Dramatic advances in neurobiology and psychopharmacology, commingled with the influences of managed health care, have conspired to eclipse the historic centerpiece of psychiatry—the art of listening. When the importance of language to organizing and communicating the contents of the mind is marginalized and clinical events are compacted into the formulary of DSM-IV, our field is significantly diminished. Unholy Ghost is a ready antidote to such diminutions—a collection of 22 astute and beautifully written essays on depression by writers whose lives carry the imprint of that illness. Editor Nell Casey’s choices highlight the variegated textures of depressive symptoms and the reflections to which they have given rise.

Many chapters are simply touching, eloquent reports of a depressive episode, what triggered it, its course, what helped and what didn’t, and the afterview. I have always held that novelists were the first psychoanalysts, and the depths of psychologically sophisticated wisdom apparent in these pages is impressive and refreshing. Russell Banks, unlikely to have read Tom Ogden or the Kleinians, discovered in intimacy with his depressed wife a "third person, who was neither of us…smiling beneficently between us, with an arm draped across our shoulders…our mutual creation containing both our pasts and our personalities." Banks’s chapter is not the only one to document that depression of one partner can insinuate itself into the life of the other and stay there. Donald Hall was married for 23 years to Jane Kenyon, whose poetry constitutes the foreword to this book and who had bipolar disorder. He was her dedicated caretaker, and 13 months after her death he suffered his first manic episode, which felt to him very much "her ghost."

Chase Twitchell reflects on the private language of his childhood depression and the interplay of language, poetry, and thinking toward an evocative definition of poetry. He reasons that when language is pressed into the service of depression, poetry becomes "the ultimate art of self-annihilation." Edward Hoagland has obviously speculated a lot on self-annihilation, and he reviews the pros and cons of suicide to conclude that, of all the many variables, speculation itself is "the high risk activity…animals neither speculate nor commit suicide." One is reminded of Allen Wheelis’s famous, nonpsychoanalytic advice to an analysand in one of his novels: "Don’t dwell on it." Unspeculatively, Lee Stringer tells how depression and substance abuse interwove to create a timeless regression that lasted the better part of a decade. Without any treatment, he finally worked his way out of the hole, alone, by writing.

Not everyone gets well. Sometimes improvement is fearsomely slow and incomplete. Such was the case for David Karp, whose depression was so stubborn that he considered himself "a career depressive." Over the years he tried all the drugs, co-counseling, self-help books, and finally, reluctantly, psychotherapy. Each thing helped, but only a little, and so his attitude toward psychiatry remained a mixture of hostility and dependency. Finally he realized that he was probably never going to be free of depression and that his struggle to be cured was central to his distress. Renouncing the expectation of a cure brought him considerable relief. Karp’s theme is given a twist by Susanna Kaysen, who argues that people with depression are the only ones who see the world as it really is and that normal life contains a considerable amount of sadness that shouldn’t be pathologized. Optimists are often fools, and pessimists have only pleasant surprises. This is clever, but Kaysen isn’t referring to the same disorder that William Styron describes as "this dreadful and raging disease of horrible intensity.…An immense aching solitude." Styron faults Adoph Meyer’s "tin ear for the finer rhythms of English" for having selected such a banal term as "depression" for a condition of such intrinsic malevolence. "The name prevents, by its very insipidity, a general awareness of how dreadful is the disease when out of control."

Styron’s own illness seemed to have a sudden and inexplicable onset at the age of 60. First he experienced a distaste for alcohol, "which had been an invaluable senior daily partner of my intellect" for the previous 40 years. He was soon overcome by malaise, a sense of fragility, then hypochondria, agitation, and unfocused dread. His depression came to "resemble the diabolical discomfort of being imprisoned in a fiercely overheated room. And because no breeze stirs this cauldron, because there is no escape from this smothering confinement…the victim begins to think ceaselessly of oblivion." Retrospectively he saw melancholy in his writing—"heroines who lurched down pathways toward doom"—long before his own fall. And so, when it finally came, "depression was no stranger. It had been lapping at my door for decades."

William Styron’s tale is followed by a different telling of it by his wife Rose, who is a poet. She writes that after joyous early years of marriage he slowly became solitary and irritable, writing and drinking late into the night. On the eve of his 60th birthday he became "insanely hypochondriacal and saw THE END on every horizon." He stopped drinking, then stopped writing, and soon required her continual presence. When she realized that he was ill, she became "the scholar of his moods" and his overseer. She sustained him through a difficult and dangerous period, finally convincing him to enter a hospital, where he made his recovery. Styron believes that but for the devotion of Rose and others he might well have succumbed to the ghastly grip of hopelessness.

Larry McMurtry’s depression following heart surgery was not so devastating, but it lingered and lingered. The only sense he could make of why he felt so changed, even long after the surgery, was to believe "that I had died for a few hours, been brought back to life, and now was attempting to live as someone similar to, but not quite exactly identical with, my real self.…Surgery contradicts the rules of survival, it is a Faustian bargain. You get to live, perhaps a long time, but not as yourself—never as yourself." It is surely true that "near death" experiences are particularly powerful, but we are all changing imperceptibly all the time, carrying our past with us, never exactly the same the next day. William Faulkner said it best: "The past isn’t dead…it isn’t even past."

The expanding universe of neuroscience has elucidated the mechanisms by which depression predisposes to more depression. We can localize and influence the structures that hold memory and regulate emotionality, but not yet those where meanings are conferred and sensibilities refined. Until that happens, and probably afterwards as well, we must safeguard the art of listening and indulge in the rewards of reading good books.