Exploring depression through literature and art

Depression is the single largest contributor to global disability¹ and this disability is compounded by the stigma that remains associated with its diagnosis. Due to the nature of the condition, it is often a very subjective, isolating experience that not only distances patients from their family and friends but also places a barrier between doctor and patient, hindering the therapeutic process.

We have turned to literature and art for further insight into depression and have been inspired by the immediate clarity offered by rich narratives, which can greatly augment our understanding and our capacity to show compassion to our patients. We wish to share some of the examples here in the hope that others too may too find them helpful.

William Styron, Darkness Visible

William Styron’s Darkness Visible² is a remarkable memoir charting the author’s decline into depression and his subsequent recovery. Styron’s title for his memoir, Darkness Visible, is from John Milton’s Paradise Lost.³ When we place the words back in to Milton’s original poem, we get a sense of Styron’s despair:

A Dungeon horrible, on all sides round …

No light, but rather darkness visible

Serv'd only to discover sights of woe,

Regions of sorrow, doleful shades, where peace

And rest can never dwell, hope never comes

… but torture without end

Milton creates a sense of oppressive hopelessness, which Styron echoes in his description of depression that:

resemble[s] the diabolical discomfort of being imprisoned in a fiercely overheated room … because there is no escape from this smothering confinement, it is entirely natural that the victim begins to think ceaselessly of oblivion.

This depiction of suffering is incredibly evocative, enabling the reader to have some insight into the severity of the distress experienced in depression. It highlights the importance of patient narratives in understanding this condition, and Styron reaffirms this:

Told that someone’s mood disorder has evolved into a storm – a veritable howling tempest in the brain, which is indeed what clinical depression resembles like nothing else – even the uninformed layman might display sympathy rather than the standard reaction that “depression” evokes, something akin to “So what?” or “You’ll pull out of it” or “We all have bad days”.

Styron clarifies, however, that ‘incomprehension has usually been due not to a failure of sympathy but to the basic inability of healthy people to imagine a form of torment so alien to everyday experience’. He documents the decline in his mental health over several months, culminating in severe suicidal depression which leads him to be hospitalised for almost seven weeks. In hospital he finds a ‘sanctuary’ and his recovery is steady; he ends his memoir with the positive affirmation that depression ‘is conquerable’.

Lewis Wolpert, Malignant Sadness: The Anatomy of Depression

As with Darkness Visible, the title of Wolpert’s Malignant Sadness⁴ alludes to the severity of the condition. The word ‘malignant’, associated with cancer in medicine, conjures a sense of invasive, unrelenting and serious harm. This ‘Malignant Sadness’ is completely different to ‘normal’ sadness; Wolpert choosing his words carefully to ‘reflect [his] conviction that normal sadness is to depression what normal growth is to cancer’. This distinction between normal sadness and depression dramatically takes form in his confession that:

It [depression] was the worst experience of my life. More terrible even than watching my wife die of cancer. I am ashamed to say that my depression felt worse than her death but it is true.

Wolpert explains how ‘For many people it is hard to think about mental illness in the same way as they think about heart disease or cancer’, and is candid in his own admission of ‘preferring’ to attribute his depression to a side-effect of a medication he had been taking rather than to accept a psychological explanation; by medicalising his depression he was able to assuage the shame he felt because ‘A biological cause implied that [he] was not responsible’. That an eminent scientist, with first-hand experience of depression, would feel this way highlights the stigma which continues to be associated with a diagnosis of mental illness; as something that cannot be seen, or objectively measured, this contributes to the trivialisation of the severity of suffering.

In the updated introduction to the latest edition of his book, Wolpert explains that he has gone on to have further episodes of what he has come to realise ‘really is a chronic condition’.

Sylvia Plath, The Bell Jar

Sylvia Plath’s The Bell Jar⁵ is a semi-autobiographical novel based on Plath’s own struggles with mental illness. Plath employs very vivid imagery to describe the experience of depression, with the title’s ‘Bell Jar’ serving as the central metaphor for depression:

I couldn’t feel a thing … because wherever I sat … I would be sitting under the same glass bell jar, stewing in my own sour air.

This evokes the sensation of an isolated, stifling existence separate from real life, as: ‘To the person in the bell jar, blank and stopped as a dead baby, the world itself is a bad dream’.

Through this imagery, Plath provides an insight into the hopelessness that can accompany the condition as the novel’s protagonist, Esther, questions, ‘How did I know that someday -… somewhere, anywhere – the bell jar, with its stifling distortions, wouldn’t descend again?’. We follow Esther through a number of suicide attempts and her attempts to get treatment, and eventually she begins to feel the bell jar lifting as her mood improves and she becomes ‘open to circulating air’. However, the ominous bell jar is never far away and the reader is left to contemplate the implications of this life-long condition when, even after successful treatment, Esther comments on the presence of ‘The bell jar hung, suspended, a few feet above [her] head’.

While Plath’s protagonist recovers, sadly Plath herself committed suicide in 1963 several weeks after the novel’s publication.

Journeys with the Black Dog: Inspirational stories of bringing depression to the heel

Journeys with the Black Dog⁶ offers patients accounts of their depression and is a book with incredibly evocative descriptions. So powerful are the descriptions that one is almost able to comprehend the emotions they describe, even when the patient themselves feel their descriptions are inadequate:

I felt besieged. It felt like my head was a hellish prison, a gloomy and frightening labyrinth alive with relentless, malevolent beasts.

Each day was like having to drag your own shadow around behind you – heavy, weighted, leaden.

Deeper and deeper I feel into the black pit of hell, tumbling down in a blacker than black bottomless pit, devoid of doors or windows. Hell on earth, a living nightmare.

It’s as if I’m possessed by something sinister. It’s like having a little man on your shoulder, whispering in your ear constantly how worthless you are.

The emotive descriptions convey a sense of the crippling despair, isolation, fear and self-loathing patients feel. When we compare these with, for example, the World Health Organization’s description of depression as ‘a common mental disorder, characterized by persistent sadness and a loss of interest in activities that you normally enjoy, accompanied by an inability to carry out daily activities’¹ we see what an important insight patient narrative can provide.

Vincent Van Gogh, Wheatfield with Crows

Vincent Van Gogh struggled with mental illness throughout his life, with his deteriorating state culminating in his suicide in July 1890. In the month before his death, he painted the Wheatfield with Crows (Figure 1). There is a sense of desolate isolation, heightened by the overpowering night sky. The darkness of the night is almost overwhelming as it looms over the landscape ominously, creating a sense of foreboding. This is worsened by the flocks of crows, as harbingers of doom. The meandering paths in the field do not seem to lead anywhere creating a sense of confusion and a sense of fearful unknown. This effect is emphasised by the deliberate brush strokes, which create the impression of a hostile, unforgiving landscape.

Figure 1.

Wheatfield with Crows (1890), Vincent van Gogh.

Edvard Munch, Melancholy

Edvard Munch presents in his painting Melancholy (1894–96), an image of isolated dejection (Figure 2). The main figure sits alone in the foreground, staring blankly ahead of him, far removed from the figures in the background who are interacting together. Munch’s use of colour is particularly effective in conveying a sense of grief, the dulled tones of brown and blue creating a sense of glum sadness. Additionally, the darkness of the figure’s hair and clothing marks him out, almost as mourning. His sullen expression and downhearted pose further convey a sense of misery.

Figure 2.

Melancholy (1894–96), Edvard Munch.

While we believe the inspiration for Melancholy to be a friend of Munch’s, this insightful depiction alludes to Munch’s own struggles with his mental health and anxiety, perhaps more starkly depicted in his 1893 painting The Scream. In 1908, Munch was institutionalised following a decline in his mental health, exacerbated by alcohol consumption. Thereafter, the remainder of his life was spent largely in isolation.

Edgar Degas, Melancholy

While the origin of the painting’s name is unclear, Melancholy was painted at a time when Degas began to develop troubles with his eyesight, troubles that would increasingly cause anxiety for the painter as he feared total blindness (Figure 3). Indeed, his failing vision was likely a significant contributing factor to the episodes of depression which would plague the painter in later life. It is interesting then that the subject in Degas’ Melancholy is huddled, doubled over in what could be physical pain. Her pained facial expression, with eyes shut and mouth open in a silent cry, very effectively adds to this sense of silent grief. The viewer is almost an intruder to this private expression of pain, and with the figure’s face cast away from us there is a sense of a barrier separating her from us.

Figure 3.

Melancholy (1874), Edgar Degas.

Degas’ use of colour adds to the sombre mood, as does his use of light and dark. While the subject’s face is gently illuminated, her eyes are closed, and the majority of the figure is in relative darkness opposed against the light background, behind the subject. This again may be a reference to Degas’ failing eyesight, which initially manifested as a sensitivity to light. This reminds us how often mental illness can coincide with and complicate physical illness.

Concluding remarks

As clinicians, it is often difficult to gain a thoughtful understanding of our patients’ mental health; traditional models of teaching medicine which focus on definitions and medical paradigms fall short of providing emotional insight and in an era of sub-specialist healthcare it is easy to view our patients with what Michel Foucault described as the ‘medical gaze’.⁷ This reductive view of our patients can be dehumanising and will prevent the clinician from understanding their patient as a whole. In contrast, explorations of depression in literature and art are full of metaphor and visual cues that promote a deeper understanding, which can ultimately facilitate our capacity for compassionate care.

Declarations

Competing interests

None declared.

Funding

None declared.

Ethics approval

Not applicable.

Guarantor

CM.

Contributorship

Conception: CM; Writing and editing of manuscript: CM and PN.

Acknowledgements

None.

Provenance

Not commissioned; peer-reviewed by Eva Cybulska.

ORCID iD

Chira Mustafa https://orcid.org/0000-0002-0524-4384