How to pronounce "protocol"

"I felt a Funeral, in my Brain,

and Mourners to and fro

kept treading -- treading -- till [it seemed]

that Sense was breaking through --

And when they all were seated,

a Service, like a Drum --

kept beating -- beating -- till I [thought]

my Mind was going numb --

And then I heard them lift a Box and creak across my Soul

with those same Boots of Lead, again,

then Space -- began to toll,

As [all] the Heavens were a Bell, and Being, [but] an Ear,

and I, and Silence, some strange Race,

wrecked, solitary, here --

[And] then a Plank in Reason, broke,

and I fell down and down --

and hit a World, at every plunge,

and Finished knowing -- then --"

We know depression through metaphors.

Emily Dickinson was able to convey it in language,

Goya in an image.

Half the purpose of art is to describe such iconic states.

As for me, I had always thought myself tough,

one of the people who could survive

if I'd been sent to a concentration camp.

In 1991, I had a series of losses.

My mother died,

a relationship I'd been in ended,

I moved back to the United States from some years abroad,

and I got through all of those experiences intact.

But in 1994, three years later,

I found myself losing interest in almost everything.

I didn't want to do any of the things I had previously wanted to do,

and I didn't know why.

The opposite of depression is not happiness, but vitality.

And it was vitality

that seemed to seep away from me in that moment.

Everything there was to do seemed like too much work.

I would come home

and I would see the red light flashing on my answering machine,

and instead of being thrilled to hear from my friends,

I would think,

"What a lot of people that is to have to call back."

Or I would decide I should have lunch,

and then I would think, but I'd have to get the food out

and put it on a plate

and cut it up and chew it and swallow it,

and it felt to me like the Stations of the Cross.

And one of the things that often gets lost in discussions of depression

is that you know it's ridiculous.

You know it's ridiculous while you're experiencing it.

You know that most people manage

to listen to their messages and eat lunch

and organize themselves to take a shower

and go out the front door

and that it's not a big deal,

and yet you are nonetheless in its grip

and you are unable to figure out any way around it.

And so I began to feel myself doing less

and thinking less

and feeling less.

It was a kind of nullity.

And then the anxiety set in.

If you told me that I'd have to be depressed for the next month,

I would say, "As long I know it'll be over in November, I can do it."

But if you said to me,

"You have to have acute anxiety for the next month,"

I would rather slit my wrist than go through it.

It was the feeling all the time

like that feeling you have if you're walking

and you slip or trip and the ground is rushing up at you,

but instead of lasting half a second, the way that does,

it lasted for six months.

It's a sensation of being afraid all the time

but not even knowing what it is that you're afraid of.

And it was at that point that I began to think

that it was just too painful to be alive,

and that the only reason not to kill oneself

was so as not to hurt other people.

And finally one day, I woke up

and I thought perhaps I'd had a stroke,

because I lay in bed completely frozen,

looking at the telephone, thinking,

"Something is wrong and I should call for help,"

and I couldn't reach out my arm

and pick up the phone and dial.

And finally, after four full hours of my lying and staring at it,

the phone rang,

and somehow I managed to pick it up,

and it was my father, and I said,

"I'm in serious trouble. We need to do something."

The next day I started with the medications and the therapy.

And I also started reckoning with this terrible question:

If I'm not the tough person

who could have made it through a concentration camp,

then who am I?

And if I have to take medication,

is that medication making me more fully myself,

or is it making me someone else?

And how do I feel about it if it's making me someone else?

I had two advantages as I went into the fight.

The first is that I knew that, objectively speaking,

I had a nice life,

and that if I could only get well,

there was something at the other end that was worth living for.

And the other was that I had access to good treatment.

But I nonetheless emerged and relapsed,

and emerged and relapsed,

and emerged and relapsed,

and finally understood

I would have to be on medication and in therapy forever.

And I thought,

"But is it a chemical problem or a psychological problem?

And does it need a chemical cure or a philosophical cure?"

And I couldn't figure out which it was.

And then I understood that actually,

we aren't advanced enough in either area for it to explain things fully.

The chemical cure and the psychological cure

both have a role to play,

and I also figured out that depression was something

that was braided so deep into us

that there was no separating it from our character and personality.

I want to say that the treatments we have for depression are appalling.

They're not very effective.

They're extremely costly.

They come with innumerable side effects.

They're a disaster.

But I am so grateful that I live now and not 50 years ago,

when there would have been almost nothing to be done.

I hope that 50 years hence,

people will hear about my treatments

and be appalled that anyone endured such primitive science.

Depression is the flaw in love.

If you were married to someone and thought,

"Well, if my wife dies, I'll find another one,"

it wouldn't be love as we know it.

There's no such thing as love without the anticipation of loss,

and that specter of despair can be the engine of intimacy.

There are three things people tend to confuse:

depression, grief and sadness.

Grief is explicitly reactive.

If you have a loss and you feel incredibly unhappy,

and then, six months later,

you are still deeply sad, but you're functioning a little better,

it's probably grief,

and it will probably ultimately resolve itself in some measure.

If you experience a catastrophic loss,

and you feel terrible,

and six months later you can barely function at all,

then it's probably a depression that was triggered

by the catastrophic circumstances.

The trajectory tells us a great deal.

People think of depression as being just sadness.

It's much, much too much sadness,

much too much grief

at far too slight a cause.

As I set out to understand depression,

and to interview people who had experienced it,

I found that there were people who seemed, on the surface,

to have what sounded like relatively mild depression

who were nonetheless utterly disabled by it.

And there were other people who had what sounded

as they described it like terribly severe depression

who nonetheless had good lives

in the interstices between their depressive episodes.

And I set out to find out what it is that causes some people

to be more resilient than other people.

What are the mechanisms that allow people to survive?

And I went out and I interviewed person after person

who was suffering with depression.

One of the first people I interviewed

described depression as a slower way of being dead,

and that was a good thing for me to hear early on

because it reminded me that that slow way of being dead

can lead to actual deadness,

that this is a serious business.

It's the leading disability worldwide,

and people die of it every day.

One of the people I talked to when I was trying to understand this

was a beloved friend who I had known for many years,

and who had had a psychotic episode in her freshman year of college,

and then plummeted into a horrific depression.

She had bipolar illness,

or manic depression, as it was then known.

And then she did very well for many years on lithium,

and then eventually, she was taken off her lithium

to see how she would do without it,

and she had another psychosis,

and then plunged into the worst depression that I had ever seen

in which she sat in her parents' apartment,

more or less catatonic, essentially without moving,

day after day after day.

And when I interviewed her about that experience some years later --

she's a poet and psychotherapist named Maggie Robbins --

when I interviewed her, she said,

"I was singing 'Where Have All The Flowers Gone,'

over and over, to occupy my mind.

I was singing to blot out the things my mind was saying,

which were, 'You are nothing. You are nobody.

You don't even deserve to live.'

And that was when I really started thinking

about killing myself."

You don't think in depression that you've put on a gray veil

and are seeing the world through the haze of a bad mood.

You think that the veil has been taken away,

the veil of happiness,

and that now you're seeing truly.

It's easier to help schizophrenics who perceive

that there's something foreign inside of them that needs to be exorcised,

but it's difficult with depressives,

because we believe we are seeing the truth.

But the truth lies.

I became obsessed with that sentence:

"But the truth lies."

And I discovered, as I talked to depressive people,

that they have many delusional perceptions.

People will say, "No one loves me."

And you say, "I love you,

your wife loves you, your mother loves you."

You can answer that one pretty readily, at least for most people.

But people who are depressed will also say,

"No matter what we do, we're all just going to die in the end."

Or they'll say, "There can be no true communion

between two human beings.

Each of us is trapped in his own body."

To which you have to say,

"That's true,

but I think we should focus right now on what to have for breakfast."

(Laughter)

A lot of the time,

what they are expressing is not illness, but insight,

and one comes to think what's really extraordinary

is that most of us know about those existential questions

and they don't distract us very much.

There was a study I particularly liked

in which a group of depressed and a group of non-depressed people

were asked to play a video game for an hour,

and at the end of the hour,

they were asked how many little monsters they thought they had killed.

The depressive group was usually accurate to within about 10 percent,

and the non-depressed people

guessed between 15 and 20 times as many little monsters --

(Laughter)

as they had actually killed.

A lot of people said, when I chose to write about my depression,

that it must be very difficult to be out of that closet,

to have people know.

They said, "Do people talk to you differently?"

I said, "Yes, people talk to me differently.

They talk to me differently insofar

as they start telling me about their experience,

or their sister's experience,

or their friend's experience.

Things are different because now I know

that depression is the family secret that everyone has.

I went a few years ago to a conference,

and on Friday of the three-day conference,

one of the participants took me aside, and she said,

"I suffer from depression and I'm a little embarrassed about it,

but I've been taking this medication,

and I just wanted to ask you what you think?"

And so I did my best to give her such advice as I could.

And then she said, "You know, my husband would never understand this.

He's really the kind of guy to whom this wouldn't make any sense,

so, you know, it's just between us."

And I said, "Yes, that's fine."

On Sunday of the same conference,

her husband took me aside,

(Laughter)

and he said, "My wife wouldn't think

that I was really much of a guy if she knew this,

but I've been dealing with this depression and I'm taking some medication,

and I wondered what you think?"

They were hiding the same medication

in two different places in the same bedroom.

(Laughter)

And I said that I thought communication within the marriage

might be triggering some of their problems.

(Laughter)

But I was also struck

by the burdensome nature of such mutual secrecy.

Depression is so exhausting.

It takes up so much of your time and energy,

and silence about it,

it really does make the depression worse.

And then I began thinking

about all the ways people make themselves better.

I'd started off as a medical conservative.

I thought there were a few kinds of therapy that worked,

it was clear what they were --

there was medication,

there were certain psychotherapies,

there was possibly electroconvulsive treatment,

and that everything else was nonsense.

But then I discovered something.

If you have brain cancer,

and you say that standing on your head for 20 minutes every morning

makes you feel better,

it may make you feel better, but you still have brain cancer,

and you'll still probably die from it.

But if you say that you have depression,

and standing on your head for 20 minutes every day

makes you feel better, then it's worked,

because depression is an illness of how you feel,

and if you feel better,

then you are effectively not depressed anymore.

So I became much more tolerant

of the vast world of alternative treatments.

And I get letters, I get hundreds of letters

from people writing to tell me about what's worked for them.

Someone was asking me backstage today about meditation.

My favorite of the letters that I got was the one that came from a woman

who wrote and said that she had tried therapy, medication,

she had tried pretty much everything,

and she had found a solution and hoped I would tell the world,

and that was making little things from yarn.

(Laughter)

She sent me some of them.

(Laughter)

And I'm not wearing them right now.

(Laughter)

I suggested to her that she also should look up

obsessive compulsive disorder in the DSM.

And yet, when I went to look at alternative treatments,

I also gained perspective on other treatments.

I went through a tribal exorcism in Senegal

that involved a great deal of ram's blood

and that I'm not going to detail right now,

but a few years afterwards I was in Rwanda,

working on a different project,

and I happened to describe my experience to someone,

and he said,

"Well, that's West Africa, and we're in East Africa,

and our rituals are in some ways very different,

but we do have some rituals

that have something in common with what you're describing."

And he said,

"But we've had a lot of trouble with Western mental health workers,

especially the ones who came right after the genocide."

I said, "What kind of trouble did you have?"

And he said, "Well, they would do this bizarre thing.

They didn't take people out in the sunshine

where you begin to feel better.

They didn't include drumming or music to get people's blood going.

They didn't involve the whole community.

They didn't externalize the depression as an invasive spirit.

Instead what they did was they took people one at a time into dingy little rooms

and had them talk for an hour

about bad things that had happened to them."

(Laughter)

(Applause)

He said, "We had to ask them to leave the country."

(Laughter)

Now at the other end of alternative treatments,

let me tell you about Frank Russakoff.

Frank Russakoff had the worst depression perhaps that I've ever seen in a man.

He was constantly depressed.

He was, when I met him,

at a point at which every month, he would have electroshock treatment.

Then he would feel sort of disoriented for a week.

Then he would feel okay for a week.

Then he would have a week of going downhill.

And then he would have another electroshock treatment.

And he said to me when I met him,

"It's unbearable to go through my weeks this way.

I can't go on this way,

and I've figured out how I'm going to end it

if I don't get better."

"But," he said to me, "I heard about a protocol at Mass General

for a procedure called a cingulotomy, which is a brain surgery,

and I think I'm going to give that a try."

And I remember being amazed at that point to think that someone

who clearly had so many bad experiences

with so many different treatments

still had buried in him, somewhere, enough optimism

to reach out for one more.

And he had the cingulotomy, and it was incredibly successful.

He's now a friend of mine.

He has a lovely wife and two beautiful children.

He wrote me a letter the Christmas after the surgery,

and he said,

"My father sent me two presents this year,

First, a motorized CD rack from The Sharper Image

that I didn't really need,

but I knew he was giving it to me to celebrate

the fact that I'm living on my own and have a job I seem to love.

And the other present was a photo of my grandmother,

who committed suicide.

As I unwrapped it, I began to cry,

and my mother came over and said,

'Are you crying because of the relatives you never knew?'

And I said, 'She had the same disease I have.'

I'm crying now as I write to you.

It's not that I'm so sad, but I get overwhelmed,

I think, because I could have killed myself,

but my parents kept me going, and so did the doctors,

and I had the surgery.

I'm alive and grateful.

We live in the right time, even if it doesn't always feel like it."

I was struck by the fact that depression

is broadly perceived to be a modern, Western, middle-class thing,

and I went to look at how it operated in a variety of other contexts,

and one of the things I was most interested in

was depression among the indigent.

And so I went out to try to look

at what was being done for poor people with depression.

And what I discovered is that poor people

are mostly not being treated for depression.

Depression is the result of a genetic vulnerability,

which is presumably evenly distributed in the population,

and triggering circumstances,

which are likely to be more severe for people who are impoverished.

And yet it turns out that if you have a really lovely life

but feel miserable all the time,

you think, "Why do I feel like this?

I must have depression."

And you set out to find treatment for it.

But if you have a perfectly awful life,

and you feel miserable all the time,

the way you feel is commensurate with your life,

and it doesn't occur to you to think,

"Maybe this is treatable."

And so we have an epidemic in this country

of depression among impoverished people

that's not being picked up and that's not being treated

and that's not being addressed,

and it's a tragedy of a grand order.

And so I found an academic

who was doing a research project in slums outside of D.C.,

where she picked up women who had come in for other health problems

and diagnosed them with depression,

and then provided six months of the experimental protocol.

One of them, Lolly, came in,

and this is what she said the day she came in.

She said, and she was a woman, by the way, who had seven children.

She said, "I used to have a job but I had to give it up

because I couldn't go out of the house.

I have nothing to say to my children.

In the morning, I can't wait for them to leave,

and then I climb in bed and pull the covers over my head,

and three o'clock when they come home,

it just comes so fast."

She said, "I've been taking a lot of Tylenol,

anything I can take so that I can sleep more.

My husband has been telling me I'm stupid, I'm ugly.

I wish I could stop the pain."

Well, she was brought into this experimental protocol,

and when I interviewed her six months later,

she had taken a job working in childcare

for the U.S. Navy, she had left the abusive husband,

and she said to me,

"My kids are so much happier now."

She said, "There's one room in my new place for the boys

and one room for the girls,

but at night, they're just all up on my bed,

and we're doing homework all together and everything.

One of them wants to be a preacher,

one of them wants to be a firefighter,

and one of the girls says she's going to be a lawyer.

They don't cry like they used to,

and they don't fight like they did.

That's all I need now, is my kids.

Things keep on changing,

the way I dress, the way I feel, the way I act.

I can go outside not being afraid anymore,

and I don't think those bad feelings are coming back,

and if it weren't for Dr. Miranda and that,

I would still be at home with the covers pulled over my head,

if I were still alive at all.

I asked the Lord to send me an angel,

and He heard my prayers."

I was really moved by these experiences,

and I decided that I wanted to write about them

not only in a book I was working on, but also in an article,

and I got a commission from The New York Times Magazine

to write about depression among the indigent.

And I turned in my story,

and my editor called me and said, "We really can't publish this."

And I said, "Why not?"

And she said, "It just is too far-fetched.

These people who are sort of at the very bottom rung of society

and then they get a few months of treatment

and they're virtually ready to run Morgan Stanley?

It's just too implausible."

She said, "I've never even heard of anything like it."

And I said, "The fact that you've never heard of it

is an indication that it is news."

(Laughter)

(Applause)

"And you are a news magazine."

So after a certain amount of negotiation, they agreed to it.

But I think a lot of what they said was connected in some strange way

to this distaste that people still have for the idea of treatment,

the notion that somehow if we went out

and treated a lot of people in indigent communities,

that would be exploitative,

because we would be changing them.

There is this false moral imperative that seems to be all around us,

that treatment of depression,

the medications and so on, are an artifice,

and that it's not natural.

And I think that's very misguided.

It would be natural for people's teeth to fall out,

but there is nobody militating against toothpaste,

at least not in my circles.

People then say,

"But isn't depression part of what people are supposed to experience?

Didn't we evolve to have depression?

Isn't it part of your personality?"

To which I would say, mood is adaptive.

Being able to have sadness and fear

and joy and pleasure

and all of the other moods that we have, that's incredibly valuable.

And major depression

is something that happens when that system gets broken.

It's maladaptive.

People will come to me and say,

"I think, though, if I just stick it out for another year,

I think I can just get through this."

And I always say to them, "You may get through it,

but you'll never be 37 again.

Life is short, and that's a whole year you're talking about giving up.

Think it through."

It's a strange poverty of the English language,

and indeed of many other languages,

that we use this same word, depression,

to describe how a kid feels when it rains on his birthday,

and to describe how somebody feels the minute before they commit suicide.

People say to me, "Well, is it continuous with normal sadness?"

And I say, in a way it's continuous with normal sadness.

There is a certain amount of continuity,

but it's the same way there's continuity

between having an iron fence outside your house

that gets a little rust spot

that you have to sand off and do a little repainting,

and what happens if you leave the house for 100 years

and it rusts through until it's only a pile of orange dust.

And it's that orange dust spot,

that orange dust problem,

that's the one we're setting out to address.

So now people say,

"You take these happy pills, and do you feel happy?"

And I don't.

But I don't feel sad about having to eat lunch,

and I don't feel sad about my answering machine,

and I don't feel sad about taking a shower.

I feel more, in fact, I think,

because I can feel sadness without nullity.

I feel sad about professional disappointments,

about damaged relationships,

about global warming.

Those are the things that I feel sad about now.

And I said to myself, well, what is the conclusion?

How did those people who have better lives

even with bigger depression manage to get through?

What is the mechanism of resilience?

And what I came up with over time

was that the people who deny their experience,

and say, "I was depressed a long time ago,

I never want to think about it again,

I'm not going to look at it

and I'm just going to get on with my life,"

ironically, those are the people who are most enslaved by what they have.

Shutting out the depression strengthens it.

While you hide from it, it grows.

And the people who do better

are the ones who are able to tolerate the fact that they have this condition.

Those who can tolerate their depression are the ones who achieve resilience.

So Frank Russakoff said to me,

"If I had a do-over, I suppose I wouldn't do it this way,

but in a strange way, I'm grateful for what I've experienced.

I'm glad to have been in the hospital 40 times.

It taught me so much about love,

and my relationship with my parents and my doctors

has been so precious to me, and will be always."

And Maggie Robbins said,

"I used to volunteer in an AIDS clinic,

and I would just talk and talk and talk,

and the people I was dealing with weren't very responsive, and I thought,

'That's not very friendly or helpful of them.'"

(Laughter)

"And then I realized,

I realized that they weren't going to do more

than make those first few minutes of small talk.

It was simply going to be an occasion

where I didn't have AIDS and I wasn't dying,

but could tolerate the fact that they did

and they were.

Our needs are our greatest assets.

It turns out I've learned to give all the things I need."

Valuing one's depression does not prevent a relapse,

but it may make the prospect of relapse

and even relapse itself easier to tolerate.

The question is not so much of finding great meaning

and deciding your depression has been very meaningful.

It's of seeking that meaning and thinking, when it comes again,

"This will be hellish, but I will learn something from it."

I have learned in my own depression

how big an emotion can be,

how it can be more real than facts,

and I have found that that experience

has allowed me to experience positive emotion

in a more intense and more focused way.

The opposite of depression is not happiness,

but vitality,

and these days, my life is vital,

even on the days when I'm sad.

I felt that funeral in my brain,

and I sat next to the colossus at the edge of the world,

and I have discovered something inside of myself

that I would have to call a soul

that I had never formulated until that day 20 years ago

when hell came to pay me a surprise visit.

I think that while I hated being depressed

and would hate to be depressed again,

I've found a way to love my depression.

I love it because it has forced me to find and cling to joy.

I love it because each day I decide,

sometimes gamely,

and sometimes against the moment's reason,

to cleave to the reasons for living.

And that, I think, is a highly privileged rapture.

Thank you.

(Applause)

Thank you.

(Applause)