Authors: Andrew Solomon
Practical purposes are also served at MDSG, especially for people who are not coddled by friends, family, and excellent health insurance. You don’t want your employer to know, or your prospective employer; what can you say without lying about it? Unfortunately, the participants with whom I came in contact mostly seemed to give each other excellent support and terrible advice. If you’ve sprained your ankle, other people with sprained ankles may be able to give you useful pointers, but if you’ve got mental illness, you should not rely on people with mental illness to tell you what to do. I drew on my reading knowledge, horrified at what bad counsel a lot of these people had had, but it was hard to achieve much authority. Christian was clearly bipolar, unmedicated, and getting manic; I am sure he will have had a suicidal phase before this book is published. Natasha should not have been
thinking
of going off Paxil so soon. Claudia had been through what sounded like badly administered and excessive ECT, and then had been overmedicated into a zombie; Jaime might, with ECT, have been able to keep his real job, but he knew nothing about how it really worked, and what Claudia had to say did not reassure him.
One time, someone was talking about trying to explain things to friends. A longtime MDSG man, Stephen, asked the group, “Do you have friends outside?” Only one other person and I said that we did. Stephen said, “I try to make new friends, but I don’t know how it works. I was such a recluse for so long. I took Prozac, and it worked for a year, and then it stopped. I think I did more that year, but I lost it.” He looked at me curiously. He was sad and sweet-natured and intelligent—clearly a lovely person, as someone said to him that evening—but he was gone. “How do you meet people, besides here?” And before I could answer, he added, “And once you’ve met them, what do you talk about?”
Like all diseases, depression is a great equalizer, but I met no one with depression who seemed a less likely figure for it than Frank Rusakoff, twenty-nine, soft-spoken and polite and good-natured and good-looking and the sort of person who seems altogether normal, except that he suffers from horrendous depression. “You want inside my head?” he once wrote. “Welcome. Not exactly what you expected? It’s not exactly what
I expected either.” A year or so after graduating from college, Frank Rusakoff was at the movies when his first depression hit him. In the seven years that followed, he was hospitalized thirty times.
His first episode came on abruptly: “On the way home from a movie, I realized I was going to drive into a tree. I felt like there was a weight pushing my foot down, like someone was pulling my hands around. I knew I couldn’t drive home because there were too many trees that way and they were getting harder and harder to resist, so I headed for the hospital.” During the years that followed, Frank went through every medication in the book and got nowhere. “In the hospital, I actually tried to choke myself to death.” He finally went in for ECT. That helped, but it also made him briefly manic. “I hallucinated, attacked another patient, had to go into the quiet room for a while,” he recalls. For five years thereafter, Frank got booster ECT (one treatment, rather than a series) whenever the depression hit again, usually about once every six weeks. He was put on a combination of lithium, Wellbutrin, Ativan, doxepin, Cytomel, and Synthroid. “ECT works, but I hate it. It’s totally safe and I would recommend it, but they’re putting electricity into your head, and that’s scary. I hate the memory problems. It gives me a headache. I’m always afraid they’ll do something wrong, or I won’t come out of it. I keep journals so I can remember what happened; otherwise, I’d never know.”
Different people have different hierarchies of treatment in their heads, but surgery is the last resort for everyone. Lobotomies, first performed at the turn of the century, became popular in the 1930s and, especially, after World War II. Returning veterans with shell shock or neurosis were routinely given clumsy operations in which their frontal lobe (or other brain sections) was severed. In the heyday of lobotomies, about five thousand were performed annually in the United States, causing between 250 and 500 deaths a year. Psychosurgery lies under this shadow. “Sadly,” says Elliot Valenstein, who has written a history of psychosurgery, “people still connect these surgeries with mind control and they run away from them.” In California, where ECT was illegal for a while, psychosurgery is still illegal. “The figures on psychosurgery are significant,” Valenstein says. “About seventy percent of the target population—people who have failed everything else—have at least some response; about thirty percent of these show really marked improvement. This procedure is done only for those people with severe and lasting psychiatric illness that has been unresponsive to pharmaceuticals and ECT, who’ve failed everything thrown at them, who remain severely disabled or ill: the most refractory cases. It is something of a last resort. We do only the gentlest procedure, and sometimes we have to do it two or three times, but we prefer that to the European model, which is to do
more major surgery right away. With cingulotomy, we have found no permanent change in memory, or in cognitive or intellectual function.”
When I first met Frank, he was just back from having a cingulotomy. In that procedure, the scalp is frozen locally and the surgeon drills a small hole in the front of the skull. He then puts an electrode directly onto the brain to destroy areas of tissue measuring about eight by eighteen millimeters. The procedure is performed under local anesthesia with sedation, using a stereotactic frame. This surgery is now done in only a few places, and the leading one is Massachusetts General Hospital, Boston, where Frank was seen by Reese Cosgrove, the leading psychosurgeon in the United States.
It is not easy to get into the cingulotomy protocol; you have to be reviewed by a screening committee and put through an endless barrage of tests and questions. The presurgery review takes at least twelve months. Mass General, the most active center, does only fifteen or twenty of them a year. As with antidepressants, the surgery usually has a delayed effect, often showing benefit after six or eight weeks, so it is probable that the benefit comes not from the elimination of certain cells but from what the elimination of those cells does to the functioning of other cells. “We don’t understand the pathophysiology; we have no understanding of the mechanisms of why this works,” says Cosgrove.
“I have hopes for the cingulotomy,” Frank told me when we met. He described the procedure with an air of mild detachment. “I heard the drill going into my skull, like when you’re at the dentist’s office. They drilled two holes so that they could burn the lesions into my brain. The anesthesiologist had said if I wanted more medication I could have it, and I was lying there and listening to my skull opening up, so I said, ‘This is kind of creepy; can you put me a little further under?’ I hope it works; if it doesn’t I have a plan, I’ve had a plan, for how to end it all, because I just can’t keep going like this.”
A few months later he was feeling marginally better and trying to reconstruct his life. “My future seems particularly clouded right now. I want to be writing, but my confidence is so low. I don’t know what kind of writing I could do. I guess being depressed all the time was actually a relatively safe place to be. I didn’t have the real-world worries that everyone else has because I knew that I simply couldn’t function well enough to take care of myself. What do I do now? Trying to break the habits of years of depression is what I’m doing for the moment with my doctor.”
Frank’s surgery, in combination with Zyprexa, has been a success. During the year that followed, he had a few blips but was not hospitalized once. During this time he wrote to me about his progress and described
being able to stay up all night to celebrate a friend’s wedding. “Before,” he wrote, “I couldn’t do that because I was always afraid I’d affect my precarious mood.” He was accepted in a graduate program at Johns Hopkins to learn science writing. With great trepidation, he decided to attend. He had a girlfriend with whom he was for the moment happy. “I’m kind of amazed when someone wants to tangle with the obvious problems that accompany me, but I’m really excited to have both companionship and romance. My girlfriend is something to look forward to.”
He successfully completed his graduate work and got a job working for an Internet start-up. He wrote me in early 2000 about Christmas. “My dad gave me two presents: first, a motorized CD rack from The Sharper Image—it’s totally unnecessary and extravagant but my dad knew I’d get a kick out of it. I opened this huge box and saw something I didn’t need at all and knew my dad was celebrating the fact that I’m living on my own, have a job I seem to love, and can pay my own bills. The other present was a photo of my grandmother, who committed suicide. As I opened the present, I began to cry. She was beautiful. She is in profile, looking downward. Dad said it was probably from the early thirties: it’s a black-and-white that he gave a soft blue matte and silver frame. My mom came over to the chair and asked if I was crying because of all the relatives I never knew and I said, ‘She had the same disease I have.’ I’m crying now—it’s not that I’m so sad—I just get overwhelmed. Maybe it’s that I could have killed myself but didn’t because those around me convinced me to keep going—and I had the surgery. I’m alive and grateful to my parents and some doctors. We live in the right time, even if it doesn’t always seem like it.”
People travel from all over West Africa, some from even farther, for the mystic
ndeup
ceremonies for mental illness that are practiced by the Lebou (and some Sérèr) people of Senegal. I set off for Africa to explore. The head of the primary mental hospital in Dakar, Dr. Dou-dou Saar, who practices Western-style psychiatry, said that he believes that all of his patients have sought out traditional treatments. “They are sometimes embarrassed to tell me about these activities,” he said. “But I believe that the traditional and modern healing, though they should be kept separate, must coexist; if I myself had a problem and foreign medicines did not cure me, I would go for traditional help.” Even at his establishment, the Senegalese customs prevail. To enroll there, the one who is sick must come with a caretaker family member so that they can both stay at the hospital; the caretaker is given instruction and learns some basic psychiatric principles so that he can ensure the continuing mental health of the person who is being treated. The hospital itself is rather basic—pri
vate rooms are $9 per day, semiprivate $5, and large rooms with rows of beds $1.75. The whole place stinks, and those who have been declared dangerously insane are locked up behind iron doors; you can hear their wailing and banging at all times. But there is a pleasant garden where residents grow vegetables, and the presence of the many caretakers somewhat mitigates the aura of frightening weirdness that makes many Western hospitals so grim.
The
ndeup
is an animist ritual that probably antedates voodoo. Senegal is a Muslim country, but the local brand of Islam turns a blind eye to these ancient practices, which take place at once publicly and somewhat secretly; you may have an
ndeup
and everyone will congregate around you for it, but you do not speak about it much. The mother of a friend of the girlfriend of a friend who moved to Dakar some years ago knew a healer who could conduct the ceremony, and through this elaborate connection I arranged to undergo an
ndeup
. Late on a Saturday afternoon, some Senegalese friends and I took a taxi from Dakar to the town of Rufisque, through tiny alleyways and run-down houses, collecting people who would be involved, until at last we reached the house of Mareme Diouf, the old woman who would perform the ceremony. Mareme Diouf’s grandmother had conducted the
ndeup
in this place and had taught Mareme; Mareme’s grandmother had learned from
her
grandmother, and Mareme said the family lore and this chain went back as far as memory. Mareme Diouf came to meet us, barefoot, wearing a headdress and a long robe that was batiked with rather frightening images of eyes and trimmed in pea-green lace. She took us to the area behind her hut, where, under the spreading branches of a baobab, there were about twenty large clay pots and as many phallic wooden posts. She explained that the spirits she brought out of people were placed in the earth beneath, and that she fed them through these pots, which were all filled with water and roots. If those people who had been through the
ndeup
found themselves in trouble, they came to bathe in or drink the water.
After we had seen all this, we followed her into a small, rather dark room. Some considerable discussion about what to do ensued, and she said that it all depended on what the spirits wanted. She took my hand and looked at it closely, as though it had writing on it. Then she blew on my hand and had me place it on my forehead, and she began to feel around my skull. She asked me about my sleeping habits and wondered whether I had headaches, and then she declared that we would appease the spirits with one white chicken, one red cockerel, and one white ram. Then began the haggling about the price of the
ndeup;
we lowered the price (to about $150) by agreeing to acquire ourselves the ingredients she would require: seven kilos of millet, five kilos of sugar, one kilo of cola nuts, one calabash, seven meters of white cloth, two large pots, one reed mat, one threshing basket, one heavy club, the two chickens, and the ram. She told me that some of my spirits (in Senegal, one has spirits everywhere, some necessary to you, some neutral, some harmful—a little bit like microbes) were jealous of my sexual relations with my living partners and that this was the reason for my depression. “We must make a sacrifice,” she declared, “to placate them, and then they will be quiet, and you will not suffer from this heaviness of depression. Your full appetites will be with you and you will sleep in peace without nightmares and the bad fear will be gone.”
We made our second trip to Rufisque at dawn on Monday. Just outside the town we saw a shepherd and stopped to buy a ram. We had some difficulty getting it into the trunk of the taxi, where it made plaintive noises and relieved itself copiously; we drove another ten minutes and once more entered the labyrinth of little streets in the sprawl of Rufisque. We left the ram with Mareme and went to the market to get the other items, which one of my friends piled up on her head like the Tower of Pisa; then we returned by horse-drawn cart to the house of Mareme Diouf.