A Journey Through Darkness
IT IS A SPARKLING DAY IN MID-JUNE, the sun out in full force, the sky a limpid blue. I am lying on my back on the grass, listening to the intermittent chirping of nearby birds; my eyes are closed, the better to savor the warmth on my face. As I soak up the rays I think about summers past, the squawking of seagulls on the beach and walking along the water with my daughter, picking out enticing seashells, arguing over their various merits. My mind floats away into a space where chronology doesn’t count: I am back on the beach of my adolescence, lost in a book, or talking to my old college chum Bethanie as we brave the bay water in front of her parents’ house in Connecticut, where she comes to visit every summer.

In the 20 or so minutes of “fresh air” allotted after lunch (one of four such breaks on the daily schedule), I try to forget where I am, imaging myself elsewhere than in this fenced-off concrete garden bordered by the West Side Highway on one side and Riverside Drive on the other, planted with patches of green and a few lonely flowers, my movements watched over by a more or less friendly psychiatric aide. Soggy as my brain is from being wrenched off a slew of antidepressants and anti-anxiety medications in the last 10 days, I reach for a Coleridgian suspension of disbelief, ignoring the roar of traffic and summoning up the sound of breaking waves.

I have only to open my eyes for the surreal scene to come back into my immediate line of vision, like a picnic area without picnickers: two barbecue grills, bags of mulch that seem never to be opened, empty planters, clusters of tables and chairs, the entire area cordoned off behind a high mesh fence. Looking out onto the highway overpass there is a green-and-white sign indicating “Exit — West 178th Street”; nearer to the entrance another sign explains: “The Patients’ Park & Garden is for the use of patients and their families only, and for staff escorting patients. It is NOT for staff use.”

I can see R., the most recent addition to our dysfunctional gang of 12 on 4 Center, sitting on a bench in his unseasonal cashmere polo, smoking a cigarette and tapping his foot with equal intensity. On either side of him are ragtag groups of people culled from several units of the hospital, including the one I am on, which is devoted primarily to the treatment of patients with depression or eating disorders. (The anorexic girls, whom R. refers to as “the storks,” are in various phases of imperceptible recovery and tend to stick together.) The garden is also home to patients from 4 South, which caters to patients from within the surrounding Washington Heights community, and 5 South, which treats patients with psychotic and substance-abuse disorders.

The people on 4 Center, hidden away as it is in a small building, have next to no contact with the other units; we might as well be on different planets. Then again, as those who suffer from it know, intractable depression creates a planet all its own, largely impermeable to influence from others except as shadow presences, urging you to come out and rejoin the world, take in a movie, go out for a bite, cheer up. By the time I admitted myself to the hospital last June after a downhill period of six months, I felt isolated in my own pitch-darkness, even when I was in a room full of conversation and light.

DEPRESSION — THE THICK BLACK paste of it, the muck of bleakness — was nothing new to me. I had done battle with it in some way or other since childhood. It is an affliction that often starts young and goes unheeded — younger than would seem possible, as if in exiting the womb I was enveloped in a gray and itchy wool blanket instead of a soft, pastel-colored bunting. Perhaps I am overstating the case; I don’t think I actually began as a melancholy baby, if I am to go by photos of me, in which I seem impish, with sparkly eyes and a full smile. All the same, who knows but that I was already adopting the mask of all-rightness that every depressed person learns to wear in order to navigate the world?

I do know that by the age of 5 or 6, in my corduroy overalls, racing around in Keds, I had begun to be apprehensive about what lay in wait for me. I felt that events had not conspired in my favor, for many reasons, including the fact that in my family there were too many children and too little attention to go around. What attention there was came mostly from an abusive nanny who scared me into total compliance and a mercurial mother whose interest was often unkindly. By age 8 I was wholly unwilling to attend school, out of some combination of fear and separation anxiety. (It seems to me now, many years later, that I was expressing early on a chronic depressive’s wish to stay home, on the inside, instead of taking on the outside, loomingly hostile world in the form of classmates and teachers.) By 10 I had been hospitalized because I cried all the time, although I don’t know if the word “depression” was ever actually used.

As an adult, I wondered incessantly: What would it be like to be someone with a brighter take on things? Someone possessed of the necessary illusions without which life is unbearable? Someone who could get up in the morning without being held captive by morose thoughts doing their wild and wily gymnastics of despair as she measures out tablespoons of coffee from their snappy little aluminum bag: You shouldn’t. You should have. Why are you? Why aren’t you? There’s no hope, it’s too late, it has always been too late. Give up, go back to bed, there’s no hope. There’s so much to do. There’s not enough to do. There is no hope.

Surely this is the worst part of being at the mercy of your own mind, especially when that mind lists toward the despondent at the first sign of gray: the fact that there is no way out of the reality of being you, a person who is forever noticing the grime on the bricks, the flaws in the friends — the sadness that runs under the skin of things, like blood, beginning as a trickle and ending up as a hemorrhage, staining everything. It is a sadness that no one seems to want to talk about in public, at cocktail-party sorts of places, not even in this Age of Indiscretion. Nor is the private realm particularly conducive to airing this kind of implacably despondent feeling, no matter how willing your friends are to listen. Depression, truth be told, is both boring and threatening as a subject of conversation. In the end there is no one to intervene on your behalf when you disappear again into what feels like a psychological dungeon — a place that has a familiar musky smell, a familiar lack of light and excess of enclosure — except the people you’ve paid large sums of money to talk to over the years. I have sat in shrinks’ offices going on four decades now and talked about my wish to die the way other people might talk about their wish to find a lover.

Then there is this: In some way, the quiet terror of severe depression never entirely passes once you’ve experienced it. It hovers behind the scenes, placated temporarily by medication and renewed energy, waiting to slither back in, unnoticed by others. It sits in the space behind your eyes, making its presence felt even in those moments when other, lighter matters are at the forefront of your mind. It tugs at you, keeping you from ever being fully at ease. Worst of all, it honors no season and respects no calendar; it arrives precisely when it feels like it.

MY MOST RECENT BOUT, the one that landed me on 4 Center, an under-the-radar research unit at the New York State Psychiatric Institute, asserted itself on New Year’s Eve, the last day of 2007. The precipitating factors included everything and nothing, as is just about always the case — some combination of vulnerable genetics and several less-than-optimal pieces of fate.

Despite my grim mood, I had somehow or other managed to put on makeup, pull on clothes, affix pearl earrings and go to a civilized old-New York type of dinner, where we talked of ongoing things — children, schools, plays to see, reasons to live as opposed to reasons to die. But even as I talked and laughed with the other guests, my thoughts were dark, scrambling ones, ruthless in their sniping insistence. You’re a failure. A burden. Useless. Worse than useless: worthless. Shortly past midnight, I watched the fireworks over Central Park and stared into the exploding bursts of color — red, white and blue, squiggles of green, streaks of purple, balls of silver, sparks of champagne. My 17-year-old daughter, Zoë, was standing nearby, and as I looked into the fireworks I sent entreaties into the sky. Make me better. Make me remember this moment of absorption in fireworks, the energy of the thing. Make me go forward. Stop listening for drum rolls. Pay attention to the ordinary calls to engage, messages on your answering machine telling you to buck up, it’s not so bad, from the ex, siblings, people who care.

For the next six months I countered the depression with everything I had, escaping into the narcotic of reading, taking on a few writing assignments (all of which I delivered weeks, if not months, late), meeting friends for dinner, teaching a writing class and even taking a trip to St. Tropez with a close friend. I gobbled down my usual medley of pills — Lamictal, Risperdal, Wellbutrin and Lexapro — and wore an Emsam patch. (I have not been free of psychotropic medication for any substantial period since my early 20s.) But this was not a passing episode that a schedule full of distractions and medication could assuage. Although many depressions resolve themselves within a year, with or without treatment, sometimes they take hold and won’t let go, becoming incrementally worse with each passing day, until suicide seems like the only exit. This was one of those depressions.

In the weeks leading up to my checking into 4 Center, I had gone from being able to put on a faltering imitation of mental health to giving up all pretense of a manageable disguise. Since I found it painful to be conscious, I had stopped doing much of anything except sleeping. Mornings were the worst: I got up later and later, first 11, then noon, and now it was more like 2 in the afternoon, the day three-quarters gone. “I wake and feel the fell of dark, not day,” observed the poet Gerard Manley Hopkins, a depressive 19th-century Jesuit priest. I don’t think I’ve ever met a depressed person who wanted to get out of bed in the morning — who didn’t experience the appearance of day as a call to burrow further under the covers, the better to embrace the vanished night.

When I was awake (the few hours that I was), I felt a kind of lethal fatigue, as if I were swimming through tar. Phone messages went unanswered, e-mail unread. In my inert but agitated state I could no longer concentrate long enough to read — not so much as a newspaper headline — and the idea of writing was as foreign to me as downhill racing. (James Baldwin: “No one works better out of anguish at all; that’s an incredible literary conceit.”) I barely ate — there is no more effective diet than clinical depression — and had dropped 30 pounds. I had essentially withdrawn from communication. When I did speak, it was mostly about my wish to commit suicide, a wish that was never all that far from my mind but at times like these became insistent.

Although some tiny part of me retained a dim sense of the more functioning person I once was — like a room with a closed door that was never entered anymore — it became increasingly difficult to envision myself ever inhabiting that version of myself again. There had been too many recurrent episodes, too many years of trying to fight off this debilitating demon of a thing. It has been called by different names at different times in history — melancholia, malaise, cafard, brown study, the blues, the black dog, acedia — and has been treated as a spiritual malady, a failure of will, a biochemical malfunctioning, a psychic conundrum, sometimes all at once. Whatever it was, it had come to define me, filling out all the available space, leaving no possibility of a “before” or an “after.” Instead I harbored the hallucinatory conviction that I had stayed around the scene of my own life too long — that I was, in some unyielding sense, ex post facto.

I had also quite literally ground to a halt, like a machine that had hit a glitch and frozen on the spot. I moved at a glacial pace and talked haltingly, in a voice that was lower and flatter than my usual one. As I discovered from my therapist and psychopharmacologist — both of whom argued that I belonged in a hospital now that my depression had taken on “a life of its own,” beyond the exertions of my will — there was a clinical name for my state: “psychomotor retardation.” My biology, that is, had caught up and joined hands with the immediate psychodynamic stressors that precipitated my nosedive — the lingering aftermath of the death two years earlier of my mother, with whom I had a complicated relationship; the imminent separation from my college-age daughter, who was my boon companion; therapy that took a wrong turn; a romance that went awry. (Much as we would like to explain clinical depression by making it either genetics or environment, bad wiring or bad nurturing, it is usually a combination of the two that sets the illness off.)

And yet I resisted my doctors’ suggestion that I check myself into a hospital. It seemed safer to stay where I was, no matter how out on a ledge I felt, than to lock myself away with other desperadoes in the hope that it would prove effective. Whatever fantasies I once harbored about the haven-like possibilities of a psychiatric facility or the promise of a definitive, once-and-for-all cure were shattered by my last stay 15 years earlier. I had written about the experience, musing on the gap between the alternately idealized and diabolical image of mental hospitals versus the more banal bureaucratic reality. I discussed the continued stigma attached to going public with the experience of depression, but all this had been expressed by the writer in me rather than the patient, and it seemed to me that part of the appeal of the article was the impression it gave that my hospital days were behind me. It would be a betrayal of my literary persona, if nothing else, to go back into a psychiatric unit.

What’s more, after a lifetime of talk therapy and medication that never seemed to do more than patch over the holes in my self, I wasn’t sure that I still believed in the concept of professional intervention. Indeed, I probably knew more about antidepressants than most analysts, having tried all three categories of psychotropics separately or in combination as they became available — the classic tricyclics, the now-unfashionable MAO inhibitors (which come with a major drawback in the form of dietary restrictions) as well as the newer S.S.R.I.’s. and S.N.R.I.’s. I was originally reluctant to try pills for something that seemed so intrinsic to who I was — the state of mind in which I lived, so to speak — until one of my first psychiatrists compared my emotional state to an ulcer. “You can’t speak to an ulcer,” he said. “You can’t reason with it. First you cure the ulcer, then you go on to talk about the way you feel.” My current regime of pills incorporated the latest approach, which called for the augmentation of a classic antidepressant (Effexor) with a small dose of a second-generation antipsychotic (Risperdal). From the time I was prescribed Prozac in my early 20s before it was approved by the Food and Drug Administration, you could say that the history of depression medication and my personal history came of age together, with me in the starring role of a lab rat.

Of course, none of the drugs work conclusively, and for now we are stuck with what comes down to a refined form of guesswork — 30-odd pills that operate in not completely understood ways on neural pathways, on serotonin, norepinephrine, dopamine and what have you. No one, not even the psychopharmacologists who dispense them after considering the odds, totally comprehends why they work when they work or why they don’t when they don’t. All the while the repercussions and the possible side effects (which include mild trembling on the one end to tardive dyskinesia, a rare condition that causes uncontrollable grimacing, on the other end) are shunted to the side until such time as they can no longer be ignored.

THE ONE THING PSYCHIATRIC hospitals are supposed to be good for is to keep you safe. But I was conflicted even about so primary an issue as survival. I wasn’t sure I wanted to ambush my own downward spiral, where the light at the end of the tunnel, as the mood-disordered Robert Lowell once said, was just the light of the oncoming train. I saw myself go splat on the pavement with a kind of equanimity, with a sense of a foretold conclusion. Self-inflicted death had always held out a stark allure for me: I was fascinated by people who had the temerity to bring down the curtain on their own suffering — who didn’t hang around, moping, in hopes of a brighter day. I knew all the arguments about the cowardice and selfishness (not to mention anger) involved in committing suicide, but nothing could persuade me that the act didn’t require a perverse sort of courage, some steely embrace of self-extinction. At one and the same time, I have also always believed that suicide victims don’t realize they won’t be coming this way again. If you are depressed enough, it seems to me, you begin to conceive of death as a cradle, rocking you gently back to a fresh life, glistening with newness, unsullied by you.

Still, one flesh-and-blood reality stood in my way: I had a daughter I loved deeply, and I understood the irreparable harm it would cause her if I took my own life, despite feeling that if I truly cared about her I would free her from the presence of a mother who was more shade than sun. (What had Sylvia Plath and Anne Sexton done with their guilt feelings? I wondered. Were they more narcissistic than I or just more strong-willed?) It was because of my daughter, after all, that I had given voice to my “suicidal ideation,” as it’s called, in the first place, worrying how she would get along without me. At the same time, I recognized that, for a person who was really set on ending it all, speaking your intention aloud was an act of self-betrayal. After all, in the process of articulating your death wish you were alerting other people, ensuring that they would try to stop you.

The real question was why no one ever seemed to figure this grim scenario out on her own, just by looking at you. This was enraging in and of itself — the fact that severe depression, much as it might be treated as an illness, didn’t send out clear signals for others to pick up on; it did its deadly dismantling work under cover of normalcy. The psychological pain was agonizing, but there was no way of proving it, no bleeding wounds to point to. How much simpler it would be all around if you could put your mind in a cast, like a broken ankle, and elicit murmurings of sympathy from other people instead of skepticism (“You can’t really be feeling as bad as all that”) and in some cases outright hostility (“Maybe if you stopped thinking about yourself so much . . . ”).

One more factor worked to keep me where I was, exiled in my own apartment, a prisoner of my affliction: the specter of ECT (electro-convulsive therapy). My therapist, a modern Freudian analyst whom I had been seeing for years and who had always struck me as only vaguely persuaded of the efficacy of medication for what ailed me — when I once experienced some bad side effects, he proposed that I consider going off all my pills just to see how I would fare, and after doing so I plummeted — had suddenly, in the last 10 days before I went into the hospital, become a cheerleader for undergoing ECT. I don’t know why he grabbed on to this idea, why the sudden flip from chatting to zapping, other than for the fact that I had once wildly thrown it out — for the drowning, any life raft will do. Then, too, ECT, which causes the brain to go into seizure, was back in fashion for treatment-resistant depression after going off the radar in the ’60s and ’70s in the wake of “One Flew Over the Cuckoo’s Nest.” Perhaps I had frightened him with my insistent talk of wanting to cut out for good; perhaps he didn’t want to be held responsible for the death of a patient who compulsively wrote about herself and would undoubtedly leave evidence that would tie him to her. But his shift from a psychoanalytic stance that focused on the subjective mind to a neurobiological stance that focused on the hypothesized workings of the physical brain left me scared and distrustful.

What if ECT would just leave me a stranger to myself, with chopped-up memories of my life before and immediately after? I may have hated my life, but I valued my memories — even the unhappy ones, paradoxical as that may seem. I lived for the details, and the writer I once was made vivid use of them. The cartoonish image of my head being fried, tiny shocks and whiffs of smoke coming off it as the electric current went through, haunted me even though I knew that ECT no longer was administered with convulsive force, jolting patients in their straps.

But in the end, no matter how much I wanted to stay put, I ran out of resistance. I spent the weekend before going into the hospital in my oldest sister’s apartment, lost in the Gothic kingdom of depression: I was unable to move from the bed, trapped in interior debates about jumping off a roof versus throwing myself in front of a car. Yet somewhere in the background were other voices — my sister’s, my doctors’ — arguing on behalf of my sticking around; I could half-hear them. I wanted to die, but at the same time I didn’t want to, not completely. Suicide could wait, my sister said. Why didn’t I give the hospital a chance? She relayed messages from each of my doctors that they would look out for me on the unit. No one would force me to do anything, including ECT. I felt too tired to argue.

THAT MONDAY MORNING, I returned home and packed up two small bags. I threw in a disproportionate number of books (especially given the fact that I couldn’t read), a couple of pairs of linen pants and cotton T-shirts, my favorite night cream (although I hadn’t touched it in weeks) and a photo of my daughter, the last with the thought of anchoring myself. In return for agreeing to undergo one of several available protocols — either switching my medication or availing myself of ECT — I would get to stay at 4 Center as long as I needed at no cost. My sister picked me up in a cab, and as I recall, I cried the whole ride up there, watching the passing view with an elegaic sense of leave-taking.

As soon as my sister gave my name to the nurse whose head appeared in the window of the locked door to the unit and we were both let in, I knew immediately that this wasn’t where I wanted to be. Everything seemed empty and silent under the fluorescent lighting except for one 40-ish man pacing up and down the hallway in a T-shirt and sweat pants, seemingly oblivious to what was going on around him. Underneath the kind of baldfaced clock you see in train stations were two run-down pay phones; there was something sad about the glaring outdatedness of them, especially since I associated them almost exclusively with hospitals and certain barren corners of Third Avenue. And then, in what seemed like an instant, my sister was saying goodbye, promising that all would turn out for the better, and I was left to fend for myself.

My bags were taken behind the glassed-in nurse’s station and checked for potential weapons of self-destruction referred to as “sharps” — razors, scissors, mirrors — which were taken away until your departure. Cellphones were also forbidden for reasons that seemed unclear even to the staff but had something to do with their photo-taking ability. In my intake interview, I alternated between breaking down in tears and repeating that I wanted to go home, like a woeful 7-year-old left behind at sleep-away camp. The admitting nurse, who was pleasant enough in a down-to-earth way, was hardly swept away by gusts of empathy with my bereft state. And yet I wanted to stay in the room and keep talking to her forever, if only to avoid going back out on to the unit, with its pathetically slim collection of out-of-date magazines, ugly groupings of wooden furniture cushioned with teal and plum vinyl and airless TV rooms — one overrun, the other desolate. Anything to avoid being me, feeling numb and desperate, thrust into a place that felt like the worst combination of exposure and anonymity.

I emerged in time for dinner, which was served at the premature hour of 5:30, as if the night ahead were so chockablock with activities that we had to get this necessary ritual out of the way. Since in reality dinner led to nothing more strenuous than another bout of “fresh air” and lots of free time until the lights went out at 11, I would have thought that it would be a good occasion to dally. But as it turned out, the other patients were finished eating within 10 or 15 minutes, and I found myself alone at the table, not yet having realized that the point was to get in and out as quickly as possible.

It didn’t help that the room we ate in was beyond dismal, featuring an out-of-tune piano and a Ping-Pong table that was never used. Or that, despite its being summer, there was barely any fresh fruit in sight except for autumnal apples and the occasional banana. There would be culinary bright moments — cream puffs were served on Father’s Day, and one Tuesday the staff set up a barbecue lunch in the patients’ park, where I munched on hot dogs and joined in a charadeslike game called Guesstures — but the general standard was determinedly low. After a while, I began requesting bottles of Ensure Plus, the liquid nutrition supplement that came in chocolate and vanilla and was a staple of the anorexics’ meal plans; if you closed your eyes it could pass for a milkshake.

It wasn’t only the anorexics’ Ensure that I coveted. From the very first night, when sounds of conversation and laughter floated over from their group to the gloomy, near-silent table of depressives I had joined, I yearned to be one of them. Unlike our group, they were required to remain at lunch and dinner for a full half-hour, which of necessity created a more congenial atmosphere. No matter that one or two had been brought on to the floor on stretchers, as I was later informed, or that they were victims of a cruel, hard-to-treat disease with sometimes fatal implications; they still struck me as enviable. However heartbreakingly scrawny, they were all young (in their mid-20s or early 30s) and expectant; they talked about boyfriends and concerned parents, worked tirelessly on their “journaling” or on art projects when they weren’t participating in activities designed exclusively for them, including “self-esteem” and “body image.” They were clearly and poignantly victims of a culture that said you were too fat if you weren’t too thin and had taken this message to heart. No one could blame them for their condition or view it as a moral failure, which was what I suspected even the nurses of doing about us depressed patients. In the eyes of the world, they were suffering from a disease, and we were suffering from being intractably and disconsolately — and some might say self-indulgently — ourselves.

I SHARED A SMALL ROOM right across from the nurse’s station with a pretty, middle-aged woman who introduced herself before dinner — the only one to do so — with a remarkable amount of good cheer, as if we were meeting at a cocktail party. For a minute I felt that things couldn’t be so terrible, that the unit couldn’t be as abject a destination as I conceived it to be if this woman had deigned to throw her lot in with the rest of us. She wore “Frownies” — little patented patches that were supposed to minimize wrinkles — to bed, which only furthered the impression she conveyed of an ordinary adjustment to what I saw as extraordinary circumstances. Clearly, she had a future in mind, even if I didn’t — one that required her to retain a fetching youthfulness. I hadn’t so much as washed my face for the past few months, but here was someone who understood the importance of keeping up appearances, even on a psychiatric unit.

The room itself, on the other hand, couldn’t have been less welcoming. Like the rest of the unit, it was lighted by overhead fluorescent bulbs that didn’t so much illuminate as bring things glaringly into view. There were two beds, two night tables and two chests of drawers. In keeping with the Noah’s-ark design ethos, the room was also furnished with a pair of enormous plastic trash cans; one stood near the door, casting a bleak plastic pall over things, and the other took up too much space in the tiny shared bathroom. The shower water came out of a flat fixture on the wall — the presence of a conventional shower head, I soon learned, was seen as a potential inducement to hanging yourself — and the weak flow was tepid at best.

I got into bed that first night, under the ratty white blanket, and tried to calm myself. The lack of a reading lamp added to my panic; even if my depression prevented me from losing myself in a book, the absence of a light source by which to read after dark represented the end of civilization as I had known it. (It turned out that you could bring in a battery-powered reading lamp of your own, albeit with the Kafkaesque restriction that it didn’t make use of glass light bulbs.) My mind went round and round the same barrage of questions, like a persistent police inspector. How did I get here? How did I allow myself to get here? Why didn’t I have the resolve to stay out? Why hadn’t anything changed with the passage of years? It was one thing to be depressed in your 20s or 30s, when the aspect of youth gave it an undeniable poignancy, a certain tattered charm; it was another thing entirely to be depressed in middle age, when you were supposed to have come to terms with life’s failings, as well as your own. Now that my mother was gone — I always thought she’d outlive me, but her lung cancer took precedence over my suicidal impulses — there was no one to blame for my depressions, no one to whom I could turn for some magical, longed-for compensation. But the truly intolerable part was that I had acquiesced in this godforsaken plan; there was ultimately no one to blame for my banishment to this remote-seeming outpost but myself.

I plumped the barracks-thin pillow, pulled up the sheet and blanket around me — the entire hospital was air-conditioned to a fine chill — and curled up, inviting sleep. There was nothing to feel so desperate about, I tried soothing myself. You’re not a prisoner. You can ask to leave tomorrow. I listened to my roommate’s calm, even breathing and wished I were her, wished I were anyone but myself. Mostly, I wished I were a person who wasn’t consumingly depressed. All over the city, less depressed or entirely undepressed people were leading their ordinary lives, watching TV or blogging or having a late dinner. Why wasn’t I among them? After staring into the darkness for what seemed like hours, I finally got up and put on my robe, having decided that I’d overcome my sense of being a specimen on display — here comes Mental Patient No. 12 — and approach the nurses’ station about getting more sleeping meds.

Outside the room the light was blinding. Two of the aides were at the desk, playing some sort of word game on the computer screen. They looked up at me impassively and waited for me to state my case. I explained that I couldn’t sleep, my voice sounding furry with anxiety. My hands were clammy and my mouth was dry. One of them got up and went into the back to check whether the resident in psychiatry who was assigned to me had approved the request. She handed me a pill in a little cup, and I mumbled something about how nervous I was feeling. “You’ll feel better after you get some sleep,” she said. I nodded and said, “Good night,” feeling dismissed. “Night,” she said, casual as could be. I was no one to her, no one to myself.

I SUPPOSE IT WOULD MAKE for some kind of symmetry — a glimpse of an upward trajectory, at least — if I said that the first night was the hardest, but the truth is that it never got any easier. My frantic sense of dislocation and abandonment persisted for the entire three weeks I spent on 4 Center, yielding only at rare moments to a slightly less anxious state of hibernation. I would eventually discover several friendlier nurses or nurses’ aides with whom it was possible to talk about the bizarre reality of being on a psychiatric unit with a locked door and fiercely regulated visiting hours (5:30 to 8 on weekday evenings and 2 to 8 on weekends) without feeling like an official mental patient. By the end of the second week, when I was no longer chained to the unit, one of the male nurses would invite me for coffee breaks to the little eatery on the sixth floor where the hospital staff repaired for their meals.

These outings were always kept short — we never lingered for more than 15 minutes — and they always brought home to me how artificial the dividing line between 4 Center and the outside world really was. It could cause vertigo if you weren’t careful. One minute you were in the shuttered-down universe of the verifiably unwell, of people who talked about their precarious inner states as if that were all that mattered, and the next you were admitted back into ordinary reality, where people were free to roam as they pleased and seemed filled with a sense of larger purpose. As I cradled my coffee, I looked on at the medical students who flitted in and out, holding their clipboards and notebooks, with a feeling verging on awe. How had they figured out a way to live without getting bogged down in the shadows? From what source did they draw all their energy? I couldn’t imagine ever joining this world again, given how my time had become so aimlessly filled, waiting for calls to come in on the pay phone or sitting in “community meetings,” in which people made forlorn and implausible requests for light-dimmers and hole-punchers and exiting patients tearfully thanked everyone on the unit for their help.

It wasn’t as if there weren’t attempts made to organize the days as they went sluggishly by. A weekly schedule was posted that gave the impression that we patients were quite the busy bees, what with therapy sessions, yoga, walks and creative-writing groups. Friday mornings featured my favorite group, “Coffee Klatch.” This was run by the same amiable gym-coach-like woman who oversaw exercise, and it was devoted to board games of the Trivial Pursuit variety. The real draw was the promise of baked goods and freshly brewed coffee.

But in truth there was more uncharted time than not, especially for the depressives — great swaths of white space that wrapped themselves around the day, creating an undertow of lassitude. Forging friendships on the unit, which would have passed the time, was touch-and-go because patients came and went and the only real link was one of duress. The other restriction came with the territory: people were either comfortably settled into being on the unit, which was off-putting in one kind of way, or raring to get out, which was off-putting in another. I had become attached to my roommate, who was funny and somehow seemed above the fray, and I felt inordinately sad when she left, in possession of a new diagnosis and new medication, halfway into my stay.

Still, the consuming issue as far as I was concerned — the question that colored my entire stay — was whether I would undergo ECT. It was on my mind from the very beginning, if only because the first patient I encountered when I entered the unit, pacing up and down the halls, was in the midst of getting a series of ECT treatments and insisted loudly to anyone who would listen that they were destroying his brain. And indeed, the patients I saw returning from ECT acted dazed, as if an essential piece of themselves had been misplaced.

During the first week or so the subject lay mostly in abeyance as I was weaned off the medications I came in on and tried to acclimatize to life on 4 Center. I met daily with Dr. R., the young resident I saw the first evening, mostly to discuss why I shouldn’t leave right away and what other avenues might be explored medicationwise. She sported a diamond engagement ring and a diamond wedding band that my eye always went to first thing; I took them as painful reminders that not everyone was as full of holes as I was, that she had made sparkling choices and might indeed turn out to be one of those put-together young women who had it all — the career, the husband, the children. During our half-hour sessions I tried to borrow from Dr. R.’s outlook, to see myself through her charitable eyes. I reminded myself that people found me interesting even if I had ceased to interest myself, and that the way I felt wasn’t all my fault. But the reprieve was always short-lived, and within an hour of her departure I was back to staving off despair, doing battle with the usual furies.

One day early into my second week, I was called out of a therapy session to meet with a psychiatrist from the ECT unit. I still wonder whether this brief encounter was the defining one, scaring me off forever. She might as well have been a prison warden for all her interpersonal skills; we had barely said two words before she announced I was showing clear signs of being in a “neurovegetative” condition. She pointed out that I spoke slurringly and that my mind seemed to be crawling along as well, adding grimly that I would never be able to write again if I remained in this state. Her scrutiny seemed merciless: I felt attacked, as if there were nothing left of me but my illness. Obviously ECT was in order, she briskly concluded. I nodded, afraid to say much lest I sound imbecilic, but in my head the alarms were going off. No, it wasn’t, I thought. Not yet. I’m not quite the pushover you take me to be. It was the first stirring of positive will on my own behalf, a delicate green bud that could easily be crushed, but I felt its force.

The strongest and most benign advocate for ECT was a psychiatrist at the institute who saw me three decades earlier and was instrumental in convincing me to come into 4 Center. In his formal but well-meaning way he pointed out that I lived with a level of depression that was unnecessary to live with and that my best shot for real relief was ECT. He came in to make his case once again as I was sitting at dinner on a Friday evening, pretending to nibble at a rubbery piece of chicken. The other patients had gone and my sister was visiting. I turned to her as he waxed almost passionate on my account, going on about the horror of my kind of treatment-resistant depression and the glorious benefits of ECT that would surely outweigh any downside. I didn’t trust him, much as I wished to. Help me, I implored my sister without saying a word. I don’t want this. Tears trickled down my cheeks as if I were a mute, wordless but still able to feel anguish. My sister spoke for me as if she were an interpreter of silence. It looked like I didn’t want it, she said to the doctor, and my wishes had to be respected.

I COULD SEE MYSELF LINGERING on in the hospital, not because I had grown any more fond of the atmosphere but because after a certain amount of time it became easier to stay than to leave. The picayune details of my life — bills, appointments, deadlines — had been suspended during my last few months at home, then left outside the hospital confines altogether, and it began to seem inconceivable that I’d ever have the wherewithal to take them on again. Instead of growing stronger on the unit, I felt a kind of further weakening of my psychological muscle. The new medication I was on left me exhausted, and I took to going back to sleep after breakfast. I was tired even of being visited, of sitting in the hideous little lounge and making conversation, of expressing gratitude for the chocolates, smoked salmon and change for the pay phones that people brought. I felt as if I were being wished bon voyage over and over again, perennially about to leave on a trip that never happened.

I went out on several day passes in the week leading to my departure, as a kind of preparation for re-entry, but none of them were particularly successful. On one, I went out on a broiling Saturday afternoon with my daughter for a walk to the nearby Starbucks on 168th and Broadway. I felt thick-headed with the new sedating medication I was on and far away from her. When she left me for a minute to make a phone call on her cell, I started crying, as if something tragic had happened. I wondered uneasily what effect seeing me in this state was having on my daughter, what she made of my being in the hospital — did she view me as a burden that she would need to shoulder for the rest of her life? Would my depression rub off on her? — but in between we laughed at small, odd things as we always did, and it occurred to me that I wasn’t as much a stranger to her as I was to myself.

With the staff’s tentative agreement — they didn’t think I was ready to go home but had no real reason to prevent me from doing so — I left 4 Center three weeks to the day I arrived, my belongings piled up on a trolley for greater mobility through the annex to the exit. It was a hot June day similar to the one I checked in on, the heat pouring off the windows of parked cars. Everything felt noisy and magnified. It felt shocking to be outside, knowing I was on a permanent pass this time, that I wouldn’t be returning to the unit.

I was sent home on Klonopin, an anti-anxiety drug I’d been on forever, as well as a duet of pills — Remeron and Effexor — that were referred to as California rocket fuel for its presumed igniting effect. As it turned out, the combo wasn’t destined to work on me. At home, I was gripped again by thoughts of suicide and clung to my bed, afraid to go out even on a walk around the block with my daughter. When I wasn’t asleep, I stared into space, lost in the terrors of the far-off past, which had become the terrors of the present. It was decided that I shouldn’t be left alone, so my sister and my good friend took turns staying with me. But it was clear this arrangement was short term, and by the end of the weekend, after phone calls to various doctors, it was agreed that I would go back into the hospital to try ECT.

And then, the Sunday afternoon before I planned to return to 4 Center, something shifted ever so slightly in my mind. I had gone off the Remeron and started a new drug, Abilify. I was feeling a bit calmer, and my bedroom didn’t seem like such an alien place anymore. Maybe it was the fear of ECT, or perhaps the tweaked medication had kicked in, or maybe the depression had finally taken its course and was beginning to lift. I had — and still have — no real idea what did it. For a brief interval, no one was home, and I decided to get up and go outside. I stopped at Food Emporium and studied the cereal section, as amazed at the array as if I had just emerged from the gulag. I bought some paper towels and strawberries, and then I walked home and got back into bed. It wasn’t a trip to the Yucatan, but it was a start. I didn’t check into the hospital the next day and instead passed the rest of the summer slowly reinhabiting my life, coaxing myself along. I spent time with people I trusted, with whom I didn’t have to pretend.

Toward the end of August I went out for a few days to the rented Southampton house of my friend Elizabeth. It was just her, me and her three annoying dogs. I had brought a novel along, “The Gathering,” by Anne Enright, the sort of book about incomplete people and unhappy families that has always spoken to me. It was the first book to absorb me — the first I could read at all — since before I went into the hospital. I came to the last page on the third afternoon of my visit. It was about 4:30, the time of day that, by mid-August, brings with it a whiff of summer’s end. I looked up into the startlingly blue sky; one of the dogs was sitting at my side, her warm body against my leg, drying me off after the swim I had recently taken. I could begin to see the curve of fall up ahead. There would be new books to read, new films to see and new restaurants to try. I envisioned myself writing again, and it didn’t seem like a totally preposterous idea. I had things I wanted to say.

Everything felt fragile and freshly come upon, but for now, at least, my depression had stepped back, giving me room to move forward. I had forgotten what it was like to be without it, and for a moment I floundered, wondering how I would recognize myself. I knew for certain it would return, sneaking up on me when I wasn’t looking, but meanwhile there were bound to be glimpses of light if only I stayed around and held fast to the long perspective. It was a chance that seemed worth taking.