essential self that lies pure as a vein of gold under the chaos of experience and chemistry. Anything can be changed, and we must understand the human organism as a sequence of selves that succumb to or choose one another. And yet the language of science, used in training doctors and, increasingly, in nonacademic writing and conversation, is strangely perverse.
The cumulative results of the brain's chemical effects are not well understood. In the 1989 edition of the standard Comprehensive Textbook of Psychiatry, for example, one finds this helpful formula: a depression score is equivalent to the level of 3-methoxy-4-hydroxyphenylglycol (a compound found in the urine of all people and not apparently affected by depression); minus the level of 3-methoxy-4-hydroxymandelic acid; plus the level of norepinephrine; minus the level of normetanephrine plus the level of metanepherine, the sum of those divided by the level of 3-methoxy-4-hydroxymandelic acid; plus an unspecified conversion variable; or, as CTP puts it: "D-type score = C1 (MHPG) - C2 (VMA) + C3 (NE) - C4 (NMN + MN)/VMA + C0." The score should come out between one for unipolar and zero for bipolar patients, so if you come up with something else — you're doing it wrong. How much insight can such formulae offer? How can they possibly apply to something as nebulous as mood? To what extent specific experience has conduced to a particular depression is hard to determine; nor can we explain through what chemistry a person comes to respond to external circumstance with depression; nor can we work out what makes someone essentially depressive.
Although depression is described by the popular press and the pharmaceutical industry as though it were a single-effect illness such as diabetes, it is not. Indeed, it is strikingly dissimilar to diabetes. Diabetics produce insufficient insulin, and diabetes is treated by increasing and stabilizing insulin in the bloodstream. Depression is not the consequence of a reduced level of anything we can now measure. Raising levels of serotonin in the brain triggers a process that eventually helps many depressed people to feel better, but that is not because they have abnormally low levels of serotonin. Furthermore, serotonin does not have immediate salutary effects. You could pump a gallon of serotonin into the brain of a depressed person and it would not in the instant make him feel one iota better, though a long-term sustained raise in serotonin level has some effects that ameliorate depressive symptoms. "I'm depressed but it's just chemical" is a sentence equivalent to "I'm murderous but it's just chemical" or "I'm intelligent but it's just chemical." Everything about a person is just chemical if one wants to think in those terms. "You can say it's 'just chemistry,' " says Maggie Robbins, who suffers from manic-depressive illness. "I say there's nothing 'just' about chemistry." The sun shines brightly and that's just chemical too, and it's chemical that rocks are hard, and that the sea is salt, and that certain springtime afternoons carry in their gentle breezes a quality of nostalgia that stirs the heart to longings and imaginings kept dormant by the snows of a long winter. "This serotonin thing," says David McDowell of Columbia University, "is part of modern neuromythology." It's a potent set of stories.
Internal and external reality exist on a continuum. What happens and how you understand it to have happened and how you respond to its happening are usually linked, but no one is predictive of the others. If reality itself is often a relative thing, and the self is in a state of permanent flux, the passage from slight mood to extreme mood is a glissando. Illness, then, is an extreme state of emotion, and one might reasonably describe emotion as a mild form of illness. If we all felt up and great (but not delusionally manic) all the time, we could get more done and might have a happier time on earth, but that idea is creepy and terrifying (though, of course, if we felt up and great all the time we might forget all about creepiness and terror).
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