December 15, 2008
The Depression Procession
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. (1)
Emily Dickinson captures in the above poem the feeling of pain within her mind. This pain could be a physical reality—in the form of a migraine or other throbbing headache, as suggested by the beating drum imagery; the pain could be a figurative reality—as psychological pain that has created a sense of mind-numbing “beating, beating;” or the pain could encompass both the physical and psychological—as one pain can cycle and create the other. The speaker of the poem witnesses the funeral and recognizes the pain she should feel, yet still feels her mind going “numb;” she may recognize that the “heavens were a bell,” yet only experiences silence. Frustration emerges, as the speaker wants to feel more, thinks she should feel more—yet in the end feels only “wrecked, solitary, here.”
Like Dickinson, writer Andrew Solomon describes the frustration and powerlessness of his depression:
With the depression, your vision narrows and begins to close down. It is like trying to watch TV through terrible static, where you can sort of see the picture but not really; where you cannot ever see people's faces, except almost if there is a close-up; where nothing has edges. The air seems thick and resistant, as though it were full of mushed-up bread. Becoming depressed is like going blind, the darkness at first gradual, then encompassing; it is like going deaf, hearing less and less until a terrible silence is all around you, until you cannot make any sound of your own to penetrate the quiet. (2)
Solomon goes on to describe his depression as a sort of personal death, as he felt dead to and disconnected from the world. He might understand Dickinson’s funeral, then, as a funeral for himself—as he remains buried, isolated and separate from the world. Solomon writes, “There was a sadness and a terrible loneliness as I contemplated what was lost. … Daphne Merkin wrote in a confessional essay on her own depression, 'Would people mourn me if I never returned, never took up my place again?'” (2).
Whether narrating a vision of another’s funeral or her own, Dickinson has captured the internal turmoil and isolation often associated with depression—turmoil and isolation shared by writers like Solomon. Dickinson suggests, too, that this depression is a process in her brain, with an almost mechanical motion to it: the pain is part of a funeral procession, a service proceeds to the beat of a drum, a casket is lifted and carried, the procession proceeds, the procession ends at the burial; yet despite the procession, even with its implied parade of people, she remains “wrecked, solitary, here.” Although Dickinson wrote her poem over 150 years prior to research into the mechanisms at work in the brain during depression, her description of this procession in the mind, which results in little satisfying fruit for the observer, is an apt metaphor.
In our culture a funeral is generally an event for a prescribed, relatively short amount of time; one attends the funeral, feels appropriate emotions of sadness and mourning, finds empathy in fellow mourners, and when over, ideally emerges more ready to live in the world without the presence of the deceased. The funeral provides a pause and bridge from the past, to the present, to the future. Like the funeral, the brain’s actions during depression have value and use: to suggest a pause, as the person withdraws from his or her environment, retreats into the therapy of sleep and rest, considers fitness for certain pursuits, and considers how to proceed in light of the loss and struggle which precipitated the depressive state (3). While the depressed feelings “perpetuate misery” as a person’s feeling of helplessness or fear continue, just as a mourner’s feelings of sadness peak at a funeral, the depressive state may serve, usefully, to prevent further hardship or harm. Psychiatrist Randolph Nesse writes, “when depression is instead seen as a state shaped to cope with unpropitious situations, it is clear how it could be useful, both to decrease investment in the current unsatisfying life enterprise and also to prevent the premature pursuit of alternative” (3).
As a funeral and associated mourning last for a relatively short period of time, so too should a depressive episode last for a defined time—enough time for the necessary changes and alterations of course to take place in one’s life. At times, however, the depressive episode cycles on, further and further removed from the event that may have originally precipitated it. As Dickinson’s funeral cycles forever on in the space of her poem, so does the funeral seem to cycle forever on in the mind of the depressed person—leaving the person feeling ever more “wrecked” and “solitary.”
In Mind Wide Open, Stephen Johnson offers some explanation for how or why the brain might remain in the depression cycle:
The brain’s architecture is designed in such a way that it does not play emotional devil’s advocate. When you’re filled with happiness and good cheer, your memory system doesn’t remind you of that upcoming tax filing or your fear of getting fired from your job… The brain doesn’t do checks and balances… These self-perpetuating cycles partially explain why being happy is so much fun, and why depression can be so devastating. Severely depressed people have to be reminded actively that there are good things in their life; happy memories just don’t pop into their minds the way they do in the minds of nondepressed people. This can be the case even if the stimulus that began the depressive cycle was fleeting, or altogether illusory. (10)
Johnson further theorizes that this same tendency in the brain towards over simplified and perhaps excessive reaction to emotional stimulus results from the brains “incestuous amplification,” where it seeks only those processes and emotions that encourage its current trajectory (10). When the brain is cycling through a healthy or productive process, such a niche would be quite beneficial—keeping the mind and body on course despite distractions and setbacks along the way. When the brain begins to cycle in the depressive state, however, the task for the person experiencing the depression would then become to redirect the brain, to move it towards a more positive and outwardly productive cycle.
When the mind’s depressive response continues to cycle, now far removed from a cause that may have healthily precipitated the first depressed feelings, a serious, even pathological depression can arise. Nesse identifies a lack of kin, beliefs, and rituals which “routinely extracted our ancestors from such cycles,” as one possible culprit for the continuation of a harmful, depressive cycle (3). Nesse is careful to emphasize that although low mood and negative feelings have useful applications, “many depressions are clearly disease states: some caused by dysregulations of negative affect and others by brain defects unrelated to low mood” (3).
In responding to depression, then, it is first necessary to understand whether the depressed feelings are a natural and healthy response to a situation, or are the result of an unhealthy and unproductive cycle within the brain. Is the brain merely attending the funeral, and likely to emerge in a short time ready to move forward, or is the brain locked into the funeral procession, as Dickinson’s speaker is forever locked into the funeral in her poem? In the case of the latter, pathological form of depression, an initially healthy and appropriate cycle remains in play, even as it cycles on in an inescapable and unhealthy manner.
Recent brain imaging has revealed more insight into the complex process at work in the brain during a depressive state, suggesting, like Dickinson’s poem, a procession of events. A “network” model of depression “incorporates neurochemistry into the concept of the brain as a circuit board or wiring diagram” (4). This approach focuses on pathways at work in depression, and invites various treatments for the unending cycle: pharmacological, electrical, surgical, or talk therapies—treatments which will connect with various parts of the circuit board.
Researchers have identified “abnormal patterns of activity in a network that includes limbic areas (a cluster of evolutionary older brain areas around the top of the brain stem), which control basic emotions and drives like fear, lust and hunger, and the newer cortex and subcortex responsible for thought, memory, motivation and reward” (4). More specifically, researchers found increased activity in “Area 25,” a part of the brain closely aligned to “fear, learning, memory, sleep, libido, motivation, reward, and other functions that went fritzy in the depressed” (4).
Dr. Helen Mayberg, a neurologist who investigates the neural network underpinnings of depression observes: “most people think of depression as a deficit state … You’re low, you’re negative. But in fact, talk to a depressed person, and you have this bizarre combination of numbness and what William James called ‘an active anguish.’ ‘A sort of psychical neuralgia,’ he said, ‘wholly unknown to healthy life.’ You’re numb but you hurt. You can’t think, but you are in pain” (4). Mayberg’s research suggests that the root of the pain is in the “neural circuit run amok”—an active process—a never ending funeral procession, perhaps—that needs to be recognized and prodded back toward a healthy course for successful treatment.
The depression procession does not appear to be uniform for all patients, as reflected in the difficulty in treating the disorder. Where one therapy works for a patient, it may not work for another. Brain imaging, which has helped researchers to understand the processes of depression, also allows researchers to understand the particular permutations of the process in each brain (5). Dr. Mayberg’s work, for example, has shown that the depression pathway appears different in the brain of a patient who responds favorably to antidepressants than it does in a patient who responds well to talk therapies. Attention to the particular procession of depression in a brain, then, will inform the targets and mechanisms of its treatment.
Dr. Kelly Lambert has investigated the neural processes involved in depression, and has suggested that depression may arise when certain systems and processes in the brain are under exercised (6, 7). Lambert theorizes that as our lives have become less active externally, making certain parts of our brain less active internally, so has the depressive process increased within a brain wired for more activity. She particularly highlights an “effort-driven rewards” mechanism in the accumbens-striatal-cortical network of the brain. Lambert writes, “because of the interconnectivity of the brain areas that control movement, emotion and thinking, doing activities that involve a number of these components fully engages the effort-driven-rewards circuit” (6). As that circuitry remains active, “neural connections are strengthened and reinforced, and neurogenesis—an important factor in recovering from depression—is stimulated” (6). When that circuitry falls passive, one’s ability—or at least one’s perception of his or her ability—to engage the environment diminishes as well, leading towards the introduction of the depressive process rather than the “effort-driven rewards” process.
Rather than attacking the depression process directly, Lambert’s research highlights more the power of activating alternate processes within the brain, which may in turn overpower the depressive process and prevent future cycles of the depressive state. To extend Lamerbt’s model to the un-ending funeral metaphor, perhaps Lambert’s vision is to strengthen in the brain those processes which encourage positive and productive emotions, so that when the funeral procession starts, it cannot become the primary work of the brain, but will eventually yield to the more productive and satisfying “effort-driven-rewards” pathway. Lambert calls both for activity on the part of the patient in combating depression, and for additional research into the neural basis for depression and the roles that neurogenesis and neural connections play in its treatment. She seeks a depression story that encompasses the integrated functioning of the brain. Furthermore, Lambert seeks a solution to depression from within the brain itself.
Recent brain imaging studies have further revealed that people prone to depression, or depressive cycles that lapse beyond reasonable control, may have circuitry particularly sensitive to the unending funeral (11). In depression-prone brains, a drug-induced decrease in dopamine and norepinephrine resulted in increased activity in a depression-related brain circuit; in contrast, brain activity in the same area decreased or remained the same in those patients whose mood varied little even with the same depletion in dopamine (11). This suggests that the brains of those who experience severe depression are more sensitive than those that less easily fall into the cycles.
Additional brain imaging has suggested that in general, as activity increases in those areas which regulate emotional response, activity decreases in the emotional response areas of the brain, so that the brain is able to control its emotional response (12). By contrast, in the brains of depressed individuals, high activity in the emotional regulation areas does not lead to a decrease in emotional response; activity remains high in the emotional response area, too, so that the regulation effort has little to no effect. The researchers report that non-depressed individuals “are able to effectively regulate their negative emotions through conscious effort, but that the necessary neural circuits are dysfunctional in many patients with depression” (12). The acutely sensitive mind, then, remains in its depressive cycle, unresponsive, even ignoring, the signals to end the cycle. This evidence resonates with both Mayberg’s and Lambert’s theories: that depression is the result of active processes, and that the brain can, in fact, regulate these cycles.
As depression is approached as a process within the brain, less reliance on medication alone for its treatment will likely arise. Drug company marketing often suggests that depression arises from a “chemical imbalance;” but no definitive evidence points to a particular or specific chemical imbalance, whether of serotonin or other neurotransmitter, as the primary cause of depression (4, 8). While antidepressant drugs are helpful in alleviating depression in some patients, the success is likely due to their interaction in the overall process of depression, rather than as a single fix of an imbalance. Drug therapy may help to treat a specific part of the depression process, but it generally does not address the process in its entirety, and may yield incomplete and unsatisfactory results. Despite drug interactions and altered chemical levels, the depression process remains rooted in the brain, bringing recurring or returning pain along with it.
Writer Andrew Solomon warns of the power of antidepressants to affect the depression process at a single node without properly extinguishing or productively redirecting the circuit. In extreme cases, this hijacked process can result in a suicide precipitated by the antidepressant itself: “Antidepressants are activating. There is a delicate balance between the processes by which they give energy and those by which they ameliorate despair, and sometimes the energizing comes first. When that happens, patients get the verve required for decisive action without getting the feeling that they can beat their problems. The result can be suicide. That is, a patient can go abruptly from wishing he were dead, to wanting to kill himself, to killing himself” (9). Rather than extinguishing the depressive cycle, the antidepressants activate the cycle even more strongly:
When we muck around with brain chemistry, we see strange and subtle effects. The emotional brain is idiosyncratic. Experiences that make one person happy -- the birth of a child, the first day of spring -- may drive another to despair. If events can have such diffuse consequences, so can medications. Most psychoactive drugs provoke paradoxical responses in a limited number of people: stimulants prove sedating, and sedatives make them tense. Anything that is strong enough to bring someone back from the brink of suicide is strong enough to push him there. Serotonin, the neurotransmitter affected by most of the antidepressants on the F.D.A. list, is not a simple happiness compound.. (9)
It follows that the process of depression is varied enough, and the direct targets of drugs unknown enough, that unwanted consequences may arise. Of course, this does not diminish the value of antidepressants in treating successfully a number of patients. But it should add weight to the view of depression as an active process in the brain—one that may start with a purpose, and one that can be unknowingly altered toward either productive or disastrous ends. The brain is at work during depression, and attention to the purpose and mechanism of that work must precede aggressive treatment. Often more effective in creating significant changes within the brain and its processes are talk therapies (8)—which generally approach depression as an ongoing, dynamic process rather than a static imbalance.
The ongoing, dynamic processes of Emily Dickinson’s mind did not leave her forever at the funeral. She also wrote the following poem about the opposite of the funeral’s despair—of hope:
HOPE is the thing with feathers
That perches in the soul,
And sings the tune without the words,
And never stops at all,
And sweetest in the gale is heard;
And sore must be the storm
That could abash the little bird
That kept so many warm.
I ’ve heard it in the chillest land,
And on the strangest sea;
Yet, never, in extremity,
It asked a crumb of me. (13)
In the above poem, Dickinson suggests--despite the presence of a funeral in the soul /brain/ mind of the first poem—that hope remains “perched” and active. The cycling funeral dirge may have drowned out the softer tune of hope; but that tune never stopped, and never even required an active acknowledgement or encouragement to keep it going. Not even asking “a crumb” from the speaker, hope cycles on. While depression can spiral beyond control, so too can hope continue beyond a conscious will. While the brain can remain stuck in its depressive circuit, so too, perhaps, can it move towards a hopeful course. The presence of the depression does not mean the absence of hope—even when that hope seems buried or lost, as Dickinson writes, “in the chillest land, / And on the strangest sea”; nor does the possibility of hope diminish the realty of the despair. But perhaps as we pay more attention to the process of depression in the brain, we can pay attention, too, to the process of hope, so that a person will never remain too long in the one without feeling and returning to the other.
1. Dickinson, Emily. “I felt a funeral in my brain” http://www.bartleby.com/113/4112.html
2. Solomon, Andrew. “I’m not Mad. Or Am I?” 6 May 2001. http://www.noondaydemon.com/imnotmad.html
3. Nesse, “Is Depression and Adaptation?” Archive of General Psychiatry 57 (2000): 14-20.
4. Dobbs, David. “A Depression Switch?” The New York Times. 2 April 2006. http://www.nytimes.com/2006/04/02/magazine/02depression.html?scp=10&sq=depression&st=cse
5. Carey, Benedict. “Lifting the Curtain on Depression. 29 August 2007. http://health.nytimes.com/ref/health/healthguide/esn-depression-ess.html?scp=19&sq=depression&st=cse
6. Lambert, Kelly. “Depressingly Easy.” Scientific American. August/September 2008.
7. Lambert, Kelly. Lifting Depression. New York: Basic Books, 2008.
8. Arkowitz, Hal and Scott Lilienfeld. “The Best Medicine?” Scientific American. October/November 2007. 80-83.
9. Solomon, Andrew. “A Bitter Pill.” The New York Times. 29 March 2004. http://query.nytimes.com/gst/fullpage.html?res=9507EFDF1030F93AA15750C0A9629C8B63&sec=&spon=&pagewanted=all
10. Johnson, Steven. Mind Wide Open. New York: Scribner, 2004.
11. National Institute of Mental Health. “Depression Patients’ Brain Circuitry Makes Them Vulnerable to Relapse.” 1 August 2008. http://www.nimh.nih.gov/science-news/2008/depression-patients-brain-circuitry-makes-them-vulnerable-to-relapse.shtml
12, University of Wisconsin-Madison. "Clinical Depression Linked To Abnormal Emotional Brain Circuits." ScienceDaily 15 August 2007. <http://www.sciencedaily.com /releases/2007/08/070814170746.htm>.
13. Dickinson, Emily. “Hope is the things with feathers.” http://www.bartleby.com/113/1032.html