Depression, Suicide and Leprosy of the Soul

In the Bible, leprosy was believed to be the outward manifestation of sin, a disease of the soul that left its mark on the body as a way of warning others to stay away, lest they be led into damnation themselves. Similarly, well into the Age of Enlightenment, many illnesses were ‘read’ by cultures as marks of inner moral weakness, plagues were seen as communal punishment for a society that had strayed from the straight and narrow. Even today, one of the challenges in limiting the spread of Ebola has been that there are strongly held superstitions in the cultures it is affecting that attribute the disease to demonic causes. With the rise of the Scientific Method, we began, very slowly, to locate diseases in their rightful places: the cells, the blood, the bones, the organs, the brain. There is still a lot we don’t know about the causes of certain illnesses, whether they are environmental or genetic or a bit of both. Mental illness has been especially hard to pin down. We know that it is a pathology of the brain. We know they often have to do with the misbehavior of certain processes. We know that there can be a very strong genetic component. But there is a lot we don’t know yet. The one thing we do know, for sure, is that it isn’t a matter of moral weakness.

I’ve been living with mental illness for half of my life. Probably longer, but like most people, I believed my symptoms stemmed from some lack of moral fiber on my part for a long time. It delayed my diagnosis, it stopped me seeking help, it forced the people around me to put up with some terrifying behavior on my part. That mistaken understanding of the causal factors of mental illness almost killed me. And I have, by most standards, a very mild form of bipolar II disorder. That is very probably why I am alive. I was simply lucky.

I don’t want to pile more shit onto Henry Rollins for his article about Robin Williams in LA Weekly. He apologized and, I think, his apology was revealing. What interests me is why, with all the easily accessible scientific information out there, which clearly establishes that major depression has tangible, measurable, neurochemical and neurological causes, do so many people keep talking about depression as if were caused by a lack of moral fibre.  These aren’t ignorant people; they include health professionals, academics, public service providers, politicians who have mental health as part of their policy remit. Literature, TV and Hollywood narratives constantly perpetuate these untruths. The suicidally depressed character is ‘saved’ by someone understanding, who tells them a few home truths about how valuable they are, how much they’re loved, and all the responsibilities they have to others.

In truth, the only things that are likely to save a suicidally depressed person from death are physical restraint, 24 hour supervision, anti-depressant medication, psychotherapy, and, if needed, anti-psychotics or electroconvulsive therapy. In fact, if you read Gray’s blog post, Under Erasure, on how his depression came on, you will notice that what saved him was a friend who simply refused to leave him unsupervised until he got treatment. He had someone who just wouldn’t allow him to pull the trigger on the gun.  It wasn’t a rational argument, or compassion, or being reminded of how his death would affect others that stopped him from blowing his brains out. It was literally constant surveillance.

In fact, it was the success that psychiatrists had with electroconvulsive treatment that finally, for good and all, exposed depression as having a physical basis in the brain. If depression had been a matter of some moral weakness, the shocks wouldn’t have worked. This treatment, often so graphically represented and considered barbaric by many, is still one of the only therapies that work on drug-resistant cases of major depression.

Sadly, it can have some very nasty side-effects, including memory loss. But then so can the drugs. The most common form of drug therapy involves the use of SSRIs (selective seratonin reuptake inhibitors). Many people do very well on these. They take about 10 days to kick in, but it can lift the depression dramatically. However, they too have their side-effects. They can leave people feeling very tired, screw up your metabolism, and kill your sex drive absolutely dead.

One of the most significant side-effects of many psychotheraputic drugs for people working in the creative industries is that the drugs can level you out, make you placid and happy, but leave you with an inability to think creatively at all. I cannot believe that Robin Williams did not, at some point or another, receive drug therapy for his depression and anxiety. I’m not a doctor and I’m not claiming this was the case, but it would not surprise me if – after receiving drug therapy for a while – he went off it because it interfered with this work. And perhaps his work and who he felt himself to be were, to him, inseparable.

And here we come to a very thorny place, because once you are receiving medication and you can think with clarity, why would you ever go off the drugs and risk falling back into madness? Here we are at a place of rational, ethical choice. Why would  you imperil yourself and the emotional well-being of those around you?

I can only speak to my own experience. Once I was diagnosed as bipolar, I spent seven  years on a drug called Tegretol (Carbamazepine) which was originally formulated as an anti-convulsive for the treatment of epileptic seizures. My doctor was one of the people who pioneered the use of this drug as an alternative to the more traditional treatment of lithium. The drug worked for me, but it isn’t a cure. It’s a symptom suppressor. So I also spent five years in psychotherapy, learning how to understand my illness, what might trigger it (because for me, certain types of stress and lack of sleep can act as very reliable triggers), and if it might be possible to live without the drugs. I was fortunate to have a psychiatrist who was also a psychoanalyst.

Although the drug evened out my manic phases and cushioned my depressions, it quickly became clear that it had another dire side-effect: I could not write on the drug. In fact, I found it impossible to free-associate at all. It was startling to realize that there was a certain mode of thinking that I’d indulged in all my life that was now impossible for me. For a while, I was just grateful not to feel the desire to hang myself from the clothes rail in my closet, happy not to get so manic I said things and did things I was later ashamed of. But slowly, I began to feel like part of me was completely missing: I found my own thoughts completely banal and unentertaining. All my life, I’d enjoyed my own company. I was able to amuse myself for days on end, just exploring my own thoughts, but now, it was like all I could do was record and playback.  I was terminally uncreative.

I was lucky to have a psychiatrist to took my complaints about this very seriously. I have subsequently heard from lots of people with mood disorders whose doctors waved away this concern. But mine considered this very worrisome. What I know now is that he knew that, sooner or later, my inability to be creative was going to prompt me to stop taking my meds. When we talked about it, he said… I know that, in the long term, this will become intolerable for you. Your ability to create is an essential part of who you are. If you are faced with the choice of being sane and non-creative or being crazy and productive, you will eventually choose the latter. So… So…. We must find a way to allow you to live without the drugs, but we must go very slowly, and you must learn new reflexes.  It will take time.

It took time. I have now mostly been living without medication for 17 years. There have been a few times when I could feel the onset of the mania and, as much as I wanted to enjoy it and revel in those highs, I went back on the Tegretol for short periods to stop it. Then I weaned myself off again.

I look at the state of most mental health programs in Europe and North America today and despair. There are no public health systems that would cover the 5 years of therapy 3 hours a week that I had the luxury to have. There are no social safety nets that will cover the first intensive couple of years in which I could not even work. Often doctors just put people on the meds, wave away the side-effects as irrelevant, and that’s it. You’re not suicidal, which looks good on everyone’s statistics, but you are left feeling like half of you is cut away.

This brings me back to the Henry Rollins article, and the myth of depression as a moral weakness. Because yes, it IS an illness and you don’t make conscious, rational choices when you are in the grip of it. But even when you get drugs and the drugs work, the side-effects can be such that you begin a debate with yourself as to what makes you ‘you.’

Our need to paint mental illness as a volitional act, a symptom of a lack of moral fibre or selfishness, or lack of a sense of responsibility stems, I think, from a core fear about what constitutes the self. If someone as bright and funny and creative as Robin Williams can kill himself, then what does it say about the rest of us? I’m sure he did get very competent help, and I’m sure he was given a lot of treatment options.  But if those options required him to lose the part of himself that he considered the part of him that was core to his being? How different is that from suicide?

Yes, you are still walking around, and yes, you look present. But if all the things that you believe constitute you have been taken away, perhaps you feel like the walking dead anyway?

I know I did. I chose to try to control my illness without drugs. I have not always been successful. I know there is always a tinge of madness to me. People can smell it. It scares some of them away. I need to trust that the ones who matter will judge me over time, and realize that I am mad within reasonably tolerable parameters. I have close and faithful friends who will tell me if they think I am no longer behaving within safe bounds but also realize that a life without risk is not living, it’s just practicing to be dead.

I know this post is going to affect the way you see me. That’s okay.  If you read my fiction, you’re probably going to see it in a different light for a while. That’s okay, too. My mental illness doesn’t give me any special insight but it does, I think, sometimes cause me to look at things from different angles. Either you are going to let what you now know about me erode whatever respect and confidence  you had in my work, or you won’t. You have found out who I am and what I’m made of. And now I get to find out the same about you.