Our state of mind, or mood, is governed by our emotional response at any one time. Sometimes we feel remarkably well, on top of the world, so that nothing seems beyond our capacity. Our attitude to those around us is joyful and duties that are usually rather irksome are discharged in a trice. This pleasant state of affairs is often the result of some pleasant outside circumstance, such as hearing good news. If we continue in this state indefinitely, we move into an ebullient elation. Pleasant as it may be for us personally, our hyperactivity and loquacity may become increasingly irritating to those around us, especially if our actions show an alarming disregard for our own worldly security. We may buy unnecessary articles of furniture or clothing to the extent of impoverishing ourselves, so that when we return to our senses we may find ourselves in sore financial straits. This is the state of hypomania; such a person is mentally ill and requires urgent psychiatric treatment. If not, the condition may soon proceed to mania in which patients lose all contact with reality, at the same time wearing themselves out in ceaseless, often destructive activity frequently accompanied by insulting language to those around them. If treatment is not speedily forthcoming the patient's life itself may be endangered as a result of foolhardy actions, or else he or she may succumb in a state of exhaustion. From all this we can see that the normal state of mind is finely balanced, and an excess of one type of emotion causes rapid mental disturbance.
The opposite emotional polarity shows itself in dejection, irritation and anger. We all have experienced this "bad mood" often enough. If we are people of a relatively normal state of mind, this negative reaction will follow some irksome or unpleasant circumstance. This may be bad news, a deeply felt disappointment following the failure of a dearly regarded plan or personal relationship, or the irremediable loss of someone dear to us. This last is the universal experience of bereavement, which may include premature retirement (and also normal retirement) from previously fulfilling work as well as marital separation or the death of someone who had previously shared our lives. A bad mood may also accompany physical ill health of a temporary nature during the early period of its development. The unhappy state of mind in all these examples tends to right itself with the passage of time, though none of these misfortunes (apart from acute illness) can be rapidly expunged from our consciousness. This applies especially to the bereavement situation, which may take a full two years for complete recovery in the case of an adult's death (recovery is never complete when a child has died). But even here the mourner learns to cope with the tragedy, helped if necessary by a bereavement counsellor, so that a reasonably efficient return to work may be effected at quite an early stage in the "work of grief", as Freud called it.
Sometimes there may be a persistent state of despondency without an obvious cause in the person's life. Alternatively the despondency may have been triggered off by one of the factors already mentioned, but a return to normal functioning simply fails to occur. Sometimes the precipitating factor is an injury, a surgical operation or a more recent successfully completed pregnancy. It would seem that once the mind is cleared of some major preoccupation, it lapses into a negative emotional state and its worst excesses of self-denigration culminating in self-destruction. This is called depression, and it is an alarmingly common mental disorder. It is a disease at least as serious as mania, for unless treated expeditiously it may terminate in a suicide attempt. Indeed, most apparently motiveless suicides have a depressive background. In some people there is such an emotional imbalance, or lability, that periods of depression and hypomania may alternate. This is called manic-depressive psychosis, or to be more learned, a "bipolar affective disorder". The word "affect" means feeling or emotion, and the bipolarity refers to the nature of the disorder veering between the two polarities of mania and depression. In others with disorders of mood it is the depressive element that alone shows itself. Some types of depression run an indolently chronic course in which the person simply has no impetus to do anything except attend to the bare functions of bodily existence, whereas other depressions have an acute onset and the patient moves rapidly into a suicidal situation if not treated forthwith by a psychiatrist or general medical practitioner administering appropriate therapy; all these conditions may be called "clinical depression". Many of the latter group require admission to hospital, but milder cases can be treated as out-patients.
What does it feel like to be depressed? Here I can cite my own experience, one that followed a severe shoulder injury ten years ago. I had already made the mistake of being available to far too many visitors. These came ostensibly to cheer me up and support me, but in fact they often used the time for counselling, thus simply using me as they often did in my own flat. A patient in hospital is a sitting target for any commiserating visitor who deposits their problems, and more importantly their emotional, psychic debris, on to the psyche of the one who lies helpless in bed. In addition, some like myself have a depressive tendency, albeit often unrecognized. And so some of my visitors spent up to an hour with me in the afternoon, when I would have been far more profitably at rest, possibly with a light book to read or some pleasant music to hear. I have no doubt that all these people had the best intentions; they bore my injury and subsequent operation fully to heart, and some gave me beautiful flowers and potted plants, but they could not give me any peace. Towards the end of the week in hospital, the nursing staff grew aware of the situation, and saw to it that the visitors stayed for only a short time. In fact no visitor should stay for more than ten minutes, and he or she should be in a good mood before arriving, also remembering to practise periods of unobtrusive silence. To be sure, intimate family will stay longer than this, but the principle of good tidings and quietness holds good.
For the last few nights before my departure I found that I could not fall asleep after I had woken up in the middle of the night, and the nursing staff gave me tablets for pain; these soon sent me to sleep again, and I did not understand the import of what was happening. Then came the time of discharge. As I left the hospital with a friend, I nearly burst into tears as I said "Now I can see what a selfish life I have been leading; I am thoroughly ashamed of myself. Now my eyes are open to the self-centred existence I enjoy." This was to say the least a very hard judgement on my life-style. Certainly all of us who live alone are in danger of being selfish and careless of the needs of other people, but the condemnation could not in truth be applied to me. When I had completed my medical lecturing and the care of my church with its various services, I spent most evenings up to 10 p.m. being available for a counselling and healing ministry. The criticism of my way of life was, and even now to a considerable extent still is, that I did far too much work and did not give myself an adequate break. But what can one do when so many people require assistance? What I demonstrated was a classical symptom of depression: a drastic lowering of self-esteem. Self-esteem is not to be confused with egoistic pride or narcissism, both of which tend to boost the personality to unreal heights. Self-esteem simply accepts the value of oneself as a person as part of the great mass of humanity in which one works and to which one bestows one's particular gift. If one lacks self-esteem, one cannot contribute properly to the social milieu: one feels one is quite useless to the point that one's absence or even death would occasion little loss to those around one.
When I left the hospital I was taken care of by a devoted parishioner, an elderly widow with whom I had a close spiritual rapport. The condition of my shoulder would have precluded living alone for some weeks or even months. But the even greater problem was the mounting depression. I was despondent, secretly tearful, and filled with doubts about the eventual recovery of the shoulder - a not entirely irrational fear, since there had been a reprehensible delay in operating on the joint. The physiotherapist was excellent, but the axillary nerve damage seemed, fortunately wrongly, to be permanent. Furthermore he was due to leave soon for some other country with his girl-friend, and I doubted whether his replacement would be nearly as efficient as he. Once again my fears proved wrong. The main suffering, however, was the intractable insomnia which had already showed itself while I was in hospital. I could fall asleep easily enough, but once I had awoken there was little possibility of any further sleep. The time of awakening could vary - any-thing from 5 a.m. to 1 a.m. - it is no joke to lie awake from the earliest hours of the morning to about 7 a.m., when the household begins its normal day. In a state of depression even well-loved books lose their savour, and so there is no question of reading oneself back to a pleasant fatigue which culminates in dropping off to sleep once more. In fact the insomnia of depression is often accompanied by fatigue but there is small chance of any ensuing sleep. Music likewise loses its inspirational quality and tends to pall in the ears, as does even the choicest food on the taste buds of the tongue.
I also was abnormally anxious; when my hostess went out early in the evening to visit friends I was in quite a state of agitation, as if the house might be entered into and burgled during her absence. When she returned I heaved a sigh of inner relief. I have pondered on the apparent foolishness of this reaction: even if I had felt quite ill, I would have been loath to disturb my elderly benefactor. And, in any case, what could she have done other than summon the doctor, an action I was quite capable of performing on my own? It seems that her immediate presence provided a support for my delicately exposed soul. Some people emit a negative psychic emanation which tends to repel sensitive individuals, whereas others are surrounded by a positive psychic force, or strength, and affection which supports anyone with poor self-esteem and personal anxiety, so that they can survive in the knowledge that at least someone really cares for them to the extent of giving themself to his or her well-being. This is a crucial test of love, that a person who cares will stop at nothing to protect and heal the other creature.
I soon consulted the general practitioner who looked after me, and he gave me a very effective antidepressant tablet that settled the insomnia within a single night. My mood swung back to something of its wonted positive response to life rather more slowly, but the relief from the sleeplessness itself gave me a more optimistic view of events, including my shoulder injury. I co-operated with the physiotherapist even more unceasingly than before, but I still had to wait several months for the injured nerve to start a repair process sufficient for me to lift the arm into the air when I was lying on a couch. And so I learned valuable lessons in faith, patience and courage.
As I convalesced from the combined effects of the surgical operation and the depression, two symptoms showed themselves. There was first an undue emotional response to music of the Romantic period: I could scarcely stop myself weeping when familiar pieces of Schumann and Mendelssohn were broadcast over the radio; such a response was quite foreign to my hearing any music, great music lover that I am. The music seemed to clear my memory of much contemporary material and lay it open to events that had occurred many years previously when I was a mere youth. It took about a week for this heightened emotional sensitivity to resolve into a normal reaction to musical stimulation.
The second symptom was again something quite foreign to me previously: a fear of enclosed places. This showed itself when I was travelling in a moderately filled London underground train. The line on which I was travelling lay close to the surface, but the train was delayed for several minutes in a tunnel. My agitation mounted almost to fever pitch; although I could see quite clearly that this reaction was unnecessary, I still could scarcely control my anxiety, which was one of dying in the tunnel. This was quite out of keeping with my usual response to death, which I had seen as a welcome phenomenon once one's work was completed in the world. Now my basic fear was unmasked despite my intellectual attitude. There was also a morbid fear of being trapped in an enclosed space, the familiar state of claustrophobia. This had never so much as occurred to me as a possibility until then. Several weeks later I was once again delayed in an underground train, this time on a line deeply under the surface, but then my reactions were quite normal.
Despite this recital of the travail of clinical depression, I have purposely omitted the most terrible feature: a feeling of being sucked into oneself where there is no one to acknowledge, let alone receive, one's existence. In other words, as far as language can describe personal feelings, I was being drawn, almost sucked, into a state of hell, where there was intolerable emotional pain emanating from the centre of the body, especially the abdominal area. The pain had a dull physical quality, and was accompanied by a sensation of utter desolation and mounting fear. I had experienced this before in moments of worry and tension, but it soon wore off. In my depression it lingered, mounting in intensity in paroxysms of hopelessness. In my present situation, in which activity was severely curtailed, I had no way of allaying the terrible suffering. I have little doubt that this "emotional pain" is the feature of severe depression that tempts its victims with the apparently blissful oblivion of suicide. For even if the punishments for vice promised by traditional religion are carried out, they pale into a gentle hue when compared with the living hell of clinical depression.
There are all varieties and stages of depression from the acute illness I have already described that responds rapidly to standard antidepressant therapy to the chronic state of hopelessness which is often accompanied by somnolence rather than insomnia. Such a person has no desire, let alone will, to do anything despite their gifts, sometimes in a number of capacities. Suicide may be threatened, but is not often carried out; it would seem as if the victim does not even possess the power to execute this resolve. Instead they remain a lasting burden on their family, whose patience is almost beyond praise; it is evident that love, sometimes hidden among the welter of destructive emotions which the incapacity of the victim evokes, remains triumphant, usually strengthened by the hope of eventual recovery. The most terrible type of depression is one in which the clinical state I described earlier simply does not respond to conventional drugs. Electro-convulsive therapy, usually shortened to ECT, sometimes works wonders in these people - an electric current is passed directly through the brain of a properly sedated patient. There may be a dramatic return to normality, nowadays with little change in the personality (this treatment is especially useful in elderly victims of depression), but sometimes this manoeuvre has no effect. Some of these cases alternate rapidly between depression and mania with only short lucid periods between them, while others remain persistently depressed with only slight periods of amelioration. The suffering here is cruel. Psychotherapy, which is frequently practised in cases of depression, finds its greatest value during periods of relative lucidity; with those in the throes of the disorder, communicative silence is by far the kindest way to approach the person.
These sombre considerations bring us to the tragic act of committing suicide. All the great world religions are at one in proclaiming the sanctity of life. Life is God's greatest gift to us; the atheist would prefer to use such a term as the "creative principle of existence" in place of the personal God of theistic religion, but there would still be a great concern for the quality of individual life. Can one dare to throw God's greatest gift to us in his face? But is life always a great gift? When one considers the great army of individuals with diseases that have been inherited, or abnormalities they have sustained at or before birth, one can hardly avoid questioning the competence, even the love, of the Creator. St Paul wrestles somewhat superficially with the problem in Romans 9.14-21, and comes to the conclusion that God is free to do what he wants with his creatures. I think there may be a greater truth here than even Paul envisaged. In a vast scheme that goes far beyond the urgent call of the present time, it is possible that we are growing into finer, more loving people. Vicissitudes play an important part in this process of growth. In this case the present hell on earth is preparing us for a caring role in the future, whether in this present life or in some posthumous existence. The story of Job's trials, their cause and their triumphant conclusion, seem to give some substance to this conjecture. I do not accept a punitive God who visits suffering on his creatures when they anger him. His nature is always merciful, but in order for us to attain truly adult stature we have to undergo various trials. If we are zealous in our prayers, we are always close to the Deity, who sustains us in our extremity. This view is helpful in those with a clear mind, but can it take in the mentally ill also? Here lies the mystery. I believe that if those afflicted with mental disease have practised prayer before their present condition struck, they will be sustained during their ordeal. This was, I am convinced, a saving factor in my own illness. Not only had I practised intercessory prayer for many years previously, but I also did not cease praying, very inadequately, when I was ill. This served in addition to lift my mind from my own pain to the sufferings of so many people I knew personally and to the world generally. In addition, the mentally ill need our intercessions at all times and in all places.
It seems to me that suicide does not help; the problem remains on the other side of death, and it demands a proper conclusion. This is why I discourage the self-destructive act unless it forms the basis of frank martyrdom in unspeakably vile circumstances. But here we have to make up our own minds, remembering the statement of Romans 12.19, "Vengeance is mine, says the Lord, I will repay". It is very easy to pass judgement as an uninvolved bystander, but when we ourselves are personally involved, whether as a near relative or a sufferer, we see things from a different perspective. A last thought: it may be commendably brave to face death calmly, but even more courageous is it to face life, a life whose quality has been tragically diminished by a bodily or mental affliction, insufficient to cause death but sufficient to deprive one of the joys that make living worthwhile. When one sees the blind, the deaf, the paralysed and the chronically mentally ill going about their business as best they can, one is filled with a compassion that steadily expands into admiration and silent homage. They have made the grade: they at least show the fibre of human excellence. It remains to be seen whether we will pass the test in our own time.