What if you could help end people’s economic problems by treating their depression?
Jacob Riis, Poor schoolchildren in New York, 1890.
Wendy was born just below the poverty line, where she spent the next 30 years of her life. These were grim times for her. When she was 6, a disabled friend of her alcoholic grandmother began abusing her sexually. In seventh grade she began to withdraw. “I felt there was no reason to go on,” she says. “I did my schoolwork and everything, but I was not happy in any way. I would just stay to myself. Everyone thought I couldn’t talk for a while, because for a few years there I wouldn’t say anything to anyone.” Her first boyfriend, from her neighborhood in the slums around Washington, was physically and verbally brutal. After the birth of her first child, when she was 17, she managed to “escape from him, I don’t know how.” Not long after, Wendy, a petite African-American woman with grave eyes and a wide mouth, was raped by a family friend. Soon after that, under pressure from her family, she married a man who was also abusive. She had three more children by him in the next two years. “He was abusing the children too, even though he was the one who wanted them, cursing and yelling all the time, and the spankings, I couldn’t take that, over any little thing, and I couldn’t protect them from it.” She also had to assume responsibility at this time for her sister’s children, because the sister was addicted to crack cocaine.
Wendy began to experience major depression — not simply the generalized despair that might be expected of someone in her position, but an organic illness that was utterly disabling: “I’d had a job, but I had to quit because I just couldn’t do it. I didn’t want to get out of bed, and I felt like there was no reason to do anything. I’m already small, and I was losing more and more weight. I wouldn’t get up to eat or anything. I just didn’t care. Sometimes I would sit and just cry, cry, cry. Over nothing. I had nothing to say to my own children. After they left the house, I would get in bed with the door locked. I feared when they came home, 3 o’clock, and it just came so fast. I was just so tired.” Wendy began to take pills, mostly painkillers. “It could be Tylenol or anything for pain, a lot of it, though, or anything I could get to put me to sleep.”
Finally one day, in an unusual show of energy, Wendy went to the family-planning clinic to get a tubal ligation. At 28, she was responsible for 11 children, and the thought of another one petrified her. She happened to go in when Jeanne Miranda, an associate professor of psychiatry at Georgetown University, was screening subjects for a study of poor people suffering from depression. “She was definitely depressed, about as depressed as anyone I’d ever seen,” recalls Miranda, who gave Wendy the diagnosis and swiftly put her into group therapy. “It was a relief to know there was something specific wrong,” Wendy says. “They asked me to come to a meeting, and that was so hard. I didn’t talk. I just cried.”
On any given day, roughly 18 million Americans meet the diagnostic criteria for mood disorders, meaning that they have reached an emotional low that impairs their functioning. Three million of those are children. Depression claims more years of useful life in America than war, cancer and AIDS put together, according to the World Health Organization’s World Health Report 2000. And the indigent depressed are among the most severely disabled populations in this country. There are no reliable figures on how many of these people there are, but 13.7 percent of Americans live below the poverty line, and according to one recent study, about 42 percent of heads of households receiving Aid to Families With Dependent Children meet the criteria for clinical depression — more than three times the national average.
Despite the extended debates in the last decade about depression’s causes, it seems fairly clear that it is usually the consequence of a genetic vulnerability activated by external stress. Most people have some level of genetic vulnerability. Those with a high vulnerability can have it triggered by a fairly minor event; those with a low degree of vulnerability will be triggered only by more significant trauma. But among the indigent, the traumas are so terrible and so frequent, says Miranda, that searching for the depressed among them is like checking for emphysema among coal miners. The depression rate among the poor is the highest of any social grouping in the United States, so high that many don’t notice or question it. “If this is how all your friends are,” Miranda says, “it begins to have a certain terrible normality to it.”
In travels to some fairly remote parts of the world, I found that much the same rules apply to trauma-prone populations everywhere. Survivors of the Khmer Rouge in Cambodia have an extremely high rate of depression. Phaly Nuon, a Cambodian woman who has founded a treatment center and an orphanage in Phnom Penh, describes seeing women who had made it through the horrific years of war only to become so depressed afterward that they let their own children starve to death in the resettlement camps. She said that these women, born to grim lives of rural poverty, had been disabled by what they had seen. I found similar phenomena among the Inuit of Greenland, tribal peoples in Senegal, the urban poor in Russia. Depression rates are very high all around the world among people with hard lives, and these people tend to be disproportionately poor.
Depression can be difficult enough to recognize among the affluent, but if you’re way down the socioeconomic ladder, the signs may be even harder to distinguish. When someone in the middle classes becomes depressed and suddenly finds that he can’t function at a high level, can’t work, begins to withdraw, he is likely to attract the attention of friends and family members. But if you’re poor, these symptoms don’t seem much of a change. Your life has always been lousy; you’ve never been able to get or hold a decent job; you’ve never expected to accomplish much; and you’ve never entertained the idea that you have much control over what happens to you.
The depressed poor perceive themselves to be supremely helpless — so helpless that they neither seek nor embrace support. This means that most people who are poor and depressed stay poor and depressed. Poverty is depressing, and depression, leading as it does to dysfunction and isolation, is impoverishing.
The poor tend to have a passive relationship to fate: their lack of self-determination makes them far more likely to accommodate problems than to solve them (they are, by extension, far less likely to commit suicide than are the empowered). This passivity also causes them to accept treatment as passively as they accept their own misery, which means they can be helped through programs of assertive outreach. Medicaid recipients qualify for extensive care, but they have to claim it, and depressed people do not exercise rights or claim what should be theirs, even if they have the rare sophistication to recognize their own condition. They can be saved only by pressing insight onto them, often through muscular exhortation.
Miranda is one of a small group of therapists who embrace this idea of assertive intervention. “If you treat their depression,” says Miranda, “you give them a new world.”
Wendy was not an easy subject at first. On more than one occasion a member of Miranda’s staff had to go to her house and persuade her to come out. She said she had no time. She was taciturn and kept people at a distance. “Then they kept calling, telling me to come, pestering and insisting, like they wouldn’t let go. I didn’t like the first meetings. But I listened to the other women and realized that they had the same problems I was having, and I began to tell them things. I’d never told anyone those things. And the therapist asked us all these questions to change how we thought. And I just felt myself changing, and I began to get stronger.”
After two months of group therapy, Wendy told her husband that she was leaving. “There was no arguing because I just didn’t argue back. I just told him, ‘I’m gone.’ I was so strong. I was so happy.”
It took two more months of therapy before Wendy found a job. Now, while she goes to work at a child-care center for the Navy, her children and her sister’s go to school or another local child-care center. With her new salary, she has set herself and the children up in a new apartment. And a year into her group therapy, she plans to continue for as long as Miranda’s program is operating. “My kids are so much happier,” Wendy says. “They want to do things all the time now. We talk for hours every day. We read and do homework all together. We joke around. We all talk about careers, and before they didn’t even think careers. I talk to them about drugs, and they’ve seen my sister, and they keep clean now. They don’t cry like they used to. They don’t fight like they did.
“I never thought I would get this far. It feels good to be happy. I don’t know how long it’s going to last, but I sure hope it’s forever.” She smiles and shakes her head in wonder. “And if it weren’t for Dr. Miranda and that, I’d still be at home in bed, if I was still alive at all.” Miranda says, “There are thousands of success stories as magical as this one, just waiting for appropriate interventions.”
The treatments Wendy received did not include psychopharmaceutical intervention. What was it that enabled this metamorphosis? In part, it was simply the steady glow of attention from the doctors with whom she worked. In part, it was a cognitive shift. Miranda described Wendy as “clearly” having depression, but this had not been clear to Wendy even when she suffered extreme symptoms. The labeling of her complaint was an essential step toward her recovery from it. What can be named and described can be contained: the word “depression” separated Wendy’s illness from her personality. If all the things she disliked in herself could be grouped elegantly together as aspects of a disease, that left her good qualities as the “real” Wendy, and it was much easier for her to like this real Wendy and to turn this real Wendy against the problems that afflicted her. To be given the idea of depression is to master a socially powerful linguistic tool. There are no people so starved for this vocabulary as the indigent depressed, which is why basic tools like cognitive group therapy can be so utterly transforming for them.
Many women in Wendy’s situation would be even more expeditiously helped by pharmaceuticals. There are four impediments to such broadband treatment programs. The first is that the indigent populations who might be helped by medication have never really been identified. The second is that to be effective, antidepressant medications must be taken on an ongoing basis over an extended period of time. The lower people’s education levels, the less likely they are to take a medication that does not have any immediately palpable effect when they take it. Such people are also unlikely to continue to take their pills once their symptoms have lifted. The third, of course, is cost, though in absolute terms it costs less to provide medication than it does to provide the social services that the indigent require. The fourth is a mode of transmission. Pharmaceutical executives to whom I mentioned all the above said they would willingly set up programs to discount medication for use in these populations if there were a way to convey it. “I simply didn’t know that such a phenomenon existed on the scale you are describing,” one executive told me. In the absence of government programs to facilitate the distribution of antidepressants to this population, however, even the most well-intentioned members of the pharmaceutical industry are stymied.
The privately financed Treatment Advocacy Center is the most conservative body issuing policy on treatment, and its position is that people whose condition can be improved through treatment should receive it whether they want to or not. It is their view that those who resist treatment place an unconscionable and unnecessary burden on society. The Bazelon Center for Mental Health Law, a nonprofit policy group at the other end of the spectrum, believes that commitment should almost always be voluntary and defines mental illness as interpretive. The A.C.L.U. takes the middle ground. It has published a statement that “the freedom to be wandering the streets, psychotic, ill and untreated, when there is a reasonable prospect of effective treatment, is not freedom; it is abandonment” — though it also supports the right of people to make decisions about their own lives. The problem is that desperate people often dislike help because they do not believe that help will set them free. The answer is neither forced treatment nor abandonment; it is a process of forceful seduction predicated on the principle that those who are treated will be glad after the fact to have received such attention.
Joseph Rogers, the head of the Mental Health Association of Southeastern Pennsylvania, was indigent and depressed himself at one time; he spent a year living on a bench in Central Park before being drawn into an outreach program. “People who are isolated and lost are usually desperate for a little human connection,” Rogers says. “Outreach can work. You just have to be willing to go out and engage them and re-engage them until they’re ready to come with you.” Rogers has helped to make Pennsylvania one of the most progressive states in the nation for mental health. In fact many people from neighboring states get shipped into Pennsylvania so they can take advantage of the systems there.
Rogers also has created a chain of what he calls “drop-in centers,” which are street-level storefronts, usually staffed by people who are themselves recovering from mental illnesses. This creates employment for the people who are just beginning to cope with a structured environment, and it gives people who are in bad shape a place to go and receive advice. Drop-in centers provide a transit zone between mental isolation and companionship.
Popular wisdom holds that you need to address unemployment before you start worrying about the fancy business of the mental health of the unemployed. And greater prosperity is a good trigger for recovery. But it is perhaps easier and equally reasonable to treat the depression itself so that these people can alter their own lives.
Our failure to identify and treat the indigent depressed is not only cruel but also costly. Many of the depressed poor are welfare recipients who cannot hold jobs. They are given to substance abuse and other self-destructive behaviors. They are sometimes violent. Infants of depressed mothers show brain-wave patterns different from those of other infants, according to a study by Tiffany Field, chair of the Touch Research Institute. These altered patterns seem to relate to the closing down of essential brain circuits that, if they do not function in childhood, are probably inoperative later on. Treat the depression in the mother, and the infant’s brain waves are likely to normalize. When a depressed mother is not treated, her children tend to end up in the welfare and prison systems: the sons of mothers with untreated depression are eight times more likely to become juvenile delinquents as are other children. Daughters of depressed mothers will have earlier puberty than other girls, according to a recent paper by Bruce Ellis and Judy Garber in the journal Child Development. And early puberty is usually associated with promiscuity, early pregnancy and mood disorders.
According to the 1998 Green Book of the House of Representatives Committee on Ways and Means, state and federal government spends roughly $20 billion on cash transfers to poor nonelderly adults and their children, and roughly the same amount for food stamps for such families. If one makes the conservative estimate that 25 percent of people on welfare are depressed, that half of them can be treated successfully and that of that percentage, two-thirds could return to productive, at least part-time, work, factoring in treatment costs, that would still reduce welfare costs by as much as 8 percent — a savings of almost $3.5 billion per year. Because the federal government also provides health care and other transfers for such families, the true savings could be quite a bit higher.
The dollar cost of interventionist treatment of depression is really quite small; the dollar cost of not treating depression is enormous. “Postponement of intervention does not result in savings,” Representative Marge Roukema, a Republican from New Jersey and the co-chairwoman of the Working Group on Mental Illness, says. “You’re really building in greater costs.”
For more than a decade, Glenn Treisman of Johns Hopkins University has been studying and treating depression among indigent H.I.V.-positive and AIDS populations in Baltimore, most of whom are also substance-abusers. “Many people get H.I.V. when they can’t muster the energy to care anymore,” Treisman says. “These are people who are utterly demoralized by life and don’t see any point in it. If we had treatments more broadly available for depression, I would guess from my clinical experience that the rate of H.I.V. infection in this country would be cut in half at least, with enormous consequent public-health savings.”
Mental-Health Services are still focused primarily on the noisy disorders, with schizophrenia and mania at the top of the list. “Of course we want to help nonviolent mentally ill people just as much as we want to help violent ones,” Roukema told me. “But to draw any kind of substantial support, we have to show people that it serves their urgent self-interest to do something about mental-health care for the poor. We have to talk about preventing atrocious crimes that could be visited on them or their constituents at any moment. We can’t talk simply about a better and more prosperous and more humane state.”
There is no discussion in Congress at present about depression among the uninsured. Senator Pete Domenici of New Mexico, who has been the joint sponsor of several important mental-health bills, says this situation is unlikely to change. “If you’re asking whether we can expect much change simply because that change would serve everyone’s advantage in immediate economic and human terms,” Domenici says, “I regret to tell you that the answer is no.”
It is hard to find anyone in Congress who is opposed on principle to healing the mentally ill. “The opposition is competition,” says Representative John Porter, an Illinois Republican who until January was the chairman of the Labor, Health and Human Services, and Education Appropriations Subcommittee. Nonetheless, while declarations about the tragic nature of suicide and the danger of psychiatric complaints accumulate on the Congressional record, legislation pertinent to these statistics does not pass easily. “Progress here is excruciatingly gradual,” says Senator Paul Wellstone of Minnesota, who has made regular attempts to introduce comprehensive legislation for mental-illness coverage. “The uninsured haven’t even made it onto the radar screen around here yet.”
There are programs, even some good ones, that are available to the poor mentally ill, but they exist inside hospitals. You have to find them yourself. Public-relations campaigns for treating mental illnesses — signs on buses, TV ad spots and so on — have had some success at bringing people into clinics, but the idea that indigent depressed people will ever have the wherewithal to seek and find help, even if they did figure out for themselves that they were depressed, is ludicrous. A program that did a basic mental-health screening at family-planning clinics or at job centers or at places where welfare checks are distributed might allow us at least to identify the people who are currently suffering from illness.
But the best place to start would probably be the welfare rolls. Major depression is frequently triggered by stresses, and there is no question that the lives of welfare recipients are extremely stressful. At the moment, however, welfare officers do no significant screening for depression. Welfare programs are essentially run by administrators, who do little or no actual social work. What tends to be noted in welfare reports as noncompliance is in many instances motivated by psychiatric trouble.
Some pilot studies are under way on the treatment of depression among the poor, and the results appear surprisingly consistent. I was given full access to subjects from several of these studies — some involved therapy, others medication, still others a combination of the two. To my surprise, everyone I met felt that his or her lot had improved during treatment. They felt better about their lives, and they lived better. Even when faced with insurmountable obstacles, they progressed, often fast and sometimes far. Over and over again, as I spoke to more poor people who had been treated for depression, I heard tones of astonishment. How, after so many things had gone wrong for them, had they been swept up by this help that had changed their entire lives? “I asked the Lord to send me an angel,” one woman told me. “And he answered my prayers.”
