For decades, the critic George Scialabba has suffered from severe clinical depression. The pain this causes, he writes in How to Be Depressed, is “the worst thing in the world.” How to convey that feeling? How to show the people positioned to help just how acute that feeling is, in the hope that something better might be done about it? Scialabba rejected writing a memoir, partly because he feels he can’t compete with the existing literature: William Styron’s Darkness Visible, Kay Jamison’s The Loony-Bin Trip, William James’ Varieties of Religious Experience. Nor is a feat of research like Andrew Solomon’s The Noonday Demon a good fit for him: Scialabba is a talented synthesist, but not a historian or investigative journalist. What he’s chosen instead is to share his treatment notes, and it’s an effective strategy even if it’s heart-sinking to read — it at once reveals the depths of his illness and the inadequacy of institutions to fully address it.
“Our distractable human intelligence needs as many ways of talking about depression as can be provided — that’s all my motivation in publishing them,” he writes. Although they lack much in the way of poignancy, who’s to say poignancy has done much good? The notes Scialabba shares run from 1969 to 2016, and the three and a half decades covered show his psychiatrists working with a stubbornly difficult case. Scialabba graduated from Harvard with ambitions to attend graduate school to study history, but struggled with depression that ensued after he made a break with the Catholic group Opus Dei. He found no stabilizing ideology to replace the one that he’d abandoned, and in the ensuing years he’s veered from, at best, a grudging acknowledgment of his capabilities as a writer and partner to debilitating despair requiring hospitalization. Antidepressants are prescribed, tweaked, abandoned, and replaced. By 2005 he was undergoing electroconvulsive therapy.
His doctors’ notes are clarifying in some ways because they are literally clinical — they track his shifting treatments and volatile moods with a steady dispassion. (Although, as Scialabba writes, the notes become less detailed over time as doctors become more mindful of liability issues.) There are attempts to grasp his complicated psyche: “He felt that to pay attention to his emotions was a sign of weakness and lack of intellectual integrity,” one doctor writes in 1969; “His superego development is extremely harsh and punitive, and he has never adequately formed an identity he can feel comfortable with,” writes another in 1988. But more often the notes are catalogs of small successes and setbacks (a book-review assignment received, a submission rejected), and larger ones (a sustained relationship, loss of vision, requests to be admitted, an anxious release back into the world). None of the interventions seem to quite be up to the job — or, at best, only keep him from slipping back too badly. In the later pages the notes read almost like everyone has thrown up their hands. 2005: “Patient will add walking to his schedule.”
The silver lining is that Scialabba has never felt suicidal in the midst of his persistent despair, and his output as a critic is a tribute to his intellectual tenacity. His willingness to request and contemplate these notes is itself a tribute to that. (I get queasy at the thought of requesting my own therapists’ notes for my much more modest experiences with depression.) This allows him a thoughtful perspective on his predicament, though of course not a clinical distance. In a Q&A with journalist Christopher Lydon that appends the book, Scialabba sees psychiatry as it’s currently practiced as often at odds with patient needs. “Success” for a patient means managing a complicated mix of intellect and emotion, but the medical system wants clear results. “The definition of everything, including success in treatment, has been conditioned by the requirements of insurance companies and hospital administrators,” he explains. “How do you quantify a long conversation in which a patient gradually sees the outlines of his or her life emerging? That may be healing, but if you can’t measure it, you can’t expect to get paid for it.”
None of which, of course, is meant to dissuade people from getting help if they need it, or to pursue pharmaceutical options if they do some good. Scialabba’s frustration stems not from treatment but its imprecision, and the greed that often exploits it. “It is still far from clear that antidepressant drugs are any more effective than placebo,” he writes. “The only group of people who have demonstrably benefited from the widespread use of antidepressants are pharmaceutical executives and investors.”
To that end, the “Tips for the Depressed” that he includes at the book’s close are skeptical about the medical-industrial complex but deeply sympathetic to the everyday suffering that depressed people face. He offers gentle encouragements to get out of bed, which can “break some deadly mental circuit. Try.” Water is good; food is good; friends and loved ones are good; a little exercise and meditation helps. Scialabba’s kindness is all the stronger for being shorn of false optimism. What he wants for us is not the sunlit sparkle of antidepressant ads on TV but that you “become yourself again, release into blessed everyday unhappiness.”
Not every reader will take to Scialabba’s particular brand of stoicism. In the Lydon interview, he explains that the closest thing he has to a replacement to his lost Catholicism is D.H. Lawrence’s paganism, which asks us to look for meaning apart from dogma or earthly needs. Scialabba’s source of comfort — a recognition that we are all spiritual creatures, adrift and seeking — may scarcely look different from the source of his troubles. But it has the virtue of not delivering false promises, and suggests we have good reasons not to give in. Both are balms when dealing with the worst thing in the world.
[Published by University of Pennsylvania Press on March 13, 2020, 160 pp., $27.50 hardcover]