Illustration of trepanning from an anatomical treatise by the Italian physician Guido da Vigevano, 1345

Musée Condé, Chantilly, France/PHAS/Universal Images Group/Getty Images

Illustration of trepanning from an anatomical treatise by the Italian physician Guido da Vigevano, 1345. In his Anatomy of Melancholy, Robert Burton lists trepanning as one of the treatments for melancholia, ‘to let out the fuliginous vapors.’

The Irish writer Joseph Sheridan Le Fanu is now best known for two works: the Gothic novel Uncle Silas and Carmilla, the first great tale of a female vampire. Of his other writings, the one most often encountered is an 1871 story called “Green Tea.”

Like several other Le Fanu stories, it is taken from the supposed casebook of a German physician resident in England, Martin Hesselius. Hesselius is approached at a party by a clergyman, the Reverend Mr. Jennings, who has heard of his open-mindedness about supernatural phenomena. After an extended and uneasy flirtation, the clergyman reveals his problem. He is haunted by a small, immaterial black monkey with fiery red eyes, of “unfathomable malignity.” This vision, it emerges, has been brought on by overconsumption of green tea. That substance, if consumed in excess, wears away at the boundaries that separate our world from other, darker ones.

At first the monkey seems weak: “Dazed and languid,” “sullen and sick.” But over time it grows more aggressive. It disturbs Jennings at prayer. It prevents him from preaching to his congregation, squatting upon the Bible in front of him so that he cannot read it. It whispers enticements to harm others, or to harm himself. Sometimes it will absent itself for as long as two or three months, but it always returns: “It is prevailing, little by little, and drawing me more interiorly into hell.”

Hesselius assures the haunted Jennings that he can help. He instructs the clergyman to summon him at once whenever the monkey next appears. He then departs for a suburban inn, to meditate on the case “without the possibility of intrusion or distraction.” When he returns to his lodgings the next morning there is a letter from Jennings: the monkey is back. Rushing to the house, Hesselius finds he is too late: the unfortunate clergyman has cut his own throat.

I first read the story some decades ago. I was impressed then by its slow buildup, its nocturnal atmosphere, its unsettling evocation of other realms. Like Le Fanu himself, both Jennings and Hesselius are readers of the Swedish mystic Emanuel Swedenborg, who thought there were many more things in heaven and earth than are dreamt of in anyone’s philosophy.

It did not occur to me until I reread it recently that “Green Tea” is—quite transparently—a story about depression. Those who have experienced the disease will recognize Jennings’s sufferings. As an embodiment of the condition, Le Fanu’s monkey deserves to be ranked with Poe’s raven, Churchill’s black dog, and the errant planet that collides with Earth in Lars von Trier’s film Melancholia.

“Melancholia” is presumably what Le Fanu would have called the disease. (The psychiatrist Adolf Meyer endorsed “depression” in an influential 1904 address, but the older term maintained its dominance into the 1930s.) In premodern medicine, melancholy, or black bile, was one of the four basic substances—humors—produced by the body; the others were blood, phlegm, and yellow bile or choler. Everyone has all four humors, but not always in equal measure. Where one is dominant, the person’s temperament is said to be sanguine, phlegmatic, choleric, or melancholic. These are not illnesses but traits, like being outgoing or left-handed.

An unhealthy excess of black bile, however, leads to an actual disease, melancholia. A work attributed to Hippocrates defines it as chronic sadness or anxiety. But ancient melancholia was not always identical with modern depression. The set of scientific Problems falsely credited to Aristotle makes it sound more like bipolar disorder. Rabies was a form of melancholia, and ancient sources describe delusional melancholics who believed themselves to be roosters or pieces of pottery. (“Keep away, you’ll break me!” shouts one.) The special connection of depressive melancholia with scholars and intellectuals is attributed to Rufus of Ephesus, a Greek doctor active around 100 AD. Only fragments of his On Melancholy survive, but he influenced Galen, and through Galen the idea made its way into the mainstream of European culture.

For English readers, melancholy is inextricably linked with the name of Robert Burton. Burton’s biography is outwardly uneventful. Born in 1577 and educated at Oxford, he spent most of his life there, as a fellow and librarian of Christ Church College. He served as rector to a parish on the outskirts of the town and enjoyed the income from several other such positions as the gift of patrons. Like all Oxford fellows before 1882, he was a bachelor. He wrote at least two plays, one of which survives. But his major work was The Anatomy of Melancholy.


An anatomy is a vast anthology, an omnium-gatherum of facts, speculations, quotations, and anecdotes, a book made of books. It was from Burton that Northrop Frye drew the title of his Anatomy of Criticism (1957), as well as his definition of the form: a ramshackle work, fictional or not, that mixes satire (including satire of itself) with “exhaustive erudition.” Thus Moby-Dick is an anatomy of whaling, The Compleat Angler an anatomy of fishing, The Name of the Rose an anatomy of the Middle Ages, and Tristram Shandy an anatomy of nothing in particular.

Burton’s library of more than 1,700 volumes was reconstructed in a 1988 study by the American scholar Nicolas Kiessling. It runs alphabetically from a work on the Antichrist by Robert Abbot to a Latin verse comedy by the Dutch humanist Jacobus Zovitius. Along the way it takes in virtually everything else: natural history, medicine, theology, travel, current events, classical authors, astronomy and astrology, magic and witchcraft, letters, sermons, plays, emblem books, religious controversy, scholarly polemics, and (as Burton often ends such catalogs) “what not?”

From these volumes and others, Burton wrote, assembled, constructed, gleaned, edited, amassed, compiled, and curated his own work. The Anatomy falls into three “partitions,” as the author called them. The first covers the causes and symptoms of melancholy, the second treatments and cures. The third deals with two special cases: lovesickness (here Burton claimed to be “a Contemplator only”) and religious despair.

The causes of melancholy as Burton lists them are Borgesian in their diversity. They include original sin, venison, anger, excessive solitude, demons, standing water, exile, cabbage, too much sex, not enough sex, the stars, milk and milk products (except asses’ milk), the death of loved ones, fruit, professional jealousy, constipation, envy, and shellfish. The roster of remedies is no less diverse, taking in borage, seasickness, farting, candles, friendship, looking at maps, listening to music, watching historical reenactments, ram’s brains cooked with spices, a hot Turkish drink called Coffee (“named of a berry as black as soot, and as bitter”), bloodletting, precious stones, the colors green, red, yellow, and white; and—for women—sewing and embroidery.

It is easy to dismiss the Anatomy as backward-looking. Burton’s view of the human body was still basically Galen’s, as mediated by early modern authorities like the Italian polymath Girolamo Cardano, the French physician André du Laurens (Burton’s “Laurentius”), and the Swiss professor of medicine Felix Plater. This creaky intellectual model was already starting to crumble under the assaults of Andreas Vesalius and William Harvey. In the same way, Burton’s inherited ideas concerning the relation between body and mind were about to be swept aside by Descartes.*

Yet Burton is no mere antiquarian. The Anatomy finds room for Egyptian hieroglyphics and the habits of the basilisk, but also for the discoveries of Galileo and Kepler, the Jesuit Matteo Ricci’s reports from China, the voyages of Drake and Cavendish, and Dutch and English expeditions to Greenland and Nova Zembla. From his study in Oxford, Burton made himself the Herodotus of despair. Like Herodotus, he is at his best in his digressions: on demons, on the ideal commonwealth, on the misery of scholars. A long fantasia imagines an aerial voyage to survey the wonders of nature, ranging in the process from the Caspian Sea to California, from the diversity of national traits to debates on the carrying capacity of hell.

The more of the Anatomy one reads, the harder it becomes to say what its real subject is. Burton’s melancholy sometimes seems identical with depression, and those who live with the disease will recognize his melancholics: “Dull, heavy, lazy, restless, unapt to go about any business.” But the more capacious ancient definition sometimes reappears: we hear of “a gentleman at Siena in Italy, who was afraid to piss, lest all the Town should be drowned.” His resourceful doctors convinced him that the town was on fire and only he could put it out. (Perhaps they were readers of Rabelais.)

In trying to define melancholy Burton sometimes found himself describing madness or folly in general, “the one being a degree to the other.” This slippage is clearest in the playful introduction, “Democritus Junior to the Reader.” (Democritus was proverbially the laughing philosopher, as Heraclitus was the weeping one.) The more expansive definition reemerges in a long digression on consolation in the second partition and dominates in the third. In these sections “melancholy” extends its reach until it becomes virtually coextensive with unhappiness. To assuage it we need not Galen and his followers but those advocates of moderation and sanity, Seneca and Horace.

For Burton, in fact, to describe melancholy was to describe the world. His book, accordingly, became a mirror of the world, a memory palace the size of the British Museum, each page filled like an aristocrat’s cabinet with “pleasant pieces of perspective, Indian Pictures made of feathers, China works, frames, Thaumaturgical motions, exotic toys, &c.” (Note that final “&c.,” as characteristic of Burton’s prose as Beckett’s “worse” or Hemingway’s “commence to.”)


The first version of the Anatomy appeared in 1621, two years before the First Folio of Shakespeare. It went through five editions in Burton’s lifetime; a sixth appeared posthumously, in 1651. Burton rarely rewrote anything, and he deleted little, so most of his changes were additions: new ornamental synonyms, new authorities, new illustrative quotations, slotted in wherever they seemed to belong. The work grew by a process of accretion, like a coral reef.

The standard scholarly version of the Anatomy is now the six-volume Clarendon Press edition published from 1989 to 2001: a complete set will run you over $2,000. Unsurprisingly, most readers have continued to encounter Burton in Holbrook Jackson’s 1932 Everyman’s Library edition (reprinted in 2001 by New York Review Books). Jackson aggressively modernized spelling and incidentals, turned Burton’s copious marginal citations into endnotes, and left some of the racier Latin passages untranslated.

Angus Gowland’s new Penguin Classics edition is based (like Jackson’s) on the posthumous sixth edition. It benefits, however, from the labors of the Clarendon team—not least because it can take their version for granted and focus instead on the general reader. Gowland has pruned Burton’s own notes, while keeping them with the text, where they belong. The losses are made good by more than two hundred pages of new annotation. He has preserved characteristic typographic features of the original: more italics, heavier capitalization, and authorial notes keyed to letters (a, b, c, etc.). Though spelling is still modernized, the result feels much more like reading a seventeenth-century book.

What would an updated Anatomy of Melancholy look like? Perhaps something like Jonathan Sadowsky’s The Empire of Depression. Sadowsky is a professor of the history of medicine at Case Western Reserve. His book is a roughly chronological survey of the modern disease, our understanding of it, and its changing treatments. Though neither a Galenist nor an Anglican priest, Sadowsky reminds one in many ways of Burton: wry, practical, humane, sometimes slightly maddening in his open-mindedness and suspension of judgment.

As Sadowsky shows, depression still holds many mysteries. Indeed, virtually everything we know about it is open to debate. It seems fitting that one of the major ancient texts, the pseudo-Aristotelian Problems, was written in question form. “Why is it that…?” begins each chapter, to which the author floats tentative hypotheses (“Is it because…?”). A doctor quoted in William Styron’s 1990 memoir Darkness Visible compared depression researchers to Columbus: “America is yet unknown; we are still down on that little island in the Bahamas.”

In Shoot the Damn Dog (2008), the British journalist Sally Brampton describes her own experience of depression:

I look at the sandwich, at the perfect half circle my teeth have formed. I must eat, I know, but it seems such a laborious process, to pick up the sandwich, to bite, to chew, to swallow.

I get up and look out of the window. People are walking briskly up and down the road. I try to imagine what I would do, if I were out on the street. Where would I be going? I can think of nowhere. The newsagent’s, perhaps, to buy a newspaper. Have I read a newspaper today?

I used to write for the newspapers. Almost all of the nationals, in fact. What was it I had to say?…

I am somebody who can’t leave her bedroom, somebody who can’t walk across a road to buy a newspaper. I start to cry. I hate crying. I hate these tears that come, unbidden, at any time of day.

We recognize the symptoms: listlessness, absence of appetite, lack of purpose or ambition, loss of interest in activities previously enjoyed, withdrawal from others, frequent weeping.

Has this condition always been with us? A case can be made that it has. The desert fathers of late antiquity knew a listless spiritual despair they called acedia. Burton’s readers battled melancholy. Baudelaire, in nineteenth-century Paris, suffered from “spleen.” But is acedia the same thing as melancholy? Is melancholy interchangeable with spleen? Are any or all of them identical with Brampton’s depression?

Does the disease attack indiscriminately, or are some groups especially vulnerable? Burton addressed himself primarily to men; today, depression seems to strike women disproportionately. Or is it that women are simply more willing to seek help? Depression has sometimes been thought to afflict white people more than minorities. But does that merely reflect other inequities—in access to health care, for example? It would be no surprise if depression were underdiagnosed in African-Americans, whose relationship with the medical establishment has been marked by racism on one side and distrust on the other. As Sadowsky notes, “European slavers created stereotypes of carefree Black people, immune from melancholy and mental illness.” (Only whites were intelligent enough to be depressed.)

For their part, some African observers have also seen depression as a purely European complaint. Counterevidence seems easy to find, at least at first glance. Speakers of Punjabi recognize a depression-like condition called “sinking heart.” Nicaraguans and Haitians speak of “thinking too much,” and the African Shona language has a similar idiom. But again, do these all name the same thing? Or is mental illness culturally specific, at least to some degree? Can a German suffer from sinking heart or a Peruvian from thinking too much?

If there is a cultural component to melancholia, is it subject to cultural trends? That seventeenth-century England was fascinated by the disease seems clear, not least from the success of the Anatomy itself. Was Burton teaching his readers how to be melancholy, as Freud taught his how to be neurotic? Burton himself was alive to the possibility: he warns the melancholic reader to skip the section on symptoms, “lest he disquiet or make himself for a time worse.”

In our own society rates of depression seem to be increasing, perhaps even to epidemic levels. But are they, or are we just getting better at diagnosing the disease? Or has the definition of depression been expanding—the sort of “diagnostic drift” we saw already in Burton? Is the industry that has grown up to treat depression extending its reach, as empires are prone to do?

Where is the line between “normal” sadness and depression? There is no customs office, no formal frontier. We may be grieving a parent’s death, feeling blue about a breakup, dealing with stress at work. From the train we watch the utility poles flick by until we realize, speeding through a station, that the border is already behind us. We are in a new country, its language strange, even its alphabet unfamiliar.

The first signs can be easy to miss. Styron spoke of “a vaguely troubling malaise, a sense of something having gone cockeyed in the domestic universe.” The Scottish poet Edwin Muir imagined Hölderlin’s descent into madness in a similar way:

What made the change? The hills and towers
Stood otherwise than they should stand,
And without fear, the lawless roads
Ran wrong through all the land.

But how far off-kilter do things have to be before it’s time to call the doctor?

And then, of course, there is the ultimate question: What causes depression? Freudian analysts had one answer. As Freud’s colleague Karl Abraham first hypothesized, and as the master himself showed in Mourning and Melancholia, the disease grew out of anger at others (often the mother), turned inward toward the self. More recent approaches emphasize the role of loss: of a parent, perhaps, or of control over one’s environment. On either reckoning, depression could be treated through counseling: some form of psychoanalysis or cognitive behavior therapy.

The mid-twentieth century brought a new understanding—in some ways a throwback to Burton’s humoral melancholy. Now depression arose from an imbalance in brain chemistry. This had the happy effect of turning it into a “real” illness, devoid of stigma and potentially treatable, like diabetes or high blood pressure. And treated it was, with a battery of new drugs, of which Eli Lilly’s Prozac was the most celebrated. Depression may be wearying, flat, and stale, but it is far from unprofitable, at least for pharmaceutical companies.

If depression is caused by a chemical imbalance, what causes the imbalance? Heredity can contribute, as can substance abuse. Styron blamed his own episode on overuse of the sleep drug Halcion, coupled with alcohol withdrawal. To the traditionally abused substances—alcohol and drugs—we might add Twitter, Facebook, and Instagram. Overindulgence in such things now has its own name: “problematic social media use,” or PSMU.

Situational factors play a part as well. Trauma and abuse, unsurprisingly, are damaging to one’s mental health. This is bad news for Native Americans, LGBTQ people, and other marginalized groups. Also unhelpful is poverty. Here the arrival of Covid has offered something of a natural experiment. At the initial peak of the pandemic, in December 2020, 42 percent of respondents to a US Census Bureau survey reported symptoms of anxiety or depression, up from 11 percent in 2019. The arrival of stimulus checks correlated with a significant drop in such reports. How much of the country’s mental health deficit would be addressed by a saner health insurance system or a universal basic income? Not all, perhaps, but surely some.

As Sadowsky stresses, these factors can interact with and reinforce one another. Here Le Fanu seems strangely prescient. His clergyman’s distress is caused by a demonic force, yes, but one enabled by situational components (loneliness and overwork), genetic factors (a “hereditary suicidal mania”), and substance abuse (too much green tea). The tea, we are told, disrupts the equilibrium of a cerebral fluid, “spiritual, though not immaterial,” which normally circulates through our brains:

This fluid being that which we have in common with spirits, a congestion found upon the masses of [the] brain or nerve…forms a surface unduly exposed, on which disembodied spirits may operate.

Disembodied spirits aside, this is oddly reminiscent of modern accounts of serotonin deficiency, which drugs like Prozac counteract.

Another treatment, electro-convulsive therapy (ECT), has been revived in recent years. Pioneered in the 1940s, ECT later fell into disrepute, tainted by the kind of abuse depicted in One Flew Over the Cuckoo’s Nest. Its premise was a theory that schizophrenia and epilepsy were incompatible, so one could relieve the former by inducing the seizures typical of the latter—like welcoming harmless blacksnakes into your crawl space to keep out copperheads. No one now believes the theory, yet the treatment seems to work anyway, not only for schizophrenia but for major depression and bipolar disorder.

None of these methods is without drawbacks. Talk therapy takes time and the talk is anything but cheap. ECT patients often report memory loss. Drugs seem to bring benefits, but not to everyone—and only in the right dosage, which varies by individual. Many have significant side effects, including sexual dysfunction. Some, ironically, can actually increase suicidal ideation, especially in young users. For mild and moderate depression, placebos are nearly as effective. This makes “effectiveness” a fraught question; herbal remedies don’t really cure your cancer, but if Saint-John’s-wort or acupuncture makes you feel less depressed, then your depression has in fact been relieved.

As Burton dispassionately concluded, “there is no Catholic [i.e., general] medicine to be had: that which helps one, is pernicious to another.” Many modern practitioners would endorse his plea for a comprehensive approach:

They take a wrong course that think to overcome this feral passion by sole Physic; and they are as much out, that think to work this effect by good advice alone, though both be forcible in themselves, yet…they must go hand in hand to this disease.

Burton claims that he studied melancholy to assuage his own case: “I write of melancholy, by being busy to avoid melancholy.” Scholars have suggested that his unusually long time-to-degree at Oxford—nine years from matriculation to BA—might conceal a depressive episode. That remains conjecture. Unlike Montaigne, whom in other respects he so much resembles, Burton reveals little of himself.

This is unusual. Nondoctors who write about depression typically do so because they have experienced it, and in discussing it they naturally draw on their own experience. In Speaking of Sadness (1996), the sociologist David Karp argued that a basic part of coming to terms with depression involves the creation of an internal narrative that incorporates the illness and resituates the sufferer’s identity in relation to it. Fittingly, his book begins with an account of his own struggles with the disease.

This characteristically modern genre—the depression memoir—is the subject of Sadowsky’s final chapter. Of early examples, the most influential was Styron’s Darkness Visible, which recognizably set the pattern for successors: Elizabeth Wurtzel’s Prozac Nation (1994), Jeffery Smith’s Where the Roots Reach for Water (1999), Brampton’s Shoot the Damn Dog, and many more.

I have called the form “characteristically modern,” but it has recognizable ancestors, from De Quincey’s Confessions of an English Opium-Eater to Plath’s The Bell Jar. And its ultimate model is far older than that. Styron’s book invokes epic antecedents: its title is drawn from Milton, and it ends with the last line of Dante’s Inferno (“And so we came forth, and once again beheld the stars”). Like Dante’s, Styron’s story is a catabasis: the narrative of a descent into hell.

The catabasis can be traced back to Homer’s Odyssey, if not further, but the most influential example occurs in the sixth book of Vergil’s Aeneid. There the Roman hero Aeneas, guided by an uncanny priestess, the sibyl, descends to the underworld. Ferried across the river Acheron, he makes his way through the world of the dead, where he meets figures from mythology and from his own past. He encounters monsters and other denizens of the underworld. He hears the cries of sinners being tortured. Finally, he is reunited with the shade of his father, who lays out a new path for him.

Consciously or not, depression memoirs tend to follow this pattern. The account often begins with the first onset—the descent. Here the focus is on the author’s own experience. At some point a therapist may appear, a sibyl to guide one through the journey. The heart of the book is devoted to exploration and sightseeing: the author reviews various scientific theories, discusses famous sufferers of the past, and surveys treatments. There may be a reckoning with family trauma. Ultimately the depression lifts and the protagonist emerges with new insight—the book you hold in your hands.

There are many depression memoirs, but few depression diaries. The reason is obvious: people in the throes of deep depression are in no condition to write about it. One might call this the paradox of melancholy. As a subject it has proven fertile for art, from Dürer’s Melencolia I to Milton’s “Il Penseroso,” from Keats’s “Ode on Melancholy” to the films of Bergman and von Trier. Yet the actual experience of depression makes it impossible to paint, write, or make films—difficult, even, to get out of bed or take a shower. Any account of the experience must be constructed later and with hindsight. It is thus potentially a falsification, creating structure where none exists, significance where none is to be found. When Vergil’s Aeneas exits hell, he leaves through the ivory gate, by which false dreams make their way to the upper world.

At first glance George Scialabba seems to have found a way around this problem. As a Harvard student in the late 1960s, Scialabba was a member of the conservative lay Catholic organization Opus Dei, which he left in 1969. They had pushed him to go to law school; he wanted to get a Ph.D. instead. He enrolled at Columbia but soon dropped out, precipitating his first depressive episode.

He spent the next few decades in low-level administrative jobs back at Harvard while working as a freelance reviewer for The Village Voice, The American Prospect, and other journals. (He is now a contributing editor at The Baffler.) His beat for most of this time has been politics and society, particularly the role of public intellectuals. If you wanted a balanced leftist assessment of the new book by Chomsky, Hitchens, or Christopher Lasch, Scialabba was the man to call. His reviews have been collected in various volumes, most recently Low Dishonest Decades: Essays & Reviews, 1980–2015. His latest book, How to Be Depressed, is different from any of them.

Burton’s method was accumulation: he aimed to encompass melancholy by collecting and sorting everything anyone had ever said about it. As we have seen, he says little about himself. Scialabba, by contrast, is a minimalist, but a deeply personal one. How to Be Depressed has various components: a short introduction, an interview with the Boston radio host Christopher Lydon, brief “Tips for the Depressed” (in glossary form). But the heart of the book, more than three quarters of the whole, is the second section, “Documentia.”

This consists, quite simply, of the memos and treatment records created over the years by Scialabba’s doctors and therapists, and made available to him under federal law. He has changed the doctors’ names (sometimes amusingly: “Trigg Clifton,” “Jeffrey F. Parsnip,” the gloriously epic “Juan Durendal”). Occasionally he expands an abbreviation. But otherwise the records appear verbatim. While Scialabba’s name is on the cover, he is the author of most of the book only in an extended sense. With Burton, he can say “’tis all mine, and none mine.”

The narrative reflects periods of medical treatment, so it is discontinuous. As if turning the dial on a radio, we pick up the signal from various episodes. From the initial crack-up in 19691970 we skip to 1981 (a bad year), then to 1986. For the next decade, section titles tell the tale: “Intermittently Hopeless,” “The Knot of Anxiety,” “Pieces of Life.” There is a gap in the late 1990s and only scattered entries from the early 2000s. In 2005 Scialabba has another bad episode and is briefly hospitalized. He is back in the hospital again in 2012 and once more in 2016. The final entry, in April of that year, is a routine notation: “Discharged from unit without incident.”

Extending over nearly a half century, the notes recapitulate the history of modern approaches. Talk therapy gives way to psychopharmacology as the doctors tinker with an endless parade of medications: lithium, Parnate, Prozac, Effexor, Zoloft, Wellbutrin, Ativan. During the 2005 episode Scialabba tried ECT, with at least temporary success.

There is also a noticeable shift in the style of the entries. The thoughtful paragraphs of the early records turn briefer and more telegraphic: “A sort of bill of lading,” Scialabba calls them, aimed only at “handing you expeditiously on to the next provider.” The change presumably reflects heavier caseloads as well as growing fear of litigation.

Threaded through the book are uniquely American concerns with health insurance. As Scialabba notes, he had a sympathetic employer and a strong union. But money worries keep creeping in: “Because of financial constraints the patient would like to close his chart.” “I indicated that I would be very willing to help him arrange [psychotherapy] on a sliding-scale basis that he could afford.” “He’s not sure if [a new therapist] is a Blue Cross provider, or if she would accept insurance.” For most Americans, “between you and your doctor” always means “between you, your doctor, and the insurance company.”

The insurance industry influenced Scialabba’s treatment in less overt ways too. Insurers want to see evidence of improvement. That can push doctors toward quick fixes: drugs over talking, cognitive behavioral therapy over traditional analysis. It can also persuade them to see progress that isn’t there. The successive editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) define not only what counts as depression, but what insurers will reimburse for.

Scialabba takes pains to absolve his doctors and therapists from blame. All seem sympathetic to his suffering; all seem to be doing their best to help. Yet the gap between physician and patient feels vast, as vast as that between Hesselius and Jennings. “Likes to write and has several published pieces,” notes a doctor in mid-2012 of the author of What Are Intellectuals Good For? (2009) and The Modern Predicament (2011). Scialabba’s readers, of course, are at not one but two removes from his experience. Through the doctors we receive and process his reports (“He tells me that his moods have not been as good in the past week,” “He says that things are much worse…and that he’s suffering intensely”). But the reality remains out of reach.

The roots of Scialabba’s depression remain unclear. The session notes register stress at work, financial concerns, ups and downs in relationships, but nothing very out of the ordinary. There was some family history (both his parents were depressive) and a difficult relationship with his mother. Scialabba himself repeatedly cites his crisis of faith and departure from Opus Dei—a modern variation on the religious despair described in Burton’s closing chapters. If we see depression as growing out of loss, the loss here was not of a parent but of certainty and metaphysical structure, of an at-homeness in the world.

Here one can perhaps begin to see links between How to Be Depressed and Scialabba’s other writings. Throughout his career Scialabba has been fascinated by “modernity.” The modern condition, as he sees it, is one of enforced doubt, an expulsion from a garden that we yearn to reenter but cannot—not if we’re intellectually honest, anyway. His own departure from Opus Dei can be seen as an epitome of this broader trauma. (Burton would have understood this; his account of melancholy’s causes begins with the Fall of Man.)

Scialabba has spent most of his career watching his country fall apart: grandiose adventurism abroad, wealth concentrated in ever fewer hands, meanness and cruelty exalted as civic virtues. Somehow he has not given up hope of progress, and the battered optimism of his other books is all the more moving when read in light of this one. As he likes to say, quoting Jefferson, “We are never permitted to despair of the commonwealth.” Yet despair seems a wholly rational response to much of the past forty years. In Burton’s view, the melancholy of individuals could reflect a broader disorder: “Kingdoms, Provinces, and politic bodies are likewise sensible and subject to this disease.” For a government that seems helpless to pass laws, defend itself against domestic enemies, take action against mass shootings, or, increasingly, even deliver the mail, depression is a tempting diagnosis.

Scialabba’s depression is no metaphor, though. Taken as a whole, it recalls Veronica Wedgwood’s verdict on the Thirty Years’ War: “Confused in its causes, devious in its course, futile in its result.” His experience, painstakingly recorded, is not remotely glamorous. He has been to hell, many times, but emerged with no unexpected insights, nor any confidence that he will not return there. The only comfort he has to offer is that depression, if it does not kill you, will eventually lift—at least for a time. “If the patient do not array himself on the side of the disease,” asserts Doctor Hesselius, “his cure is certain.”

But sometimes the monkey wins.