You see, I have a son who suffers from this disease, and I don’t want him to think that it’s a reason for not having a good life. I get up every single day, and I make breakfast for my kids. Some days I can keep going, and some days I have to go back to bed afterwards, but I get up every day. I come into this office at some point every day. Sometimes I miss a few hours, but I’ve never missed a whole day from depression.” She had tears rolling down her face as we spoke, but her jaw was set and she went right on speaking. “One day last week I woke up and it was really bad. I managed to get out of bed, to walk to the kitchen, counting every step, to open the refrigerator. And then all the breakfast things were near the back of the refrigerator, and I just couldn’t reach that far. When my kids came in, I was just standing there, staring into the refrigerator. I hate being like that, being like that in front of them.” We talked about the day-to-day battle: “Someone like Kay Jamison, or someone like you, gets through this with so much support,” she said. “My parents are both dead, and I’m divorced, and I don’t find it easy to reach out.”

Life events are often the triggers for depression. “One is much less likely to experience depression in a stable situation than in an unstable one,” Melvin McInnis of Johns Hopkins says. George Brown, of the University of London, is the founder of the field of life-events research and says, “Our view is that most depression is antisocial in origin; there is a disease entity as well, but most people are able to produce major depression given a particular set of circumstances. Level of vulnerability varies, of course, but I think at least two-thirds of the population has a sufficient level of vulnerability.” According to the exhaustive research he has done over twenty-five years, severely threatening life events are responsible for triggering initial depression. These events typically involve loss—of a valued person, of a role, of an idea about yourself—and are at their worst when they involve humiliation or a sense of being trapped. 

Andrew Solomon

Depressed people cannot lead a revolution because depressed people can barely manage to get out of bed and put on their shoes and socks. I could no more have joined a revolutionary movement during my own depression than I could have had myself crowned king of Spain. The truly depressed were not made invisible by asylums; they had always been largely invisible because their very disease causes them to sever human contacts and allegiances. The general reaction of other members of the proletariat (or, indeed, of any other class) to people who are severely depressed is revulsion and discomfort.

Andrew Solomon

But family and friends are often unable to do that, and unable to understand. Some are almost too indulgent. If you treat someone as totally disabled, he will see himself as totally disabled, and that can cause him to be totally disabled, perhaps more totally disabled than he need be. The existence of medication has increased social intolerance. “You got a problem?” I once heard a woman say to her son in a hospital. “You get on that Prozac and get over it and then you give me a call.” To set the correct level of tolerance is necessary not only for the patient but also for the family. “Families must guard themselves,” Kay Jamison once said to me, “against the contagion of hopelessness.”

What remains unclear is when depression triggers life events, and when life events trigger depression. Syndrome and symptom blur together and cause each other: bad marriages cause bad life events cause depression causes bad attachments, which are bad marriages. According to studies done in Pittsburgh, the first episode of major depression is usually closely tied to life events; the second, somewhat less; and by the fourth and fifth episodes life events seem to play no part at all. Brown agrees that beyond a certain point, depression “takes off on its own steam” and becomes random and endogenous, dissociated from life events. Though most people with depression have survived certain characteristic events, only about one in five who have experienced those events will develop depression. It is clear that stress drives up rates of depression. The biggest stress is humiliation; the second is loss.

Andrew Solomon