Although some tiny part of me retained a dim sense of the more functioning person I once was — like a room with a closed door that was never entered anymore — it became increasingly difficult to envision myself ever inhabiting that version of myself again. There had been too many recurrent episodes, too many years of trying to fight off this debilitating demon of a thing. It has been called by different names at different times in history — melancholia, malaise, cafard, brown study, the blues, the black dog, acedia — and has been treated as a spiritual malady, a failure of will, a biochemical malfunctioning, a psychic conundrum, sometimes all at once. Whatever it was, it had come to define me, filling out all the available space, leaving no possibility of a “before” or an “after.” Instead I harbored the hallucinatory conviction that I had stayed around the scene of my own life too long — that I was, in some unyielding sense, ex post facto.

I had also quite literally ground to a halt, like a machine that had hit a glitch and frozen on the spot. I moved at a glacial pace and talked haltingly, in a voice that was lower and flatter than my usual one. As I discovered from my therapist and psychopharmacologist — both of whom argued that I belonged in a hospital now that my depression had taken on “a life of its own,” beyond the exertions of my will — there was a clinical name for my state: “psychomotor retardation.” My biology, that is, had caught up and joined hands with the immediate psychodynamic stressors that precipitated my nosedive — the lingering aftermath of the death two years earlier of my mother, with whom I had a complicated relationship; the imminent separation from my college-age daughter, who was my boon companion; therapy that took a wrong turn; a romance that went awry. (Much as we would like to explain clinical depression by making it either genetics or environment, bad wiring or bad nurturing, it is usually a combination of the two that sets the illness off.)

And yet I resisted my doctors’ suggestion that I check myself into a hospital. It seemed safer to stay where I was, no matter how out on a ledge I felt, than to lock myself away with other desperadoes in the hope that it would prove effective. Whatever fantasies I once harbored about the haven-like possibilities of a psychiatric facility or the promise of a definitive, once-and-for-all cure were shattered by my last stay 15 years earlier. I had written about the experience, musing on the gap between the alternately idealized and diabolical image of mental hospitals versus the more banal bureaucratic reality. I discussed the continued stigma attached to going public with the experience of depression, but all this had been expressed by the writer in me rather than the patient, and it seemed to me that part of the appeal of the article was the impression it gave that my hospital days were behind me. It would be a betrayal of my literary persona, if nothing else, to go back into a psychiatric unit.

What’s more, after a lifetime of talk therapy and medication that never seemed to do more than patch over the holes in my self, I wasn’t sure that I still believed in the concept of professional intervention. Indeed, I probably knew more about antidepressants than most analysts, having tried all three categories of psychotropics separately or in combination as they became available — the classic tricyclics, the now-unfashionable MAO inhibitors (which come with a major drawback in the form of dietary restrictions) as well as the newer S.S.R.I.’s. and S.N.R.I.’s. I was originally reluctant to try pills for something that seemed so intrinsic to who I was — the state of mind in which I lived, so to speak — until one of my first psychiatrists compared my emotional state to an ulcer. “You can’t speak to an ulcer,” he said. “You can’t reason with it. First you cure the ulcer, then you go on to talk about the way you feel.” My current regime of pills incorporated the latest approach, which called for the augmentation of a classic antidepressant (Effexor) with a small dose of a second-generation antipsychotic (Risperdal). From the time I was prescribed Prozac in my early 20s before it was approved by the Food and Drug Administration, you could say that the history of depression medication and my personal history came of age together, with me in the starring role of a lab rat.

Of course, none of the drugs work conclusively, and for now we are stuck with what comes down to a refined form of guesswork — 30-odd pills that operate in not completely understood ways on neural pathways, on serotonin, norepinephrine, dopamine and what have you. No one, not even the psychopharmacologists who dispense them after considering the odds, totally comprehends why they work when they work or why they don’t when they don’t. All the while the repercussions and the possible side effects (which include mild trembling on the one end to tardive dyskinesia, a rare condition that causes uncontrollable grimacing, on the other end) are shunted to the side until such time as they can no longer be ignored.

THE ONE THING PSYCHIATRIC hospitals are supposed to be good for is to keep you safe. But I was conflicted even about so primary an issue as survival. I wasn’t sure I wanted to ambush my own downward spiral, where the light at the end of the tunnel, as the mood-disordered Robert Lowell once said, was just the light of the oncoming train. I saw myself go splat on the pavement with a kind of equanimity, with a sense of a foretold conclusion. Self-inflicted death had always held out a stark allure for me: I was fascinated by people who had the temerity to bring down the curtain on their own suffering — who didn’t hang around, moping, in hopes of a brighter day. I knew all the arguments about the cowardice and selfishness (not to mention anger) involved in committing suicide, but nothing could persuade me that the act didn’t require a perverse sort of courage, some steely embrace of self-extinction. At one and the same time, I have also always believed that suicide victims don’t realize they won’t be coming this way again. If you are depressed enough, it seems to me, you begin to conceive of death as a cradle, rocking you gently back to a fresh life, glistening with newness, unsullied by you.

Still, one flesh-and-blood reality stood in my way: I had a daughter I loved deeply, and I understood the irreparable harm it would cause her if I took my own life, despite feeling that if I truly cared about her I would free her from the presence of a mother who was more shade than sun. (What had Sylvia Plath and Anne Sexton done with their guilt feelings? I wondered. Were they more narcissistic than I or just more strong-willed?) It was because of my daughter, after all, that I had given voice to my “suicidal ideation,” as it’s called, in the first place, worrying how she would get along without me. At the same time, I recognized that, for a person who was really set on ending it all, speaking your intention aloud was an act of self-betrayal. After all, in the process of articulating your death wish you were alerting other people, ensuring that they would try to stop you.