From: Mark Plus (markplus@hotmail.com)
Date: Sat May 05 2001 - 08:54:17 MDT
From:
http://www.nytimes.com/2001/05/06/magazine/06POVERTY.html?pagewanted=all
(registration required)
May 6, 2001
A Cure for Poverty
By ANDREW SOLOMON
What if you could help end people's economic problems by treating their
depression?
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."
Andrew Solomon is the author of "The Noonday Demon," to be published in June
by Scribner.
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