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In a dark time, the eye begins to see.
- Theodore Roethke
With two people with the same disease why may one fare very differently from the other? Why can one recover and build a good life, even if with residual symptoms, while another remains impaired and beset with suffering as a primary mode of living? This disparity applies equally to all chronic diseases: diabetes, heart and lung diseases, arthritis, many cancers, as well as a host of mental and substance use disorders, including depression, bipolar disease, PTSD, eating disorders, addiction, even schizophrenia.
I kept thinking about variation in the expression of diseases as I read Daphne Merkin’s new book, This Close to Happy: A Reckoning with Depression, which archives her life with depression.
Hippocrates, the “father of medicine” declared, “It is more important to know what sort of person has a disease than to know what sort of disease a person has.” And so it remains today when we seek to better understand how a disease can be so different from one person to another.
Merkin is a wonderful writer whose keen eye for detail and human foibles enables her to brilliantly light her subject, which is as much her as it is depression. In page after page, she delivers elegant, evocative prose, the kind of writing that earned her in the past the coveted position as a staff writer for The New Yorker. The challenge with her memoir, for the reader and for the writer, is the subject she ‘reckons’ with: her experience with depression - from childhood on. There is no levity to lighten her deep and dark exploration of this potentially soul-destroying condition.
What predicts our health or malaise? While genetic inheritance always has been a prominent factor, we have come to recognize that our genes are turned on and off over our lifetime, called ‘epigenetics’. We now know that cellular DNA, the genetic base pairs that instruct our biology, physiology as well as the expression of underlying, inherited diseases like diabetes, cancer, and depression, is modulated by how we lead our lives, namely our behaviors and our environments. In other words, DNA need not be destiny.
DNA can go awry. Was there an intrauterine infection or a compromised birth? Were there powerful environmental disrupters in childhood, including parental neglect and deprivation (emotional and nutritional), or physical or sexual abuse, or violence in the child's home or in the neighborhood? Or repeated foster care homes or addiction or serious untreated mental illness in the home? All these, and more, are known to unleash a wide variety of physical and mental conditions by adolescence, or even earlier. Drug use (including cannabis and K2 - synthetic marijuana - as well as MDMA and crystal meth) can do real damage when the adolescent brain is developing. Toxins in the air and water can do damage at any age.
These are all potential provocateurs to disrupting the normal functions of our DNA, stirring its capacity to dysfunction: for example, when a dormant gene is activated to become one that produces illness - including conditions like diabetes, depression auto-immune diseases and many more.
There are also protective epigenetic factors that help our fragile DNA helices. These include stable, safe homes and neighborhoods, a life spared of discrimination and poverty, predictable food on the table, loving parents, a decent education, and faith.
For Daphne Merkin, as she so frankly writes, depression had already implanted its roots from the time she was quite young. She has had three psychiatric hospitalizations, the first as a young child, then another after her daughter's birth, and then after her mother died. Merkin's mood disorder is severe and persistent. She has felt some but not a lot of relief from the broad range of treatments she has pursued. In this memoir, she does hand to hand literary combat with depression, a truly unwelcome visitor that can arrive unexpectedly and provide little clue as to when it will leave.
She is most angry at her parents. Born into an immigrant but very prosperous New York Jewish family living on Park Avenue, Daphne and her siblings, as she tells it, would not be given enough to eat. They had to wear flimsy clothing and shoes, and use worn out soap bars and towels – while her parents lived lavishly in the same luxurious apartment. She portrays her mother as only interested in herself, and given to physical threats - especially to Daphne and her sisters. Her father was preoccupied with making money and entertaining prominent Jews, especially Israelis. He had no time for his children, who were treated like strangers in his home, as Merkin tells it. Her animus for her parents seems unabated, still after all these years and their passing. Why? Why can some put their traumas behind them, not forgetting them but discharging their toxic effects, while others wake up each day enraged and psychologically beaten?
I only know Daphne Merkin from her writings. My comments, thus, are as a psychiatrist and public health doctor long familiar with mental disorders - depression in this instance - but not with Merkin and her illness, except as she presents it in her memoir. I am left thinking how great and persistent has been her psychic pain. That can, and does, happen when depression has a strong genetic basis and its expression amplified by early neglect and trauma. Later disappointments in love and work can further fuel the depressive flames, leaving the illness resistant to the many effective treatments we now have.
Merkin's anguish, anger, and quotidian struggles populate this memoir. As keen is her commentary on being ill I missed more of her literary brilliance, which seemed overshadowed by the depressive voice of the book.
At the end of the memoir, she struggles to portray some high ground from her illness, some sense of inner quiet, some rays of hope. Yet, these seem fragile and ephemeral. Her clinical depression, and how it has shaped her very being, her work and her relationships, continues to dominate her life. This is the gravity and anguish her memoir depicts, leaving me hoping that further advances in neuroscience and psychiatric therapeutics will provide more than Merkin has realized in her ongoing battle with depression.
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Dr. Lloyd Sederer is a psychiatrist and public health doctor. The opinions offered here are entirely his own. He takes no support from any pharmaceutical or device company.
