Homicide is more common than suicide among the disenfranchised, while suicide is higher than homicide among the powerful. Contrary to popular belief, suicide is not the last resort of the depressive mind. It is not the last moment of mental decay. The chances of suicide are actually higher among people recently returned from a hospital stay than they are among people at a hospital, and not simply because the restraints of the hospital setting have been lifted. Suicide is the mind’s rebellion against itself, a double disillusionment of a complexity that the perfectly depressed mind cannot compass. It is a willful act to liberate oneself of oneself. The meekness of depression could hardly imagine suicide; it takes the brilliance of self-recognition to destroy the object of that recognition. However misguided the impulse, it is at least an impulse. If there is no other comfort in a suicide not avoided, at least there is this persistent thought, that it was an act of misplaced courage and unfortunate strength rather than an act of utter weakness or of cowardice.
My mother took Prozac, then a brand-new drug, for a month during her fight with cancer. She said it numbed her too much—and it made her jittery, which, in combination with the side effects of her chemo, was too much to bear. “I was walking down the street today,” she said, “and I thought, I am probably dying. And then I thought, should we have cherries or pears at lunch? And the two things felt too much the same.” She had a sufficient external reason to be depressed, and she was a great believer in authenticity. As I have said, I think she had suffered from mild depression for years; if I have depression genes, I suspect they came from her. My mother believed in order and in structure. I cannot remember—and in psychoanalysis I sought hard—a single time that my mother broke a promise she had made. I cannot remember her ever being late for an appointment. I believe now that she kept this martial law over her life not only out of regard for others, but also because it circumscribed a wistfulness that was always in her. My greatest happiness when I was a little boy came from making my mother happy. I was good at it, and it was not easy to do. I think, in retrospect, that she always needed to be distracted from sadness. She hated to be alone. Once she told me that it was because she had been an only child. I think a reservoir of loneliness was in her, something that went far deeper than being an only child. For the sake of her surpassing love for her family, she held it in check, and she was fortunate to have the capacity to do that. Nonetheless, the depression was there. And I think that this is why she was so well prepared for the rigor of killing herself.
I would say of suicide not that it is always a tragedy for the person who dies, but that it always comes too soon and too suddenly for those left behind. Those who condemn the right to die are committing a grave disservice. We all want more control over life than we have, and dictating the terms of other people’s lives makes us feel safe. That is no reason to forbid people their most primitive freedom. Nonetheless, I believe that those who, in supporting the right to die, distinguish some suicides absolutely from others are telling a lie to accomplish a political objective. It is up to each man to set limits on his own tortures. Fortunately, the limits most people set for themselves are high. Nietzsche once said that the thought of suicide keeps many men alive in the darkest part of the night, and I would say that the more fully one comes to terms with the idea of rational suicide, the safer one will be from irrational suicide. Knowing that if I get through this minute I could always kill myself in the next one makes it possible to get through this minute without being utterly overwhelmed. Suicidality may be a symptom of depression; it is also a mitigating factor. The thought of suicide makes it possible to get through depression. I expect that I’ll go on living so long as I can give or receive anything better than pain, but I do not promise that I will never kill myself. Nothing horrifies me more than the thought that I might at some stage lose the capacity for suicide.
CHAPTER VIII
History
The history of depression in the West is closely tied to the history of Western thought and may be divided into five principal stages. The ancient world’s view of depression was startlingly similar to our own. Hippocrates declared that depression was essentially an illness of the brain that should be treated with oral remedies, and the primary question among the doctors who followed him was about the humoral nature of the brain and the correct formulation of these oral remedies. In the Dark and Middle Ages, depression was seen as a manifestation of God’s disfavor, an indication that the sufferer was excluded from the blissful knowledge of divine salvation. It was at this time that the illness was stigmatized; in extreme episodes, those who suffered from it were treated as infidels. The Renaissance romanticized depression and gave us the melancholic genius, born under the sign of Saturn, whose dejection was insight and whose fragility was the price of artistic vision and complexity of soul. The seventeenth to nineteenth centuries were the era of science, when experiment sought to determine the composition and function of the brain and to elaborate biological and social strategies for reining in the mind gone out of control. The modern age began in the early twentieth century with Sigmund Freud and Karl Abraham, whose psychoanalytic ideas of the mind and self gave us much of the vocabulary still in use to describe depression and its sources; and with the publications of Emil Kraepelin, who proposed a modern biology of mental illness as an affliction separable from or superadded to a normal mind.
Disruptions long called melancholia are now signified by the strangely causal word depression, which was first used in English to describe low spirits in 1660, and which came into common usage in the mid–nineteenth century. I use depression here to describe states for which we would now use that term. It is fashionable to look at depression as a modern complaint, and this is a gross error. As Samuel Beckett once observed, “The tears of the world are a constant quantity.” The shape and detail of depression have gone through a thousand cartwheels, and the treatment of depression has alternated between the ridiculous and the sublime, but the excessive sleeping, inadequate eating, suicidality, withdrawal from social interaction, and relentless despair are all as old as the hill tribes, if not as old as the hills. In the years since man achieved the capacity for self-reference, shame has come and gone; treatments for bodily complaints have alternated and crossed with treatments for spiritual ones; pleas to external gods have echoed pleas to internal demons. To understand the history of depression is to understand the invention of the human being as we now know and are him. Our Prozac-popping, cognitively focused, semi-alienated postmodernity is only a stage in the ongoing understanding and control of mood and character.
The Greeks, who celebrated the idea of a sound mind in a sound body, shared the modernist idea that an unsound mind reflects an unsound body, that all illness of the mind is connected in some fashion to corporeal dysfunction. Greek medical practice was based on humoral theory, which viewed character as the consequence of the four bodily fluids: phlegm, yellow bile, blood, and black bile. Empedocles described melancholy as the consequence of an excess of black bile, and Hippocrates, astonishingly modernist, had imagined a physical cure by the end of the fifth century B.C., at a time when the idea of illness and doctors was itself just emerging. Hippocrates located the seat of emotion, thought, and mental illness in the brain: “It is the brain which makes us mad or delirious, inspires us with dread and fear, whether by night or by day, brings sleeplessness, inopportune mistakes, aimless anxieties, absentmindedness, and acts that are contrary to habit. These things that we suffer all come from the brain when it is not healthy, but becomes abnormally hot, cold, moist, or dry.” Hippocrates thought that melancholy mixed internal and environmental factors, that “a long labor of the soul can produce melancholy”; and he distinguished illness that arose in the wake of terrible events from illness without apparent cause. He classified both as versions of a single illness precipitated when excess of black bile—cold and dry—unbalanced ideal equilibrium with the other three humors. Such an imbalance, he said, might have a uterine origin—one might be born with
a tendency toward it—or might be induced by trauma. The Greek words for black bile are melaina chole, and the symptoms of its malign ascendancy, which Hippocrates associated with the autumn, included “sadness, anxiety, moral dejection, tendency to suicide,” and “aversion to food, despondency, sleeplessness, irritability, and restlessness” accompanied by “prolonged fear.” To rebalance the humors, Hippocrates proposed changes in diet and the oral administration of mandrake and hellebores, cathartic and emetic herbs thought to eliminate excess black and yellow bile. He also believed in the curative properties of advice and action; he cured the melancholy of King Perdiccas II by analyzing his character and persuading him to marry the woman he loved.
Theories about the temperature, location, and other details of black bile became increasingly complex during the next fifteen hundred years, which is curious because there actually is no such thing as black bile. Yellow bile, produced in the gallbladder, may turn quite brownish, but it is never black, and it seems unlikely that discolored yellow bile was the stuff described as melaina chole. Black bile, hypothetical or otherwise, was nasty; it was said to cause not only depression but also epilepsy, hemorrhoids, stomachache, dysentery, and skin eruptions. Some scholars have suggested that the word chole, meaning bile, was often used in association with the word cholos, which means anger, and that the notion of black bile may have come from a belief in anger’s darkness. Others have proposed that the association of darkness with negativity or pain is an inbuilt human mechanism, that depression has been represented cross-culturally in black, and that the notion of a black mood is amply established in Homer, who describes “a black cloud of distress,” such as afflicted the depressive Bellerophon, “But the day soon came / When even Bellerophon was hated by all gods. / Across the Alean plain he wandered, all alone, / Eating his heart out, a fugitive on the run / From the beaten tracks of men.”
The divide between the medical view and the philosophical/religious view of depression was strong in ancient Athens. Hippocrates denounced the practitioners of “sacred medicine,” who invoked the gods to effect cures, as “swindlers and charlatans”; and he said that “all that philosophers have written on natural science no more pertains to medicine than to painting.” Socrates and Plato were resistant to Hippocrates’ organic theories and claimed that though mild impairments might be treated by physicians, deep disorders were the province of philosophers. They formulated notions of the self that have exerted a powerful influence in modern psychiatry. Plato originated the developmental model that suggests that a man’s childhood may determine the quality of his adult character; he speaks of the family’s power to determine for good or ill a man’s lifelong political and social attitudes. His tripartite model of the adult psyche—the rational, the libidinal, and the spiritual—is uncannily like Freud’s. Hippocrates is, in effect, the grandfather of Prozac; Plato is the grandfather of psychodynamic therapy. During the span of two and half millennia between them and the present, every variation on their two themes has been introduced, and genius and folly seem to have alternated like pistons.
Doctors soon began to propose oral remedies for melancholy. In the post-Hippocratic ancient world, Philotimus, for example, having noticed that many depressives complained of “a light head, arid, as though nothing existed,” put a lead helmet on his patients so that they might be made fully aware that they had heads. Chrysippus of Cnidus believed that the answer to depression was the consumption of more cauliflower, and he cautioned against basil, which he claimed could cause madness. Philistion and Plistonicus, opposing Chrysippus, proposed that basil was the best treatment for patients who had lost all feelings of vitality. Philagrius believed that many symptoms of depression came from the loss of too much sperm in wet dreams, and he prescribed a mixture of ginger, pepper, epithem, and honey to control them. Anti-Philagrians of the period thought depression was the organic result of abstinence from sex and sent their patients back to the bedroom.
Within seventy years of the death of Hippocrates, the School of Aristotle began to exert powerful influence on how we think about thinking. Aristotle accepted neither Hippocrates’ diminution of the importance of the soul and its philosophers, nor Plato’s dismissal of the doctor as a mere artisan. Aristotle proposed instead a theory of a united self in which “a disturbance of the body affects the soul; the diseases of the soul come from the body, except those that are born in the soul itself. Passion changes the body.” His wisdom on human nature is not matched by any particular knack for anatomy. Saying that “the brain is a residue lacking any sensitive faculty,” Aristotle proposed that the heart had a regulatory mechanism that controlled the balance of the four humors, and that either heat or cold could disrupt this balance. Aristotle’s view of depression, unlike that of Hippocrates, was not entirely negative. Aristotle took from Plato the notion of divine madness and medicalized it by associating it with melancholia. Though Aristotle sought ways to understand and alleviate the ailment, he also felt that a certain amount of cold black bile was necessary to genius: “All those who have attained excellence in philosophy, in poetry, in art, and in politics, even Socrates and Plato, had a melancholic habitus; indeed some suffered even from melancholic disease.” Aristotle wrote, “We are often in the condition of feeling grief without being able to ascribe any cause to it; such feelings occur to a slight degree in everyone, but those who are thoroughly possessed by them acquire them as a permanent part of their nature. Those who possess an atrabilious temperament in slight degree are ordinary, but those who have much of it are quite unlike the majority of people. For, if their condition is quite complete, they are very depressed; but if they possess a mixed temperament, they are men of genius.” Heracles was the most famous of the classical geniuses afflicted with the black bile complaints, and they also touched Ajax (“the flashing eyes of Ajax raging, and his mind weighted down,” as it is written in The Sack of Troy). This notion of inspired melancholia was carried forward by Seneca, who said that “there has never been great talent without some touch of madness”; it resurfaced in the Renaissance and has reared up regularly ever since.
In the fourth to first centuries B.C., medical science and philosophy developed along closely associated lines, describing psychiatry in an increasingly unified way. Melancholy was seen in this period to be a universal destiny in one form or another; the fourth-century poet Menander wrote, “I am a man, and that is reason enough for being miserable.” The Skeptics believed that it was important to study the visible world and therefore looked to symptoms without theorizing about the origins of those symptoms or their deep meaning. Uninterested in the big, difficult questions of the nature of the physical and cerebral self that had preoccupied Hippocrates and Aristotle, they tried to categorize symptoms to delineate disease.
In the third century B.C., Erasistratus of Juli separated the brain and the cerebellum, determining that intelligence resided in the brain and that motor ability was based in the cerebellum; and Herophilus of Calcedonius then determined that from the brain “motive power goes toward the nerves,” so establishing the idea of a controlling organ supervising a nervous system. Menodotus of Nicomedia, who lived in the first century A.D., combined all previous wisdom, incorporating the thoughts of the symptom-oriented empiricists with those of the grand philosophers and the early doctors. He recommended for depression the same hellebores that Hippocrates had discovered, and the same self-examination that had come from Aristotle, and introduced also the use of gymnastics, travel, massage, and mineral water to help the depressive. Such a total program is just what we strive for today.
Rufus of Ephesus, Menodotus’ contemporary, isolated melancholy delusion from the rest of the mind and spoke of melancholy as a discrete aberration that occurred in otherwise stalwart minds. He cataloged the delusions of some depressive patients: Rufus treated at various stages a man who believed himself to be an earthenware pot; another who believed that his skin had desiccated and was peeling off his body; and one who thought that he had no head. Rufu
s noted the physical symptoms of what we now recognize to be hypothyroidism, a hormonal imbalance whose symptoms are similar to depression’s. He believed that the primary causes of melancholy were heavy meats, inadequate exercise, too much red wine, and inordinate intellectual toil, and he noted that a genius might be particularly prone to the complaint. Some melancholiacs “are that way by nature, by virtue of their congenital temperament,” while others “become that way.” He also spoke of degrees and types of melancholy: one in which black bile infected all the blood, one in which it affected only the head, and one in which it affected “the hypochondria.” Rufus found that his melancholy patients also suffered the buildup of unreleased sexual fluids, whose putrefaction infected the brain.
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