Paul Golden, MD Speaks; Depression & Bipolar Disorders
“Opening the Black Box on Mental Illness” Seminar, part I: Depression & Bipolar Disorders and…
William Styron – Major Depression Disease by Paul Golden
William Styron’s book Darkness Visible – A Memoir of Madness, (1990, Vintage) has become a Third Testament for the afflicted and the students of major depression. It’s a first personal narrative that all writers and many speakers are going to reference and quote. He writes about his first major depression only five years after it occurred and his description of what it feels like during a major depression is unpatrolled. I read the short eighty-one page piece the year it was released and was mesmerized. Of course, Styron’s business is writing, Sophie’s Choice, for example so what better person to write metaphorically.
I took my copy to my psychiatrist at the time to read. Actually, I never got it back. For the purposes of this book and quotes I used in both my first two books, I obtained by ordering another copy a few years ago. I asked Dr. S.Q. if it would be a good source to give to people newly diagnosed with major depression disease (MDD). Without hesitation he said oh, no, no. It was far too dark for an acutely ill individual to read and for some time after their first episode, he said. I am not sure I subscribe to this opinion.
William Styron was born in 1925 and died of natural causes in 2006. It is true that he indicates that his first depression was in 1985 while in Paris for an award. Although that would make him sixty-years old I maintain that he probably had less severe episodes for many years considering how rare a first episode of an affective order to occur so late in life. I suspect he was able to manage those without help.
In particular the episode he describes in the book is in October of 1985. In fact IT began the previous June. He suffered for six months before being hospitalized in December at which point he was suicidal. He was in Paris in October to receive the Prix Mondial Cino del Duca when as he says when the feelings that started that summer, “…that I first became fully aware that the struggle with the disorder in my mind—a struggle which had engaged me for several months—might have a fatal outcome.” He realized that even a nostalgic memory of his hotel and the “festive occasion” for which he had come to Paris did not bring any pleasure
He writes, “Depression is a disorder of mood, so mysteriously painful and elusive in the way it becomes known to the self—to the mediating intellect—as to verge close to being beyond description. It thus remains nearly incomprehensible to those who have not experienced it in its extreme mode…”
“Of the many dreadful manifestations of the disease, both physical and psychological, a sense of self-hatred—or, put less categorically, a failure of self-esteem—is one of the most universally experienced symptoms, and I had suffered more and more from a general feeling of worthlessness as the malady had progressed…Depression is a disorder of mood, so mysteriously painful and elusive in the way it becomes known to the self-to the mediating intellect—as to Berge close to being beyond description. I thus remains nearly incomprehensible to those who have not experienced it in its extreme …”
He goes on to say that in the six months since its onset, “But at the time of which I write I had descended afar past those familiar, manageable doldrums. In Paris, I am able to see now, I was at a critical stage in the development of the disease, situated at an ominous way station between its unfocused stirrings earlier that summer and the near-violent denouement of December, which sent me into the hospital.”
I will show that as in so many of the luminaries I have discussed that he did not have to suffer so long if he had gotten the right care. I have to be careful in saying this because when this “indiscernible” descended on me for the first time I did not realize that I was suffering of a disease of the mind for about four weeks. It was then that I was lucky to be in medical school and studying in a University Hospital so when I did seek care, I found a doctor the same day who diagnosed “It” immediately and started me on medications.
Styron puts his finger on a problem that I have emphasized many times. “The intense and sometimes comically strident factionalism that exists in present-day psychiatry—the schism between the believers in psychotherapy and the adherents of pharmacology—resembles the medical quarrels of the eighteenth century (to bleed or not to bleed) and almost defines in itself the inexplicable nature of depression and the difficulty of its treatment.”
I am not castigating psychotherapy for in the present this term is synonymous with PhD psychologists which in an ideal world work as two prongs along with psychiatrists as the treatment of affective disorders and schizophrenia. (The old term for psychologists as I have used it in other biographies was psychoanalysts based on variably useless Freudian techniques.)
But, it is hard enough in these days of extreme difficulty in access to psychiatrists with insurance that even with the latter psychology is mostly cash pay. In my case even with good insurance in the last twenty years or so, the benefits of using it were such that I paid cash to get good private psychiatrists. I feel for and cannot imagine if my first episode in 1973 had occurred in 2018.
Styron found no joy in the ceremony for the presentation of the award and almost flew home as to be a no show.
Here are some of the terms to describe his depression: “actual pain, indescribable, dimension of the torment, alien to everyday experience, trance, helpless stupor, cognition replaced by anguish, insomnia, zombie, failure of even forced laughter, failure of speech, near suicidal, meltdown.
Styron makes a statement that is THE REASON WE EMBARKED ON THIS DOCUMENARY AND SO MANY OTHER ADVOCATES ARE DOING THE GREAT WORK OF SPREADING THE WORD: “The prevention of many suicides will continue to be hindered until there is a general awareness of the nature of this pain.”
Before his book Styron had written a short piece for Vanity Fair. After this book’s publication Styron was amazed that “I had apparently underestimated the number of people for whom the subject had been taboo, a matter of secrecy and shame…I had helped unlock a closet from which many souls were eager to come out….”
In the body of the book lists the huge number of poets, writers, artists and I might add political figures and war heroes who suffered from MDD or BPD. I more comprehensive list can be found in the appendix of Kay Redfield Jamison’s book, Touched with Fire: Manic-Depressive Illness and the Artistic Temperament, 1993, Simon and Schuster. The upside of these highly heritable/genetic disease is there association with very high cognitive function, in short very intellectual/smart people!
By October Styron returned to his farmhouse home he had sunk so low that he felt an “a palpable quality of ominousness.”
I personally have felt the end of string of symptoms is the inability to concentrate as in reading a book or writing. Shortly after his return he remembers, “I could no longer concentrate in those afternoon hours, which for years had been my working time, and the act of writing itself, becoming more and more difficult …then finally ceased.”
Just before going to Paris he goes on to say “a weird and shocking relation, like that of some long-be shrouded metaphysical truth—that this condign would cost me my life if it continued on such a course.” Imagine an anguish beyond anguish before going to Paris to receive his award.
FINALLLY, upon returning from Paris he began seeing a psychiatrist. He mentions that his pick had gone to Yale. But, here comes my beef again. The doc began with psychotherapy which Styron says might have been okay early in his depression back in June, but “its usefulness at the advanced stage I was in has to be virtually nil.” Styron’s felt at that first visit that what he needed was “help through pharmacology.
Exhaustion combined with sleeplessness is a rare torture. The first drug he mentions as treatment is Halcion, a sleeping pill in the group benzodiazepines like the first one, Librium then valium. The particular two later formulations, Halcion, which only gives two to three hours of sleep and then Ambien, in my experience and others can do the opposite, namely cause wakefulness, activities while asleep and depression.
He was then switched to Ativan with the instructions “take as casually as aspirin.” Soon he was taking three times the usual dose.
He was asked if he was suicidal and in a stream of consciousness Styron lists in his mind six methods as well as passive suicide as from a heart attack. Thus he began to see this “Yale,” so he must be good psychiatrist twice a week. The first anti-depressant he prescribed was Ludiomil which is related to the more commonly known Elavil but many annoying side-effects and lack of efficacy as the same class was all that was available when I required treatment in 1973. Neither it nor its relatives so electroconvulsant therapy was the magic bullet. The first really effective, side-effect free drug is Wellbutrin but it was not released until 1989. He would have been a perfect candidate for ECT which can have an immediate effect.
When that did not work, he turned to a rational psychoanalyst who, of course, found the roots to all his depression were founded in suffering of various sorts during his childhood. He does say that although ineffective if he had had such support early on in his depression she might have helped.
By November he was so far into the dark hole that after a photo shoot for a magazine the photographer requested a do over because “even the ones with smiles were ‘too full of anguish.’” Having already been having serous suicidal ideation by one early December afternoon he was driven by his wife to the psychiatrist’s office (“I could no longer drive). Still, he was tried on a medication and this time I have never been on nor prescribed nor seen any of my patients come to me already taking. Nardil is in a class called monoamine oxidase inhibitor or MAOI. This class has so many side-effects and can react so negatively with certain food groups that it should only be used when all other types of anti-depressants have failed. Even lithium would have been a better choice because it does reduce the frequency of depressions. BUT, as in my case ECT not only works quickly but it works particularly well in highly intellectual people and older adults.
Particularly as all these older drugs take four to six weeks to kick in, Styron speaks of hopelessness and “that no remedy will come—not in a day, an hour, a month or a minute.” It is here that he uses the phrase “despair of despair.” He began to enter a dissociative state with some delusions. He has crossed over to delusional or psychotic depression.
Having realized that he could not commit suicide, FINALLY he was admitted to a hospital. Get this. Earlier in his sessions with his unnamed psychiatrist the latter had said “that I should try to avoid the hospital at all costs, owing to the stigma I might suffer…I’m convinced I should have been in the hospital weeks before. For, in fact, the hospital was my salvation….”
The staff felt he was a good candidate for ECT.” The only reason he avoided it was that he began to get well slowly which he attributes to the feeling of safety in the hospital. It is also true that after a certain number of weeks, eight in fact in one of mine, the depression sort of burns out on its own so long as one has not committed “self-slaughter” in the meantime.
Styron make mention at this point that when he told the staff psychiatrist he was on Halcion, the response that he was on three times the recommended dose, not indicated at his age and could contribute to his depression because of its short duration of action. Finally he was switched to Dalmane which at the time was a new age benzodiazepine that is effective and was and still is used for years. Styron noted that soon after starting Dalmane he was getting good sleep and his suicidal thoughts disappeared. In fact much evidence subsequently has been to that effect.
After seven weeks he left the hospital. “Mysterious in its coming, mysterious in its going, the affliction runs its course, and one finds peace.
Beside the anger instilled in me as I read Styron’s book of the needless six months he needlessly have to suffer at the hands of his Ativan doctor, his Halcion doctor and his psychoanalyst, there is the near the end the following paragraph. “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 unaffiliated counterparts. Save for the awfulness of certain memoires it leaves, acute depression inflicts few permanent would. …a great number—as many as half—of those who are devastated once will be struck again; depression has the habit of recurrence.” This and a subsequent few lines lead the reader to believe that another episode is likely not to happen or if it does will likely be less severe.
If you look at many of the biographies on my website you will see the angst I feel in the course of the depressions or manic psychoses of particularly the poets.
Amen. “Here ends my catechism.”