Sunday, September 17, 2017

Book review: "The Noonday Demon" by Andrew Solomon

As an undergraduate, I had dreamed of being a writer so accomplished that students there would study my work. But when I hatched that fantasy, I didn't envision the work as a memoir assigned in an Abnormal Psych course. (From the Epilogue, p. 445)

Andrew Solomon, resembling a cross between Tobey Maguire and Sheldon from bad sitcom The Big Bang Theory, is a tremendous public speaker and storyteller. He is somewhat of a regular on the Ted talk circuit. You can hearing him holding forth on adversity and identity, as well as parenthood. One of his most interesting talks concerns depression. This talk is a primer for his much more in-depth treatment of this topic in "The Noonday Demon", a modern classic on the subject.

Solomon discusses his own experience of depression in depth, giving a sometimes poetic description of the phenomenology of his depression, and describing clearly how his level of activity was drastically reduced. He gives a warts-and-all account, describing not only his suicidal ideation but also how distorted thoughts led to self-destructive behaviour that must have seemed illogical to Solomon himself with hindsight. A memorable aspect of these accounts is his fear of relapse, and how he seemed to predict one relapse following a physically painful accident (whether it was a self-fulfilling prophecy, we cannot say).

In discussing depression, Solomon highlights the confusion in how we discuss body and mind (e.g. how a "chemical depression" can make some patients feel that it's not their fault, as if it would be their fault were it more "purely" psychological). He follows this controversy and confusion over the mind-body problem back to the days of Ancient Greece, when the more medical model of Hippocrates contrasted with the views of Plato and Socrates, with Aristotle taking the view of a closer interaction between the body and mind.

In a similar vein, when Solomon moves on to the subject of treatment, he wastes no time in attacking a duality between talk therapy "versus" pharmacological treatment. He touches on this in his own continuing use of pharmacological treatment to avoid relapse, where he feels that there is some pressure to come off medication now that he is better. Although no simple cheerleader for dualism himself, to some extent Solomon needs to find some way of distancing from his own experience of severe clinical depression, initially describing it as something outside of himself; indeed, his cross-cultural experiences of depression lead him to praise traditional approaches to treatment that externalise  depression by linking it to spirits. Nonetheless, he also harks back to days when it felt the depression may have always been there in the background, waiting to be triggered

The mind-body relationship appears again in Solomon's investigation into the politics of mental health. From meetings in the USA's halls of power, he notes the bipartisan support for funding in mental health. However, as the book was originally published just a few years after the 1996 Mental Health Parity Act, he points the history of differing health insurance policy with regard to mental compared to physical health. Politics again rears its heads in the issue of poverty and depression. Solomon does not shy away from the role that poverty can play in precipitating depression (and childhood abuse, though hardly unique to poorer people, seems to be a recurring theme on this point). Nonetheless, Solomon is also a champion of individual treatment of depression in poorer patients (although what treatments they can/will afford is another issue...)

In discussing suicide within a book about depression, it is positive that Solomon highlights that many suicidal people do not have depression and vice versa. It is on this topic that he is perhaps at his most confessional, outlining how he helped his mother in assisted suicide. Suicide throws up thorny ethical questions about self-determination (as does the question of involuntary institutionalisation), and although Solomon offers an even-handed view he is not afraid to grasp some of these nettles.

Although this book is authoritative in its research and brave in its exposition, it is flawed. Some aphorisms don't come off quite so strong: Solomon prefaces some statistics with " is a mistake to confuse numbers with truth" (mind = blown, man). Notwithstanding that the book was written over 15 years ago, it seems a bit off that exercise is listed as an "alternative" treatment for depression when religion is in the same chapter (on mainstream treatment) as psychotherapy and psychopharmacology. As for listing homeopathy as a "serious" alternative-Jesus wept. Nonetheless, Solomon is at pains not make empty promises about relief from depression. He is clear that every treatment out there will work for some people but not others, and he warns that relapse is always a possibility.

Indeed, in a new epilogue, included in the 2015 edition, Solomon maintains that a relapse could always be on the horizon for him, though he seems arguably more accepting about it now, feeling that recovery will follow relapse. Solomon updates his account of treatment with an outline of the grandchildren of electroconvulsive therapy, including more precise methods such as transcranial magnetic stimulation and even more precise (though highly invasive) methods such as deep brain stimulation-the development of which (including setbacks and ongoing uncertainty) is laid out with great narrative drive. He also follows up people he interviewed for the main text of the book, and discusses whether stigma surrounding depression (and the treatment thereof) has changed; well-known reactionary Irish journalist John Waters comes in for a (less than glowing) mention here.

This is a sprawling overview of a deeply complex topic, that goes some way towards conveying how depression is different for everyone it touches, yet still places it within a broader social and political context. I would highly recommend it to anyone looking for a reasonably accessible book on this subject, as long as they are willing to sit with this subject for some time.

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Stigma "goes meta"

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