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epression cuts across class boundaries, but depression treatments
do not. This means that most people who are poor and depressed
stay poor and depressed; in fact, the longer they stay poor and depressed,
the more poor and depressed they become. Poverty is depressing and
depression is impoverishing, leading as it does to dysfunction and isola­
tion. Poverty’s humility is a passive relationship to fate, a condition that
in people of greater ostensible empowerment would require immediate
treatment. The poor depressed perceive themselves to be supremely
helpless, so helpless that they neither seek nor embrace support. The rest
of the world dissociates from the poor depressed, and they dissociate
themselves: they lose that most human quality of free will.
When depression hits someone in the middle classes, it’s relatively
easy to recognize. You’re going about your essentially okay life and sud­
denly you begin feeling bad all the time. You can’t function at a high
level; you don’t have the will to get to work; you have no sense of control
over your life; it seems to you that you will never accomplish anything
and that experience itself is without meaning. As you become increas­
ingly withdrawn, as you approach catatonia, you begin to attract the
notice of friends and coworkers and family, who cannot understand
why you are giving up on so much of what has always given you pleas­
ure. Your depression is inconsistent with your private reality and inex­
plicable in your public reality.
If you’re way down at the bottom of the social ladder, however, the
signs may be less immediately visible. For the miserable and oppressed
poor, life has always been lousy and they’ve never felt great about it;
they’ve never been able to get or hold a decent job; they’ve never
expected to accomplish anything much; and they’ve certainly never
entertained the idea that they have control over what happens to them.
The normal condition of such people has a great deal in common with
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depression, and so there’s an attribution problem with their symptoms.
What is symptomatic? What is rational and not symptomatic? There is
a vast difference between simply having a difficult life and having a
mood disorder, and though it is common to assume that depression is the
natural result of such a life, the reality is frequently just the other way
around. Afflicted by disabling depression, you fail to make anything of
your life and remain stranded at the lowest echelon, overwhelmed by the
very thought of helping yourself. Treating the depression of the
depressed indigent often allows them to discover within themselves
ambition, competence, and pleasure.
Depression is a big field full of subcategories, many of which have
been studied at length: depression among women; depression among
artists; depression among athletes; depression among alcoholics. The
list goes on and on. And yet-indicatively-little work has been done
on depression among the poor. This is curious, because depression
occurs more often among people living below the poverty line than in
an average population; indeed, welfare recipients have a rate of depres­
sion approximately three times as high as the general population. It has
been fashionable to talk about depression in isolation from life events.
In fact, most of the poor depressed fit several profiles for initial onset of
depression. Their economic hardship is only the beginning of their
problems. They are often in bad relationships with parents, children,
boyfriends, girlfriends, husbands, or wives. They are not well educated.
They do not have easy distractions from their sorrow or suffering, such
as satisfying jobs or interesting travel. They do not have the fundamen­
tal expectation of good feelings. In our rage to medicalize depression,
we have tended to suggest that “real” depression occurs without refer­
ence to external materiality. This is simply not true. Lots of poor people
in America suffer from depression-not just the hangdog, low-down
feeling of being at the bottom, but the clinical illness whose symptoms
include social withdrawal, inability to get out of bed, disruptions of
appetite, excessive fear or anxiety, intense irritability, erratic aggression,
and inability to care for the self or others. Virtually all of America’s indi­
gent are, for obvious reasons, displeased with their situation; but many
of them are, additionally, paralyzed by it, physiologically unable to con­
ceive of or undertake measures to improve their lot. In this era of wel­
fare reform, we are asking that the poor pull themselves up by their
bootstraps, but the indigent who suffer from major depression have no
bootstraps and cannot pull themselves up. Once they have become
symptomatic, neither reeducation programs nor civic citizenship initia­
tives can help them. What they require is psychiatric intervention with
medication and with therapy. It is being amply demonstrated in several
independent studies across the country that such intervention is rela­
tively inexpensive and highly effective, and that most of the indigent
depressed, liberated from their depression, are keen to better them­
Indigence is a good trigger for depression; relief of indigence is a good
trigger for recovery. The focus of liberal politics has been on ameliorat­
ing the external horrors of indigent lives, with the assumption that this
will make people happier. That goal should never be discounted. It is
sometimes more feasible, however, to relieve the depression than to fix
the indigence. Popular wisdom holds that unemployment must be reme­
died before the fancy business of the mental health of the unemployed is
addressed. This is poor reasoning; fixing the mental health problem may
well be the most reliable way to return people to the workforce. In the
meanwhile, some advocates for the disenfranchised have worried that
Prozac will be added to the tap water to help the miserable tolerate the
intolerable. Unfortunately, Prozac neither makes nor keeps the miser­
able happy, and so the paternalistic totalitarian scenario sketched by
social alarmists has no basis in reality. Treating the consequences of
social problems will never substitute for solving them. Indigent people
who have received appropriate treatment may, however, be able to work
in concert with liberal politics to change their own lives, and those
changes can cause a shift in the society as a whole.
Humanitarian arguments for treating depression among the indigent are
sound; the economic arguments are at least equally sound. Depressed
people are an enormous strain on society: 85 to 95 percent of people in
the United States with serious mental illness are unemployed. Though
many of them struggle to lead socially acceptable lives, others are given
to substance abuse and self-destructive behaviors. They are sometimes
violent. They pass these problems on to their children, who are likely to
be mentally slow and emotionally dysfunctional. When a poor depressed
mother is not treated, her children tend to head into the welfare and
prison systems: the sons of mothers with untreated depression are far
more likely to become juvenile delinquents than are other children.
Daughters of depressed mothers will go through puberty earlier than
other girls, and this is almost always associated with promiscuity, early
pregnancy, and emotional instability. The dollar cost of treating depres­
sion in this community is modest when compared to the dollar cost of
not treating depression.
It is extremely difficult to find any poor people who have had sus­
tained treatment for depression, because there are no coherent programs
in the United States for locating or treating depression in this popula337
The Noonday Demon
tion. Medicaid recipients qualify for extensive care but have to claim it,
and depressed people seldom exercise rights or claim what should be
theirs, even if they have the sophistication to recognize their condition.
Aggressive outreach programs-which seek out people who may need
treatment and bring that treatment to them,even if such people are dis­
inclined to pursue help-are morally justified, because those seduced
into treatment are almost always glad to have received such attention;
here more than elsewhere, the resistance is a symptom of the illness.
Many states promise more or less adequate treatment programs for those
among the indigent depressed who are able to visit the appropriate
offices,fill in the appropriate forms,wait in the right lines,provide three
kinds of photo identification,research and enroll in programs,and so on.
Few indigent depressed people have these capacities. The social status
and serious problems of the indigent depressed make it virtually impos­
sible for them to function at this level. This population can be treated
only by addressing illness before addressing the passivity with which
they tend to experience that illness. Speaking of mental health interven­
tion programs, Steven Hyman, director of the NIMH,says,”It’s not like
the KGB rolling up in a bread truck and pulling you in. But you need to
pursue these people. You could do this in the workfare programs.If you
want to have the most effective transition from welfare to work,that is a
good place to start. It is probably an unprecedented experience in these
people’s lives to have somebody really interested in them.” Most people
are initially uncomfortable with unprecedented experiences. Desperate
people who dislike help are usually unable to believe that help will set
them free. They can be saved only through muscular exhortation of mis­
sionary zeal.
It is hard to make specific numerical estimates of the costs associated
with serving this population,but 13.7 percent of Americans are below the
poverty line, and according to one recent study, about 42 percent of
heads of households receiving Aid to Families with Dependent Children
(AFDC) meet the criteria for clinical depression-more than twice the
national average. A staggering 5 3 percent of pregnant welfare mothers
meet the same criteria. From the other side, those with psychiatric dis­
orders are 38 percent more likely to receive welfare than are those with­
out. Our failure to identify and treat the indigent depressed is not only
cruel but also expensive. Mathematica Policy Research,Inc.,an organi­
zation that compiles social-issue statistics,confirms that “a substantial pro­
portion of the welfare population …have undiagnosed and/or untreated
mental health conditions,” and that offering services to these individuals
would “enhance their employability.” State and federal governments
spend roughly $20 billion per year on cash transfers to poor nonelderly
adults and their children. We spend 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 could be
treated successfully, and that of that percentage two-thirds could return
to productive work, at least part-time, factoring in treatment costs, that
could still reduce welfare costs by as much as 8 percent-a savings of
roughly $3.5 billion per year. Because the U.S. government also provides
health care and other services to such families, the true savings could be
substantially higher. At the moment, welfare officers do no systematic
screening for depression; welfare programs are essentially run by admin­
istrators who do little social work. What tends to be described in welfare
reports as apparently willful noncompliance is in many instances moti­
vated by psychiatric trouble. While liberal politicians tend to emphasize
that a class of miserable poor people is the inevitable consequence of a lais­
sez-faire economy (and is therefore not subject to rectification through
mental health interventions), right-wingers tend to see the problem as one
of laziness (which is therefore not subject to rectification through mental
health interventions). In fact, for many of the poor, the problem is neither
the absence of employment opportunities nor the absence of motivation
toward employment, but rather severe mental health handicaps that
make employment impossible.
Some pilot studies are under way on depression among the indigent.
A number of doctors who work in public health settings are accustomed
to addressing this population, and they have shown that the problems of
the indigent depressed are manageable. Jeanne Miranda, a psychologist
at Georgetown University, has for twenty years been advocating sound
mental health care for inner-city residents. She recently completed a
treatment study of women in Prince George’s County, Maryland, a
poverty-stricken district outside Washington, D.C. Since the services of
family planning clinics are the only medical care available to the indigent
population in Maryland, Miranda selected one for random screenings for
depression. She then enrolled those whom she judged to be depressed in
a treatment protocol to address their mental health needs. Emily Hauen­
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