Despite a decade of efforts by public figures such as Tipper Gore and Mike Wallace, as well as by countless health journalists, depression remains a baffling and controversial illness. Its manifestations seem to run the gamut from extreme and destructive dementia to what strikes some observers as not much more than a prolonged bad mood. Take two recent developments: In the case of Andrea Yates, who allegedly murdered her five children, Americans were told that she acted in the throes of an ongoing, severe postpartum depression. A few days later, the publishers of Psychology Today announced that they are launching a new magazine, called Blues Busters, aimed at depression sufferers and billed as "a new antidote to the blues." Within the course of a single week, we've been presented with depression as the cause of homicidal psychosis and as the premise for a lifestyle.
When it comes to the prevalence of the illness, improbably large numbers get thrown around: According to Andrew Solomon, author of the new book "The Noonday Demon: An Atlas of Depression," chronic depression afflicts more than 19 million Americans. If you're not among that group, it's easy to be skeptical; the seemingly functional relative, friend or acquaintance seeking treatment for depression is still often viewed as a self-absorbed, neurotic malingerer or morally weak pill popper. According to Solomon, 60 million prescriptions for antidepressants were written in 1998 alone. Are the people who take these pills dupes of the pharmaceutical industry, or genuine sufferers looking for relief?
Part of depression's public relations problem stems from the fact that it's an exaggerated form of common experiences -- grief, hopelessness and fear about the future. The line between ordinary depression, which is part of being human, and what's now called "clinical depression," which if left untreated can ravage a life in big and small ways, isn't always a clear one.
The widespread perception of depression as a "disease of affluence" doesn't help either. Many see it as a sickness that only seems to afflict the well-off and whiny. What used to be called "melancholia" has always been with us, but "depression" in its present form only appeared on the scene, after all, in the middle of the 20th century, after life became cushy and stoicism (or what some would call moral backbone) went out of fashion. Is there perhaps something about our godless, impersonal, materialistic society that has caused middle-class people's brains to short-circuit somehow? Or perhaps depression is the equivalent of the "neurasthenia" that afflicted wealthy women at the turn of the 20th century but has since disappeared as a medical diagnosis: A sort of mass hysteria through which the idle and self-indulgent convince themselves that they are "sick" and need special attention.
One thing that Solomon's exhaustive and eloquent book makes abundantly clear is that, despite depression's well-to-do and lily-white public image, it's not true that serious depression is largely a province of the privileged. The rise of antidepressants may be a phenomenon of affluence, but depression itself is not. In fact, Solomon argues, since clinical depression is often the brain's response to trauma, physical hardship and a persistent lack of self-determination in one's everyday life, we shouldn't be surprised that poor people actually suffer from it more often than do the middle class and rich. The overwhelming obstacles encountered during a life spent in poverty can breed passivity, and passivity, or "learned helplessness," is "a precursor state of depression."
"Checking for depression among the indigent," as Solomon puts it, "is like checking for emphysema among coal miners." A chronic sense of despair may strike a poor and barely educated person as a fitting response to a life vulnerable to both the caprices of impersonal forces and sudden violence. "If this is how all your friends are," one therapist told Solomon, "it has a certain terrible normality to it. You attribute your pain to external things and, believing these externals can't change, you assume that nothing internal can." That's no doubt why welfare recipients have a rate of depression three times the national average, according to Solomon.
We don't hear those people's stories. Poor depressed people suffer in silence, often without a full understanding of what's happening to them. More educated and economically stable depressed people realize what's wrong, get the best available care and usually get better. Depression, as Solomon puts it, "is a thing that a certain class has the luxury of articulating and addressing."
It's these articulate middle-class people who have become the public face of the disease. That media-savvy spokespeople like Solomon have helped create a thriving cultural cottage industry around depression is, to say the least, ironic. The most isolating of illnesses, a disorder that turns its sufferers into notoriously self-absorbed shells of their former selves, is taking on all the hallmarks of a cultural movement, one in which writers play a key role. Since William Styron's "Darkness Visible" appeared in 1990, the publishing industry has offered us many depression memoirs -- 1999's "Where the Roots Reach for Water" is just one example. This season, Solomon's book is joined by an anthology, "Unholy Ghost: Writers on Depression," edited by Nell Casey, which includes essays by Lauren Slater, Kay Redfield Jamison and Martha Manning. Depression's new literary visibility is not limited to the written word, either. In a recent sold-out event sponsored by the hip New York series called the Moth (in which writers and actors tell lightly rehearsed stories), an upbeat crowd packed the nightclub Nell's for "An Evening of Stories on Depression," at which Solomon was the final speaker.
Solomon is himself a sort of poster child for many of the contradictions in this new trend: He has been through extreme, debilitating depression, but he's living what looks to be a very visibly fabulous lifestyle, in which he gets plenty of attention as a result of his illness. He's a writer who lives in Manhattan (author of the novel "A Stone Boat" and a nonfiction book, "The Irony Tower: Soviet Artists in a Time of Glasnost") and has published his work in the New Yorker, including an account of his first breakdown in 1999 that received a flood of mail and became the germ of "The Noonday Demon." He's also independently wealthy -- the heir to a pharmaceuticals fortune -- and frequently refers to his Yale and Oxford degrees. His media appearances include a recent turn in the New York Times Home section in which he showed off the grand, landmark townhouse he has lovingly decorated in an eclectic style that includes "silk brocaded sofas, doges' lanterns, Russian paintings, polar bear rugs and Chinese dragon robes"; he lives there with his "staff of two."
"The Noonday Demon" presents itself as a be-all and end-all on depression. There are fact-filled chapters on treatments (Solomon is, no surprise, vehemently pro-antidepressant, though he advocates using them along with talk therapy), suicide, addiction, how depression affects different populations and more. Solomon fills plenty of pages of "The Noonday Demon" with the details of his own illness -- he's been through three breakdowns and now depends on a perpetually evolving regime of antidepressants and anti-anxiety medication to stay well -- and his expensive, globe-trotting search for the best possible care.
But however unlikely a champion he may appear to be, Solomon deserves credit for devoting much of his book to the experiences of poor depressed people, such as Lolly Washington of Prince George's County, Md. Lolly bore her first child at 17, was raped shortly after that and bore the rapist's child as well, then married a physically abusive man under family pressure and had three more kids in two-and-a-half years.
Her major depression arrived soon after. Solomon quotes her own description of what it was like: "I'd had a job but I 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. Just cry. I just wanted to be by myself. My mom helped with the kids, even after she got her leg amputated, which her best friend accidentally shot off around then. 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, three o'clock, and it just came so fast. My husband was telling me I was stupid, I was dumb, I was ugly. My sister has a problem with crack cocaine, and she has six kids, and I had to deal with the two little ones, one of them was born sick from the drugs. I was tired. I was just so tired."
By chance, Lolly became part of a Georgetown University study of indigent depressed women: She'd gone to the hospital to get her tubes tied and was spotted by someone screening for study subjects. It took pestering and several visits at home to persuade her to enroll in the study, which entailed therapy and group-support sessions. Once she did, her depression lifted very quickly. Solomon reports that Lolly's is one of the many "Cinderella-like" stories he encountered among poor depressed women given basic mental-health care: Four months later, she'd left the abusive husband, found a new job and moved the kids to a new apartment. "If it wasn't for Dr. Miranda and that," Lolly says of her therapist, "I'd still be at home in bed, if I was alive at all."
The stories Solomon tells of depression among the poor are not all so open and shut. Mental-health care, whether it's getting and filling a prescription or showing up for weekly therapy appointments, requires the kind of regular routine that many poor people find impossible to sustain. Emily Haunstein, a therapist who works with rural indigent women in southern Virginia, describes a typical patient's situation to Solomon: "When she has to come to the clinic on Monday, she asks her cousin Sadie, who asks her brother to come and get her to bring her in, while her sister-in-law's sister takes care of the kids, except if she gets a job that week, in which case her aunt can cover if she's in town. Then the patient has to have someone else come and pick her up, because Sadie's brother goes to work just after he drops her off. Then if we meet on Thursday, there's a whole other cast of characters involved. Either way, they have to cancel about 75 percent of the time, leaving her to make last-minute arrangements."
Nevertheless, poor depressed women are better off than poor depressed men. Male depression in general is harder to spot, Solomon says, because men tend to deal with the feelings of depression "not by withdrawing into the silence of despondency, but by withdrawing into the noise of violence, substance abuse, or workaholism." Indigent men's depression shows up in ways that "put them in jail or the morgue more often than in depression treatment protocols" like the one that saved Lolly Washington.
The links between poverty and depression aren't just a problem in the U.S., either. Solomon also traveled to Greenland to study the illness among the closeknit Inuit, who, he says, have a depression rate as high as 80 percent. Greenlanders have universal free healthcare, education and unemployment benefits. But they also live in a freezing climate in which the sun disappears entirely for three months each winter, everyday life is filled with stories of suicides, tragic deaths in snowstorms and iceberg-filled seas, and the traditional culture has a "taboo on talking about yourself."
Solomon reports that a few of the Inuit women he met have begun talking about their problems with therapists and each other and have found some relief. One Inuit woman told him "she had found the cure for sadness, which was to hear of the sadness of others."
All this appears to bolster Solomon's claim that the salutary effect of talking about depression holds true even outside the confessional climate of contemporary America. But is it possible that in this country, where the prevalence of everything from memoirs to talk shows to support groups sometimes makes the topic of depression (and antidepressants) seem inescapable, we've gone too far? Will all of this attention help suffering people feel better and function better, or will it encourage them to stay permanently depressed, or at least permanently identified with depression, as a "community" clustered around the disorder flourishes?
These are knotty questions even an exhaustive book like Solomon's can't answer. For his part, he preaches a two-part gospel: First, antidepressants, about which his only ambivalence concerns the sexual side effects they produce (delayed or nonexistent orgasm and lowered libido, in most people), and talk therapy -- on a grandly ambitious scale.
It's the second half of his agenda that's more intriguing: an activist anti-depression movement akin to the environmental movement. "We must start doing small things to lower the level of socio-emotional pollution," Solomon writes. "We must look for faith (in anything: God or the self or something in between) and structure. We must help the disenfranchised whose suffering undermines so much of the world's joy -- for the sake both of those huddled masses and of the privileged people who lack profound motivation in their own lives. We must practice the business of love, and we must teach it too."
In a way, Solomon's book, like his life, embodies the contradictions of depression's new high profile. It's the work of a man who meets the stereotype of the seemingly idle, pampered depressed person, the sort of perpetual patient who talks at length and in detail about himself and his problems. It would be all too easy to dismiss him out of hand. And yet it takes someone like Solomon -- articulate, well connected and never bored with the minutiae of a disease that, let's face it, tends to make its victims tragically boring -- to be the kind of tireless advocate and booster that depressed people require. Certainly less well-off sufferers need every last iota of the energy they recover from the disease just to put their lives back together. By helping the "disenfranchised," as Solomon hints, the rich and aimless depressed may find yet another kind of cure. And if the floodlight directed on depression's more privileged victims dispels some of the darkness surrounding the less glamorous ones, then maybe it's not such a bad thing after all.