A CURE FOR POVERTY

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."

endy 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.

opular 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."

ental-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.