Depression indicates the imperfection of love. To be loving beings, we also need to be desperate to lose what we love, and depression is the mechanism of this despair. When it comes, it leads to the destruction of our Self and ultimately to the decline of the ability to give and receive love. Depression-the embodiment of the idea that each of us is alone within ourselves-destroys not only our connection with others, but also our ability to be at peace with ourselves. Love, although it does not serve as a prevention of depression, softens the tossing of our mind and protects it from itself. Drugs and psychotherapy can restore the mechanism of this protection, making it easier to love and be loved, and this is the meaning of their use. Being in a good mood, people love: someone-themselves, someone-others, someone-work, someone-God, but any of these passionate feelings gives a person that vital sense of meaningfulness of being, which is the opposite of depression. Sometimes love goes away from us and we go away from love. In a state of depression, the meaninglessness of any undertaking and any emotion, the meaninglessness of life itself, becomes obvious. The only feeling that persists in the absence of love is the feeling of insignificance.
Life is full of sorrow. No matter what we do, we will all eventually die; each of us is confined in a solitary cell of an autonomous body; time passes, and the past will never return. Suffering is our first experience of the unwilling world, and it never leaves us. It is difficult for us when we are torn from the comfort of our mother’s womb, and when this pain subsides, physical suffering takes its place. Even those to whom their faith promises that everything will be different in the other world cannot escape the torments of this world; Christ himself is called the “Man of Sorrows”  . However, we live in a time when there are many alternatives; now, more than ever before, it is easy to decide what to feel and what not to feel. There are fewer and fewer unpleasant things in life that people who have the means to do so cannot avoid. But despite the enthusiastic claims of pharmacological science, it is impossible to completely eliminate depression as long as we remain Self-aware beings. At best, it can be suppressed; it is precisely this suppression that the modern treatment of depression is aimed at.
Politicized, narrow-minded conversations have blurred the distinction between depression and its consequences — between how you feel and how you behave under the influence of it. This is partly a social and medical phenomenon, but also the result of linguistic confusion following emotional confusion. Perhaps it is best to define depression as a mental suffering that takes hold of us against our will and then ceases to depend on external circumstances. Depression is not just a lot of suffering, but too much suffering can turn into depression. Sadness is a depression commensurate with the circumstances; depression is a sadness incommensurable with them. It is a misery like the tumbleweed grass, which feeds as it were on air alone and grows, although it is torn from the nutritious soil. It can only be described by metaphor and allegory. When St. Anthony the hermit was asked how he distinguished the angels who came to him in humble guise from the demons who appeared in splendor, he replied that you can distinguish them by what you feel after they leave. When an angel leaves you, you feel that his presence has given you strength, and when the demon leaves, you feel horror. Sadness is a humble angel, after whose departure you are left with strong, clear thoughts, with a sense of your own depth. Depression is a demon, a demon that leaves you in turmoil.
Depression is conventionally divided into small (light, or dysthymic) and large (severe). Mild depression builds up gradually and is sometimes permanent; it undermines a person as rust corrodes iron. This is too deep sadness for too small an occasion, suffering that borrows from other emotions and then represses them. The bodily abode of such depression is the eyelids and the muscles that support the spine. It affects the heart and lungs, causing the muscles that are not controlled by volitional effort to contract more than they should. Like physical pain, which turns into a chronic form, it is excruciating not so much because it is unbearable at any given moment, but rather by waiting: you have known her in the past and expect to meet her in the future. The present time of mild depression does not provide for relief, because it is like knowledge for you.
In the book “Jacob’s Room”, Virginia Woolf wrote about this state with chilling clarity: “Jacob went to the window and stood there with his hands in his pockets. Outside the window, he saw three Greeks in short tunics, the masts of ships, idle and busy commoners strolling, or walking purposefully, or gathering in groups and gesturing animatedly. They did not care about him, but it was not because of this that his dejection came, but from some deeper conviction — not that he happened to feel lonely, but that everyone is lonely.” She goes on to describe how “a strange sadness rose in her soul, as if time and eternity were shining through her skirts and waistcoats, and she saw people moving towards a tragic end. But God knows Julia isn’t such a fool.” It is this acute consciousness of transience and limitation that constitutes a mild depression. Mild depression, which for years just somehow got along with, is increasingly becoming the object of treatment as doctors try to deal with the variety of its forms.
Perhaps the present captures what is now absent, or perhaps it only becomes apparent as the factors that usually obscure the picture disappear. In any case, you become smaller than you are, and you fall into the grip of something alien. Attempts at healing too often focus on only one aspect of the problem: they focus only on the presence or only on the absence. But you still need to cut hundreds of pounds of liana, and re-learn the technique of photosynthesis and the use of the root system. Drug therapy “chews through” the invader. You feel it happening, like the medicine is poisoning the parasite, and it’s withering, withering, withering. You feel the weight falling off, and the branches manage to regain much of their natural posture. Until you get rid of the vine, it’s impossible to think about what’s lost. But even when it is destroyed, you may have too few leaves and too thin roots, and it is very difficult to rebuild yourself with the help of existing medicines. When the parasite plant’s oppression is relieved, the few leaves scattered over the tree’s skeleton begin to require serious top dressing, but this is not the most important thing. Rebuilding yourself during and after depression requires love, deep vision, hard work, and, most of all, time.
Diagnosis is as complex as the disease itself. Patients ask the doctor: “Am I depressed?” – as if they were asking about the result of a blood test. The only way to know if you are depressed is to listen and observe yourself, become aware of your feelings, and then think about them. If most of the time you feel bad for no reason — you are most likely depressed. If most of the time you feel bad for some reason, you are also depressed, but in this case, eliminating the cause may be a better way to move forward than leaving the circumstances unchanged and leading the attack on depression. If depression makes you disabled, it is a severe depression, if it only slightly bothers you, it is not severe. The psychiatrists ‘ handbook of Diagnostic and Statistical Manual, fourth edition (hereinafter referred to as DSM-IV), loosely defines depression as the presence of five or more symptoms out of the nine listed below. The problem with this definition is that it is completely arbitrary. There is no specific reason to classify the presence of five symptoms as a sign of depression, four symptoms are also considered more or less depression, and the presence of six symptoms is considered less severe than when there are seven. Even one symptom is an extremely unpleasant thing. Having all the symptoms in a mild form may be less of a problem than having two in a severe form. After being diagnosed, most people look for the cause of the disease, although knowing the cause of the disease has little effect on treatment.
The disease of the soul is a real disease and can have serious consequences for the body. People who come to the doctor with a complaint of stomach cramps often say: “Come on, you don’t have any special disorders, you’re just depressed.” Depression, if it is so severe that it can cause stomach cramps, is actually a real and very serious disorder, and it must be treated. If you go to the doctor with a complaint of shortness of breath, no one will say to you: “Oh, well, there are no violations here, you just have emphysema.” Psychosomatic ailments are as real to those who experience them as stomach cramps are to a person with food poisoning. They exist in the unconscious region of the brain, which sends distorted signals to the stomach, so they exist in the stomach. Diagnosis-determining what is wrong with you: in the stomach, or in the appendix, or in the brain; it is important for the purpose of treatment and is not easy. The brain is also a very important organ, and its dysfunction should be paid appropriate attention.
To eliminate the discord between the soul and the body, chemistry is often called upon. The relief people feel when a doctor tells them that their depression is “chemical” is based on the belief that there is an indissoluble Self that exists in time, and on the fictitious divide between causally caused melancholy and that which arose completely by accident. The word “chemical” seems to remove the sense of responsibility for the discontent brought to a stressful state, caused by the fact that people do not like their work, are afraid of approaching old age, fail in love, hate their relatives. The “chemical” is associated with a sweet sense of freedom. If your brain is prone to depression, you don’t have to blame yourself. Well, don’t blame yourself, blame evolution, but remember that guilt can also be seen as a chemical process, and that the feeling of happiness is also chemical. Chemistry and biology do not encroach on the” real ” Self; depression cannot be separated from the person who suffers from it. Treatment is not concerned with removing the stratification of your whole into its components, bringing you back to any norm; it adjusts the many components of that whole, changing just a little bit who you are.
Anyone who has studied natural sciences in school knows that human beings are made up of chemicals, and that the study of these substances and the structures they form is called biology. Everything that happens in the brain has chemical manifestations and chemical sources. If you close your eyes and start thinking intently about polar bears, it will produce a chemical effect in your brain. If you are a proponent of the policy of eliminating tax breaks on capital gains, this has a chemical effect in your brain. When you recall an episode from the past, you do it through a complex chemical process of memory. Childhood trauma and subsequent life difficulties change the chemistry of the brain. Thousands of chemical reactions occur in your brain when you decide to read this book, pick it up, look at the shape of the letters on the page, extract meaning from that shape, and react intellectually and emotionally to what they tell you. If time allows you to wait for the end of the cycle and get out of the depression, the chemical changes are no less specific and complex than those caused by antidepressants. The external determines the internal, just as the internal builds the external. This is difficult to accept: not only are all the outlines blurred, but the boundaries of what makes us ourselves are also somewhat blurry. There is no essential Self that lies as pure as a gold mine under the chaos of external perception and chemistry. Everything changes, and we must understand the organization of the human being as a sequence of multiple Selves, dissolving into each other or choosing each other. But the language of science used in the training of practitioners, as well as in scientific conversations and publications, is strangely perverted.
The cumulative results of chemical processes in the brain are not very clear. So, in the classic textbook of psychiatry Comprehensive Textbook of Psychiatry, published in 1989, we find a useful formula: the degree of depression is equivalent to the content of 3-methoxy-4-hydroxyphenylglycol (a substance found in the urine of all people and is unknown how dependent on depression) minus the content of 3-methoxy-4-hydroxymindal acid plus the content of norepinephrine minus the content of normetanephrine plus the level of metanephrine, and all this divided by the content of 3-methoxy-4-hydroxymindal acid plus undefined conversion factor; in other words, as printed in the textbook, “the degree of D-type = Q (MHPG) − C2 (VMA) + C3 (NE) − C4 (NMN + MN)/VMA + C0”. There should be a certain amount between one for patients with unipolar  depression and zero for patients with bipolar disorder, so if you get something else, you have made a mistake in the calculations. How much will this formula help you understand? How can it even be applied to such a vague thing as a state of mind? Even to determine to what extent these experiences led to a particular depressive state, and then it is difficult; moreover, we cannot say by what chemical processes a person begins to react to external circumstances with depression, and we cannot calculate what exactly makes him prone to this ailment.
Popular publications and the pharmaceutical industry talk about depression as if it were a single-effect disease, like diabetes; but this is not true. Moreover, depression is strikingly different from diabetes. In diabetics, an insufficient amount of insulin is produced, and therefore diabetes is treated by increasing and stabilizing the content of insulin in the blood. Depression is not the result of a reduced level of anything that we are able to measure today. Increasing the level of serotonin in the brain involves a process that, over time, allows many depressed people to feel better, but this is not because they have low levels of serotonin. Moreover, serotonin does not have an immediate beneficial effect. You can pump a gallon of serotonin into the brain of a depressed patient and it won’t make them feel any better, although a long-term steady increase in serotonin levels has a known effect on alleviating the symptoms of depression. To say ,” I’m depressed, but it’s just chemistry,” is the same as saying, “I’m bloodthirsty, but it’s just chemistry,” or “I’m smart, but it’s just chemistry.” If we prefer to talk in these terms, then everything in a person is” only ” chemistry. “You can say’ it’s just chemistry ‘ all you want,” says Maggie Robbins, who suffers from manic — depressive disorder, “and I say that chemistry is not ‘just’. The sun is shining, and that too is chemistry; the chemistry is that the rocks are hard, and the sea is salty, and that some spring evenings bring with their gentle breeze something that stirs the soul, a certain nostalgia, vague desires and images that have hitherto slept under the snows of a long winter. “This serotonin trick,” says David McDowell of Columbia University,”is part of modern neuromythology.” And this is a very strong system of myths.
The inner and outer realities exist in the same coordinate system. What exactly happened, and how you understand what happened, and how you react to the fact that it happened-all this is usually interrelated, but here neither is able to predict the other. If reality itself is often relative, and the personality is in a state of permanent change, then the transition from mild melancholy to extremely severe is a glissando  . Disease, consequently, is an extreme state of emotion, and it is not without reason that we can call emotion in general a mild form of the disease. If we were constantly in high spirits and feeling great (but without manic excesses), we could do much more; perhaps our time on earth would be happier, but this thought makes us uneasy and even a little creepy (however, if we were constantly in high spirits and felt great, we could safely forget about all sorts of “uneasy” and “creepy”).
With the flu, everything is simple: today you don’t have the virus that causes it in your body, but tomorrow you do. HIV is transmitted from one person to another in a certain definable fraction of a second. And depression? This is like trying to formulate clinical indications of hunger, which haunts us several times a day, but in its extreme form is a tragedy with human victims. Some people need more food, others less; some can function in conditions of severe malnutrition; others quickly weaken and faint on the street. So is depression: it affects different people in different ways — some are disposed to resist it or fight it for the entire period of the attack, others, falling into its grip, become helpless. Pride and stubbornness in one person can allow him to withstand such a depression that will bring down another, with a softer and more compliant character.
Depression interacts with our personality in different ways. Some people are courageous in the face of depression (during and after it), others are weak. Since individuality also has no clearly defined framework, and its chemistry is incomprehensible to the mind, you can write everything off as genetics, but this will also be a simplification. “There is no such thing as a mental state gene,” says Stephen Hyman, director of the National Institute of Mental Health (NIMH). — It’s just a symbol for a very complex interaction between genes and the environment.” If everyone is able to experience depression to some extent in certain circumstances, then everyone is able to deal with it to some extent in certain circumstances. Often the struggle takes the form of a search for the treatment that would be most effective against the disease: this is both seeking help while you still have the strength to do it, and the effort to live as fully as possible in the intervals between the most severe attacks. There are people with terrible symptoms who can achieve real success in life; others are destroyed by the mildest form of the disease.
There are certain benefits to going through a mild form of depression without medication. There is a feeling that you can correct your chemical imbalance by the effort of “chemical will”. Learning to walk barefoot on hot coals is also a triumph of the psyche over what seems to be the inevitable chemistry of physical pain, and an exciting way to discover the pure power of the mind. “Independent” passage through depression allows you to avoid the social discomfort associated with psychiatric drugs. This path is connected with the idea that we accept ourselves as we were created, and rebuild ourselves using only our internal mechanisms, without outside help. A gradual, step-by-step way out of a difficult situation gives meaning and significance to the disease itself.
However, it is difficult to mobilize internal mechanisms, and they are often insufficient. Depression often destroys the power of the mind over the state of mind. Sometimes the complex chemistry of longing is set in motion by the loss of a loved one, and then the chemistry of loss and love can turn on the chemistry of depression. When a person falls in love, this specific chemistry is set in motion for quite obvious external reasons, or for reasons that the heart does not inform the mind. If we had wanted to cure this madness of emotion, we might have succeeded. When teenagers hate their parents, who try their best for them, this is also madness on their part, but the madness is generally accepted, always more or less the same, and we accept it without much question. Sometimes the same chemistry is set in motion for reasons that are also external, but, according to conventional standards, are not strong enough to explain despair: you are slightly pushed in a crowded bus — and you want to cry, or you read about the overpopulation in the world — and your life becomes unbearable. Everyone has experienced disproportionate emotions on a trivial occasion, or emotions whose source is unclear, or emotions without any source at all. Often, chemistry is set in motion for no apparent external reason. Most people had moments of inexplicable despair, often in the middle of the night or in the morning, before the alarm went off. If such feelings last for ten minutes, it is a strange but brief state of mind. If they last for ten hours, it is an alarming symptom of a brain disorder, and if they last for ten years, it is a devastating disease.
The state of happiness is often-too often! – it is accompanied by a sense of its fragility, whereas depression, when you enter it, seems to be a state that will never end. Even knowing that the mood can change and that no matter what you feel today, tomorrow everything will be different-you can not give yourself to joy as you give yourself to sadness. Sadness for me has always been and still is a stronger feeling; it may not be the case for everyone, but it is probably the soil on which depression grows. I hate being depressed, but it was in this state that I learned how much space I had, what the scope of my soul was… When I am happy, this state confuses me, as if it does not use some part of my soul and brain that needs exercise. Depression requires action. Possession becomes stronger and feels sharper in the moment of loss: I see the full beauty of the glass vase the moment it slips out of my hands and falls to the floor. “We find pleasure much less pleasant, and suffering much more painful, than we expected,” wrote Schopenhauer. — We constantly need a certain amount of care, or sadness, or need, just as a ship needs ballast to keep on a straight course.”
The Russians have this expression: if you wake up and you don’t have any pain, know that you are already dead. Let there be not only suffering in life, but the feeling of suffering, which stands out from all sensations by its intensity — is one of the most unmistakable signs of the presence of the vital force. Schopenhauer said: “Imagine this family moved to a certain Utopia, where everything grows by itself, and fried turkeys fly around, where people find their loved ones without the slightest expenditure of time and keep them without any difficulty: in such a place people will die of boredom or hang themselves, and some will start fighting and killing each other and so will create more trouble for themselves than those that nature has already given them … the polar opposite of suffering is boredom.” I believe that suffering should be transformed, but not forgotten; denied, but not banished.
I’ve been convinced that some of the most generalizing figures about depression are based on reality. Although it would be a mistake to confuse the numbers with the truth, but they tell about frightening things. According to a recent study, about 3 % of Americans — about 19 million-suffer from chronic depression. More than 2 million of them are children. Manic-depressive psychosis, often called bipolar disorder because the mental state of its victims varies from mania to depression, affects about 2.3 million and is the second leading cause of death in young women and the third in young men. Depression, according to the DSM-IV, is the leading disability factor in the United States and globally among people over the age of five. Around the world, including in developing countries, depression causes more damage than all other diseases other than cardiovascular diseases-if you count premature death, coupled with years of life spent on disability. Depression accounts for more lost years than war, cancer, and AIDS combined. Many diseases, from alcoholism to heart attack, mask depression when it leads to them; if you take this into account, it may turn out that depression is the world’s worst killer.
Now there are ways to treat depression, but only half of Americans who have ever suffered from a severe form of it have sought any kind of help — even from a priest or a consultant doctor. About 95 % of those 50% go to their regular doctors, who know little about mental illness. In the average American adult suffering from depression, the disease will be recognized in about 40 % of cases. At the same time, about 28% of Americans regularly take SSRI (selective serotonin reuptake inhibitors, the type of drug to which prozac belongs) and many other medications. Less than half of the diagnosed patients will receive adequate treatment. As the definition of depression is constantly expanding to include more and more people, it is becoming increasingly difficult to calculate accurate death rates. Traditional statistics say that 15 % of depressed people eventually commit suicide; the same figure is true for people with an extreme form of the disease. Recent studies that have also studied milder forms of depression show that 2% to 4% of people who suffer from this disease will commit suicide directly as a result of the disease. These are also terrible numbers. Twenty years ago, about 1.5 % of the population suffered from depression requiring treatment; now it is 5 %, and another 10 % of all living Americans can expect to have a serious episode of depressive disorder during their lifetime. About 50 % of them will experience depression syndromes. The number of clinical problems has increased; there are many more ways to treat them. Diagnostics become more accurate, more cases are recognized, but the scope of the problem is not explained by this. Cases of depression are increasing in developed countries, particularly among children. Depression affects young people, making its first visit (on average) about twenty-six years — ten years earlier than in the previous generation; bipolar disorder, or manic-depressive psychosis, manifests even earlier. Things are getting worse and worse.
There are few painful conditions that are treated so insufficiently and at the same time so excessively as depression. People who become completely non-functional end up being hospitalized and are more likely to be treated, although sometimes their depression is confused with the physical illness through which it is felt. At the same time, the world is full of people who can barely hold on and, despite the great revolutions in psychiatry and psychopharmacology, continue to live in terrible torment. More than half of those seeking help — another 25 % of those suffering from depression-do not receive any treatment. About half of those who receive — about 13% of depressed patients-receive the wrong treatment; often it is tranquilizers or inappropriate psychotherapy. Half of the remaining patients — about 6% of patients with depression-receive inadequate doses for an inadequate time. So, that leaves about 6 % — those who receive adequate treatment. But many of them often stop taking their medications, usually due to side effects. “About 1% to 3% receive optimal treatment,” says John Greden, director of the Institute for Psychiatric Research at the University of Michigan,”and this is in the case of a disease that can be well controlled with relatively inexpensive medications with few serious side effects.” Meanwhile, at the other end of the spectrum, there are people who believe that a blissful life is their birthright, and therefore swallow strings of pills in a vain effort to eliminate any slight discomfort from which any life is woven.
It is now well known that the emergence of the top model phenomenon has damaged women’s perception of themselves, as it has set unrealistically high standards. The psychological top model of the XXI century is even more dangerous than the physical one. People relentlessly analyze their psyche and deny their mental states. “This is the Lourdes phenomenon,” says William Potter, who headed the National Institute of Mental Health’s psychopharmacology department during the 1970s and ‘ 80s, when new drugs were being developed. — When you show a large number of people something that they have reason to believe works positively, you get stories of miracles — and, of course, tragedies.” Prozac is treated with such easy tolerance that almost everyone can take it,and almost everyone does. It is given to people with mild malaise, who do not need to be subjected to the discomfort of older antidepressants — monoamine oxidase inhibitors or tricyclics. Even if you’re not depressed yet, it can narrow the boundaries of your longing — anything is better than living and suffering, eh?
We pathologize the curable, and conditions that can be easily modified are treated as diseases, even if they were previously considered a character trait or mood. Once we have a cure for violence, violence becomes a disease. There are many “gray” states between the blackness of full-blown depression and the whiteness of mild pain, accompanied by disturbances of sleep, appetite, energy, or interest; we have begun to classify an increasing number of such states as diseases, because we are finding new ways to correct them. But the critical point remains arbitrary. We decided that an intelligence quotient (IQ) of 69 means mental disability, but it happens that a person with an IQ of 72 is in particularly good shape, whereas at 65 someone can be more or less controlled; we announced that you should keep your cholesterol at no higher than 220, but if you have it at 221, you probably won’t die from it, and if 219, you need to take care of yourself. Here, 69 and 220 are arbitrary numbers, and what we call illness is actually quite arbitrary, too; and in the case of depression, it is also constantly changing.
Depressive people constantly use the expression “over the edge”, indicating the transition from pain to insanity. This is a very specific image, meaning “falling into the abyss”. Isn’t it strange that so many people use a homogeneous vocabulary — after all, “edge” is quite an abstract metaphor. Few of us have ever fallen off the edge of anything, and certainly not into the abyss. The Grand Canyon? Norwegian fjord? South African diamond mines? It’s hard for us to even find a chasm to fall into. As a rule, in conversation, people describe the gap uniformly. First of all, it is dark. You fall out of the sunlight and fly towards a place where the shadows are black. There, inside, nothing is visible and dangers await from all sides (there is no soft bottom or soft walls in this abyss). While you’re falling, you don’t know how deep you’ll reach or if you’ll be able to stop. You hit invisible objects again and again, already bruised, but as long as the movement continues, you can’t catch on to anything.
Fear of heights is the most common phobia in the world. Apparently, it served our ancestors well, because those who were not afraid, probably found their abyss and fell into it, thereby ridding the human race of their genetic material. Standing on the edge of the cliff and looking down, you feel dizzy. Your body doesn’t start working any better than it always does to allow you to move away from the edge with perfect precision. You think you’re going to fall, and if you look long enough, you might actually fall. You’re paralyzed. I remember going with my friends to Victoria Falls, where a huge sheer cliff falls into the Zambezi River. We were young, and we teased each other a little, posing for photos as close to the edge as we dared. Each of us, approaching the cliff, felt sick and paralyzing powerlessness. In my opinion, depression is not actually falling over the edge (people die very quickly from this), but an excessive approach to the edge, to the moment of fear when you have crossed the line and dizziness has already deprived you of the ability to maintain balance. At Victoria Falls, we found out that an unapproachable point is an invisible edge that lies at a decent distance from where the rock actually breaks off. Three meters from the cliff, we all felt great. Within a meter and a half, most of us were passing. At some point, a friend who was photographing me wanted to capture the bridge to Zambia in the frame.
— Can you move a little to the left?” — she asked, and I obediently moved to the left-about 30 centimeters. I was smiling — a nice smile, it was preserved in the photo, and she said:
“You’re too close to the edge.” Let’s go back.
Standing there, I felt absolutely comfortable, but then I looked down: I saw that I had crossed my line. The blood drained from my face.
“It’s all right,” the girl said, coming closer and holding out her hand. The smooth drop was a quarter of a meter away, but I had to get down on my knees, then lie flat on the ground and crawl a meter or two until I felt solid ground again. I know that I have an adequate sense of balance, and I can stand quite easily on a 40-centimeter platform; I even know how to tap dance, and quite confidently, without falling. And I couldn’t stand at the same distance from the Zambezi.
Depression relies on a paralyzing sense of imminent danger. What you can safely do at a height of fifteen centimeters, you are not able to do when the ground below you descends, opening a cliff of three hundred meters. The dread of falling squeezes you, even if that dread is the very thing that will make you fall. What happens to you during depression is terrible, it feels like everything is wrapped up in what is about to happen to you. Among other things, you feel like you’re about to die. To die would be all very well, but to live on the verge of dying, in a state not yet quite beyond the physical edge, is absolutely terrible. During severe depression, the hands outstretched to you are out of your reach. You can’t get down on all fours because you feel: as soon as you lean, even in the opposite direction from the cliff, you will immediately lose your balance and fall. Oh, yes, the image of the abyss is quite accurate: the darkness, the sense of danger, the loss of control. But if you imagine that you are really falling into a bottomless abyss, then you can not talk about control. An endless fall and a complete lack of self-control. That’s where you get this terrifying feeling that you’re out of control at the exact moment when you need it most and you’re entitled to it. The inevitability of the impending horror completely takes over the present moment. When you can no longer keep your balance, despite the wide safety zone, the disease has gone too far. In depression, everything that happens in the present moment is a foretaste of suffering in the future, and the present itself no longer exists.
Depression is a condition that is almost impossible to imagine for someone who did not know it. The only way to talk about the experience of her experience is through metaphors: creepers, trees, cliffs, etc. It is not easy to diagnose it, because you have to rely on metaphors, and the metaphors chosen by one patient are different from those preferred by another. Little has changed since Antonio of the Merchant of Venice complained:
It’s a burden to me; I hear you are too.
But where did I catch sadness, find it, or get it, what makes it, what gives birth to it, —
I’d like to know!
My senseless sadness is my fault,
That it is difficult for me to understand myself.
Let’s face it: we don’t really know what causes depression. We don’t really know what constitutes depression. In fact, we do not know why certain remedies are effective against depression. We don’t know how depression made its way through the evolutionary process. We do not know why one person becomes depressed under circumstances that do not concern the other in the least. We do not know how our will works in this context.
People around us expect people who are depressed to pull themselves together: there is no place for moping in our society. Spouses, parents, and children are dragged into the abyss with them — and they do not want to be near immeasurable suffering. From the abyss of deep depression, no one can do anything, except ask for help (and then not always), but when help is given, you still need to be able to accept it. We’d like prozac to help us, but in my experience, prozac can’t do it on his own if we don’t help him. Listen to those who love you. Believe that they are worth living for, even if you don’t believe it. Look for the memories that depression takes away from you and project them into the future. Be fearless; be strong, take your pills. Do exercise because it’s healthy, even if each step weighs a ton. Eat, even if you are sick of food. Reason with yourself, even if you have lost the ability to reason. These admonitions, like notes taken out of a Christmas fortune cookie, sound standard, but the surest way to get out of a depression is not to love it and not to allow yourself to get used to it. Block out the terrible thoughts that invade your mind.
It’s been many years since I started treatment for depression. I wish I knew how it happened. I have no idea how I fell so low, and I know very little about how I got out and fell again, and again, and again… I fought the presence of the invader — the creeper-by all the conventional means I could find, and then figured out how to correct my own absence – as diligently, but also intuitively, as I had once learned to walk and talk. I had many mild episodes of depression, then two serious ones, then a break, then a third breakdown , then a few more relapses. Now I’m doing everything I have to do to avoid new shocks. Every morning and every evening I look at the pills in my palm: white, pink, red, turquoise. Sometimes they look like inscriptions on my hand, hieroglyphic prophecies that everything may be all right for me in the future and that my duty to myself is to live and see. Sometimes I feel like I’m swallowing my own funeral twice a day, because without those pills, I wouldn’t be here anymore. When I’m not away, I see a therapist twice a week. Sometimes our sessions are boring, sometimes I want something different that has nothing to do with it, and sometimes I have a sense of epiphany. Thanks in part to what the man had told me, I had rebuilt myself enough to be able to “swallow” my own funerals rather than put them into practice. There was a lot of talk; I believe that words are strong and can overcome fear when the aversion to it is stronger than the feeling that life is good. With more and more refined attention, I turned to love. Love is another way forward. They must advance together: the pills themselves are poison, but weak, love itself is a knife, but dull, knowledge itself is a rope that only tightens when pulled too hard. With the whole set, if you are lucky, you will be able to save your tree from the creeper.
I love my age. Of course, I would very much like to be able to travel in time: I would enjoy visiting biblical Egypt, Renaissance Italy, Elizabethan England, seeing the heyday of the Incas, meeting the inhabitants of Greater Zimbabwe, seeing what America was like when it was owned by the indigenous people. But I would not have preferred any other time to my own. I love modern comfort. I love the complexity of our philosophy. I love the sense of constant change that accompanies us in this new millennium, the sense that we are the possessors of knowledge such as humanity has never had before. I like the relatively high level of social tolerance in the country where I live. I love the opportunity to travel around the world again and again and again. I like that people are living longer than ever before, that time is on our side when compared to a thousand years ago.
However, we are facing an unprecedented crisis in our physical environment. We consume the fruits of the earth with terrifying rapidity, causing terrible harm on land, at sea, and in the air. Rainforests are being destroyed; oceans are overflowing with industrial waste; the ozone layer is thinning. There are more people in the world than ever before, and next year there will be more, and then more. We are creating problems that will beset the next generation, and the next, and the next. Man has been transforming the earth ever since he carved the first knife out of stone, when the Anatolian farmer threw the first grain into the ground, but now the speed of change is getting out of control. I am convinced that we must take steps to change our current course if we do not want to lead our ship into oblivion.
We are looking for new solutions to problems, and this is a sign of the flexibility of the human race. The world goes on, and so does our species. Skin cancer is much more common than it used to be, because the atmosphere protects us much less from the sun. In the summer, I use creams and lotions with a high sun protection level, and I feel safer with them. From time to time, I go to a dermatologist, and one day he took a section from my overgrown freckle and sent it for analysis. Children who used to run around the beach naked are now smeared with a thick layer of protective cream. Men who used to work naked to the waist in the midday heat now wear shirts and try to work in the shade. This is the side of our crisis that we are learning to deal with. We are inventing new defenses that are very far from living in the dark. But other than that, we must try not to destroy what’s left. There’s still a lot of ozone up there right now, and it’s doing its job pretty well so far. It would be good for the environment if everyone stopped using cars, but that won’t happen unless we are hit by a massive tidal wave of the ultimate crisis. I honestly believe that people would rather live on the moon than have a society without motor transport. Radical changes are impossible and in many ways undesirable, but they are certainly necessary.
It seems that depression has existed since a person developed the ability to think self-consciously. Or maybe it existed even earlier, and monkeys, and rats, and even, probably, octopuses suffered from it even before the two-legged humanoids entered their caves. The symptomatology of our time is more or less indistinguishable from what Hippocrates described two and a half thousand years ago. Neither depression nor skin cancer are products of the twenty-first century. Like skin cancer, depression is a bodily ailment that has grown in recent times for very specific reasons. Let’s not stand still for too long and ignore the clear signs of growing problems. Much of what we are vulnerable to now would have gone unnoticed in previous eras, but now it is blooming like a full-blown clinical disease. We must not only find timely solutions to current problems, but also strive to keep these problems within bounds and not let them steal our minds. The increase in the incidence of depression is certainly a consequence of the modern lifestyle. The pace of life, the technological chaos, the alienation of people from each other, the breakdown of traditional family structures, the loneliness of epidemic proportions, the collapse of belief systems (religious, moral, political, social — everything that gave life meaning and direction) took on the character of a catastrophe. Fortunately, we have the means to deal with the problems. We have medicines aimed at combating organic disorders, and therapeutic methods aimed at supporting people with chronic emotional disorders. Depression is costing our society more and more, but it is not ruinous. We have the psychological equivalents of sunscreens, peaked caps, and shades.
But do we have the equivalent of an environmental movement, a system to contain the harm we do to the social ozone layer? The fact that we know how to treat should not be a reason for us to ignore the problem that we are able to solve. We should be horrified by the available statistics. What to do? Sometimes it seems that the level of morbidity and the number of cures seem to compete with each other — who will overtake whom. Few of us are willing or able to abandon the modern way of thinking, as well as the modern way of material existence. But we must start doing at least a little right now to reduce the level of contamination of the social and emotional environment. We must look for faith (in anything-in God, in ourselves, in other people, in politics, in the beautiful, in almost everything that exists) and build a structure of help. We must help the socially excluded, whose sufferings so detract from the joys of the world, both for the sake of the crowded masses, and for the sake of the privileged, but deprived of the deep motivations of their lives. We must practice active love, and we must teach it. We must change for the better the circumstances that lead to appalling levels of stress. We must speak out against violence and, perhaps, against its demonstration. This is not a sentimental wish; it is as relevant as the cries for saving the rainforest.
At some point, which we haven’t reached yet, but I think we will soon, the level of damage will exceed the progress that we are paying for with this damage. There will be no revolution, but there will probably be different types of schools, different models of family and society, different processes of information transmission. If we’re going to stay on the ground, we’re going to have to work hard. We will learn to link the treatment of the disease with the change in the circumstances that cause it. We will strive as much for prevention as for treatment. As we grow up in the new millennium, we will hopefully save the rainforests, the ozone layer, the rivers, streams, and oceans of this earth; in addition, I am sure that we will save the minds and hearts of the people who live on it. Then we will curb our growing fear of the ” demons of the afternoon “ – anxiety and depression.
The people of Cambodia are living in a tragedy unprecedented in history. In the 1970s, revolutionary Pol Pot established a Maoist dictatorship in Cambodia in the name of what he called the Khmer Rouge. During the years of the civil war that followed, 20% of the country’s population was destroyed. The educated elite was slaughtered, the peasants were systematically driven from place to place, many were thrown into prisons where they were bullied; the whole country lived in constant fear. Wars are hard to rank — the recent atrocities in Rwanda were particularly violent — but the Pol Pot era was as horrific as any period of modern history anywhere in the world. What happens to your emotional life when you have seen a quarter of your fellow countrymen killed, or have experienced the horrors of a brutal regime yourself, or when you work against hopelessness to rebuild a devastated country? I wanted to see what happens to the feelings of the citizens of the country who have experienced terrible stress with it, who live in desperate need, who have almost no resources and no chance of getting an education or a job. I could have chosen another country where people are suffering, but I didn’t want to go to a place where there is a war, because the psychology of wartime despair is usually violent; the despair that comes with devastation is more blunt and all-encompassing. Cambodia is not a country where one group of the population brutally fought with another; this is a country where everyone was at war with everyone, where all the mechanisms of society were completely destroyed,where no one had any love and ideals left.
Cambodians are generally friendly and extremely friendly to visiting foreigners. Most of them are quiet, gentle and friendly people. It is hard to believe that such a glorious country is the place where Pol Pot committed his outrages. Everyone I met had their own explanation for how the Khmer Rouge could have come about, but none of them makes sense, any more than the explanations of the Cultural Revolution, Stalinism, and Nazism make sense. This happens to a country, and in hindsight, you can understand why this people was exposed to this; but in what region of the human imagination lie the sources of such a course of action is unknowable. The social fabric is always very thin, but why it is thinned to dust, as happened in these societies, it is impossible to know. The American Ambassador to Cambodia told me that the biggest problem of the Khmer people is that traditional Cambodian society does not know the peaceful mechanisms of conflict resolution. “If they have disagreements,” he said, ” they must completely deny them or suppress them, otherwise they will have to take out their daggers and fight.” One member of the current Cambodian Government explained that the people had been subservient to the absolute monarch for too long and had not decided to fight against the authorities until it was too late. I’ve listened to at least a dozen other stories, and I’m skeptical of all of them.
Speaking to people who have suffered from the atrocities of the Khmer Rouge, I noticed that most of them prefer to look to the future. When I insisted on hearing a personal story, they involuntarily switched to the mournful verbs of the past tense. What I heard was inhumane, horrifying, disgusting. Every adult I have met in Cambodia has experienced traumatic experiences that would have led any of us to insanity or suicide. In the back of their minds, what they had experienced represented another level of nightmare. I was traveling to Cambodia to experience humility in the face of other people’s suffering; I was humbled to the ground.
Five days before leaving the country, I met with Fali Nuon, who was once a Nobel Prize candidate; she had set up a children’s shelter and a center for desperate women in Phnom Penh. She decided to try to return to normal life women with such mental disorders that other doctors refused them, believing that they could not be resurrected. Fali Nuon has achieved great success: her orphanage employs almost exclusively women, whom she has helped and who have formed a kind of relief society around her. They say that if you save the women, they, in turn, will save the children, and so the chain will save the country.
We met in a small room in an old office building near the center of Phnom Penh. She was sitting in a chair against the wall, and I was sitting on the couch across from her. Fali Nuon’s asymmetrical eyes seem to see right through you and at the same time welcome you. Like most Cambodians, she is too small by Western standards. Her graying hair is slicked back from her face, giving it a hard edge. She may be insistent when pursuing a thought, but she is mostly shy and smiling, and when she is silent, she lowers her eyes.
We started with her own story. In the early 70s, Fali Nuon worked as a stenographer in the Cambodian Ministry of Finance and in the Chamber of Commerce. In 1975, when Pol Pot and the Khmer Rouge captured Phnom Penh, she was arrested at home with her husband and children. Her husband had been sent away somewhere, and she had no idea whether he had been executed or left alive. She and her twelve-year-old daughter, three-year-old son, and newborn baby were sent to the village to do field work. The conditions were terrible, there was barely enough food, but she worked like everyone else, “saying nothing to anyone, never smiling, because we knew that at any moment we could be sent to our deaths.” A few months later, she and her children were sent to another place. At the stage, she was tied to a tree and her daughter was raped and killed right in front of her eyes. A few days later, it was Fali Nuon’s turn. Together with several other employees, she was brought out of town. Her hands were tied behind her back and her legs were tied together. They forced her to kneel, tied her to a bamboo trunk, and began to bend her to the sodden ground, so that she had to strain her legs to keep her balance. The plan was that she would lose her strength and fall face-first into the liquid mud, unable to move, choking on it. Her three-year-old son screamed and cried beside her. He was tied to her so that if she fell, he would drown too — Fali Nuon would be the murderer of his own child.
Fali Nuon lied. She said that she had worked for a senior member of the Khmer Rouge Party before the war and had been his mistress; he would be very angry if she was killed. Few people ever escaped the deadly fields alive, but the captain, who might have believed her story, finally said that he could no longer bear the screams of her children, and that it would be too wasteful to waste a bullet on her; he untied Fali Nuon and ordered her to run. With a baby on one arm and a three-year-old on the other, she took refuge in the jungles of northeastern Cambodia. There she spent three years, four months, and eighteen days. She never spent the night in the same place. While wandering, the woman gathered leaves and dug roots to feed herself and her children, but even those were few, and often other, stronger foragers ravaged the forests before her. She began to wither from terrible malnutrition. She soon ran out of milk, and the baby, which she could not feed, died in her arms. With the remaining child, she somehow clung to life, lasted until the end of the war.
When she got to this point in her story, we were sitting side by side on the floor; Fali Nuon was crying and rocking back and forth on her haunches, and I was sitting with my knees drawn up to my chin, my hands on her shoulders-something as close to an embrace as her trance — like state would allow throughout the story. She lowered her voice to a whisper. When the war ended, she found her husband. He was severely beaten on the head and neck, causing him to become mentally disabled. She and her husband and son were placed in a camp near the border with Thailand, where thousands of people lived in temporary tent structures. Some camp workers subjected them to physical and sexual abuse, while others helped them survive. Fali Nuon was one of the few educated people in the camp; she could speak the languages and speak to the aid workers. She began to play an important role in camp life, and she and her family were given a wooden hut, which was considered a luxury by camp standards. “I was helping humanitarian workers at the time,” she recalls. — Everywhere I went, I saw women in a terrible state, many of them seemingly paralyzed, unable to move, unable to speak, unable to feed or care for their children. I saw that, having survived the war, they could now die from depression, from completely debilitating post-traumatic stress.” Fali Nuon made a request to the aid workers, and they set up a hut for her in the camp, a kind of psychotherapy center.
To begin with, she used traditional Khmer medicine (consisting of a diverse combination of more than a hundred herbs). If it didn’t help, or if it didn’t help enough, she used Western medicine if it was available, and sometimes it was. “I stashed away any antidepressants that the aid workers brought,” says Fali Nuon, ” so that I could have them in reserve for the most severe cases.” She brought her patients to her home for meditation sessions, where she set up a Buddhist altar with flowers. She gradually led the women to open up to her. At first, she spent three hours with each of them, so that they would tell her their story. After that, she visited each one regularly, trying to learn more, until she gained the full confidence of the desperate women. “I needed to know their stories,” she explains, ” to understand very specifically what each one had to overcome.”
After going through this initiation with them, Fali Nuon would proceed to the established procedure. “It’s done in three stages —” she says. — I teach them to forget first. We have exercises for every day, so that every day they can forget a little of what they will never completely forget. At this time, I try to distract them with music, embroidery or knitting, concerts, sometimes TV-anything that can work and that they like. Depression is all over the body, it sits right under the skin, and we can’t just take it out and pull it out. But we can try to forget it, even though it remains there.
When their soul is freed from what they forget, when they learn to forget well, I teach them to work. Whatever work they want to do, I’ll always find a way to teach them. Some of them can only learn how to clean the house or babysit. Others learn skills that can be used in working with orphans, and some begin to move towards a real profession. They should learn to do it well and be proud of it.
And finally, when they master the work, I teach them to love. I made an extension to my hut and built a steam bath there, and I have one in Phnom Penh now, only better built. I take them there to get them used to physical cleanliness, I teach them to give each other manicures and pedicures, because it makes them feel beautiful, and they need to be beautiful! This, in addition, brings them into contact with the bodies of others, forces them to leave their body to someone else’s care. This brings them out of physical isolation, which is usually perceived painfully, contributing to the release of emotional isolation. By washing and painting their nails together, they begin to talk, and little by little they learn to trust each other, and then they become friends, so that they no longer have to pine alone. And then they begin to tell their stories, which they have never told to anyone but me, to each other.”
Later, Fali Nuon showed me her professional tools as a psychologist: bottles of colorful nail polish, a steam room, manicure supplies, towels. Mutual grooming is one of the primary forms of socialization in primates, and this return to mutual grooming as a socializing factor in the human environment struck me as unusually organic. I told her that I found it very difficult to teach myself or another person to forget, to work, to love, and to be loved. But she said that if you can do these three things yourself, it’s not so difficult to teach someone else. She told me how the women she had healed had formed a community and how well they were doing in caring for the orphans.
“There is one last step, — she said after a long pause. — At the end, I teach them the most important things. I teach them that these three skills — forgetting, working, and loving-are not three different skills, but parts of a huge whole, and that everything depends on using all three together, each as part of the others. It’s the hardest thing to explain — “she laughed —” but they all understand, and then, well, then they’re ready to go back to the world.”
Depression exists today as a personal and social phenomenon. To treat it, a person must understand what happens during a breakdown, how medications work, and how the most common forms of psychotherapy (psychoanalytic, personality-oriented, and cognitive) work. Experience is a good teacher, and the methods of conventional treatment have already been tried and tested by experience; but many other methods promise good prospects-from the treatment of St. John’s wort to psychosurgery  , although there is more quackery here than in any other field of medicine. Reasonable treatment requires intensive study of specific segments of the population: the variants of depression differ markedly in children, the elderly, and representatives of different genders. Abusers of known substances make up a separate large subcategory. Suicide in all its various forms is a complication of depression; it is vital to understand how depression can lead to death.Fali Nuon lied. She said that she had worked for a senior member of the Khmer Rouge Party before the war and had been his mistress; he would be very angry if she was killed. Few people ever escaped the deadly fields alive, but the captain, who might have believed her story, finally said that he could no longer bear the screams of her children, and that it would be too wasteful to waste a bullet on her; he untied Fali Nuon and ordered her to run. With a baby on one arm and a three-year-old on the other, she took refuge in the jungles of northeastern Cambodia. There she spent three years, four months, and eighteen days. She never spent the night in the same place. While wandering, the woman gathered leaves and dug roots to feed herself and her children, but even those were few, and often other, stronger foragers ravaged the forests before her. She began to wither from terrible malnutrition. She soon ran out of milk, and the baby, which she could not feed, died in her arms. With the remaining child, she somehow clung to life, lasted until the end of the war.
These empirical questions lead us to epidemiological questions. It is fashionable to view depression as a modern disease, but this is a gross mistake, which becomes clear when studying the history of psychiatry. It is also fashionable to consider it as the prerogative of the middle class, rather homogeneous in its manifestations. This is also not true. When we study depression among the poor, we see how a variety of taboos and prejudices prevent us from helping the part of the population that is particularly responsive to this help. The problem of depression among the poor naturally leads to political problems. We legally recognize the existence or non-existence of various ideas about what a disease and treatment are.
Biology can’t be considered fate — we have ways to have a good life in the presence of depression. Moreover, people who learn from their depression can develop a special moral depth based on this experience, and this is the winged one that hides at the bottom of their box of misfortunes. There is a certain basic spectrum of emotions that we cannot and should not run away from, and I believe that depression is located within this spectrum, somewhere near not only sadness, but also love. Moreover, I am sure that all strong emotions stand side by side and that each of them is inseparable from the one that we usually consider its opposite. I have now learned to avoid the disability caused by depression, but depression itself is forever written into the code of my brain — it has become a part of me. To declare war on depression is to fight against yourself, and it is very important to know this before starting the battle. I believe that the only way to completely destroy depression is to undermine the emotional mechanisms that make us human. Science and philosophy must make do with half measures.
“Accept this suffering —” Ovid once wrote,”for you will learn from it.” It is possible (though not yet likely) that we can use chemical manipulation to localize, control, and eliminate the “electronic circuitry” of the brain responsible for suffering. I hope this never happens. To take this away from us would be to trivialize our experience of life, to encroach on a structure whose value far exceeds the torment that is its component parts. If I could see the world in nine dimensions, I would be willing to give a lot for it. But I would rather live forever in a fog of longing than give up the ability to suffer. Suffering in itself cannot be called acute depression: we love and are loved through great suffering, and we are alive to the experience of it. What I really want to banish from my life is the state of walking death into which depression plunges, and this book is intended to serve as a weapon against such dying.