Hemingway's Brain

by Andrew Farah

  Though their dietary and supplement intake is often fine, the majority of depressed individuals have less than optimal levels of B vitamins for use in the brain’s chemical pathways. The reason for this is that there are multiple variances in our abilities to metabolize B vitamins to the forms needed by the brain. We can now prescribe these metabolized or reduced forms and circumvent the pathways that caused the deficiencies.

  Offering Hemingway the forms of B6, B9, and B12 that the brain needs would be safe and likely therapeutic. It might also help prevent a further decline in his dementia illness. The prescription product is Enlyte, currently the only available agent of its kind—offering depression relief and potential neurological protection.3

  Next we turn to the underlying illness, the dementia itself. All of our current dementia therapies are indicated for the Alzheimer’s type, but when patients present with other types or with a mixed dementia like Hemingway’s, we often treat them the same as Alzheimer’s patients. They may actually have a component of Alzheimer’s dementia as well, and many do, but, even if they don’t, they may still benefit from the medications, lifestyle changes, and natural remedies, despite the exact category of illness.

  The nonpharmaceutical options are welcomed by virtually all patients, and Hemingway was already used to the exercise regimen of walking the roads of Ketchum each day. Exercise does improve brain functioning, even in dementia cases. The mechanism is not fully understood, but improving blood flow while busying mind and body seem intuitively beneficial. Also, soft music should play while the patient sleeps to keep the brain “active” through the night—another drugless strategy for preserving cognitive ability.

  The cornerstone of preventing a decline for patients at risk of developing dementia or who already show mild symptoms is a combination of the vitamins in the Enlyte preparation, plus an additional pill, a potent antioxidant. One theory as to why brain cells deteriorate and eventually die prematurely in cases of dementia is related to their exposure to two main “toxins”: free radicals and homocysteine. The vitamins in Enlyte lower homocysteine levels, and we recommend an antioxidant to eliminate the free radicals.

  An essentially infinite number of chemical reactions can occur in cells throughout a lifetime, and these reactions have the potential to release electrically charged particles that, simply stated, must attach to something. Chemically, they are impelled to bind to another particle to satisfy the free electrical charge. Theses free radical are, however, very damaging to cells, and the brain handles them by generating natural antioxidants. But the brain’s natural antioxidant chemicals can be easily overwhelmed, and taking a chemical precursor for the brain’s natural “garbage collector” drastically boosts the system. That precursor is an amino acid, n-acetyl-cysteine (NAC); the brain converts it to glutathione, which eliminates free radicals. Thus, NAC is our best defense against oxidative stress. Fortunately, it is safe and natural (a protein building block, that is, an amino acid). It can be ingested and crosses the blood-brain barrier. It is the most potent antioxidant we can take.4

  New evidence suggests that taking omega-three fatty acids or “fish oil” may also be of benefit in dementia. For brain health, we usually prescribe the docosahexaenoic acid type (or DHA). The mechanism of the benefit is unknown, but DHA constitutes approximately 50 percent of brain cell membranes. Since the loss of membrane integrity is thought to be critical in the cascade of events that results in cell death, it makes sense to provide the body with this raw material.5

  Another component in the mechanism of brain cell death is the influx of calcium ions from outside the cell’s membrane into the cell itself. And this calcium accumulation may be accelerated in damaged brain cells, such as those found in people who have suffered strokes or concussions. A prescription medication, memantine (Namenda), is thought to help prevent this mechanism of cell death and improve cognitive functioning in some patients with dementia.6 Even when patients report no noticeable improvement in memory, it is best to continue this medication because it may help prevent a further decline.

  Other prescription medications include donepezil (Aricept) and rivastigmine (Exelon), which may improve memory in some patients. Because the brain uses acetylcholine to store and retrieve memories, medications that block the metabolism of acetylcholine may be of benefit (these medications are inhibitors of the enzyme that breaks down acetylcholine, acetylcholinesterase, and for rivastigmine, butyrylcholinesterase as well). The cholinesterase inhibitors are not wonder drugs, but about a third of patients see some modest benefit. They also seem to work better when combined with memantine rather than when administered alone.

  For his delusional beliefs, we might use a small amount of an antipsychotic medication. There are the side effects to consider, and the FDA requires that we warn patients about the small risk of increasing the likelihood of a stroke. (In one study of dementia-related psychosis, the patients receiving study drug had a 4.5 percent chance of stroke, while the placebo group risk was 2.6 percent).7 As with any medical therapy, the risks are weighed against the benefits. The potential benefit for Hemingway would be the end to his delusional torment. The two best choices would have been a low dose of iloperidone at bedtime, because it has a placebo rate of movement side effects, such as Parkinsonism, and might even help lower his blood pressure. Or he might have benefited from a low dose of lurasidone, which has no risk of weight gain and does not cause glucose or lipid elevation. An older agent that has very few side effects and often works very well in the geriatric population is perphenazine. Hemingway, so concerned about finances, would appreciate its cost, which is about $4 per month.

  Though this seems like a great many things to recommend all at once, three of his prescriptions would have been for vitamins, omega three fatty acids (fish oil), and amino acid formulations. Further, I stress to patients that it is not the number of drugs you are taking but the number of receptors they affect in the body that matters. I would rather prescribe five separate agents that target five separate receptors in the brain than one medication that targets ten receptors. And when it comes to preserving the brain’s microanatomy and functioning, any and all strategies should be considered.

  Thus, Hemingway’s modern medical chart would read as follows:

  Assessment

  Axis I.

  Dementia, mixed etiology

  Depression, recurrent, severe

  Psychosis secondary to the above two

  Axis II.

  Narcissistic traits

  Axis III.

  Diabetes, hypertension, history of hepatitis, fatty liver, multiple/various injuries, multiple concussions and resultant CTE

  Treatment Plan

  1. Alcohol detox vs. discontinue alcohol and prescribe diazepam, 5 mg in morning, 10 mg in evening

  2. Enlyte one a day (a preparation of B vitamin for depression)

  3. Omega-three, DHA preparation

  4. Desvenlafaxine 50 mg a day, escalate to 100 mg a day if needed in three weeks

  5. NAC (n-acetyl cysteine) 600 mg a day, may escalate to two a day if needed

  6. Optional: antipsychotic, best choices perphenazine 2–4 mg at bedtime, or lurasidone 20 mg a day, or iloperidone 4 mg at bedtime

  7. Memantine 28 mg a day

  8. Optional: Exelon patch, apply daily, escalate to maximum dose as tolerated

  9. Oral hypolgycemics if needed (for diabetes)

  10. For blood pressure, pindolol, a beta blocker that also may enhance antidepressant effects

  11. Exercise regimen: Keep writing! Keep the brain as active as possible, even while sleeping!

  And one final recommendation: remove all guns from the home. It is now standard to ensure that all guns are not “locked up” but rather removed from the home of suicidal individuals. Prior to discharge, this must be arranged.

  Results with this type of aggressive therapy have been generally positive. If such a plan had been fully implemented, Hemingway’s future would have been vastly different—but for hi
s time, his diagnosis, and the options available, his outcome was inevitable.

  vortioxetine =

  Trintellix

  desvenlafaxine =

  Pristiq

  escitalopram =

  Lexapro

  n-acetyl-cysteine =

  NAC

  pindolol =

  Visken

  perphenazine =

  Trilafon

  iloperidone =

  Fanapt

  lurasidone =

  Latuda

  memantine =

  Namenda

  rivastigmine =

  Exelon

  diazepam =

  Valium

  Enlyte =

  reduced B vitamins and micronutrients that lower homocysteine and treat depression

  Epilogue

  He thought of the ruins of the Grecian worship, and it seemed, a temple was never perfectly a temple, till it was ruined and mixed up with the winds and the sky and the herbs.

  D. H. Lawrence, The Rainbow

  Because grace under pressure is more than just suffering; it is an active achievement, a positive triumph and the figure of St Sebastian is its best symbol, if perhaps not in art generally, but certainly in the art of writing.

  Thomas Mann, Death in Venice

  Hemingway’s ending appeared to set the tone for the decade. Marilyn Monroe overdosed thirteen months later on Nembutal and chloral hydrate, and JFK was murdered in November 1963. The Louisville Courier-Journal understood perfectly what Hemingway and the legend of Hemingway meant: “It is almost as though the Twentieth Century itself has come to a sudden, violent, and premature end.”

  As Montale observed, Hemingway “died twice.” The false alarm after the African plane crashes only added to the myth. The banner headline that he clipped from the front page of the New York Daily Mirror read: “HEMINGWAY, WIFE KILLED IN AIR CRASH.”1 And he kept two scrapbooks of the obituaries that followed, referring to them for entertainment at various times for the rest of his life. Though he was fairly well battered at this point, the evidence still indicates that the only thing that could bring him down was himself.

  Suicide, in modern Western society, is virtually always considered the product of a deranged mind. By definition, suicidality is mental illness, and attempting or just threatening suicide constitutes legal grounds for forcing an individual into psychiatric treatment. But it is not a diagnosis itself; rather, it is a symptom of a larger ailment that requires medication and psychotherapy until the patient is deemed (to a “reasonable degree of medical certainty”) no longer in a state of acute danger of self-harm. In the United States, a completed suicide by a patient who is receiving mental health care is the number one reason psychiatrists are sued. Suicide is the tenth leading cause of death among adults and the second among teens. Each year, nearly a million people worldwide take their own lives. Unlike Hemingway, the majority of patients who are successful in their suicide attempts never come to the attention of a psychiatrist or therapist before their deaths—fewer than half do.

  Mike in The Sun Also Rises explains that he went bankrupt in two ways, “Gradually and then suddenly.”2 The last years of Hemingway’s life testify that a man can also decline in physical and mental health with the same trajectory. Health matters are certainly the responsibility of the biographer, yet one is entitled to ask what they matter to the student of the work. Yet because so much Hemingway scholarship involves exactly what he resisted—his fiction as autobiography—a clear understanding of his mental state at the time of his writing is critical. It seems the works can never stand apart from his large shadow; such is the price of legend. But what scholars have generally missed is that when Hemingway identified his therapist as his typewriter, he was identifying the fact of his working, not the content he produced, as doing the work of therapy (of course, it would have been of no use to tell him that both were in fact therapeutic).

  His Nobel Prize acceptance speech, which was written in 1954, contained the lines “There is no lonelier man than the writer when he is writing except the suicide. Nor is there any happier, nor more exhausted man when he has written well. If he has written well everything that is him has gone into the writing and he faces another morning when he must do it again. There is always another morning and another morning.”3 He deleted the passage, but, in contemplating the honor and magnitude of the Nobel Prize, few would bring suicide into the discussion and, oddly, place it on par with the writing life. And, yes, when he wrote well, he did pour all of himself into the work, but the fatalistic passage applies more accurately to Sisyphus than to the majority of professional writers.

  Suicide was an unusually common theme in his work, his letters, and his conversations. He insisted that his mother send the pistol that his father had used to kill himself; he had plans to exorcise the demons. Though Leicester had also requested the handgun, their mother deferred to Ernest’s request. In her classic passive-aggressive manner, Grace mailed it in a box that contained a chocolate cake (a book for “Bumby,” cookies, and two of her paintings—desert scenes). Of course, the gun arrived covered in chocolate. Despite her irreverence, Hemingway still gave it what most conclude was a “ritualistic burial” in a mountain lake.4

  In 1936, he told Archie MacLeish that he would never kill himself because of what the trauma might do to his sons, which is indeed why many patients seek help rather than commit the act: they don’t want to leave their children with the trauma and legacy of suicide. During the Spanish Civil War, he expressed to the Stalin operative Joris Ivens that the best way was not like his father’s method, with a bullet through the temple, but “with a shotgun in the mouth.”5 He actually asked his friend Clara Spiegel to make a suicide pact with him and proposed they warn each other if either of them ever planned to carry it through. She rejected the idea. When Hemingway arrived home in Ketchum after his last hospital admission, she invited him to dinner, but he asked her to come to his home instead, specifically on July 2; after that date, he warned, “he would have no social life.” Clara didn’t take him seriously, as she believed he was crying wolf yet again. 6

  There were numerous suicidal threats and discussions, as well as an unusually high number of other suicides that touched his life: Dr. Hemingway, Hadley’s father, Helen Breaker, Harry Crosby, Jules Pascin, and Charles Fenton. And there was no shortage of suicide attempts by others: his Grandfather Hall, Scott Fitzgerald, and Jane Mason. Even Hemingway’s love interest (or infatuation) from his early teens, Prudy Boulton, who appears as the Indian girl Prudence Mitchell in the story “Ten Indians,” committed suicide at age sixteen. She was rumored to be pregnant by the older man she lived with at the time. They both swallowed strychnine.7

  And though his feelings toward his third wife, Martha, were less than generous after they parted ways, he still admired her 1944 novel, Liana, a complex work that has been called essentially an allegory of the end of her marriage with Ernest. The book ends with Liana’s suicide. And Martha also committed suicide. She was just shy of ninety years of age when she overdosed, suffering from cancer and near total blindness.

  As a young man in 1926, the year he filed his first set of divorce papers, Hemingway agonized over loving two women and expressed his suicidality to both of them. He described perfectly how the depressed mind wanders into thoughts of self-destruction: “When I feel low, I like to think about death and the various ways of dying. And I think about probably the best way, unless you could arrange to die some way while asleep, would be to go off a liner at night. That way there could be no doubt about the thing going through and it does not seem a nasty death. There would be only the moment of taking the jump and it is very easy for me to take almost any sort of jump. Also it would never be definitely known what had happened and there would be no post mortems and no expenses left for any one to pay and there would always be the chance that you might be given credit for an accident.”8 In a passage he wrote for To Have and Have Not, his 1937 Depression-era book of complicated morality, and the
n deleted, he described this exact death. And he eerily predicted the very method of death for the poet Hart Crane, with all the attendant ambiguities he had described.

  Hemingway and Crane shared the exact same birthday, July 21, 1899, and Crane, like Ernest, also drank heavily, but, more like Scott Fitzgerald, he held his liquor less well. He was suffering from writer’s block, something he hoped a trip to Mexico on a Guggenheim Fellowship would cure. On the liner home, he was beaten after making homosexual advances to the wrong crew member (biographers report that this was not the first time; he seemed to have a knack for choosing the least receptive and most violent individuals). Thus, beaten up, depressed, drinking, and probably intoxicated while en route to New York in 1932, he jumped off the USS Orizaba in the Gulf of Mexico; reports are conflicting regarding his last words and whether he reached for a life preserver or sank, ignoring it.9

  All of these examples and thoughts served to erase the taboo; suicide was certainly not an unknown exit, and it was justified if the suffering was great enough. And Hemingway had been daring himself for decades. He was playing a dangerous one-sided game of chicken in his head for most of his life. But he didn’t blink; he was too ill to play the game anymore. He just reached the point where he “couldn’t stand things.”