Andrew Solomon Interview, plus links to author biography, book summaries, excerpts and reviews

An interview with Andrew Solomon

An in-depth interview with Andrew Solomon as he shares his insights on the many facets of depression.

An interview with Andrew Solomon, author of The Noonday Demon: An Atlas of Depression

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 him.

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 knowledge.

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 depression.

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 across history.

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.