For the thing which I greatly feared is come upon me, and that which I was afraid of Is come into me. I was not in safety, neither had I rest, neither was I quiet; Yet trouble came. —Job To many of us who knew Abbie Hoffman even slightly, as I did, his death in the spring of 1989 was a sorrowful happening. Just past the age of fifty, he had been too young and apparently too vital for such an ending; a feeling of chagrin and dreadfulness attends the news of nearly anyone’s suicide, and Abbie’s death seemed for me especially cruel. I had first met him during the wild days and nights of the 1968 Democratic convention in Chicago, where I had gone to write a piece for The New York Review of Books, and I later was one of those who testified in behalf of him and his fellow defendants at the trial, also in Chicago, in 1970. Amid the pious follies and morbid perversions of American life, his antic style was exhilarating, and it was hard not to admire the hell-raising and the brio, the anarchic individualism. I wish I had seen more of him in recent years; his sudden death left me with a particular emptiness, as suicides usually do to everyone. But the event was given a further dimension of poignancy by what one must begin to regard as a predictable reaction from many: the denial, the refusal to accept the fact of the suicide itself, as if the voluntary act—as opposed to an accident, or death from natural causes—were tinged with a delinquency that somehow lessened the man and his character. Abbie’s brother appeared on television, grief-ravaged and distraught; one could not help feeling compassion as he sought to deflect the idea of suicide, insisting that Abbie, after all, had always been careless with pills and would never have left his family bereft. However, the coroner confirmed that Hoffman had taken the equivalent of 150 phenobarbitals. It’s quite natural that the people closest to suicide victims so frequently and feverishly hasten to disclaim the truth; the sense of implication, of personal guilt—the idea that one might have prevented the act if one had taken certain precautions, had somehow behaved differently—is perhaps inevitable. Even so, the sufferer—whether he has actually killed himself or attempted to do so, or merely expressed threats— is often, through denial on the part of others, unjustly made to appear as a wrongdoer. A similar case is that of Randall Jarrell—one of the fine poets and critics of his generation—who one night in 1965, near Chapel Hill, North Carolina, was struck by a car and killed. Jarrell’s presence on that particular stretch of road, at an odd hour of the evening, was puzzling, and since some of the indications were that he had deliberately let the car strike him, the early conclusion was that his death was suicide. Newsweek, among other publications, said as much, but Jarrell’s widow protested in a letter to that magazine; there was a hue and cry from many of his friends and supporters, and a coroner’s jury eventually ruled the death to be accidental. Jarrell had been suffering from extreme depression and had been hospitalized; only a few months before his misadventure on the highway and while in the hospital, he had slashed his wrists. Anyone who is acquainted with some of the jagged contours of Jarrell’s life—including his violent fluctuations of mood, his fits of black despondency—and who, in addition, has acquired a basic knowledge of the danger signals of depression would seriously question the verdict of the coroner’s jury. But the stigma of self-inflicted death is for some people a hateful blot that demands erasure at al costs. (More than two decades after his death, in the summer-1986 issue of The American Scholar, a onetime student of Jarrell’s, reviewing a collection of the poet’s letters, made the review less a literary or biographical appraisal than an occasion for continuing to try to exorcise the vile phantom of suicide.) Randal Jarrell almost certainly killed himself. He did so not because he was a coward, nor out of any moral feebleness, but because he was afflicted with a depression that was so devastating that he could no longer endure the pain of it. This general unawareness of what depression is really like was apparent most recently in the matter of Primo Levi, the remarkable Italian writer and survivor of Auschwitz who, at the age of sixty-seven, hurled himself down a stairwell in Turin in 1987. Since I had survived a near-fatal siege of depression myself a year or so earlier, I had been more than ordinarily interested in Levi’s death, and so, late last year, when I read an account in The New York Times about a symposium on the writer and his work held at New York University, I was fascinated but, finally, appalled. For, according to the article, many of the participants, worldly writers and scholars, seemed mystified by Levi’s suicide, mystified and disappointed. It was as if this man whom they had al so greatly admired, and who had endured so much at the hands of the Nazis—a man of exemplary resilience and courage—had by his suicide demonstrated a frailty, a crumbling of character they were loath to accept. In the face of a terrible absolute—self-destruction—their reaction was helplessness and (the reader could not avoid it) a touch of shame.

My annoyance over all this was so intense that I was prompted to write a short piece for the op-ed page of the Times. The argument I put forth was fairly straightforward: the pain of severe depression is quite unimaginable to those who have not suffered it, and it kills in many instances because its anguish can no longer be bourne. The prevention of many suicides will continue to be hindered until there is a general awareness of the nature of this pain. Through the healing process of time—and through medical intervention or hospitalization in many cases—most people survive depression, which may be its only blessing; but to the tragic legion who are compelled to destroy themselves there should be no more reproof attached than to the victims of terminal cancer. I had set down my thoughts in this Times piece rather hurriedly and spontaneously, but the response was equally spontaneous—and enormous. It had taken, I speculated, no particular originality or boldness on my part to speak out frankly about suicide, and the impulse toward it, but I had apparently underestimated the number of people for whom the subject had been taboo, a matter of secrecy and shame. The overwhelming reaction made me feel that inadvertently I had helped unlock a closet from which many souls were eager to come out and proclaim that they, too, had experienced the feelings I had described. It is the only time in my life I have felt it worthwhile to have invaded my own privacy, and to make that privacy public. And I thought that, given such momentum, it might be useful to try to briefly chronicle some of my own experiences with depression, and in the process perhaps establish a frame of reference out of which one or more valuable conclusions might be drawn. Such conclusions, it has to be emphasized, must still be based on the events that happened to one man. In setting these reflections down I don’t intend my ordeal to stand as a representation of what happens, or might happen, to others. Although as an illness depression manifests certainly unvarying characteristics, it also allows for many idiosyncracies; I’ve been amazed at some of the freakish phenomena—not reported by other patients— that it has wrought amid the twistings of my mind’s labyrinth. Depression afflicts millions directly, and many millions more who are relatives or friends of victims. As assertively democratic as a Norman Rockwell poster, it strikes indiscriminately at all ages, races, creeds, and classes, though women are at considerably higher risk than men. The occupational list (dressmakers, barge captains, sushi chefs, Cabinet members) of its patients is too long and tedious; it is enough to say that very few people escape being a potential victim of the disease, at least in its milder form. Despite depression’s eclectic reach, it has demonstrated with fair convincingness that artistic types (especially poets) are particularly vulnerable to the disorder—which in its graver, clinical manifestation takes upward of 20 percent of its victims by way of suicide. Just a few of these fallen artists, all modern, make up a sad but scintillant roll call: Hart Crane, Vincent Van Gogh, Virginia Woolf, Arshile Gorky, Cesare Pavese, Romain Gary, Sylvia Plath, Mark Rothko, John Berryman, Jack London, Ernest Hemingway, Diane Arbus, Tadeusz Borowski, Paul Celan, Anne Sexton, Sergei Esenin, Vladimir Mayakovsky—the list goes on. (The Russian poet Mayakovsky was harshly critical of his great contemporary Esenin’s suicide a few years before, which should stand as a caveat for all who are judgmental about self-destruction.) When one thinks of these doomed and splendidly creative men and women, one is drawn to contemplate their childhoods, where, to the best of anyone’s knowledge, the seeds of the illness take strong root; could any of the m have had a hint, then, of the psyche’s perishability, its exquisite fragility? And why were they destroyed, while others—similarly stricken—struggled through?

When I was first aware that I had been laid low by the disease, I felt a need, among other things, to register a strong protest against the word “depression.” Depression, most people know, used to be termed melancholia, a word which appeared in English as early as the year 1303 and crops up more than once in Chaucer, who in his usage seemed to be aware of its pathological nuances. “Melancholia” would still appear to be a far more apt and evocative word for the blacker forms of the disorder, but it was usurped by a noun with a bland tonality and lacking any magisterial presence, used indifferently to describe an economic decline or a rut in the ground, a true wimp of a word for such a major illness. It may be that the scientist generally held responsible for its currency in modern times, a Johns Hopkins Medical School faculty member justly venerated—the Swiss-born psychiatrist Adolf Meyer—had a tin ear for the finer rhythms of English and therefore was unaware of the semantical damage he had inflicted by offering “depression” as a descriptive noun for such a dreadful and raging disease; nonetheless, for over seventy-five years the word has slithered innocuously through the language like a slug, leaving little trace of its intrinsic malevolence and preventing, by its very insipidity, a general awareness of the horrible intensity of the disease when out of control. As one who has suffered from the malady in extremis yet returned to tell the tale, I would lobby for a truly arresting designation. “Brainstorm,” for instance, has unfortunately been pre-empted to describe, somewhat jocularly, intellectual inspiration. But something along these lines is needed. Told that someone’s mood disorder had evolved into a storm—a veritable howling tempest in the brain, which is indeed what a clinical depression resembles like nothing else—even the uninformed layman might display sympathy rather than the standard reaction that “depression” evokes, something akin to “So what?” Or “You’ll pull out of it.” Or “We all have bad days.” The phrase “nervous breakdown” seems to be on its way out, certainly deservedly so, owing to its insinuation of a vague spinelessness, but we still seem destined to be saddled with “depression” until a better, sturdier name is created. The depression that engulfed me was not of the manic type—the one accompanied by euphoric highs—which would have most probably presented itself earlier in my life. I was sixty when the illness struck for the first time, in the “unipolar” form, which leads straight down. I shall never learn what “caused” my depression, as no one will ever learn about their own. To be able to do so will likely forever prove to be an impossibility, so complex are the intermingled factors of abnormal chemistry, behavior, and genetics. Plainly, multiple components are involved—perhaps three or four, most probably more, in fathomless permutations. That is why the greatest fallacy about suicide lies in the belief that there is a single immediate answer—or perhaps combined answers—as to why the deed was done. The inevitable question, “Why did he (or she) do it?” usually leads to odd speculations, for the most part fallacies themselves. Reasons were quickly advanced for Abbie Hoffman’s death: his reaction to an auto accident he had suffered, the failure of his most recent book, his mother’s serious illness. With Randall Jarrell it was a declining career, cruelly epitomized by a vicious book review and his consequent anguish. Primo Levi, it was rumored, had been burdened by caring for his paralytic mother, which was more onerous to his spirit than even his experience at Auschwitz. Any one of these factors may have lodged like a thorn in the sides of the three men, and been a torment. Such aggravations may be crucial and cannot be ignored. But most people quietly endure the equivalent of injuries, declining careers, nasty book reviews, family illnesses. A vast majority of the survivors of Auschwitz have borne up fairly well. Bloody and bowed by the outrages of life, most human beings still stagger on down the road, unscathed by real depression. To discover why some people plunge into the downward spiral of depression, one must search beyond the manifest crisis—and then still fail to come up with anything beyond wise conjecture.

The storm which swept me into a hospital in December of 1985 began as a cloud no bigger than a wine goblet the previous June. And the cloud—the manifest crisis—involved alcohol, a substance I had been abusing for forty years. Like a great many American writers, whose sometimes lethal addiction to alcohol has become so legendary as to provide in itself a stream of studies and books, I used alcohol as the magical conduit to fantasy and euphoria, and to the enhancement of the imagination. There is no need to either rue or apologize for my use of this soothing, often sublime agent which had contributed greatly to my writing; although I never set down a line while under its influence, I used it otherwise—often in conjunction with music—as a means to let my mind conceive visions that the unaltered, sober brain has no access to. Alcohol was an invaluable senior partner of my intellect, besides being a friend whose ministrations I sought daily—sought also, I now see, as a means to calm the anxiety and incipient dread that I had hidden away for so long somewhere in the dungeons of my spirit. The trouble was, at the beginning of this particular summer, that I was betrayed. It struck me quite suddenly, almost overnight: I could no longer drink. It was as if my body had risen up in protest, along with my mind, and had conspired to reject this daily mood bath which it had so long welcomed and, who knows, perhaps even come to need. Many drinkers have experienced this intolerance as they have grown older. I suspect that the crisis was at least partly metabolic—the liver rebelling, as if to say, “No more, no more”—but at any rate I discovered that alcohol in minuscule amounts, even a mouthful of wine, caused me nausea, a desperate and unpleasant wooziness, a sinking sensation, and ultimately a distinct revulsion. The comforting friend had abandoned me not gradually and reluctantly, as a true friend might do, but like a shot—and I was left high and certainly dry, and unhelmed. Neither by will nor by choice had I become an abstainer; the situation was puzzling to me, but it was also traumatic, and I date the onset of my depressive mood from the beginning of this deprivation. Logically, one would be overjoyed that the body had so summarily dismissed a substance that was undermining its health; it was as if my system had generated a form of Antabuse which should have allowed me to happily go on my way, satisfied that a trick of nature had shut me off from a harmful dependence. But, instead, I began to experience a vaguely troubling malaise, a sense of something having gone cockeyed and awry in the domestic universe I’d dwelt in so long, so comfortably. While depression is by no means unknown when people stop drinking, it is usually on a scale that is not menacing. But it should be kept in mind how idiosyncratic the faces of depression can be. It was not really alarming at first, since the change was subtle, but I did notice that my surroundings took on a different tone at certain times: the shadows of nightfall seemed more somber, my mornings were less buoyant, walks in the woods became less zestful, and there was a moment during my working hours in the late afternoon when a kind of panic and anxiety overtook me, just for a few minutes, accompanied by a visceral queasiness—such a seizure was at least slightly alarming, after all. As I set down these recollections, I realize that it should have been plain to me that I was already in the grip of the beginning of a mood disorder, but I was ignorant of such a condition at that time. When I reflected on this curious alteration of my consciouness—and I was baffled enough from time to time to do so—I assumed that it all had to do somehow with my enforced withdrawal from alcohol. And, of course, to a certain extent this was true. But it is my conviction now that alcohol played a perverse trick on me when we said farewell to each other: although, as everyone should know, it is a major depressant, it had never truly depressed me during my drinking career, acting instead as a shield against anxiety. Suddenly vanished, the great ally which for so long had kept my demons at bay was no longer there to prevent those demons from beginning to swarm through the subconscious, and I was emotionally naked, vulnerable as I had never been before. Doubtless, depression had hovered near me for years, waiting to swoop down. Now I was in the first stage—premonitory, like a flicker of sheet lightning barely perceived—of depression’s black tempest.

I was on Martha’s Vineyard, where I’ve spent a good part of the year since the 1960s, during that exceptionally beautiful summer. But I had begun to respond indifferently to the island’s pleasures. I felt a kind of numbness, an enervation, but more particularly an odd fragility—as if my body had actually become frail, hypersensitive, and somehow disjointed and clumsy, lacking normal coordination. And soon I was in the throes of a pervasive hypochondria. Nothing felt quite right with my corporeal self; there were twitches and pains, sometimes intermittent, often seemingly constant, that seemed to presage all sorts of dire infirmities. (Given these sings, one can understand how, as far back as the seventeenth century—in the notes of contemporary physicians, and in the perceptions of John Dryden and others—a connection is made between melancholia and hypochondria; the words are often interchangeable, and were so used until the nineteenth century, by writers as various as Sir Walter Scott and the Brontës, who also linked melancholy with a preoccupation with bodily ills.) It is easy to see how this condition is part of the psyche’s apparatus of defense: unwilling to accept its own gathering deterioration, the mind announces to its indwelling consciousness that it is the body with its perhaps correctable defects —not the precious and irreplaceable mind—that is going haywire. In my case, the overall effect was immensely disturbing, augmenting the anxiety that was by now never quite absent from my waking hours and fueling still another strange behavior pattern—a fidgety restlessness that kept me on the move, somewhat to the perplexity of my family and friends. Once, in late summer, on an airplane trip to New York, I made the reckless mistake of downing a scotch and soda—my first alcohol in months—which promptly sent me into a tailspin, causing me such a horrified sense of disease and interior doom that the very next day I rushed to a Manhattan internist, who inaugurated a long series of tests. Normally, I would have been satisfied, indeed elated, when, after three weeks of high-tech and extremely expensive evaluation, the doctor pronounced me totally fit; and I was happy, for a day or two, until there once again began the rhythmic daily erosion of my mood—anxiety, agitation, unfocused dread. By now I had moved back to my house in Connecticut. It was October, and one of the unforgettable features of this stage of my disorder was the way in which my old farmhouse, my beloved home for thirty years, took on for me—especially in the late afternoon, when my spirits regularly sank to their nadir—an almost palpable quality of ominousness. The fading evening light—akin to that famous “slant of light” of Emily Dickinson’s, which spoke to her of death, of chill extinction—had none of its familiar autumnal loveliness, but ensnared me in a suffocating gloom. I wondered how this friendly place, teeming with such memories of (again in her rhyme) “Lads and Girls,” of “laughter and ability and Sighing, / And Frocks and Curls,” could almost perceptibly seem so hostile and forbidding. Physically, I was not alone. My wife, Rose, was always present and listened with unflagging patience to my complaints. But I felt an immense and aching solitude. I could no longer concentrate during those afternoon hours, which for years had been my working time, and the act of writing itself, becoming more and more difficult and exhausting, stalled, then finally ceased. There were also dreadful, pouncing seizures of anxiety. One bright day on a walk through the woods with my dog I heard a flock of canada geese honking high above trees ablaze with foliage; ordinarily a sight and sound that would have exhilarated me, the flight of birds caused me to stop, riveted with fear, and I stood stranded there, helpless, shivering, aware for the first time that I had been stricken by no mere pangs of withdrawal but by a serious illness whose name and actuality I was able, for the first time, to acknowledge. Going home, I couldn’t rid my mind of the line of Baudelaire’s, dredged up from the distant past, that had for several days been skittering around at the edge of my consciousness: “I have felt the wind of the wing of madness.”

Our perhaps understandable modern need to dull the sawtooth edges of so many of the afflictions we are heir to has led us to banish the harsh old-fashioned words: madhouse, asylum, insanity, melancholia, lunatic, madness. But never let it be doubted that depression, in its extreme form, is madness. The madness results from an aberrant biochemical process. It has been established with reasonable certainty (after strong resistance from many psychiatrists, and not all that long ago) that such madness is chemically induced amid the neurotransmitters of the brain, probably as the result of systemic stress, which for unknown reasons causes a depletion of the chemicals norepinephrine and serotonin, and the increase of a hormone, cortisol. With all of this upheaval in the brain tissues, the alternate drenching and deprivation, it is no wonder that the mind begins to feel aggrieved, stricken, and the muddied thought processes register the distress of an organ in convulsion. Sometimes, though not very often, such a disturbed mind will turn to violent thoughts regarding others. But with their minds turned agonizingly inward, people with depression are usually dangerous only to themselves. The madness of depression is, generally speaking, the antithesis of violence. It is a storm indeed, but a storm of murk. Soon evident are the slowed-down responses, near paralysis, psychic energy throttled back close to zero. Ultimately, the body is affected and feels sapped, drained. That fall, as the disorder gradually took full possession of my system, I began to conceive that my mind itself was like one of those outmoded small-town telephone exchanges, being gradually inundated by floodwaters: one by one, the normal circuits began to drown, causing some of the functions of the body and nearly all of those of instinct and intellect to slowly disconnect. There is a well-known checklist of some of these functions and their failures. Mine conked out fairly close to schedule, many of them following the pattern of depressive seizures. I particularly remember the lamentable near disappearance of my voice. It underwent a strange transformation, becoming at times quite faint, wheezy, and spasmodic—a friend observed later that it was the voice of a ninety-year-old. The libido also made an early exit, as it does in most major illnesses—it is the superfluous need of a body in beleaguered emergency. Many people lose all appetite; mine was relatively normal, but I found myself eating only for subsistence: food, like everything else within the scope of sensation, was utterly without savor. Most distressing of all the instinctual disruptions was that of sleep, along with a complete absence of dreams. Exhaustion combined with sleeplessness is a rare torture. The two or three hours of sleep I was able to get at night were always at the behest of the minor tranquilizer Halcion—a matter which deserves particular notice. For some time now many experts in psychopharmacology have warned that the benzodiazepine family of tranquilizers, of which Halcion is one (Valium and Ativan are others), is capable of depressing mood and even precipitating a major depression. Over two years before my siege, an insouciant doctor had prescribed Avitan as a bedtime aid, telling me airily that I could take it as casually as aspirin. The Physician’s Desk Reference manual, the pharmacological bible, reveals that the medicine I had been ingesting was (a) three times the normally prescribed strength, (b) not advisable as a medication for more than a month or so, and (c) to be used with special caution by people of my age. At the time of which I am speaking, I had become addicted to Halcion as a sleeping aid, and was consuming large doses. It seems reasonable to think that this was still another contributory factor to the trouble that had come upon me. Certainly, it should be a caution to others. At any rate, my few hours of sleep were usually terminated at three or four in the morning, when I stared up into yawning darkness, wondering and writhing at the devastation taking place in my mind, and awaiting the dawn, which usually permitted me a feverish, dreamless nap. I’m fairly certain that it was during one of these insomniac trances that there came over me the knowledge—a weird and shocking revelation, like that of some long-beshrouded metaphysical truth—that this condition would cost me my life if it continued on such a course. What I had begun to discover is that, mysteriously and in ways that are totally remote from normal experience, the gray drizzle of horror induced by depression takes on the quality of physical pain. But it is not an immediately identifiable pain, like that of a broken limb. It may be more accurate to say that despair, owing to some evil trick played upon the sick brain by the inhabiting psyche, comes to resemble the diabolical discomfort of being imprisoned in a fiercely overheated room. And because no breeze stirs this caldron, because there is no escape from this smothering confinement, it is entirely natural that the victim begins to think ceaselessly of oblivion.

One of the memorable moments in Madame Bovary is the scene where the heroine seeks help from the village priest. Guilt-ridden, distraught, miserably depressed, the adulterous Emma—heading toward eventual suicide—stumblingly tries to prod the abbé into helping her find a way out of her misery. But the priest, a simple soul and none too bright, can only pluck at his stained cassock, distractedly shout at his acolytes, and offer Christian platitudes. Emma goes on her quietly frantic way, beyond comfort of God or man. I felt a bit like Emma Bovary in my relationship with the psychiatrist I shall call Dr. Gold, whom I began to visit as October became November, when the despair had commenced its merciless daily drumming. I had never before consulted a mental therapist for anything, and I felt awkward, also a bit defensive; my pain had become so intense that I considered it quite improbable that conversation with another mortal, even one with professional expertise in mood disorders, could alleviate the distress. Madame Bovary went to the priest with the same hesitant doubt. Yet our society is so structured that Dr. Gold, or someone like him, is the authority to whom one is forced to turn in one’s crisis, and it is not entirely a bad idea, since Dr. Gold—Yale-trained, highly qualified—at least provides a focal point toward which one can direct one’s dying energies, offers consolation if not much hope, and becomes a receptacle for one’s outpouring of woes during fifty minutes that also provide relief for one’s wife. Still, while I would never question the potential efficacy of psychotherapy in the beginning manifestations or milder forms of the illness—or possibly even in the aftermath of a serious onslaught—its usefulness at the advanced stage I was in has to be virtually nil. My more specific purpose in consulting Dr. Gold was to obtain help through pharmacology—though this too was, alas, a chimera for a bottomed-out victim such as I had become. He asked me if I was suicidal, and I reluctantly told him yes. I did not particularize—since there seemed no need to—did not tell him that in truth many of the artifacts of my house had become potential devices for my own destruction: the attic rafters (and an outside maple or two) a means to hang myself, the garage a place to inhale carbon monoxide, the bathtub a vessel to receive the flow from my opened arteries. The kitchen knives in their drawers had but one purpose for me. Death by heart attack seemed particularly inviting, absolving me as it would of active responsibility, and I had toyed with the idea of self-induced pneumonia—a long, frigid, shirtsleeved hike through the rainy woods. Nor had I overlooked an ostensible accident, a la Randall Jarrell, by walking in front of a truck on the highway nearby. These thoughts may seem outlandishly macabre—a strained joke—but they are genuine. They are doubtless especially repugnant to healthy Americans, with their faith in self-improvement. Yet in truth such hideous fantasies, which cause well people to shudder, are to the deeply depressed mind what lascivious daydreams are to persons of robust sexuality. Dr. Gold and I began to chat twice weekly, but there was little I could tell him except to try, vainly, to describe my desolation. Nor could he say much of value to me. His platitudes were not Christian but, almost as ineffective, dicta drawn straight from the pages of The Diagnostic and Statistic Manual of the American Psychiatric Association (most of which I’d already read), and the solace he offered me was an antidepressant medication called Ludiomil. The pill made me edgy, disagreeably hyperactive, and when the dosage was increased after ten days, it blocked my bladder for hours one night. Upon informing Dr. Gold of this problem, I was told that ten more days must pass for the drug to clear my system before starting anew with a different pill. Ten days to one stretched on such a torture rack is like ten centuries—and this does not begin to take into account the fact that when a new pill is inaugurated several weeks must pass before it becomes effective, a development which is far from guaranteed in any case. This brings up the matter of medication in general. Psychiatry must be given due credit for its continuing struggle to treat depression pharmacologically. The use of lithium to stabilize moods in manic-depression is a great medical achievement; the same drug is also being employed effectively as a preventive in many instances of unipolar depression. There can be no doubt that in many moderate cases and some chronic forms of the disease (the so-called endogenous depressions) medications have proved invaluable, often altering the course of a serious disturbance dramatically. But until that day when a swiftly acting agent is developed, one’s faith in a pharmacological cure for major depression must remain provisional. The failure of these pills to act positively and quickly—a defect which is now the general case—is somewhat analogous to the failure of nearly all drugs to stem massive bacterial infections in the years before antibiotics became a specific remedy. And it can be just as dangerous. So I found little of worth to anticipate in my consultations with Dr. Gold. On my visits he and I continued to exchange platitudes, mine haltingly spoken now—since my speech, emulating my way of walking, had slowed to the vocal equivalent of a shuffle—and I’m sure as tiresome as his. Despite the still-faltering methods of treatment, psychiatry has, on an analytical and philosophical level, contributed much to an understanding of the origins of depression. Much obviously remains to be learned (and a great deal will doubtless continue to be a mystery, owing to the disease’s idiopathic nature, its constant interchangeability of factors), but certainly one psychological element has been established beyond reasonable doubt, and that is the concept of loss. Loss in all of its manifestations is the touchstone of depression—in the progress of the disease and, most likely, in its origin. At a later date I would gradually be persuaded that a devastating loss in childhood figured as a probable genesis of my own disorder; meanwhile, as I monitored my retrograde condition, I felt loss at every hand. The loss of self-esteem is a celebrated symptom, and my own sense of self had all but disappeared, along with any self-reliance. This loss can quickly degenerate into dependence, and from dependence into infantile dread. One dreads the loss of all things, all people close and dear. Of the images of myself recollected from that time the most bizarre, and discomfiting, remains the one of me, age four and a half, tagging through a market after my long-suffering wife; not for an instant could I let out of my sight the endlessly patient soul who had become nanny, mommy, comforter, priestess, and, most important, confidante—a counselor of rocklike centrality to my existence whose wisom far exceeded that of Dr. Gold. I would hazard the opinion that many disastrous sequels to depression might be averted if the victims received support like that which she gave me. But meanwhile my losses mounted and proliferated. There is no doubt that as one nears the penultimate depths of depression—which is to say just before the stage when one begins to act out one’s suicide instead of being a mere contemplator of it—the acute sense of loss is connected with a knowledge of life slipping away at accelerated speed. One develops fierce attachments. Ludicrous things—my reading glasses, a handkerchief, a certain writing instrument—became the objects of my demented possessiveness. Each momentary misplacement filled me with a frenzied dismay, each item being the tactile reminder of a world soon to be obliterated.

November wore on, bleak, raw, and chill. One Sunday a photographer and his assistants came to take pictures for an article to be published in a national magazine. Of the session I can recall little except the first snowflakes of winter dotting the air outside. I thought I obeyed the photographer’s request to smile often. A day or two later the magazine’s editor telephoned my wife, asking if I would submit to another session. The reason he advanced was that the pictures of me, even the ones with smiles, were “too full of anguish.” I had now reached that phase of the disorder where all sense of hope had vanished, along with the idea of a futurity; my brain, in thrall to its outlaw hormones, had become less an organ of thought than an instrument registering, minute by minute, varying degrees of its own suffering. Mornings were bad enough, as I wandered about lethargic following my synthetic sleep, but afternoons were the worst, beginning at about three o’clock, when I’d feel the horror, like some poisonous fogbank, roll in upon my mind, forcing me into bed. There I would lie as long as six hours, stuporous and virtually paralyzed, gazing at the ceiling and waiting for that moment of evening when, mysteriously, the crucifixion would ease up just enough to allow me to force down some food and then, like an automaton, seek an hour or two of sleep again. Why wasn’t I in a hospital? The answer is forthcoming. For years I had a kept a notebook—not strictly a diary, its entries were erratic and haphazardly written—whose contents I would not have particularly liked to be scrutinized by eyes other than my own. I had hidden it well out of sight in my house. I imply no scandalousness; the observations were far less raunchy, or wicked, or self-revealing, than my desire to keep the notebook private might indicate. Nonetheless, the small volume was one that I fully intended to make use of professionally and then destroy before the distant day when the specter of the nursing home came too near. So as my illness worsened I rather queasily realized that if I once decided to get rid of the notebook that moment would necessarily coincide with my decision to put an end to myself. And one evening during December this moment came. That afternoon I had been driven (I could no longer drive) to Dr. Gold’s office, where he announced that he had decided to place me on the antidepressant Nardil, an older medication which had the advantage of not causing the urinary retention of the other two pills he had prescribed. However, there were drawbacks. Nardil would probably not take effect in less than four to six weeks—I could scarcely believe this—and I would have to carefully obey certain dietary restrictions, fortunately rather epicurean (no sausage, no cheese, no pâté de foie gras), in order to avoid a clash of incompatible enzymes that might cause a stroke. Further, Dr. Gold said with a straight face, the pill at optimum dosage was likely to have the side effect of impotence. Until that moment, although I’d had some trouble with his personality, I had not thought him totally lacking in perspicacity; now I was not at all sure. Putting myself in Dr. Gold’s shoes, I wondered if he seriously thought that this juiceless and ravaged semi-invalid with the shuffle and the ancient wheeze woke up each morning from his Halcion sleep eager for carnal fun. There was a quality so comfortless about that day’s session that I went home in a particularly wretched state and prepared for the evening. A few guests were coming over for dinner—something which I neither dreaded nor welcomed and which in itself (that is, my torpid indifference) reveals a fascinating aspect of depression’s pathology. This concerns not the familiar threshold of pain but a parallel phenomenon, and that is the probable inability of the psyche to absorb pain beyond predictable limits of time. There is a region in the experience of pain where the certainty of alleviation often permits superhuman endurance. We learn to live with pain in varying degrees daily, or over longer periods of time, and we are more often than not mercifully free of it. When we endure severe discomfort of a physical nature our conditioning has taught us since childhood to make accommodations to the pain’s demands—to accept it, whether pluckily or whimpering and complaining, according to our personal degree of stoicism, but in any case to accept it. Except in intractable terminal pain, there is almost always some form of relief; we look forward to that alleviation, whether it be through sleep or Tylenol or hypnosis or a change of posture or, most often, through the body’s powers of self-healing, and we embrace this eventual respite as the natural reward we receive for having been, temporarily, such good sports and drought sufferers, such optimistic cheerleaders for life at heart. In depression this faith in deliverance, of ultimate restoration, is absent. The pain is unrelenting, and what makes the condition intolerable is the foreknowledge that no remedy will come—not in a day, an hour, a month, or a minute. It is hopelessness even more than pain that crushes the soul. And so the decision-making of daily life involves not, as in normal affairs, shifting from one annoying situation to another less annoying— or from discomfort to relative comfort, or from boredom to activity—but moving from pain to pain. One does not abandon, even briefly, one’s bed of nails, but lies upon wherever one goes. That December evening, for example, I could have remained in bed as usual during those worst hours, or agreed to the small dinner party my wife had arranged downstairs. But the very idea of a decision was academic. Either course was torture, and I chose the dinner not out of any particular merit but through indifference to what I knew would be indistinguishable ordeals of fogbound horror. At dinner I was barely able to speak, but the guests, who were all good friends, were aware of my condition and politely ignored my catatonic muteness. Then, after dinner, sitting in the living room, I experienced a curious inner convulsion that I can describe only as despair beyond despair. It came out of the cold air; I did not think such anguish was possible. While my friends quietly chatted in front of the fire I excused myself and went upstairs, where I retrieved my notebook from its special place. Then I went to the kitchen and with gleaming clarity—the clarity of one who knows he is engaged in a solemn rite—I noted all the trademarked legends on the well-advertised articles which I went about assembling for the volume’s disposal: the new roll of Viva paper towels I opened to wrap up the book, the Scotch-brand tape I encircled it with, the empty Post Raisin Bran box I put the parcel into before taking it outside and stuffing it deep down into the garbage can, which would be emptied the next morning. Fire would have destroyed it faster, but in garbage there was an annihilation of self appropriate, as always, to melancholia’s fecund self-humiliation. I felt my heart pounding wildly, like that of a man facing a firing squad, and I knew I had made an irreversible decision.

A phenomenon that a number of people have noted while in deep depression is the sense of being accompanied by a second self—a wraithlike observer who, not sharing the dementia of his double, is able to watch with dispassionate curiosity as his companion struggles against the oncoming disaster, or decides to embrace it. There is a theatrical quality about all this, and during the next several days, as I went about stolidly preparing for extinction, I couldn’t shake off a sense of melodrama—a melodrama in which I, the victim-to-be of self-murder, was both the solitary actor and lone member of the audience. I had not as yet chosen the mode of my departure, but I knew that step would come next, and soon, as inescapable as nightfall. I watched myself in mingled terror and fascination as I began to make the necessary preparation: going to see my lawyer in the nearby town—there rewriting my will—and spending part of a couple afternoons in a muddled attempt to bestow upon posterity a letter of farewell. It turned out that putting together a suicide note, which I felt obsessed with a necessity to compose, was the most difficult task of writing that I had ever tackled. There were too many people to acknowledge, to thank, to bequeath final bouquets. And finally I couldn’t mange the sheer dirge-like solemnity of it; there was something I found almost comically offensive in the pomposity of such a comment as “For some time now I have sensed in my work a growing psychosis that is doubtless a reflection of the psychotic strain tainting my life” (this is one of the few lines I recall verbatim), as well as something degrading in the prospect of a testament, which I wished to infuse with at least some dignity and eloquence, reduced to an exhausted stutter of inadequate apologies and self-serving explanations. I should have used as an example the mordant one-liner of the Italian writer Cesare Pavese, who in parting wrote simply, Not too much gossip, please. But even few words came to seem to me long-winded, and I tore up all my efforts, resolving to go out in silence. Late one bitterly cold night, when I knew that I could not possibly get myself through the following day, I sat in the living room of the house bundled up against the chill; something had happened to the furnace. My wife had gone to bed, and I had forced myself to watch the tape of a movie in which a young actress, who had been in a play of mine, was cast in a small part. At one point in the film, which was set in late-nineteenth-century Boston, the characters moved down the halfway of a music conservatory, beyond the walls of which, from unseen musicians, came a contralto voice, a sudden soaring passage from the Brahms Alto Rhapsody. This sound, which like all music—indeed, like all pleasure—I had been numbly unresponsive to for months, pierced my heart like a dagger, and in a flood of swift recollection I thought of all the joys the house had known: the children who had rushed through its rooms, the festivals, the love and work, the honestly earned slumber, the voices and the humble commotion, the perennial tribe of cats and dogs and birds, “laugher and ability and Sighing, / And Frocks and Curls.” All this I realized was more than I could ever abandon, even as what I had set out so deliberately to do was more than I could inflict on those memories, and upon those so close to me, with whom the memories were bound. And just as powerfully as I realized I could not commit this desecration on myself. I drew upon some last gleam of sanity to perceive the terrifying dimensions of the mortal predicament I had fallen into. I woke up my wife and soon telephone calls were made. The next day I was admitted to the hospital.

It was Dr. Gold, acting as my attending physician, who was called in to arrange for my hospital admission. Curiously enough, it was he who told me once or twice during our sessions (and after I had rather hesitantly broached the possibility of hospitalization) that I should try to avoid the hospital at all costs, owing to the stigma I might suffer. Such a comment seemed then, as it does now, extremely misguided; I had thought psychiatry had advanced long beyond the point where stigma was attached to any aspect of mental illness, including the hospital. This refuge, while hardly an enjoyable place, is a facility where patients still may go when pills fail, as they did in my case, and where one’s treatment might be regarded as a prolonged extension, in a different setting, of the therapy that begins in offices such as Dr. Gold’s. It’s impossible to say, of course, what another doctor’s approach might have been, whether he too might have discouraged the hospital route. Many psychiatrists, who simply do no seem to be able to comprehend the nature and depth of the anguish their patients are undergoing, maintain their stubborn allegiance to pharmaceuticals in the belief that eventually the pills will kick in, the patient will respond, and the somber surroundings of the hospital will be avoided. Dr. Gold was such a type, it seems clear, but in my case he was wrong; I’m convinced I should have been in the hospital weeks before. For, in fact, the hospital was my salvation, and it is something of a paradox that in this austere place with its locked and wired doors and desolate green hallways—ambulances screeching night and day ten floors below—I found the repose, the assuagement of the tempest in my brain, that I was unable to find in my quiet farmhouse. This is partly the result of sequestration, of safety, of being removed to a world in which the urge to pick up a knife and plunge it into one’s own breast disappears in the newfound knowledge, quickly apparent even to the depressive’s fuzzy brain, that the knife with which he is attempting to cut his dreadful Swiss steak is bendable plastic. But the hospital also offers the mild, oddly gratifying trauma of sudden stabilization—a transfer out of the too familiar surroundings of home, where all is anxiety and discord, into an orderly and benign detention where one’s only duty is to try to get well. For me the real healers were seclusion and time.

The hospital was a way station, a purgatory. When I entered the place my depression appeared so profound that, in the opinion of some of the staff, I was a candidate for ECT, electroconvulsive therapy—shock treatment, as it is better known. In many cases this is an effective remedy—it has undergone improvement and has made a respectable comeback, generally shedding the medieval disrepute into which it was cast—but it is plainly a drastic procedure one would want to avoid. I avoided it because I began to get well, gradually but steadily. I was amazed to discover that the fantasies of self-destruction all but disappeared within a few days after I checked in, and this again is testimony to the pacifying effects that the hospital can create, its immediate value as a sanctuary where peace can return to the mind. I stayed in the hospital for nearly seven weeks. Not everyone might respond in the way I did; depression, one must constantly insist, presents so many variations and has so many subtle facets—depends, in short, so much on the individual’s totality of causation and response—that one person’s panacea might be another’s trap. But certainly the hospital (and, of course, I am speaking of the many good ones) should be shorn of its menacing reputation, should not so often be considered the method of treatment of last resort. The hospital is hardly a vacation spot; the one in which I was lodged (I was privileged to be in one of the nation’s best) possessed every hospital’s stupefying dreariness. If in addition there are assembled on one floor, as on mine, fourteen or fifteen middle-aged males and females in the throes of melancholia of a suicidal complexion, then one can assume a fairly laughterless environment. This was not ameliorated for me by the sub-airline food or by the peek I had into the outside world: Dynasty and Knots Landing and the CBS Evening News unspooling nightly in the bare recreation room, sometimes making me at least aware that the place where I had found refuge was a kinder, gentler madhouse than the one I’d left. As I got better I found distraction of sorts in the hospital’s routine, with its own institutionalized sitcoms. Group Therapy, which I am told has value for some people, did nothing for me except make me seethe, possibly because it was supervised by an odiously smug young shrink, with a spade-shaped dark beard (der junge Freud?), who in attempting to get us to cough up the seeds of our misery was alternately condescending and bullying, and occasionally reduced one or two of the women patients, so forlorn in their kimonos and curlers, to what I’m certain he regarded as satisfactory tears. (I thought the rest of the psychiatric staff exemplary in their tact and compassion.) Time hangs heavy in the hospital, and the best I can say for Group Therapy is that it is a way to occupy the hours. More or less the same can be said for Art Therapy, which is organized infantilism. Our class was run by a delirious young woman with a fixed, indefatigable smile who was plainly trained at a school offering courses in Teaching Art to the Mentally Ill; not even a teacher of very young retarded children could have been compelled to bestow, without deliberate instruction, such orchestrated chuckles and coos. Unwinding long rolls of slippery mural paper, she would tell us to take our crayons and make drawings illustrative of themes that we ourselves had chosen. For example: My House. In humiliated rage I obeyed, drawing a square, with a door and four cross-eyed windows, a chimney on top issuing forth a curlicue of smoke. She showered me with praise, and as the weeks advanced and my health improved so did my sense of comedy. I began to dabble happily in colored modeling clay, sculpting at first a horrid little green skull with bared teeth which our teacher pronounced a splendid replica of my depression. I then proceeded through intermediate stages of recuperation to a rosy and cherubic head with a Have a Nice Day smile. Coinciding as it did with the time of my release, this creation truly overjoyed my instructress (whom I’d become fond of in spite of myself), since, as she told me, it was emblematic of my recovery and therefore but one more example of the triumph over disease by Art Therapy. By this time it was early February and although I was still shaky I knew I had emerged into light. I felt myself no longer a husk but a body with some of the body’s sweet juices stirring again. I had my first dream in many months, confused but to this day imperishable, with a flute in it somewhere, and a wild goose, and a dancing girl.

By far the great majority of the people who go through even the severest depression survive it, and live ever afterward at least as happily as their unafflicted counterparts. Save for the awfulness of certain memories it leaves, acute depression inflicts few permanent wounds. There is a Sisyphean torment in the fact that a great number—as many as half—of those who are devastated once will be struck again; depression has the habit of recurrence. But most victims live through even these relapses, often coping better because they have become psychologically tuned by past experience to deal with the ogre. It is of great importance that those who are suffering a siege, perhaps for the first time, be told—be convinced, rather—that the illness will run its course and that they will pull through. A tough job, this; calling “Chin up!” from the safety of the shore to a drowning person is tantamount to insult, but it has been shown over and over again that if the encouragement is dogged enough—and the support equally committed and passionate—the endangered one can nearly always be saved. Most people in the grip of depression at its ghastliest are for whatever reason, in a state of unrealistic hopelessness, torn by exaggerated ills and fatal threats that bear no resemblance to actuality. It may require on the part of friends, lovers, family, admirers, an almost religious devotion to persuade the sufferers of life’s worth, which is so often in conflict with a sense of their own worthlessness, but such devotion has prevented countless suicides. After I began to recover in the hospital it occurred to me to wonder—for the first time with any really serious concern—why I had been visited by such a calamity. The psychiatric literature on depression is enormous, with theory after theory concerning the disease’s etiology proliferating as richly as theories about the death of the dinosaurs or the origin of black holes. The very number of hypotheses is testimony to the malady’s all but impenetrable mystery. As for that initial triggering mechanism—what I have called the manifest crisis— can I really be satisfied with the ideas that abrupt withdrawal from alcohol started the plunge downward? What about other possibilities—the dour fact, for instance, that at about the same time I was smitten I turned sixty, that hulking milestone of mortality? Or could it be that a vague dissatisfaction with the way in which my work was going—the onset of inertia which has possessed me time and time again during my writing life, and made me crabbed and discontented—had also haunted me more fiercely during that period than ever, somehow magnifying the difficulty with alcohol? What part did the addiction to a tranquilizer play? Unresolvable questions, best left unresolved. These matters in any case interest me less than the search for earlier origins of the disease. What are the forgotten or buried events that suggest an ultimate explanation for the evolution of depression and its later flowering into madness? Until the onslaught of my own illness and its dénouement, I never gave much thought to my work in terms of its connection with the subconscious—an area of investigation belonging to literary detectives. But after I had returned to health and was able to reflect on the past in the light of my ordeal, I began to see clearly how depression had clung close to the outer edges of my life for many years. The sovereign protection of alcohol always kept it at bay; I banished fear through self-medication. Suicide has been a persistent theme in my books— three of my major characters killed themselves. In rereading, for the first time in years, sequences from my novels—passages where my heroines have lurched down pathways toward doom—I was stunned to perceive how accurately I had created the landscape of depression in the minds of these young women, describing with what could only be instinct, out of a subconscious already roiled by disturbances of mood, the psychic imbalance that led them to destruction. Thus depression, when it finally came to me, was in fact no stranger, not even a visitor totally unannounced; it had been tapping at my door for decades. The morbid condition proceeded, I have come to believe, from my beginning years—from my father, who battled the Gorgon for much of his lifetime, and had been hospitalized in my boyhood after a despondent spiraling downward that in retrospect I saw greatly resembled mine. The genetic roots of depression seem now to be beyond controversy. But I’m persuaded that an even more significant factor was the death of my mother when I was thirteen; this disorder and early sorrow—the death of a parent, before or during puberty—appears repeatedly in the literature on depression as a trauma sometimes likely to create nearly irreparable emotional havoc. The danger is especially apparent if the young person is affected by what has been termed “incomplete mourning”—has, in effect, been unable to achieve the catharsis of grief, and so carries within himself through later years an insufferable burden of which rage and guilt, and not only dammed-up sorrow, are a part, and become the potential seeds of self-destruction. In an illuminating new book on suicide, Self-Destruction in the Promised Land (Rutgers), Howard I. Kushner, who is not a psychiatrist but a social historian, argues persuasively in favor of this theory of incomplete mourning and uses Abraham Lincoln as an example. While Lincoln’s hectic moods of melancholy are legend, it is much less well known that in his youth he was often in a suicidal turmoil and came close more than once to making an attempt on his own life. This behavior seems directly linked to the death of Lincoln’s mother, Nancy Hanks, when he was nine, and to unexpressed grief exacerbated by his sister’s death ten years later. Drawing insights from the chronicle of Lincoln’s painful success in avoiding suicide, Kushner makes a convincing case not only for the idea of early loss precipitating self-destructive conduct but also auspiciously, for that same behavior becoming a strategy through which the person involved comes to grips with his guilt and rage and triumphs over self-willed death. Such reconciliation may be entwined with the quest for immortality—in Lincoln’s case, no less than that of a writer for fiction, to vanquish death through work honored by posterity. So if this theory of incomplete mourning has validity, and I think it does, and if it is also true that in the nethermost depths of one’s suicidal behavior one is still subconsciously dealing with immense loss while trying to surmount all the effects of its devastation, then my own avoidance of death may have been belated homage to my mother. I do know that in those last hours before I rescued myself, when I listened to the passage from the Alto Rhapsody—which I’d heard her sing—she had been very much on my mind.