Book Review: A Cure for Darkness: The Story of Depression and How We Treat It

Even though we are taught to not allow depression to subsume our identity — we are people with depression, afflicted with it as one is afflicted by any other disease or ailment — it has a way of doing that. So much so, that when its pernicious rewiring (degradation) of the brain ceases, and is lifted, we feel like an entirely new person. We were carrying that this whole time? Indeed. Alex Riley, a British science writer and a person who is afflicted with depression, too, aptly said on the first page of his treatise on the topic, 2021’s A Cure for Darkness: The Story of Depression and How We Treat It: “The suicide plan that I had once sketched out didn’t just seem like a distant memory, but the memory of a different person.” When I think back to my longer-suffering 20s with depression (maybe even longer), where I also thought regularly of suicide and had etched a plan in my head of how depression would one day kill me, once I came out the other side healthier and depression abated, that person and his daily thoughts seemed remote enough from where I am now to be a different person. Riley’s book, part-memoir and part-tour de force through depression and its various treatments across millennia and several continents, from talk therapies to electroconvulsive therapy (ECT) to gut bacteria to psychedelics to Friendship Benches, is a clarion call that depression need not kill so many of us globally, nor hamper our quality of life. Shame and stigma reinforce the disparate approach, however, alongside particular policy choices and an unwillingness to see mental health as a challenge global in nature. A holistic treatment plan for depression, taking into account how inaccessible such treatment plans are for large swaths of the global population and remedying such inaccessibility, is what is needed to end the scourge of depression. As Riley said, we may not be able to “kill depression, but, with treatment, we can stop it from killing us.”

Riley, who is the same age I am, was taking sertraline, a selective serotonin reuptake inhibitor (SSRI), for his depression, which I believe was after a miserable experience on a prior SSRI. But Riley didn’t want to be reliant, for lack of a better word, on the drug for the rest of his life. Sertraline was also mitigating the vibrancy of life, the intimacy of life, he said. This is where talk about his previous suicide plan came from: he surmised he was in a better place and thus, better able to manager his depression. So, he decided to go off of sertraline in February 2020. Oof. While much of Riley’s book goes on to deal with the tension that’s existed more than a century between the physiological and the psychological underpinnings of depression — nature versus nature — obviously, an event like a once-in-a-century global pandemic and its attendant consequences can and does exacerbate all manner of mental illnesses, including depression. I was on the opposite journey as Riley during the pandemic. It was January 2021 when I first sought out antidepressants, a big step for me. However, that antidepressant, much like Riley’s, didn’t work and had side effects I didn’t like. It would take me another six months — and a brutal and embarrassing bottoming out — before I not only tried a different, better antidepressant (venlafaxine), but I also sought therapy, along with changing my diet and exercising more. I brought to bear the entire holistic approach Riley espouses in his book to my depression. And it worked tremendously. But I understand Riley’s initial apprehension at being on a SSRI for an extended period of time, if not indefinitely. You start to wonder who you actually are. The you who planned a suicide was you, but not one you’d like to go back to. But the new you who doesn’t consider suicide anymore is also you, but it’s a you augmented, or perhaps, steadied, by a drug. I think the ideal for any person experiencing depression would be to not have depression and also not have to rely on a SSRI and its side effects to combat it. Alas. Additionally, Riley, like me, also worried about having children. Having a child, while engendering many happy moments and feelings, can also exacerbate depression symptoms, in addition to the concern about genetically passing down depression to a child. Indeed, studies have shown that having a depressed parent increases the risk of depression in children threefold. While Riley rightly noted that predisposition isn’t destiny, it’s still something to consider with some trepidation, at least for me. At the end of the book, Riley revealed that he not only went forward with a child with his significant other, but that he went back on sertraline, embracing it. He said, “I came to the conclusion that antidepressants are effective treatments for my depression and feel overwhelmed with relief that they exist.” That is the same conclusion I arrived at as soon as I realized venlafaxine worked. That aforementioned lifting of depression and the oppressive, repeated negative and suicidal thoughts is a game-changer for a better quality of life. While, again, I approached my depression in a multifaceted way, venlafaxine deserves much of the credit.

The two poster children of biological versus environmental, physical treatment versus psychological treatment, are Emil Kraepelin and Sigmund Freud, both of whom were born within months of each other in 1856. But, if what I’ve said about Riley’s thesis has been any indicator, this is a false choice and ultimately, always was. Treating depression isn’t a binary matter. We have to take into consideration all of it: biology and the environment, physical treatment and psychological treatment. Kraepelin is also the one who categorized depression. While it’s hard to fully categorize something as amorphous as depression, such categorizations at least provide some light in the darkness: endogenous depression (coming from within) and reactive depression (instead of biologically determinant, it’s a reaction to life events and found in certain personality types). There’s a third category I’ll take about shortly. That all said, I did see a binary of a sorts, a “versus” between the disposition of Kraepelin and Freud. The former came across humble and candid about the shortcomings of his scientific endeavors, while Freud was arrogant and stubborn about admitting fault, and had a vested interest in achieving fame and fortune. Early on, though, he would receive scorn for helping to propagate cocaine, which he took in liquid form, and to him, was magic. Cocaine was essentially the first antidepressant before that word was coined, albeit, obviously, its use was scorned by Freud’s peers for a reason.

What I can’t help but ruminate on while I’m discussing Freud is that four of his sisters were murdered by the Nazis. This is the backdrop of most great advancements in science, health, and society: war and genocide often interferes, disrupts, squelches, or in some cases, also aids in the advancement of, such progress. Fortunately, Freud escaped, albeit he died shortly thereafter in 1939, and other notable Jews did escape, too, who went on to make game-changing discoveries and contributions to the advancement of society. Nonetheless, I always am left wondering about all the Jews who didn’t make it out, or the disabled, or those deemed mentally disturbed. What would our society look like today had they escaped and also been able to forge ahead in life to make their own discoveries and contributions to society? It’s also startling to think, if I, who suffered for years with depression, was born in a different time, I might have been confined to suffer and torture at a mental hospital, or been lobotomized, or sterilized, or exterminated. On a much lighter note, it is somewhat amusing to think about both sides of WWII being drugged up to the gills, between the Allies taking amphetamines and the Nazis taking methamphetamine.

Psychiatry is rife with horrors, abuse, maliciousness, and extermination of “undesirables.” So, it’s not altogether shocking that there were many stumbles along the road to treating depression. The “rest cure” was in vogue in the late 1800s, for example, “treating” even Virginia Woolf. It’s exactly what it sounds like, but more barbaric. Picture not being permitted to move, even your hands, for up to four or five weeks, while also being separated from loved ones and friends. “Forced feedings, rectal enemas, and even lashings were used,” Riley said. I also was not surprised that one of the longest running “cures” for any ailment, bloodletting, was also used to “treat” those thought manic and depressed, stemming from Galen’s (Greek physician and philosopher) notion of “black bile” in the body. When anatomists ultimately found no such bile in the body, bloodletting persisted because there was “no other alternative yet proposed.” The lobotomy is only rivaled by ECT for being the most notorious treatment to the general public, thanks to movies and books, and of course, the brutal reality of how it was practiced in its early days. Walter Freeman popularized the lobotomy in America in the 1940s. I find it rather unconscionable that a “doctor” would perform this procedure without any actual expertise about what they were quite literally poking the brain with and its effects. Indeed, 10 percent of patients were killed by the lobotomy, which is likely a conservative estimate. Rosemary Kennedy, sister of future President John F. Kennedy, was someone who was rendered forever incapacitated by the lobotomy performed by Freeman. ECT, a very brief burst of electricity into the brain, on the other hand, while not performed with the best of practices after its introduction in fascist Italy in 1938 (marring it from the get-go and to this day in Italy), ECT in its modern form is done with anesthesia and at least for the psychotic form of depression (when one experiences delusions), the third category of depression, is superior to drugs as a treatment option. I admittedly did not know much about ECT prior to Riley’s book other than the two broad sweeps: that it was maligned after much use, including of people who didn’t actually need it, and that contrary to conventional wisdom, its not only still in use, but it’s safe. In fact, I didn’t realize, despite its name, that ECT is inducing epilepsy, a disease, as a mitigator of another disease (depression), similar, I suppose, to how some vaccines, are created from a disease, to mitigate a disease.

But, as evidenced by the good ECT does, psychiatry is also replete with wonders and life-saving advancements. Nathan Klein, probably a bastard in his private life, is an example, thanks to his boisterous support of drug treatments for millions of people suffering from depression, which at the time, was abhorred by the dominant, Freudian-influenced, strain of depression treatment: psychoanalysts. Riley talked about the introduction of antipsychotic drugs in the 1950s due to Klein’s efforts, as a game-changer. Instead of patients rotting away in mental hospitals, they could actually leave after being treated with such drugs, a revolutionary concept. Aaron Beck is another great example, thanks to his pioneering work that also pushed back against Freudian psychoanalysis, with cognitive behavioral therapy, or CBT. CBT was as instrumental in my recovery as venlafaxine. While psychoanalysis was focused on sexual repression and inward-facing anger, Beck saw that it was more about self-hatred and magnifying the little things in life that then became insurmountable. The behaviorists, like B.F. Skinner, also pushed back against CBT, thinking it was just a subset of what they had already established. Skinner saw CBT as dangerous because he viewed depression as a conditioned response to the environment. “By ignoring this external element, Skinner feared, there would be no political pressure to change, say, unemployment, poverty, poor housing, or diseases that take their toll on the mental health of a population,” Riley said. Of course, as the name would indicate, these rivalrous factions ultimately fused into what CBT is today. In other words, behavioral changes are used to promote cognitive change, according to Marjorie Weishaar, a cognitive therapist. What differentiates CBT from SSRIs, for example, as Riley noted and then experienced himself, is that CBT is effective at preventing relapse long-term, whereas taking a SSRI is only effective as long as you take it. At one point, Riley was prescribed what I take, venlafaxine, but decided against it due to its severe withdrawal effects. I can attest to that. One time in between shipments, I didn’t have any pills, so I went a day without venlafaxine. It was brutal, and then within literal minutes of taking it again, I was well. But since I have no plans of stopping, I’m not worried about such withdrawal issues. Finally, I’d be remiss if I didn’t mention Myrna Weissman, another person I think who made important contributions to our understanding of depression because she quite literally endeavored to understand how many people were depressed and who it was affecting. In other words, she approached depression from an epidemiological standpoint.

Then are three areas of treatment for depression that are relatively new and/or still need to break through due to limitations or legal issues Riley covered in the book. First, is deep brain stimulation, or DBS, primarily used on patients who have been proven to have treatment-resistant depression. An electrode is implanted in the patient’s brain at a specifically important region (area 25), which is controlled by a pacemaker in their chest. Researchers then documented eight years of stimulation. It seemed to be effective for some of the research group, where by the second year, 30 percent were in full remission from their depression. So far, DBS is still considered experimental. Second is the relationship between our gut bacteria, or the microbiome, and depression. Is depression more a factor of the gut than the mind? Is treating low-inflammation the pathway to treating depression? Does depression cause the inflammation or does inflammation cause the depression? There at least appears to be a link between those with depression and high levels of inflammation in their blood (it could even be a predictor of depression later in life). Third is the cocaine of it all. I jest, but it is rather amusing that more than 100 years after Freud was slurping cocaine, we’re back to the struggle with drugs deemed “illicit” and thus, unable to be used for medicinal purposes or even to be researched in a way that isn’t cost prohibitive. In the modern context, drugs like LSD, which contains psilocybin, could have medicinal uses for treating depression. Psilocybin seemed to shut down the overactive part of a depressed person’s brain, according to one study Riley mentioned. The drug disrupted the negative inner-thought process those with depression experience. Ketamine is another one, which made me chuckle given its negative connotation right now, owing to its connection to Elon Musk. The reason researchers started looking into LSD and ketamine is because we still don’t quite know why SSRIs have lag time, i.e., the multiple weeks it takes for a SSRI to be effective once ingested. Riley rightly pointed out how dangerous of a time that is as a suicide-risk for people. Certainly, I would think the next frontier in pharmacology is finding an effective drug without such a lag time.

Finally, there are the two treatments that Riley and I both used because we can do them ourselves: diet and exercise. He embraced the Mediterranean diet and running. Both diet and regular exercise were also crucial to my recovery from depression and suicidal ideation. Therefore, to overcome the scourge of depression, I needed venlafaxine, CBT, diet and exercise, and that sneaky fifth item that is also vital: support from family and friends. Riley credits his significant other in the Acknowledgements for her support.

The throughline for all these treatments, established or experimental, at our disposal or not, is that fundamentally, we still have a long way to go to not only understanding the brain and the role of the microbiome, but depression itself. Only then, once we have a more complete understanding of depression, as one doctor Riley quoted said, can we truly work toward a cure.

Riley’s thesis is that we do not need to let depression kill us, but his call-to-action underpinning that is for psychiatry and governments the world over to overcome the obstacle of getting preventive treatments for depression to the people who need them, no matter where they live. Obviously, much of the world’s poorest do not have access to such treatments. Worse still, they face a different form of barrier to treatment than those in the West do in terms of stigma: racism and misguided assumptions about the global poor. Whether it’s scientists of old, or even some on the far-left these days talk like this, there’s a racist assumption that those facing extreme poverty, brutish conditions, war, famine, and the like, are not depressed because “they don’t know any different.” As Riley noted, it goes back to the Swiss philosopher Jean-Jacques Rousseau’s ideas about civilization being a “scourge” and it being better to be outside of it, i.e., that one would be happier without the trappings of civilization. Which is to say, again, even today, people see depression as a modern disease, a product of civilization, the Industrial Revolution. Of course, depression has been around for as long as humans have been recording reflections on society; it has just gone by different names, like melancholia. Similarly, it isn’t that those in developing countries, like Zimbabwe, which also had to deal with colonization and decolonization, don’t suffer from depression. They absolutely do! They just call it something else in their culture, and it’s up to us and the doctors looking to treat depression to understand the culture around it. Riley said 90 percent of people living in low-income countries do not have access to evidence-based therapies, such as antidepressants and psychotherapy (for high-income countries, the figure is 60 percent). To that point then, perhaps the most salient, profound quote of the book comes from Shekhar Saxena, the former director of the Department of Mental Health and Substance Abuse at the World Health Organization, “[W]hen it comes to mental health, we are all developing countries.”

If psychiatry approached depression the same way Riley does, with an open mind and a holistic approach aimed at treating depression and in a globally accessible way, then I do believe we could save and heal a lot of lives. I also look forward to a day when we understand depression and its machinations (along with the brain and the microbiome) better.

Riley’s book is a wonderful addition to my thinking around my own depression, both through Riley’s vulnerable personal experience and his scientific and historical run through depression, as well as offering fascinating insights into treatment options and addressing the inaccessibility issue. I highly recommend A Cure for Darkness to everyone.