Why did you write this book?

I’m encountering more and more people over the last few years, particularly post-COVID, who have the perception that the categories we use in psychiatry have a kind of fixed, objective, and quite rigid reality. Twenty years ago, when I started as a GP, I might have seen somebody who said, “I feel anxious all the time,” whereas now I’m more likely to meet somebody who’ll say, “Well, I have generalized anxiety disorder.” That’s a shift in the way that society talks about mental illness. At the same time, a lot of people are questioning these categories’ usefulness, so there’s a paradox—a sort of polarization.

I wanted to write a book which explains, from my perspective, A, how the way we think about mental illness has always been shifting and evolving. How we think about mental illness changes with culture, time, and geography. And B, if we can adopt a more flexible and humble approach to our current understanding, that actually offers more hope to patients. Because believing “I have generalized anxiety disorder,” rather than “I feel anxious,” can sometimes be helpful, but it can also box you in and become self-fulfilled. I’m seeing that same shift across the whole spectrum of mental illness and suffering, and the book is a call to question that and reassess where we’re at in the mid-2020s—and a plea for a little bit more kindness and flexibility.

What would that look like in practice?

For example, if somebody comes to me saying, “Well, I have generalized anxiety disorder, so I can’t do this stuff,” part of my work is to help that patient adopt a more hopeful perspective: that there are strategies that they can learn, that there are medications that can help, and that our mind is shaped by many different influences. There may be explanations for their anxiety that have to do with the brain and neurotransmitters and so on. But in most people, there are also more influential factors that have to do with their early childhood experiences and their current social setup, the precarity of their relationships or their economic situation, the quality of their sleep, or the substandard nature of their housing. There are all sorts of other factors that are having a bearing on their anxiety that I would seek to help them explore, rather than them just blanketly saying, “I have generalized anxiety disorder—can you give me the pill for that?” I’m trying to encourage my patient to say, “Yeah, there are pills that can help. But there are all these other factors that we need to think about. And do I really find that label helpful?” For some people, once you start to dig into it, they don’t.

We can extend that way of thinking to people who’ve had a psychotic episode. Between 10% and 20% of people who have a psychotic episode will never have another. For substantial numbers of people, their psychotic episode is actually a product of all sorts of stressors that are on them at that time. If you can find a way to modify their stressors, put them in a more supported state, and understand what place that episode has in the story of their life, you can then make a story that makes sense of that episode as the product of a uniquely difficult moment in their life. That can help people get over that episode and also, I hope, make it more likely that they don’t have subsequent episodes. Or, if they do, then they’re able to return fully to their normal functioning in between.

You write, “For the last forty years much Western psychiatry has behaved… as if our thinking is a simple matter of chemical levels in the brain. The truth is far more complicated.” For example, a 2023 study you cite challenged the serotonin theory of depression. [1] Why do you think that the chemical imbalance narrative has persisted?

There’s a number of reasons. That hypothesis came through at a time when our lab technology was starting to be able to measure neurotransmitters, and it offered a good story. If you become depressed, you feel as if you’re lacking something—as if you’re lacking some kind of fuel or energy. That lack translates very easily, in our metaphor-making minds, to the idea that there must be some kind of lack between our brain cells.

At the same time that this technology was becoming widespread, there was the promotion of a drug which seemed to help: Prozac. There’s no doubt that SSRIs do make a difference. Again and again, they’re shown to be better than placebo. The effect is probably a lot smaller than a lot of the drug companies would tend to promote in their materials, but they do help, and I continue to prescribe them. But what that study you’re referring to was saying was that, even if these drugs help, they don’t help by boosting serotonin levels. We can’t find evidence that substantiates that theory.

The first half of the 20th century was governed by Freudian ideas. Psychiatry in much of the West was dominated by those kinds of psychoanalytic ideas. Then, during the ’50s and ’60s, as we started to develop tricyclic antidepressants and experiment with other kinds of antidepressants—the first were anti-tuberculosis drugs—the idea grew that there might be a chemical solution, which fit very well into our technologically and pharmaceutically focused medical culture. Then, from the late ’90s, there was a huge explosion of the idea that, actually, a lot of it was genetic.

Now, even the idea that neurotransmitters are strictly excitatory or inhibitory is starting to be questioned. Essentially, the whole picture is vastly more complicated than the neurotransmitter hypothesis from the ’90s suggested. I don’t take that as a great failure of the hypothesis; it was an attempt to make sense of something very complicated, and the drugs that spoke to that metaphor are useful and are still among some of the most widely prescribed in the world. But the fact that we no longer think that low mood is purely because of low serotonin is a really positive step forward. It encourages us to embrace more fully the biopsychosocial approach to mental illness. The field of psychology and psychiatry is not known for consensus, but one thing everybody agrees on is that it’s not just biology, it’s not just psychology, and it’s not just sociology—it’s all these influences that have an effect on our mental health.

Are there other common assumptions about mental illness that you think deserve closer scrutiny?

Every age uses the metaphor of its highest technology to make sense of the mind. In the 19th century, the mind was famously described as an enchanted loom; the mind was thought to be weaving our experience, moment by moment. We’ve now got these very pervasive metaphors of wiring, which I find quite unhelpful because the brain is nothing like a circuit board. It would be like a circuit board made of jelly that can fix itself. So I think the wiring metaphor, although it has its uses, has gone too far because it’s too deterministic. It’s not organic enough.

Half a century ago, Stanford psychologist David Rosenhan wrote, “A psychiatric label has a life and an influence of its own.” To what extent can psychiatric labels help, and to what extent can they hinder?

There’s a lot of controversy about the Rosenhan experiment. [2] He’s been accused of being a charlatan and fabricating quite a lot of his data. But I think the value of his reflections still stands. I’ve definitely seen in my clinical practice that people will be treated differently because of a label that has been put in their notes, even though that label might have changed several times. I’ve had patients who’ve had four or five different labels in the course of their career, while they’ve had actually pretty much the same kinds of experiences and distress throughout all of those.

What I find really helpful in my conversations with patients is the fact that we don’t always have to give a label. If someone is really keen for one, then I’m happy to explore that with them and tell them, “These are the psychiatric categories that are on offer in the current edition of the DSM. Some people find them really useful, but with every new edition of the manual, they change, so they’re not describing something discrete, fixed, or in the natural order of things. They’re a way of describing and approaching distress, so let’s talk about how much they would be helpful for you.”

Now, in the U.S., I understand that labels can be essential because of insurance-based medical payments. In a U.K. context, a label may not be as useful because our psychiatric services are organized differently. I gently explore with each patient how much for them it’s going to be transformative. If it’s going to help ease their suffering and get them the treatments that they want, then I embrace it and help them get the one that fits best. But if it’s not going to be transformative in terms of how they can access care, then I tend to try to avoid giving a label because that can allow a level of optimism and dynamism about their state of mind. It more genuinely reflects the possibility of change and adaptation, rather than risking somebody changing the way they think of themselves.

As human beings, we’ve got such a huge tendency to put shame on one another. What labels seem to do in our current moment is absolve people of that shame in a really helpful way. I’ve had patients say to me, for example, that until they got their diagnosis of ADHD, they felt so ashamed of not being able to focus properly at work, and what that label did was offer a kind of absolution from that shame because it said, “There is this category of being that is separate from you and which seems to be affecting you, but it’s not your fault.” That can be wonderfully liberating. In those kinds of situations, I’m often keen to embrace the label if it’s going to help the patient cast off their shame. But I’m also questioning: Why have we got that shame? Isn’t it a pity that people often feel that they need to embrace a medical diagnostic label in order to rid themselves of that shame?

What strengths do primary care physicians bring to mental healthcare compared to someone more specialized?

One great advantage of somebody in my kind of role is that I’m embedded in the community. I often know the whole family, and I’m seeing people for all kinds of other problems which have a bearing on their mental health. I’ve become more aware of the connections between families and individuals; a specialist only sees the one individual with a particularly distressing problem—for longer appointments, granted, but removed from that context.

There’s a wonderful GP writer in the U.K. called Iona Heath, who has written a lot about the fact that it’s in the primary care consulting room where suffering is either given a label and understood within a medical model, or not. Some people see primary care physicians as essentially holding a line, or acting as some kind of gatekeeper, between the huge mass of human experiences that are out there and which ones become medicalized. A lot of people will come and see me about something fairly banal—almost to try me out, to try and figure out whether I’m going to be kind, compassionate, friendly, or approachable. Once they’ve tried me with a symptom that they’re not too fussed about, then they’ll risk sharing the one that they’re really worried about.

As a primary care physician, I feel I have a very privileged role: You’re not part of the family, but you’re not part of the establishment—you’re somewhere between the two. I’m often the first port of call for people hoping to make sense of their experience.

One line from your book that struck me: You write that today’s DSM categories will one day “seem as overconfident as the old phrenology charts.” How literal or hyperbolic do you mean that comparison to be?

Phrenology was debunked about 130 years ago. By the late 19th century, it was already starting to lose its traction because good thinkers were realizing it was a load of rubbish. If I could fast forward to 2176 and ask the doctors of that time what they’ll make of the DSM-5, I don’t think they would see it as phrenology, but they would certainly see it as utterly obsolete and unhelpful to them because it’s a cultural document of the West in the early 2000s. We can’t imagine what Western culture is going to look like in 2176. I’d argue that it’s quite likely that it will be very different from our current culture, that our neuroscience and genetics will have progressed in huge leaps and bounds, and that the organization of our society—while it may not have progressed—will have changed utterly. The DSM-5 will be of purely historical interest. When I was born in the ’70s, they were using the DSM-II, which is now considered very much a historical document—and that’s within my lifetime. I’m hopeful that the DSM-6, if and when it ever appears, is going to be an improvement on the DSM-5.

What inspired the book’s title?

From my chair in the clinic, I don’t see people’s minds as brittle and fragile. I see people as immensely resourceful, resilient, adaptive, and dynamic. People are incredible; they always amaze me with their ability to get over even the most extraordinary difficulties, suffering, and traumas. In my seat, I see the mind as far more unfragile than a lot of the rhetoric in our culture suggests.

The Unfragile Mind: Making Sense of Mental Health
Gavin Francis
Publisher: The Experiment, New York. 2026. 256 pages.

[1] Moncrieff, J., Cooper, R. E., Stockmann, T., Amendola, S., Hengartner, M. P., & Horowitz, M. A. (2023). The serotonin theory of depression: A systematic umbrella review of the evidence. Molecular Psychiatry, 28, 3243–3256. 
https://doi.org/10.1038/s41380-022-01661-0

[2] In the 1970s, Rosenhan and eight pseudo-patients feigned auditory hallucinations to gain admission to a dozen psychiatric hospitals across the U.S. Once inside, Francis writes, they “declared themselves free of the hallucinated noises, but found it very difficult to be believed, and be discharged” (p. 47).

Web image created from book cover by Medhum.

Daudet tried all sorts of therapy, including mashed bulls’ testicles and elixir of guinea pig. Nothing worked, with the exception of large quantities of morphine and chloral hydrate, which made his life bearable. Daudet also coped with his intractable pain by writing about it. He planned to write a complete memoir of his life with pain, but by the time of his death in 1897, he hadn’t gotten farther than 60-odd pages of notes and reflections. About twenty-five years ago, the English author Julian Barnes translated and collected these fragments into a small jewel of a book called In the Land of Pain.¹

The title is illustrative. Those who suffer from chronic pain live in a different country from the healthy, and they gradually find themselves speaking a language that others don’t understand. At first, Daudet introduces details of his discomfort into conversation but soon realizes how repetitive and boring this is to his friends. “Pain is always new to the sufferer,” he writes, “but loses its originality for those around him. Everyone will get used to it, except me.” (p. 19) Daudet finds himself living in a land where suffering is pervasive, “Pain finds its way everywhere, into my vision, my feelings, my sense of judgment; it’s an infiltration.” (p.23) Toward the end he writes, “I’ve passed the stage where illness brings any advantage or helps you understand things; also, the stage where it sours your life, puts a harshness in your voice, makes every cogwheel shriek.” (p. 65)

Although Daudet was not known as a poet, many of these presumably random notes are, in fact, miniature poems. Consider this example: “In the dining room: the man who quite suddenly finds himself unable to read the menu. His wife bursts into tears and leaves the table…” (p. 63) And here is another: “The hotel. The bell-board. The bath times. / Solitude. / Encroaching darkness.” (p. 65)

One of the more depressing aspects of medicine today is the fact that many doctors are still “very poor at discerning things,” at least when it comes to pain. I get a knot in the pit of my stomach whenever I hear a resident discussing whether a patient’s pain is “real” or “imaginary,” or making a cynical comment about drug seeking behavior, especially when the resident herself has prescribed a grossly inadequate course of analgesia. Some of my colleagues believe that a person has to be visibly anguished before they take seriously his reported experience of severe pain. And others get exasperated with patients who describe having more pain than their condition (according to the doctor) warrants, and tell them, “You’re overreacting,” or “It’s all in your head.” When I hear this, I want to shake the physician by their shoulders and yell, “Of course it is! All pain, no matter what causes it, exists in the head. Where else could the experience be generated?”

In the Land of Pain illustrates that chronic pain sufferers can live calm, productive lives despite constant agony. Daudet continued writing, publishing, and socializing until the end of his life, even though he wrote, near the beginning of his journal, “My friends, the ship is sinking, I’m going down, holed below the water line.” (p.7) At the same time, the author’s strength, compassion, and humor illuminate his little book. He emerges as a generous person, who was well loved by his contemporaries. If you were his physician, what would your assessment be?

Would you accuse him of exaggerating his pain because he doesn’t appear desperate?

Daudet refers to his pain as an “unwanted guest,” to whom he intends to give “no special attention.” (p. 79) At another point he reflects on “the ingenious efforts a disease makes in order to survive.” (p. 26) The writer never questions his enemy’s ultimate victory, but neither does he turn in upon himself. He remains a source of joy to others, especially his family, as indicated in this note: “I only know one thing, and that is to shout to my children, ‘Long live life!’ But it’s hard to do so while I am ripped apart by pain.” (p.49)

Chronic pain remains challenging for doctors to treat. One set of barriers are the moral and legal concerns about overuse of opioid analgesics. Questions about the threat of addiction, or the possibility of being manipulated, favor resisting the patient’s suffering, rather than responding with compassion. Many are uncertain about how to proceed because they lack knowledge of treatment protocols that include nonpharmacologic modalities, or referral to pain control clinics for invasive procedures. Alphonse Daudet’s little book invites us to imagine ourselves living, at least for a little while, in the land of pain.

1. Daudet A. In the Land of Pain. Edited and translated by Julian Barnes. New York, Alfred K. Knopf, 2002. (page numbers indicated in the text).

Photo of Alphonse Daudet from Wikicommons.

The house sits at the foot of a spring-green mountain, painted over with long cascading strokes of darker green, giving the impression of a verdant and peaceful setting. Contrast this to the brown ridge where the figure is sitting, huddled in a long sleeve jacket, hands tucked into pockets. The ridge is barren except for a single tree that is mostly bare branches with sparse pale-pink leaves.

Matthew Wong was a rising young painter who died of suicide on October 2, 2019. In a moving obituary by the New York Times, his mother explained that Mr. Wong “was on the autism spectrum, had Tourette’s syndrome and had grappled with depression since childhood.” This helps to explain the sense of isolation and longing in the painting, depicted by the solitary figure on a barren ridge, looking back at a house in lush green surroundings. The figure also appears to be physically cold, wrapped in long sleeve coat, hands tucked in pockets, with no skin showing, but is sadly separated from shelter by an icy white distance. This dynamic, amidst a landscape of majestic mountain rising into star-crowded sky, gives a sense of melancholy beauty and loneliness.

The title of the painting, “See you on the Other Side,” can be interpreted in numerous ways. Mr. Wong is known for incorporating mythical elements into his work, so is this the beginning of the hero’s journey? If the tree in the foreground is interpreted as being laden with pale pink flower buds, there is a sense of hope and promise that the figure is leaving home and will return triumphant on the other side. But the tree can also be seen as a representation of fall transitioning into winter, hanging onto a few withered leaves, as the last bright red autumnal leaf blows away. Is the figure heading away from the verdant house and mountain into winter, the season that classically symbolizes death? Does the other side refer to an afterlife? A third interpretation to consider is that the figure is not leaving the house, but actually trying to get there. In this case, on the other side would refer to crossing the vast white expanse where no path is marked and no help is in sight.

View the painting at Museum of Fine Arts Boston ➔

Matthew Wong’s Biography: www.matthewwongfoundation.org/biography
A previous version of this review was published in the NYU Literature, Arts, and Medicine Database.
Web image from www.matthewwongfoundation.org/

A turning point comes in the fifth sestet and, to signal it, Lowell takes as his first line the famous “Una noche oscura” of St. John of the Cross, another dour poet/mystic: “One dark night”. This line begins the first of two consecutive sestets that are concerned with corporal love, bracketing a middle line that announces, to no reader’s surprise, “My mind’s not right.” The second of these sestets moves from a maudlin song refrain to a frankly depressive, almost suicidal pose: “I hear / my ill-spirit sob in each blood cell, / as if my hand were at its throat. . . .” and ends with “I myself am hell; / nobody’s here –“, which is a quotation from Satan in Book IV of Paradise Lost.

Enter the titular skunks: as a parenthetical predicate to the final line of the preceding sestet (“nobody’s here –“), the poet corrects the apparently psychological meaning of “nobody’s here –” to refer to physical presence, noting that in fact there is someone here, namely a family of skunks.

The final two sestets are among the most visually powerful images in poetry with the paradoxically high drama one would not expect from skunks. The hungry skunks “march on their soles up Main Street” in search of food with fiery red eyes as the poet, in response to their upward march, stands “on top / of our back steps” and takes a deep breath of the “rich air”, watching the mother skunk jab her head into a cup of sour cream–a mother skunk who, in a fitting yet curiously ambiguous final line, “will not scare.”

This is one of my favorite poems for a number of reasons. The honesty that eventually surfaces–the poem is after all about the self-recognition of a mind that “is not right”–is stark. It confronts the reader with the admission and dares him or her to probe into the poet’s reading of the persons and events around him. The poet’s choice of skunks as an implied comparison of his affectual state, one that feels isolated, a pariah among fellow animals, is stunning. The last lines are assertive and, one hopes for the poet’s sake, encouraging, as though the narrator finds in the skunks’ indomitable nature a source of self-reliance. As opposed to the dark “red fox stain” covering Blue Hill in the third sestet, red now promises a more optimistic interpretation, describing as it does the skunks’ defiant eyes: “moonstruck eyes’ red fire”.

As gloomy as the tone is, the poet cannot refrain from puns, another trace of his reluctance to give up poetic creativity in the face of depression. Lowell describes the Ford as a Tudor (two door). The love cars “lay together, hull to hull,” enjoying the double entendre of “lay.” The skunks “march on their soles [read “souls”] up Main Street” under the Trinitarian Church.

The economy and denseness of this poem is remarkable. Within 48 lines one encounters many of the colors of the rainbow (we have white, blue, orange, red) with a clever use of red as a focal point for a possible mood shift, with the second instance subverting the meaning of the first, as mentioned above. The puns of course add semantic value. We also have references and implicit indictments of physical love and the church as organized religion (the poet’s Ford climbs “the hill’s skull,” i.e., Golgotha, when he begins his voyeuristic watch for “love-cars”; the skunks’ “white stripes, moonstruck eyes’ red fire” contrast with “the chalk-dry and spar spire of the Trinitarian Church.”)

Much of the compressed effect derives from the force of the last lines–often spondaic–in the sestets, telegraphic lines that reinforce the gravity of the drear poetic commentary. The sequential staccato lines are: “she’s in her dotage”; “and lets them fall”; “A red fox stain covers Blue Hill”; “he’d rather marry”; “My mind’s not right”; “nobody’s here”; “of the Trinitarian Church”; “and will not scare.” The last line, “and will not scare” is reminiscent of the ending of the last line of Tennyson’s Ulysses: “[To strive to seek to find] and not to yield.” Strength and meaning are found within, in one’s self, not in the decadent civilization we see in the first four sestets.

This poem is dedicated to Lowell’s contemporary and friend, Elizabeth Bishop (1911-1979), who wrote “The Armadillo” (1957), inscribed to Robert Lowell. Both are poems about animals outré even in the animal kingdom, quadriped analogies to dissident and isolated poets, and both poets depict them as defiant and insouciant rebels worthy of human attention.

Read the Poem Online

Source Life Studies
Publisher Random House/Vintage
Edition 1959
Place Published New York
Miscellaneous The book in which this poem appeared won the National Book Award.
A previous version of this review was published in the NYU Literature, Arts, and Medicine Database. 
Web photo of Robert Lowell created from an original from Wiki Commons.

4:48 Psychosis raises the question of what constitutes theater. Is this a case study in psychotic depression, a work of art, or both? Can one call language without boundaries a play? What direction remains for contemporary theater to take following total fragmentation?  
 

These concerns have not stood in the way of 4:48 Psychosis being produced - if anything, it seems to be gaining in popularity. What could be stumbling blocks are seen by directors as a challenge to be met creatively. The play’s initial production, at London’s Royal Court (2000) divided the words among three performers. All three initially learned the whole text, and although most lines were eventually allocated, others were voiced spontaneously by different actors from performance to performance. The “action” appeared to take place within the mind of the protagonist. Projections onto a mirror helped create a Rorschach-like effect. As evidence that the play encourages a wide variety of interpretations, in the celebrated TR Warszawa production, six actors embodied discrete characters, creating encounters between a central character and her doctor, family members, or friends. This production, brought to New York in 2014, employed a Polish translation with English surtitles.  Another production, by Theatre du Pif of Hong Kong in 2016, purported to bring “an Asian sensibility” to the play, using a Korean designer and Hong Kong musicians.”  

In conclusion, 4:48 Psychosis is clearly not everyone’s idea of entertainment (one critic likened watching it to being locked in a freezer). However, it provides a beautiful, albeit brutal, window into the depressed, suicidal mind.  

A previous version of this review was published in the NYU Literature, Arts, and Medicine Database.  

Primary Source Sarah Kane: Complete Plays 
Publisher Bloomsbury Methuen Drama 
Place Published New York 
Page Count 43 
Web Art: File:4.48 psychose.JPG – Wikimedia Commons 

There is nothing to read on the psych unit but a bulletin board listing the daily activities and some magazines. This makes Chihaya think about her relationship to books, which is a complex one. She muses that “it is every writer’s fear that our books will be the death of us” (p. 11) and humorously writes about how she once had a bookshelf that was so wobbly she worried it would topple over on her. However, the real damage that books inflict may be insidious. The author first began to read as an escape from her unhappy childhood, but she fears she now “love[s] books to a dangerous degree” (p. 20).  They have become her life to the extent that she does not know if she “would be anyone at all” (p.12) without them. A feature of her depression is that she has completely lost interest in reading. She half-seriously coins the diagnosis “bibliophobia” to describe her condition. It will take just the right book to cure her, and when she finds it, she begins to read again, and to heal.  

Over the course of Bibliophobia Chihaya tells us about the books that have been of vital importance to her, many of which she associates with relationships or with stages in her life. Eventually, she reads the DSM about her own psychiatric diagnosis, and she reads books that other people have written about their depression. Working with a therapist, she realizes she needs to move on, and she lets go of her academic career. By the end of Bibliophobia we learn that Chihaya has finally written a book, but it is not the one she was expecting to write. It is Bibliophobia.

Bibliophobia is an unusual hybrid of a book that is part literary criticism part memoir. The author has been influenced by numerous mental health memoirs including recent celebrated works by Donald Antrim, Esmé Weijun Wang, and George Scialabba.

The first chapter, the subsequent emotional journey of the author, and her conclusions all captured my attention. I must confess that much of the rest of this book interested me less for the simple reason that I had not read any of the books the author discusses in detail. I do not even think we have the same taste in literature. However, this may not prove to be a stumbling block to potential readers who are fans of Toni Morrison, Anne Carson or Anne of Green Gables, or who just love reading about books.

According to the American Psychiatric Association, stigma around mental health is common in Asian American communities. One praiseworthy attribute of Bibliophilia is how it calls attention to the challenges that these groups experience in accessing care. Chihaya, was raised by a Japanese father and a Japanese Canadian mother who “did not believe in the concept of mental health; everyone was either fine or just complaining” (p. 49). Growing up with the message that depression is “not for the children of immigrants [but] something that happen[s] to white people in independent films” (p. 7) it goes without saying that Chihaya cannot bring her symptoms to her parents’ attention. Filled with shame, it takes her many years until she can no longer ignore them. Fortunately, Chihaya has given us a book filled with insights that one hopes will inspire others to seek help.

Bibliophobia
Sarah Chihaya
Random House, New York, 2025, 214 pages

References:
https://www.psychiatry.org/psychiatrists/diversity/education/asian-american-patients
Web image from Wikicommons.

A precocious young person on a track to success, Wang experiences a manic episode at Yale that leads to her first hospitalization. After a second hospitalization, her college washes its hands of her. Hitting roadblocks time and time again requires her to rebuild her life over and over. This is not a conventional chronological autobiography but rather essays that provide different approaches to the author’s experience of mental illness. The plural “schizophrenias” of the title encompasses the whole schizophrenic spectrum of disorders. As Wang explains, her own diagnosis is “the fucked-up offspring of manic depression and schizophrenia” (p. 10).   

In an essay entitled “High-Functioning” we learn how the author, having been a fashion editor, knows how to pass for normal: “My makeup routine is minimal and consistent. I can dress and daub when psychotic and when not psychotic. I do it with zeal when manic. If I’m depressed, I skip everything but the lipstick. If I skip the lipstick, that means I haven’t even made it to the bathroom mirror” (p.44).   

Later, in “The Choice of Children,” volunteering at a camp for bipolar children makes Wang think about what it would be like to inflict her diagnosis on her own offspring. In “Reality, On-Screen” she attempts to convey the sensation of decompensating to psychosis. And in “Yale Will Not Save You” she considers the failure of universities to accommodate mentally ill students.  

This is a special and rare book. As with Elyn R. Saks in The Center Cannot Hold, Wang’s disability seems not to have robbed her of her cognitive faculties, resulting in a sense of lucidity. Yet, at the same time, we are never far from madness. As a result, the essays glisten like polished jewels while the author’s voice retains the air of authenticity.   

While Wang has understandably had ambivalent experiences, in every case where The Collected Schizophrenias might have lapsed into an anti-psychiatry rant, the author instead considers a range of perspectives. She is devoted to taking her medication, yet she open-mindedly explores alternative therapies, spirituality, and even the notion that her illness might have bestowed talents or some evolutionary advantage on her.   

We should not have to be reminded that once civilians become patients they do not lose their intelligence. Wang writes that “a primary feature of the experience of staying in a psychiatric hospital is that you will not be believed about anything” (p. 98). Indeed, when she is asked how she is doing and she replies she is doing well, she is said to be lacking in insight. At other times, she is advised by certain well-meaning people that given her diagnosis “I should be proud of how coherent I am” (p. 54), and by others “who don’t believe in mental illness… that in other cultures, a person who would be diagnosed with schizophrenia in the West might be lauded as a shaman and a healer…They are likely to be the type who boast about never taking aspirin for a headache” (p. 23).  

There are many insights to be found in this book that should prove eye-opening to mental health practitioners. It should be required reading for anyone who wants to understand the experience of having an illness.   

Publisher Graywolf Press 
Place Published Minneapolis 
Edition 2019 
Page Count 202 

Web image from Wikicommons
An earlier version of this review was published in the NYU Literature, Arts, and Medicine Database. 

Author George Scialabba ascribes his “exceptionally flimsy…shock absorbers” to his “constantly worried” parents (p.3). While studying at Harvard he becomes involved with a strict religious organization. After leaving that group he undergoes a crisis of faith and his first episode of depression. Paralyzed by self-doubt, he drops out of graduate school and begins a cycle of clerical jobs that are beneath his intellectual capability. After many years he gradually wins distinction as a freelance essayist. However, due to his incapacitating symptoms he never has a steady writing job and has difficulty attaining financial security.   

In his introduction, Scialabba tells us that “the pain of a severe clinical depression is the worst thing in the world. To escape it, I would do anything” (p.1). As attested to by the notes of his well-meaning psychiatrists and psychotherapists, he has diligently applied himself to a wide variety of treatments. Sadly, if anything he gets worse over time, and eventually requires electroconvulsive therapy.  

The task of wading through more than a hundred pages of treatment notes induces a feeling of helplessness. This gives us a taste of the author’s own experience of his illness. He often seems to get better or worse without rhyme or reason. Diagnoses come and go. At various times he has been called borderline, obsessive-compulsive, narcissistic or schizoid. He himself questions the literary quality of the notes, considering them “anti-writing” (p.7). Nevertheless, persevering through the material does yield insights for the reader.   

For one thing, the notes document changes in psychiatry over the past half century. The early note takers took their time, and their writing is thoughtful and descriptive. Later notes are comparatively terse and center on the patient’s response to medication. The author suggests that the change reflects a greater fear of litigation. The reality is multifactorial. Less attention is devoted nowadays to understanding a patient’s psychodynamics. Insurance companies pay for symptom relief and want documented results.  

Any sense of tedium the reader might feel from reading the author’s mental health records is made up for by his “tips.” Scialabba gives practical suggestions about pharmaceuticals, what to eat, and how to sleep. Sufferers of depression will be pleased to hear about these things not from a doctor, but from someone who has been through the same ordeal.  

In short, How To Be Depressed is a self-help book that is somewhat out of the ordinary, and whose flippant title belies its serious content. It provides an intellectual perspective on a devastating and common disease. 

Publisher University of Pennsylvania Press 
Place Published Philadelphia 
Edition 2020 
Page Count 146 

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An earlier version of this review was published in the NYU Literature, Arts and Medicine Database. 

A MacArthur Fellow and author of several acclaimed novels, Antrim has previously published a memoir of his upbringing with his alcoholic mother. In this new memoir, flashbacks of childhood neglect and chaos are juxtaposed with the present day as he takes the reader through the acute phase of his illness: a lengthy hospitalization, a course of ECT, discharge from the hospital, rehospitalization, and eventual stabilization.  

The author considers his condition to be suicide, noting that “depression is a concavity, a sloping downward and a return. Suicide, in my experience, is not that. I believe that suicide is a natural history, a disease process, not an act or a choice, a decision or a wish…I will refer to suicide, not depression” (pp. 14-15).   

The book ends on a hopeful note. After several relationships that might be described as codependent, Antrim meets his current partner, whom he marries. He sees the roof of his building through his window and remembers a certain Friday in April but is comforted by the sound of his wife playing Chopin and Bach on the piano.  

This is an exceptionally brave book. Antrim does not attempt to whitewash his situation in any way. Surely it is humiliating for someone so successful to acknowledge he has been utterly debilitated. He loses track of time. He gains weight and cannot fit into his clothes. His new book is released, but he is in no condition to help promote it. At first, he objects to being called psychotic but eventually it comes as a relief to know he is understood. One Friday in April will be inspirational to others who have suffered to see how an accomplished person is reduced to being allowed to use his razor only under strict supervision.   

At times Antrim touches on the link between mental illness and creativity. If he had hoped the cathartic exercise of writing about his childhood would have stopped his illness he learns otherwise: “Writing had not stopped my dying. (p. 80)” At another point, his friends joke that his diagnosis “might enhance my literary reputation” (p. 115). Finally, in one of the more poignant episodes in the book, Antrim gets a call from the novelist David Foster Wallace and is encouraged to undergo ECT. He has an excellent response to that treatment, but later learns that Wallace has hanged himself.  

While a diagnosis of psychotic depression fits best with the range of symptoms the author manifests, his point about suicide as a distinct disorder is well taken. In fact, the most recent edition of the DSM (Diagnostic and Statistical Manual) took the major step of including Suicidal Behavior Disorder as a “condition for further study.” This corroborates the author’s experience and means that SBD might be included in a later edition. (see also https://www.frontiersin.org/articles/10.3389/fpsyt.2020.499980/full)   

Those who are looking for an exposé or critique of the mental health system will not find it here. Antrim credits his psychiatrists and the hospital with helping him get through an unbearable time. One Friday in April is a book that will give reassurance to people who have endured suicidal thoughts that if they persist they will get better.  

Publisher W.W. Norton & Company 
Place Published New York 
Edition 2021 
Page Count 141 

Web image from Wikicommons
An earlier version of this review was published in the NYU Literature, Arts and Medicine Database 

View poem from Poetry Foundation

This beautiful poem in The Collected Poems of Theodore Roethke appears in a section called “Sequence, Sometimes Metaphysical.” It is a penetrating rendering, at one and the same time, of “pure despair” and of transcendence; of the curse and simultaneous exaltation of heightened awareness; of the personal experience of “madness,” “my shadow pinned against a sweating wall,” “the edge is what I have,” and of a more profound soul-searching that contemplates union with nature and with God: “I climb out of my fear / The mind enters itself, and God the mind, / And one is One, free in the tearing wind.”

Roethke, a Pulitzer Prize winning poet, suffered from manic depressive illness. This poem is remarkable in conveying a life experienced between extremes and at the edge; we might even recognize elements here that surface from time to time in ourselves. But the poet probes beyond mere personal anguish and that is, perhaps, how he survives.

A Film about Theodore Roethke from PublicResource.Org

Remarkable People – Theodore Roethke by Seattle Colleges Cable Television

The Collected Poems of Theodore Roethke
New York: Doubleday, 1966, 270 pages

An earlier version of this review was published in the NYU Literature, Arts, and Medicine Database (Litmed).
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