THIS BOOK BEGAN as a suicide note. But the essayist and critic George Scialabba did not, ultimately, use it as a farewell to the world. “I was, fortunately, too exhausted and disorganized to plan a suicide, much less compose an elegant rebuke to an uncaring world,” he writes.

Instead Scialabba transformed his note into How To Be Depressed, a slim memoir-cum-medical-journal that recounts his four-decade experience with depression.

The physical or mental causes of depression still evade definitive analysis. But Scialabba argues that economic conditions can certainly exacerbate existing depression or trigger someone into a depressive episode. In one of its guises, depression makes people feel worthless, in both the cultural and economic senses. Unemployment can move someone from “the merely miserable” into actual, clinical depression.

The recent coronavirus pandemic that brought unemployment claims to record numbers has thrown this vulnerability into sharp relief. Worries over mental health have skyrocketed; the Washington Post reported that the pandemic has caused a “historic” rise in mental health issues. So, in this sense, depression is indeed an economic issue; as Scialabba wryly notes, one’s susceptibility to depression, like the skills and talents one may have at birth, are apportioned largely at random.

Suffering exists, and will exist. Money, however, and our ability to use it to ameliorate that suffering, is not random and can be directed where it is needed. Better mental health services, or a wider social safety net, might have ameliorative effects on people balanced on the edge. The suffering of many caused by depression, diagnosed or otherwise, “would also have been lessened by crumbs of that wealth”; transferred to the “already rich” over the last four decades. Scialabba’s own life is testament to that; although he remained generally consistently employed, he has never been financially secure, a concern that has only grown over his years of treatment.

How To Be Depressed opens with an essay called “Message from Room 101,” that room in Orwell’s Nineteen Eighty-Four that contains your deepest fear, the fear you would wish upon another to avoid yourself. But for those with depression, you cannot avoid it. Depression will come, as a weight, or as a feeling of life draining away, or as a writhing sort of pain, and you are back in Room 101. Scialabba resorts to classic literary depictions of depression to explain how it feels; his models are Kay Jamison, Kate Millett, William Styron, and William James.

All are vivid portrait artists. Jamison felt her life was “bloodless, pulseless, and yet present enough to allow a suffocating horror and pain. All bearings are lost; all things are dark and drained of feeling.” Styron called it a “fiercely over-heated room. And because no breeze stirs this cauldron, because there is no escape from this smothering confinement, it is entirely natural that the victim begins to think ceaselessly of oblivion.” Not just think it, in some cases; as Scialabba suggests, sometimes to actively wish for oblivion.

Styron’s metaphor works in two ways. A victim feels trapped within the body, as in a closed room; you feel separated from your physical self that in certain extreme cases can result in a kind of disassociation. But at the same time, you also feel closed off from everyone else as well. For Scialabba, James’s description is most fitting; depression is a “positive and active anguish, a form of psychical neuralgia.” It is also, as someone once said about the experience of starting a family, both totally individual and completely cliché. The pain is thoroughly unique, and you cannot believe that anyone else has experienced it, or that it will ever end, although you know both to be true.

But the literary analysis soon ends; Scialabba does not mean to simply add yet another personal account. During a depressive episode, the pain takes over completely and makes it difficult to process what is happening, much less describe it. But when the episode ends, the brain compensates and tries to take control by describing that experience and and normalizing it. Deception, of oneself and others, is perhaps inevitable.

Instead, Scialabba lets diagnosis take center stage. The book’s longest section, “Documentia,” and its most distinctive feature, is not in Scialabba’s own voice. The section contains more than four decades’ worth of therapist and medical reflections, the actual notes written from 1969 to 2016.

Scialabba is initially referred to a therapist in 1969 as a “courtesy” shortly after his graduation from Harvard. Over the decades, we see him cycle through a series of them, the notes serving, as he puts it, as a “bill of lading” for this merchandise of a human psyche they are trying to understand and repair. By 2005, he is having yet another episode, this one perhaps one of the worst, and is prescribed electroconvulsive treatment. It seems to work, though no one knows why. Then it is back to antidepressants in 2007; over the years, he is prescribed more than a dozen different drugs. In 2016, glaucoma and the loss of sight in one eye trigger another relapse; the doctor reports that Scialabba “feels his life is over.” Finally, Scialabba retires after working for 35 years: one life in a hundred pages.

The onset of depression seems to have been caused by his decision to leave Opus Dei, a Catholic religious group, and eventually to leave the Church and religious faith altogether. The first entry records that Scialabba “comes with very intense questions regarding Catholicism,” and the significance of this break to his mental health comes up again and again through the 1970s and 1980s. A doctor recounts that Scialabba “feels he has been paralyzed emotionally and intellectually ever since he broke with his Catholic faith and left Opus Dei to study intellectual history.” By 1991, the notes record that Scialabba “all of this began” after he left Opus Dei and the anxiety that caused has never quite gone away.”What Scialabba himself thinks of the connection between his loss of faith and his depression comes through only indirectly; he attributes the psychological earthquake his loss of faith caused to a combination of factors, including genetics, what he calls a lack of emotional or mental shock absorbers supple enough to handle trauma or catastrophic life events.

In a “Conversation About Depression” included here, Scialabba acknowledges his religious break was important, but it was followed by another shock. Opus Dei enabled him to engage intellectually, as a way out of his relatively uneducated family background. But he found too high a demand was placed on “orthodoxy and lack of investigation,” as that 1969 report has it. Scialabba thought perhaps becoming a priest would be a “way of connecting with a cosmopolitan organization.”

When he lost his faith, however, he was still comforted. Having gone to college, unlike his parents, he saw intellectual stimulation could be found outside religion. “I thought […] I would be placing myself in the ranks of a great army of liberation going all the way back to the first modern philosophers,” going back to the Enlightenment. But there was a catch: once the scaffolding fell away the liberation lasted only so long, and the withdrawal he felt “was one of agitation and anxiety.” The consolations of D. H. Lawrence’s paganism, the tradition with which Scialabba says he now most closely identifies, were insufficient recompense.

A person suffering from depression does not choose “how” to be depressed. The feeling simply comes in like a tide, washing your vision with a filter that renders everything you see not quite clear — Styron’s locked room again. But once you have lived with depression, one indeed has to choose “how” to live it. Scialabba chose a particular path, selecting relatively routine jobs and maintaining his literary life. Regular teaching or academic scholarship was, it seems, too much.

The book ends with Scialabba’s own advice for depressives. In contrast to the political and economic themes set forth in the earlier sections and the clinical diagnoses of the documentia, this last chapter is personal, with deeply compassionate advice both to the suffering and those who live with and care for them. Friends, food, water, rest, exercise, caregivers, and reading are ways to take control, and if all else seems lost, remember what he calls a truth “close to a scientific certainty; depressions virtually always end.”

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Gerald Russello is editor of The University Bookman.