Darkness Visible

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 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 Ativan as a bedtime aid, telling me airily that I could take it as casually as aspirin. The Physicians’ Desk Reference, 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 was no longer taking Ativan but had become addicted to Halcion 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. This must have been just before my trip to Paris. Death, as I have said, was now a daily presence, blowing over me in cold gusts. I had not conceived precisely how my end would come. In short, I was still keeping the idea of suicide at bay. But plainly the possibility was around the corner, and I would soon meet it face to face.

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.

V

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 abbe 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 immediately after my return from Paris, 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 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 the receptacle for an outpouring of woes during fifty minutes that also provides relief for the victim’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, shirt-sleeved 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 Statistical Manual of the American Psychiatric Association (much of which, as I mentioned earlier, 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 someone 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 certain 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. For reasons that are still not clear to me, neither medications nor psychotherapy were able to arrest my plunge toward the depths. If the claims of responsible authorities in the field can be believed— including assertions made by physicians I’ve come to know personally and to respect—the malign progress of my illness placed me in a distinct minority of patients, severely stricken, whose affliction is beyond control. In any case, I don’t want to appear insensitive to the successful treatment ultimately enjoyed by most victims of depression. Especially in its earlier stages, the disease yields favorably to such techniques as cognitive therapy—alone, or in combination with medications—and other continually evolving psychiatric strategies. Most patients, after all, do not need to be hospitalized and do not attempt or actually commit suicide. 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 a lot 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