An interview with Andrew Solomon, author of The Noonday Demon: An Atlas of DepressionYou are extremely articulate and self-aware, which no doubt proved hugely useful in both your talk therapy and work with a pychopharmocologist. However, how do less communicative, less aware people fare? Is recovery or degree of recovery linked to the ability to speak?
The ability to speak about your mood states absolutely helps in the process of recuperation. It's not that people who don't know how to talk about depression get sicker, but that they stay sick for longer, make less satisfactory recoveries. I found several people during my research who said that the day someone called their problem depression and gave them a word to use for it was the day they began to get better. I put forward in my book the idea that there is actually a neuroanatomical reason why talking about things makes you feel better about them. Describing your depression can activates bits of brain circuitry that are extremely positive. Though obsessing about your problems makes them worse, talking about them gives you some control of them. One of my aims in writing this book was to show people how to talk about depression, to give them a vocabulary for what they're experiencing. I believe this will help them get better faster.
Many families are destroyed by depression. Yet you say that it gave you your family back and in fact dedicated the book to your father. Can you explain?
Any kind of trauma brings people together and pulls them
apart. When you're depressed, you're a dead weight, and you're forced to rely on
your family and your closest friends. In many families, the negativity, the
self-obsession, and the lugubriousness are irritants, and because depression is
physically inivisble, families often doubt that it is real, and blame the
sufferer. On the other hand, when you are depressed you are sort of stripped
naked of all your pretensions and appearances, and sometimes that can bring
people closer to you. Taking care of someone who is depressed is an extremely
intimate experience. I was not in a relationship when I had my first breakdown,
and I was really very lucky that my father was prepared to take charge of my
life. He's a very nurturing, caretaking, generous man, and when I became his
helpless child again, I moved into his house. He persuaded me to eat every night
and stayed with me during the day when I was at my worst and offered constant
reassurance. By the time I began to get better, I felt he had seen quite deep
into me, and that he was gentler with me after that; and I had seen the
essential things about his character, and was less prickly after that. We used
to have a tense, brittle relationship marked by constant argument; now we are
incredibly close and hardly ever argue at all. His care helped me get strong
enough to write this book, so it seemed only right that I dedicate it to
Why did you write this book?
When I was recovering from my first breakdown, I read
everything on the subject, and felt that the book I needed wasn't there. Most of
the books that were there fell into one of three categories. They were
first-person narratives that were moving, but so anecdotal as to be largely
irrelevant to anyone else; or they were medical texts that were very dry and
highly abstract; or they were written in the patronizing abstract of self-help.
There was nothing synthetic, nothing sweeping, nothing in which I could
recognize myself and learn what I needed to know. So I decided to write an atlas
of depression -- to map the illness in its entirety and try to convey every
useful insight that can be adduced from our current state of
What was it like to write such a highly personal book and how did you work on it?
It was not easy to write about my own depression; in fact,
it was agonizing. But I felt that by writing down what I had been through, I
could get some perspective on it, and I thought that perspective would be
helpful to others. Depression is a totally unconstructive state, and after
you've been through a severe depression you naturally want to make some
retrospective use of all the time you've lost. Writing this book made me feel
that I was using my own difficulty to make things easier for other people, and
there was a certain redemptive value in that.
What is depression?
Depression is a very extreme version of bad feelings we all
have on a day-to-day basis. It's so extreme that it feels like something else,
but it really is an exaggerated form of the worst of the mood spectrum. If
you've ever woken up in a state of fear and dread in the half-light hour before
sunrise, then you know what depression is. It's a state of anxiety and sadness
and of being overwhelmed. When you're depressed, the most routine things seem
almost impossible. There is a very blurry borderline between illness and
personality -- what used to be someone's "take on the world" is now described as
a severe illness just because we have the technology to change it. The better
our treatments get, the broader our definition of depression becomes.
What advice would you give to the family member or friend or mate of someone suffering from depression?
Depression is a disease of loneliness, and the best thing
you can do is to mitigate the isolation of a depressed person. No matter how
withdrawn that person is, it is helpful to him to have constant concrete
manifestations of support around him. It is important to remember that the
depressive's belief in the intractability of his condition is one of the
symptoms of the illness. Keep reminding the person who suffers that the
situation is temporary, that things will change, and that the voices he hears
within himself are the voices of depression and not the voice of reason.
Encourage your depressed friend to seek the professional help he may need -- to
find medications if appropriate (and they usually are) and to find some form of
talking therapy to enable the emergence from despondency. Give encouragement.
Don't, however, keep telling the person to cheer up, or remind the person in
great detail of how wonderful his life is. Don't be patronizing. Accept that the
statements being made by the depressive, no matter how distorted they may seem,
are his truth. Have some respect for the reach of the illness.
The Noonday Demon has not only your story, but also the stories of an incredibly broad range of people who have suffered with depression -- from survivors of the Khmer Rouge to Greenlandic Inuit to tribal societies in Senegal. How did you get such diverse groups to open up?
I wanted to break down the myth that depression is a modern
middle-class Western illness. Depression is a fundamental part of the human
experience and it exists in every conceivable context. The intimacy I achieved
during my adventures with foreign cultures was possible because on this
particular issue, what had happened to me was so closely related to what had
happened to them. There was something deeply familiar about the Cambodian woman
who teaches depressed Khmer Rouge survivors, in her words, "to forget, to work,
and to trust"; and about the Inuit elders who, in a small village, have
introduced the idea of open therapeutic conversation about emotions; and about
the Senegalese who perform ritual exorcisms to drive the unwelcome spirits out
of the depressive. I found that almost everyone in the world finds depression
isolating and burdensome, and that if you can only put people at their ease,
almost all of them are glad of an occasion to open up.
Women are twice as likely to suffer depression as men. Why? What are the key issues for women and depression?
There are two factors that cooperate to create this
statistic. One is biology. One is society. Women suffer from depression more
frequently than men because the shifting hormone patterns around menstruation
create a state of regular emotional disruption. Sudden shifts in levels of
estrogen have been shown to predispose women toward depression, and of course
women often get severe postpartum depression caused by the chemical fluctuations
around childbirth. Women are also more likely to suffer depression because they
have more intense attachments to their children than do men; according to one
study, if you discount all the depression that is associated with motherhood,
you get a rate of female depression that is about the same as male depression.
But women are also more likely to be disenfranchised than men: to be living
within abusive relationships; to be unable to assert themselves in the
workplace; to be pushed into unwelcome subsidiary roles in their lives. Women's
disadvantaged situation often causes them to live with horrors that men might be
able to escape, and depression is a result of such accommodation. All those are
factors that lead to depression. Finally, many depressed men express their
depression by acting out -- they become batterers and substance abusers -- and
so we think of them as criminals rather than as depressives. Women are more
likely to repress their feelings, and that repression results in
You talk about depression among children and adolescents. What causes depression in this group; how can you recognize it; and what can you do about it? Can you depression-proof your kids?
The rate of depression in young people is going up
astonishingly fast, and the rate of suicide attempts among such people is just
enormously high. More and more often I hear stories of children jumping out of
windows or trying to hang themselves. It's very alarming. And adolescent
depression is, if anything, even higher. I think that we need to pay much more
attention to what our kids say and to how they act. If they are really sad or
really angry or are acting really badly, we should sit up and take notice. We
have to try to draw them out, to teach them a vocabulary for articulating their
feelings, to themselves as much as to us, so that they can recognize mood states
and understand the transient nature of much negative emotion. If you can nip
depression in the bud, you can hold it in abeyance forever. If you wait until it
is really out of control, you will never be able to get it out of someone's
basic life in the world. We have to start paying much more attention much
sooner. Some kids may need to pull themselves up by their bootstraps and learn
discipline, but if they are in real pain, that pain must be assuaged before
bootstraps can be brought into the conversation.
In the course of researching and writing this book, what surprised you most?
The sheer numbers. I would go out to any social event and
say that I was writing a book about depression, and without exception, people
would say to me, "Oh, I've had such-and-such a problem" or "My sister seems to
have been depressed for a long time" or "One of my children keeps talking about
suicide." It was just stupefying. And most of them said they didn't really talk
about this too much. I don't think there are any lives in America that haven't
been significantly touched by depression. It's molded the people of our
generation the way Vietnam molded the life of the late '60s.
You write that no two people have the same depression. How does this affect diagnosis and treatment?
I'm amazed by how many people buy into the idea that
depression is a single consistent phenomenon that operates the same way in
everyone. It's just not true. Each person has his own constellation of symptoms;
in each person, the depression crystallizes around a unique set of
circumstances. There's a bad tendency in our society just to throw Prozac at
people. Each person has a highly individual biology and psychology which respond
in very particular ways to very particular treatments -- I, for example, take a
carefully negotiated cocktail of four medications and see a therapist once a
week. You need to get to a really good, smart doctor who can make excellent,
sophisticated judgments about what you're going through. But a lot of it is
still trial and error. You have to look at what your individual symptoms are and
what makes them better and what makes them worse.
You write that the opposite of depression is not happiness, but vitality. Can you explain this?
Popular usage of the word depression has made many people
think that the state is a form of unhappiness. It's true that one often feels
sad when one is depressed, but depression itself is a state of nullity. It's not
the presence of negative emotion so much as the muting or obliteration of all
emotion, positive and negative -- except for fear and anxiety. And the fear is
utterly disabling. It makes it impossible to do anything -- you feel as though
you'll die if you even try to take a shower or to get dressed. So the opposite
of that is the feeling that you can do things, that the world is full of
possibilities, that life is in the living. When you feel really alive and
vigorous, you're not depressed; when you achieve vitality, you have broken out
of the gray kingdom of depression.
What is the link between socioeconomic standing and depression?
People tend, mistakenly, to think that depression is an affliction of the middle classes. Well, there's a good reason for this. If your life is essentially OK in most external ways and yet you feel horrible all the time, you know you must have an illness. If your life is a mess and you feel horrible all the time, you'll assume that you're just responding appropriately to your reality. But that's not true -- some poor people are full of vitality, and others are totally defeated. The highest rates of depression are actually among the poor. Often, the sequencing is confused. It's not that you feel depressed because your life is so bleak. Your life is so bleak because you are depressed. Depressed people have a hard time bringing about positive change; they give way to the impediments that greet all of us at every turn; and they tumble down and down, to the very lowest rung on the socioeconomic ladder. Treating the depression often allows these people to achieve the dynamism they need to improve their lives. I encountered one amazing story after the next of people living in total poverty and misery and squalor who vastly improved their lives after their depression was treated, and who were able to enter a socioeconomic position that had once seemed inconceivable to them -- as well as to engage fully with their children and families, and to lead good, fulfilling meaningful lives.
Many people talk about depression as the great epidemic of the twenty-first century. Yet you found that the ancient world had a view of depression very similar to our own. What are the historical through lines of depression?
Depression has been around as long as people have been
around. In fact, there are depression-like states even in pre-human mammals. In
the fifth century BC, Hippocrates stated very clearly that depression was an
organic illness of the brain that should be treated with oral remedies. So the
whole concept behind Prozac was there already 2500 years ago. At the same time,
Aristotle was talking about depression as an affliction of the spirit that came
particularly to men of genius, and his views on the subject eventually led to
the systems of talk therapy that we use today. Neither the problem nor the
treatments are particularly modern. In the medieval period, all illness was
described as illness of the body or illness of the soul, and depression was
definitely an illness of the soul. That's when it started to be shameful. During
the Inquisition, depression was seen as a sign that you had despaired of
ultimate forgiveness and redemption; it was therefore sinful. You could be
imprisoned for being depressed in this period. Then in the renaissance,
depression became a fashionable affliction of the intelligentsia and a sign of
sophistication and wealth. In the eighteenth century, the medicalization of
depression began, and from there it was a pretty direct line to our current
attitudes. But the original descriptions given by ancient sources mostly sound
like they could have been spoken yesterday. It's been astonishingly consistent
Despite these historical models, depression seems to be on the up and up. Why?
Depression is definitely increasing. There are three primary
reasons why this is so. The first is that depression is a frequent consequence
of chronic stress, and the level of chronic stress is incredibly high in modern
society. People deal with vast numbers of other people; they confront inhuman
institutions all the time; they are in the grip of authorities they do not
understand. The second is the failure of informed choice. Once upon a time,
people had very fixed social positions and geographical situations. You had a
limited number of choices of career and of spouse, and while you didn't always
get what you wanted, you always had the chance to review the available options.
You knew where you stood. Nowadays, these choices are made into the great chaos
of modern life, where you can never know or understand the range of your
possibilities. The third is that we've imposed unreasonable standards of mental
health. It's been fairly well established that supermodels have hurt women's
understandings of themselves and have promulgated feelings of inadequacy. We
have a psychological supermodel going strong in modern times, a notion of
perfect happiness, to which we absurdly aspire, which makes most people feel bad
about their actual psychological condition. You realize you are not perfectly
happy; you worry about it; the worrying is negative; that makes you feel worse;
so you worry more -- it's a downward spiral.
New studies are released all the time about the link between depression and physical ailments. How did depression affect your physical health? How would the successful treatment of depression affect other kinds of disease?
My episodes of depression were often triggered by physical
complaints -- I had terrible kidney stones before my first episode, and I had a
dislocated shoulder before the third one. I think the link between physical and
psychological trauma is very intimate. Though physical symptoms can spur
psychological ones, the pattern we're really looking at here is of psychological
ones causing physical ones. According to the World Health Organization,
depression accounts for more loss of useful life years world-wide than AIDS,
cancer, and war put together. When you are depressed, every part of your body
suffers. You are more likely to have heart problems; you are more likely to have
cancer. You are more likely to be careless is sexual situations, so you are more
likely to have AIDS. You are more likely to eat badly, so you are more likely to
have various kinds of malnutrition. If we could bring depression under control,
we'd cut the disease burden of the world by a remarkable percentage.
What do you think of talk therapies as opposed to medications for treating depression?
I think the arguments about the superiority of one system
over the other are ridiculous. Depression is a serious complaint that is
responsive to various kinds of intervention, and the best way forward is to use
them all in concert. Would you ask whether someone's heart condition should be
treated with blood pressure medications or with a healthy lifestyle? Both are
necessary. In my experience, the medications are often necessary to bring
someone out of the most profound darkness, which can be impenetrable to talk.
Once someone has been brought toward the light, however, a fundamental
reassessment of the self must take place. You must struggle to understand who
you are and what the depression means to your self. You often need medication to
get to the place where you can be helped by therapy. Even more fundamentally,
however, you need the support of an informed therapist to help you get the most
out of your medications. Antidepressants help those who help themselves; you
can't just take medication and sit back and wait for it to have a beneficial
effect. Without a good supportive therapy, you don't know how to help yourself.
If you're going to battle depression, you have to learn a whole set of skills.
On the other hand, all those skills won't do you a bit of good without
appropriate medical support. These are two necessary parts of modern treatment
-- we have both, and smart people will avail themselves of both.
Can you describe the role of stress in depression?
When you are highly stressed, your body secretes a hormone called cortisol. Now in the wild, animals are usually subjected to short-term stress. A lion is stalking you. You secrete a lot of cortisol and it raises your level of awareness and sensitivity. You decide between fight and flight. But in modern human societies, stress is often chronic. You are in a job you don't like or an unsatisfactory marriage and you continue trying to live your life despite these obtrusions. So instead of having a momentary peak in cortisol, you have a permanent elevation of it. The cortisol system is very closely tied to the neurotransmitter systems that regulate mood, and having high or dysregulated cortisol on a continuing basis will have a very negative effect on your neurotransmitters, with the consequence that you will become depressed. We simply weren't made for the ongoing stress we experience in modern life.
You explore depression through virtually every aspect of human experience in this book -- biology, psychology, philosophy, spirituality, economics, cultural preferences and prejudices, art, politics, gender. Do we need to approach the illness with this kind of multi-layered complexity?
At the moment, there are debates about depression in a
stupefying number of arenas. In each area, there are some coherent and
intelligent arguments being made, but there is chaos in the kingdom: the
philosophers don't hear the psychiatrists and the chemists don't hear the
priests and the legislators don't hear the artists and so on. One of the
objectives of The Noonday Demon is to bring some kind of universal field
theory to this arena of confusion. So long as we continue to debate the most
fundamental questions of human identity in this shattered, diffuse way, we won't
be able to learn anything. The ground work in all these different field has been
done; now it's time to look at how they can influence one another, to arrive at
a vast, synthetic understanding of depression.
Describe current policy in America with regard to depression. What's wrong or right with it? What has to change?
Well, what's right with U.S. policy is that it increasingly recognizes major depression as a severe complaint that warrants serious intervention and reasonable financial support. We have had some moves in recent years to ensure that mental health problems are not ignored by major insurers. We are seeing depression as a physical complaint, and we don't blame the patient as much as we used to. That being said, we still offer less coverage for mental health problems than we do for physical problems, and this reflects an underlying attitude that if you have depression, it's because you're weak, and that if you were stronger you wouldn't require this assistance. We still deny people hospitalization for depression except when they're acutely suicidal. We have no programs for treating depression among the poor or indigent, and even though it can be shown that developing such programs would serve the national interest, we choose not to do it. We have never set up programs of effective public outreach or education. And of course the biggest problem is the simple economics of modern American health care. People with severe depression find it very difficult to cope with getting up and feeding themselves, and they definitely don't have the capacity to squeeze even the benefits that are ostensibly due to them out of the American health care system. Depressed people are likely to be unemployed, delinquent, and in pain, and unless they have the wherewithal to figure out what kind of help they need and track down that help, they won't get it.
On the one hand, you talk hopefully about a world in which depression has been conquered. On the other hand, you say that when we lose depression, we will lose a great deal with it. How do you reconcile these two attitudes?
The kind of disabling clinical depression that many of the
people in my book have suffered -- that I have suffered -- is a monstrosity and
a horror and if we can alleviate it we most certainly should do so. On the other
hand, I would say that I learned a great deal from my depression. Suffering is
an interesting process. It deepens you. I don't like it and I would avoid it,
but it makes life richer. Further, negative emotion throws positive emotion into
relief. I believe that having gone through depression, one is more aware of joy.
I live much more fully than I did before I had my first episode. But I would do
almost anything to avoid having an episode again -- I've had enough
character-enriching experiences to last me a really long time. I would not want
to see emotional range limited, but it is my hope that when we cure depression,
we will allow people to have their suffering in more interesting places and for
more profound reasons.
Did we develop depression for some good evolutionary reason?
I think we developed the capacity for mood for good reasons, and that the ability to change our state of mind -- to be relaxed, to be tensed for action, to be happy, to be sad -- is extremely useful. If loss were not painful, we would not avoid it. Grief is a powerful motivator; avoidance of grief is one of the most profound mechanisms of action. Like physical pain, spiritual pain is there to tell us something. When you can't feel pain, you aren't warned off the dangerous and bad things of life. If we didn't feel grief, how could we really learn the extent of love? I think depression, however, is a useful mechanism that's got stuck and that is no longer doing us any good. I think it's clearly a dysfunction that is a price we pay for evolution's developed mood spread. Depression itself is not useful in evolutionary terms.
Since depression is still "the family secret everyone has," do you think there has been any improvement in people's willingness to be open about their own depression? Do you think there is greater public acceptance of depressed people?
More and more people are speaking openly about depression.
Treating the illness as a medical complaint rather than a spiritual deficit or
weakness of character has been enormously helpful, and has made it easier for
people to admit to depression. A number of celebrities have spoken openly about
their struggles. I was very proud that most of the people in this book were
willing to speak on the record and by name about their experiences with the
illness. But we are still at the tip of the iceberg. I was at a weekend party in
England, and on the first night, a woman took me aside to ask me some questions
about depression. She told me that she was taking medication but didn't want her
husband to know. A few days later, her husband took me aside to tell me that he
was taking medication but didn't want his wife to know. So while there is more
openness, while things are definitely better than they used to be, we have a
long long way to go.
Is it possible to cultivate happiness?
I've met a lot of depressed people during my research. A lot of them. And I observed a very strange phenomenon. Some people with serious depression were nonetheless able to live surprisingly rewarding lives. They made something of themselves between bouts of the illness and they managed to connect to people and they were both loving and beloved. I met other people who, despite having relatively mild depression, were utterly devastated by it, so much so that their lives seemed hardly to be worth living. They were lost, isolated, and alone. I think you have to fight depression all the time. You can't make yourself happy just by wishing, and at the depths of a depressive episode you are probably not capable of much joy. But you can't wait for the doctors to cure your depression. You have to keep fighting for happiness all the time. It's your life, and you have to make of it what you can.
Unless otherwise stated, this interview was conducted at the time the book was first published, and is reproduced with permission of the publisher. This interview may not be reproduced or reprinted without permission in writing from the copyright holder.
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