My Generation (23 page)

[
Sewanee Review
, Summer 1997.]

W
hy did the eminent Italian writer Primo Levi die in the shocking way he did?

In the depths of a clinical depression, Mr. Levi, an Auschwitz survivor who had written eloquently of his ordeal under the Nazis, jumped down a stairwell in Turin in 1987.

The question appeared to haunt—indeed, nearly dominate—a recent symposium held at New York University and dedicated to Mr. Levi and his work, according to an article in
The New York Times
.
¹
Some participants reacted with simple incredulity.

Alfred Kazin, a distinguished literary critic, was quoted as saying: “It is difficult for me to credit a will to blackness and self-destruction in a writer so happy and full of new projects.”

A friend, rejecting the idea that the writer had planned to kill himself, saw the death as the result of a “sudden uncontrollable impulse”—as if rational deliberation might have somehow colored the act with wrongdoing. In this and other statements, there was at least a tinge of disapproval, an unspoken feeling that through some puzzling failure of moral strength Mr. Levi had failed his staunchest admirers.

Apparently not expressed at the symposium, though quoted in the article, was the harshest example of such a viewpoint: a suggestion in
The New
Yorker
that “the efficacy of all his words had somehow been cancelled by his death.”
²
This idea leaves the implication that the force and fervor of a writer's work is rendered invalid if, instead of expiring of natural causes, he takes his life.

What remains most deeply troubling about the account is the apparent inability of the symposium participants to come to terms with a reality that seems glaringly obvious. It is that Mr. Levi's death could not be dissociated from the major depression with which he was afflicted, and that indeed his suicide proceeded directly from that illness.

To those of us who have suffered severe depression—myself included—this general unawareness of how relentlessly the disease can generate an urge to self-destruction seems widespread; the problem badly needs illumination.

Suicide remains a tragic and dreadful act, but its prevention will continue to be hindered, and the age-old stigma against it will remain, unless we can begin to understand that the vast majority of those who do away with themselves—and of those who attempt to do so—do not do it because of any frailty, and rarely out of impulse, but because they are in the grip of an illness that causes almost unimaginable pain. It is important to try to grasp the nature of this pain.

In the winter of 1985–86, I committed myself to a mental hospital because the pain of the depression from which I had suffered for more than five months had become intolerable. I never attempted suicide, but the possibility had become more real and the desire more greedy as each wintry day passed and the illness became more smotheringly intense.

What had begun that summer as an off-and-on malaise and a vague, spooky restlessness had gained gradual momentum until my nights were without sleep and my days were pervaded by a gray drizzle of unrelenting horror. This horror is virtually indescribable, since it bears no relation to normal experience.

In depression, a kind of biochemical meltdown, it is the brain as well as the mind that becomes ill—as ill as any other besieged organ. The sick brain plays evil tricks on its inhabiting spirit. Slowly overwhelmed by the struggle, the intellect blurs into stupidity. All capacity for pleasure disappears, and despair maintains a merciless daily drumming. The smallest commonplace of domestic life, so amiable to the healthy mind, lacerates like a blade.

Thus, mysteriously, in ways difficult to accept by those who have never
suffered it, depression comes to resemble physical anguish. Such anguish can become every bit as excruciating as the pain of a fractured limb, migraine, or heart attack.

Most physical distress yields to some analgesia—not so depression. Psychotherapy is of little use to the profoundly depressed, and antidepressants are, to put it generously, unreliable. Even the soothing balm of sleep usually disappears. And so, because there is no respite at all, it is entirely natural that the victim begins to think ceaselessly of oblivion.

In the popular mind, suicide is usually the work of a coward or sometimes, paradoxically, a deed of great courage, but it is neither; the torment that precipitates the act makes it often one of blind necessity.

The origins of depression remain a puzzle, despite significant advances in research. Many factors seem to be involved. Aside from the basic chemical disturbance in the brain and behavioral and genetic influences, psychological reasons must be added to the equation. Mr. Levi may have been bedeviled by buried conflicts unrelated to Auschwitz.

Or, indeed, his ordeal at Auschwitz may have imposed on his soul an insupportable burden; other writers wounded by the Holocaust (Paul Celan and Tadeusz Borowski come to mind) decided upon suicide as a way out of the blackness of memory. But the overwhelming majority of camp survivors have chosen to live, and what is of ultimate importance to the victim of depression is not the cause but the treatment and the cure.

What is saddening about Primo Levi's death is the suspicion that his way of dying was not inevitable and that with proper care he might have been rescued from the abyss.

Depression's saving grace (perhaps its only one) is that the illness seems to be self-limiting: Time is the real healer and with or without treatment the sufferer usually gets well.

Even so, presumptuous as it may be to speculate from such a distance, I find it difficult not to believe that if Mr. Levi had been under capable hospital attention, sequestered from the unbearable daily world in a setting where he would have been safe from his self-destructive urge, and where time would have permitted the storm raging in his brain to calm itself and die away, he would be among us now.

But, in any event, one thing appears certain: He succumbed to a disease that proved to be malignant, and not a shred of moral blame should be attached to the manner of his passing.

[
New York Times
, op-ed, December 19, 1988.]

After the essay on Primo Levi was published in
The New York Times
I received an enormous number of letters, almost all of them from people who had experienced depression, directly or as a result of being associated with victims of depression, and who felt I had given voice to a subject too-long buried. The essay prompted an invitation from the department of psychiatry of the Johns Hopkins School of Medicine for me to speak at a symposium on mood disorders; this speech was eventually expanded into a long article in
Vanity Fair
, and eventually into a book,
Darkness Visible
.—W.S. (1993)

I
n the spring of 1991 I was invited to give the keynote address at a symposium to be held in Washington, D.C., for the purpose of discussing depression and the ways to cope with the disease. The gathering, I was told, was to be made up of what might loosely be called semiprofessionals, that is, people who, though not psychiatrists or therapists, had an interest in knowing more about depressive illnesses; they would include social and welfare workers, hospital administrators, public health and police officials, paramedics, and the like. As a result of my book
Darkness Visible
, in which I describe my successful struggle with severe clinical depression, I have received a lot of such invitations, and accepted a few (perhaps more than I should have) out of some missionary urge; many people who finally vanquish melancholia's unspeakable demons have the charitable impulse to tell others similarly afflicted not to give up hope, that they can get well. Such support is of critical importance to someone felled by depression. Since countless people
don't
think they can make it, and play seriously with the idea of suicide, the recovered victim is walking testimony to the radiant fact that most sufferers, despite their nearly unbearable ordeal, do indeed get well; the very presence of the survivor and his words of encouragement can be lifesaving.

This message of hope was central to my little book; its upbeat nature, not falsely optimistic but rooted in the simple reality that treatment is available
and usually effective, would make the foundation for the opening speech I had been asked to give. But I began to have second thoughts. While I still felt the note of cheer was important, and resolved to begin in that spirit, it seemed to me that this might be an opportune moment to sound a warning. And the warning should be one especially meaningful to the participants in the symposium, who I felt had to be put on their guard about a matter that I continue to feel is neglected or consciously shunted aside in most forums on the treatment of depression, and that is the misuse of medications, primarily tranquilizers. Tranquilizers should not be confused with antidepressants, although they are often prescribed to sedate people with depression.

I wanted to point out that my own bleak experience had convinced me that virtually all the commonly prescribed minor tranquilizers (also known as benzodiazepines) are of questionable value even for healthy people; for those suffering from depression they should be shunned like cyanide, and of them all the most indisputably monstrous is a tiny gray-green oval called triazolam, better known by the brand name Halcion.

Halcion has become a kind of famous national gargoyle, part nightmare, part joke. People who haven't heard of Listerine know the name Halcion. Wasn't Halcion the sleeping medicine George Bush was on when he barfed in the lap of the prime minister of Japan? TV comics have made sport of it. But Halcion is not a very funny pill, as I discovered through personal experience. I took this tranquilizer as a remedy for the insomnia that so often accompanies depression. Although the depression I describe in my book was not directly caused by Halcion, and I said as much, I've become convinced that the pill greatly exaggerated my disorder, intensified my suicidal feelings, and finally forced me to be hospitalized. I was not aware of this cause-and-effect relationship at the time, for when my illness occurred, in 1985, Halcion had yet to be implicated as the origin of such dire mischief, and I made no connection myself.

Five years later, however, when I was writing
Darkness Visible
, I was able retrospectively to perceive the connection, greatly helped by the amount of information that was suddenly being made public concerning Halcion's malign effects. When the book was published I was stunned by the volume of mail I received, but nothing impressed me more than the large number of correspondents—I would estimate perhaps as many as fifteen or twenty percent—who spoke of their own Halcion-induced horrors, homicidal fantasies, near-suicides, and other psychic convulsions. This outpouring
has given me a rare perspective on all aspects of depression, including the effect (or non-effect) of medications. Other pills were mentioned, notably Prozac, the antidepressant, which appears to be beneficial for many people; the spontaneous testimonials in favor of that medication convince me that, if my thick archive of correspondence is a revealing cross section, Eli Lilly's bonanza drug cannot be lightly dismissed. But Prozac, scarcely an all-purpose miracle medicine, is merely an improvement on an old formula. What is distressing is the fact that a significant number of people do have very bad reactions to Prozac, chiefly suicidal impulses (the letters to me reflect this), and it is Lilly's concerted efforts to minimize such sinister side effects that remain even now indefensible.

In a recent
Nation
column (“Beat the Devil,” December 7, 1992), Alexander Cockburn describes how Lilly, annoyed by evidence that its remedy might cause such harmful reactions (while already suffering a $150 million lawsuit based on this proposition), and further distressed by attacks on their product by the Church of Scientology, turned matters around by enlisting the press in a campaign that resulted in lurid onslaughts against the church in
The Wall Street Journal
and in
Time
, where the church was the subject of a cover story. There were other craftily orchestrated PR tie-ins, but this was basically the old chronicle of overpowering corporate muscle and deafening propaganda, successfully applied. Meanwhile, the advisory committee of the Food and Drug Administration that was organized to study Prozac—five of whose eight members, according to Cockburn, had “serious conflicts of interest, including substantial financial backing from Lilly”—gave the medication its OK.

I'm afraid my esteem for the Church of Scientology, unlike that of Cockburn, is lower even than my esteem for
Time
. The church's indiscriminate attacks on virtually all psychiatric medicines is nothing but medieval zealotry, and one would wish that the adversarial voice raised against Lilly were backed by credentials sounder than those deriving from L. Ron Hubbard's loony theology. While Cockburn's attempt to incriminate Lilly for its sorry excesses is a worthy one, he never addresses the nature of Prozac, which for many people is a very effective antidepressant. It is not a wonder drug, but it is by no means without value, and, as I say, my correspondence has reflected this fact. Lilly's wrong springs not so much from its product as from a hucksterism that admits to no deficiencies.

But no one who wrote to me had anything but ghastly tales to tell about
Halcion, and in my Washington talk it seemed necessary to focus on my own devastating experiences with this pill, made by the Upjohn Company. Many years ago the phrase “ethical drug manufacturers” came into being as a result of the industry's justifiable desire to differentiate its members from the patent-medicine makers, ostensibly ethical cretins, who peddled Lydia E. Pinkham's Vegetable Compound, snake oil, Dr. Moog's Love Balm, magic crystal beads, Spanish fly, Peruna, and other shady nostrums. But even the noblest ethics suffer attrition, and it is plain that various corporations have become less ethical than others, some to the point of knavery. If there are the Tiffanys of the trade—I've heard people in the know about such topics murmur Merck with reverence—there are also those at the bottom end, and there Upjohn is clearly the Crazy Eddie of the industry. Not long ago
The Nation
ran a piece describing the disgraceful hype Upjohn brought to bear in advertising its potent and (like all benzodiazepines) potentially hazardous anti-anxiety drug Xanax, another multimillion-dollar winner, attempting to make it appear as free of the need for precaution as Gatorade. (See Cynthia Cotts, “The Pushers in the Suites,”
Nation
, August 31/September 7, 1992.) Even closer to its snake-oil origins is Upjohn's recent campaign for liquid Rogaine, an only marginally effective treatment for baldness whose capacities, according to
Consumer Reports
, the company has attempted to inflate by putting it into a totally ineffective shampoo called Progaine.

But beyond this relatively commonplace sleaze lies Upjohn's refusal to face up to the Frankenstein's monster its Kalamazoo laboratories let loose in the shape of Halcion. Public awareness of the dangers of the pill dates back to 1979, when a Dutch psychiatrist, Dr. C. van der Kroef, disquieted by the psychotic symptoms reported by many patients taking Halcion, carried out an in-depth investigation and sounded the alarm; the pill was soon categorically banned in the Netherlands. Shamefully, Upjohn's own awareness of the serious risk inherent in its medication goes back to the early 1970s, when the company's experiments with a volunteer group of inmates at the Jackson State Prison in Michigan came up with disturbing—or what should have been disturbing—results. The human guinea pigs developed all sorts of aberrant reactions—memory loss, paranoid feelings—that were not consonant with the safe, readily tolerated hypnotic that Halcion was intended by its makers to be.

About a year ago, both in a
60 Minutes
program and a BBC documentary
(in which I had a cameo role as a damaged but recovered victim), evidence that can only be described as revolting revealed that Upjohn had had full knowledge of the injurious nature of its product but put it on the market anyway. After that, sales of Halcion, which had been a top earner for years, were mercifully slowed by the adverse publicity it received; the pill has been implicated in numerous suicides and acts of violence, including several murders, the most recent of which, in Dallas County, Texas, resulted in a jury deciding that the drug was partly responsible for the killing.
¹

Halcion has now been banned in Britain and four other countries. Despite this and its appalling record, and the obvious fact that other readily available tranquilizers don't produce such calamitous side effects, Halcion last spring was once more approved by the ever-supine Food and Drug Administration, which insisted only that Upjohn strengthen its warning about dosage. In fairness, it should be pointed out that it is frequently an inadvertent overdose—though more often than not an extremely small one, amounting to a fraction of a milligram—that produces these evil reactions. Even so, the normally prescribed dosage has many times precipitated disastrous behavior. In any case, viewing the FDA's cavalier decision, one wonders how long aspirin would remain on the market if a small overdose of one more than the commonly recommended two tablets caused some people to lapse into paranoia and violence.

At the beginning of his new novel,
Operation Shylock
, which I've read in manuscript and which will be published this year, Philip Roth has a brilliant and harrowing description of Halcion-induced madness, based on his own experience in 1988, when he had been innocently taking the pill for sleep after minor knee surgery. “I thought about killing myself all the time. Usually I thought of drowning: in the little pond across the road from the house…if I weren't so horrified of the water snakes there nibbling at my corpse; in the picturesque big lake only a few miles away…if I weren't so frightened of driving out there alone. When we came to New York that May…I opened the window of our fourteenth-floor hotel room…and, leaning as far out over the interior courtyard as I could while still holding tight to the sill, I told myself, ‘Do it. No snakes to stop you now.' ”
²

Withdrawal from Halcion invariably results in a disappearance of the symptoms, and Roth of course survived, as did I. But the ordeal verges on being beyond description in its nearly unalleviated anguish. Like Roth, I thought about drowning. And like Roth's, my own trial began with a surgical
problem: A long-ago injury to my neck, received when I was a marine in the Korean War, had caused a nerve compression that resulted in my losing much strength in my right arm. An operation in Boston was imperative but was delayed, and during the two-week wait I had time to brood and was ravaged by anxiety. The anxiety began to hinder sleep, and to conquer the sleeplessness I commenced taking Halcion, still serenely unaware of the pill's involvement in my breakdown four years before, which was described in
Darkness Visible
. I had gone to California, fulfilling an obligation to teach at Claremont College. There, in that sunny landscape, I was all but totally consumed by thoughts of suicide that were like a form of lust. Somehow I managed to get through my classroom duties, but my mind was never free of exquisite pain, a pain that had but one solution—self-extinction. One night, visiting at my daughter's house in Santa Monica, I stayed awake for hours thinking only of walking out into the ocean and being engulfed by the waves. At Claremont, I kept constant schemes in mind to have my wife lured away so I could secrete myself in a closet and end it all with a plastic bag.

I held on to my sanity long enough to fly back to Boston for the operation. Although the procedure was a complete success, the raging depression hung on during the postoperative convalescence. Many times I contemplated sneaking out of the hospital and leaping into the Charles River from the bridge I could see from my window. Then suddenly a curious intervention occurred. I was consulting with a staff psychiatrist, and he asked about my sleeping habits. I told him that I was sleeping poorly but that what sleep I did get was courtesy of Halcion. The eyes of the doctor, a man plainly privy to the latest pharmaceutical alarms, sharpened interestingly, and it required no more than a few seconds for him to tell me that he was switching me immediately to a new drug. A day or two later, peering into my shaving mirror, I realized the bizarre configuration around my lips was a smile. Thus began my education about Upjohn's baneful remedy, and my shaky and haunted but eventually full recovery….

This was the chronicle I related to the audience in Washington, not the gladdening sermon that had been expected of me, perhaps, but a cautionary tale that I felt very much needed telling. But I must back up for a moment. Just a few days before my appearance, the lecture agent who had arranged my visit called me with some stimulating but hardly surprising news. The fee I was receiving for my lecture, he said, would be paid by Eli Lilly and
Company, makers of Prozac, which was underwriting the symposium. Did I have any qualms about the pharmaceutical tie-in? Not really, I said, though it might depend on the company; I'd never take a penny from Upjohn. Drug companies often finance psychiatric conferences. It was not a practice I was enthusiastic about, and if I were in the profession I might feel embarrassed; as a layperson, however, I would feel compromised only if an attempt was made to censor or fiddle around with what I had to say. I told the lecture agent that I planned to make a vigorous attack on Halcion. I heard the agent catch his breath, saying he was happy the pill wasn't made by Lilly.