Danquille has now become a sort of community resource, teaching friends and strangers her methods for depression control. “A whole lot of people keep asking me, ‘How did you change?’ Since I think positive, I laugh all the time, smile all the time. Now, I had this happen to me, that the Lord started sending people for me to help. I said, ‘Lord, will you give me what they need to hear and help me listening?’ ” Danquille listens to her children now, and she listens to the people she knows at her church. When someone there was suicidal, “I told him, ‘You not by yourself. I was like that.’ And I said, ‘I made it. Ain’t nothing that bad you can’t get through.’ I said, ‘You start thinking positive and I promise you that girl what is leaving you now, she gonna call.’ He told me yesterday, ‘If it wasn’t for you, I would’ve been dead.’ ” Danquille has taken a new place in her family. “I’m breaking a pattern more or less. My nieces, they come to me instead of to their parents, and the pattern of not listening be broken. They say to me, since I been talking to you, I want to live. And I say to everyone, you got a problem, you get help. That’s what God put them doctors here for, to help you. I say that loud with these people, they just dogs eating dog. And anyone can be saved. I had one woman, she drank, smoke, had been with my husband, right with him, no saying she was sorry either, and then with my new friend, but when she come round, I gonna help her, ’cause in order for her to get better she gotta have someone to help her.”
The poverty-stricken depressed are not represented in the statistics on depression because the research those statistics reflect is based primarily on work with people within existing health plans, who are already a middle-class—or at least a working—population. Raising expectations among disadvantaged populations is a tangled issue, and it is true that planting false goals in people’s minds can be dangerous. “I’ll never stop seeing Dr. Chung,” one woman told me confidently, though the actual parameters of the study had been explained to her over and over. It is heartbreaking that if she were to have another collapse later in life, she will perhaps be unable to get the kind of help that has pulled her through—though all the therapists involved in these studies feel an ethical obligation to provide, paid or not, ongoing basic services to their patients. “To withhold treatment to people who are suffering acutely because it’s going to raise expectations,” says Hauenstein, “well, that’s ignoring the large ethical issue for the sake of the small one. We try our best to give people a set of skills they can use themselves in another situation—to do all we can do to help them stay afloat.” The cost of ongoing medication is an enormous problem. The problem is partly resolved by industry-based programs that distribute antidepressants to the poor, but these barely begin to meet needs. One feisty Pennsylvania doctor I met told me that she got “truckfuls of samples” from pharmaceutical salesmen to give to her indigent patients. “I tell ’em that I’ll use their product as my first-line treatment on patients who can pay and who are likely to renew over a lifetime,” she said. “In exchange, I tell ’em I’ll need a more or less unlimited supply of product so that I can medicate my low-income patients for free. I write a hell of a lot of prescriptions. The smart salesmen always say yes.”
Schizophrenia occurs twice as often among low-income populations as in the middle class. Researchers initially assumed that difficulty triggered schizophrenia in some way; but more recent research shows that schizophrenia leads to difficulty: mental illness is expensive and confusing, and a chronic illness that impairs productivity and occurs in youth tends to pull a person’s entire family down a rung or two on the social ladder. This “downward drift hypothesis” appears to hold true for depression as well. Glenn Treisman says of the indigent HIV population, “Many of these people have never had a success in their whole lives. They can’t have a relationship, or a long-term commitment to a job.” People think of depression as being a consequence of HIV, but it is often in fact an antecedent. “If you have a mood disorder, you’re much more careless about sex and about needles,” Treisman says. “Very few people get HIV from a broken condom. Many people get HIV when they can’t muster the energy to care anymore. 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 HIV infection in this country would be cut in half at least, with enormous consequent public health savings.” The public health costs of an illness that enables HIV infection and then disables people from taking appropriate care of themselves (and others) is absolutely gigantic. “HIV takes away all your money and assets and often your friends and family too. Society disenfranchises you. So these people sink to the very bottom.” The researchers I met all stressed the need for treatment, but they also talked about the need for good treatment. “There’s a really small number of people that I would trust the care of these people with,” says Hauenstein. The standards of mental health care for those few indigent people who are sick enough to get treatment—outside these studies—are terribly low.
The only depressed indigent men I have interviewed are HIV-positive. They are among the few who have been forced up against the reality of their depression—because indigent men’s depression manifests in ways that put them in jail or the morgue more often than in depression treatment protocols. Men are certainly much more resistant than women to being drawn into depression therapy when their mood disorders are noted. I asked the women I interviewed whether their husbands or boyfriends might be depressed, and many said yes; and they all told me about their depressed sons. One of the women in Miranda’s study said that her boyfriend, who had given her some rosy bruises, had confided he wanted to find a group to attend himself—but he found the idea of following through “too embarrassing.”
I was taken aback when Fred Wilson came in to talk to me one afternoon at Hopkins. He was six foot six and wore gold rings, a big gold medallion, and a pair of sunglasses; he had an almost shaved head; he had impressive muscles; and he seemed to take up about five times as much room as I did. He was just the kind of person I cross the street to avoid, and as we talked, I realized that this was a good policy. He had had a heavy drug habit, and to keep it going he had mugged people, broken into stores and homes, knocked down old women for their handbags. He had been homeless for a while and he was tough. Though he provoked righteous indignation, this scary man had an air of despair and loneliness.
Fred’s therapeutic breakthrough had occurred when he recognized that he had a mood disorder that had probably started him on drugs, that he wasn’t “just messed up by smack.” He was, when I saw him, seeking an antidepressant that would help him. Fred had charisma and a hard-knocks grin; he had known what it was to be on top of the world. “I always had the ability to get whatever I wanted. And when you got that ability, you just don’t really work or nothing, you just go get it. I didn’t know what it was like to be patient. There weren’t no limits,” he said. “There were no precautions, you know what I’m saying? Just getting what I wanted and getting high. Getting high, you know? With that I kind of had some acceptance. It helped me get past the blame and the shame.” Fred took the HIV test after he got “incarcerated off the street” and soon thereafter found out that his mother was also positive. Since her death from AIDS, “it never seemed like nothing mattered, because the end result of life always gonna be death. I achieve some goals, man, I be looking at other things I’ve gotta do, you know? But anyways, I just start disliking myself even more. Then one of them times when I got arrested, when I was living out on the street, I realized I was living like I was living because of the choices I was making. I changed to face that, you know what I’m saying? Because I was all alone at that time. And ain’t nobody gonna give you the drugs when you’re needing ’em unless you got the money to pay.”
Fred has been given a regimen of meds for HIV, but he stopped taking them some time ago because they weren’t making him feel good. His side effects were slight, and the inconvenience of the drugs was a
lso slight, but “before I go, I may as well enjoy myself,” he said to me. His HIV doctors, disappointed, persuaded him to stick with antidepressants; they hope these medications will waken in him the wish to stay alive, to take the protease inhibitors.
Strength of will is often the best bulwark against depression, and in this population, the will to go on, the tolerance of trauma, is often quite extraordinary. Many among the indigent depressed have personalities so passive that they are free of aspirations, and such people may be the most difficult to help. Others retain a zest for life even during their depression.
Theresa Morgan, one of Emily Hauenstein’s and Marian Kyner’s patients, is a sweet-natured woman whose life has been dotted with a surreal helping of horror. She lives in a house about the size of a double-wide trailer, right in the middle of Buckingham County, Virginia, five miles south of the Highway of Faith Congregation and five miles north of Gold Mine Baptist Church. When we met, she told me her story with an air of great specificity, as though she had been taking notes her whole life.
Theresa’s mother became pregnant at fifteen, gave birth to Theresa at sixteen, and was seventeen when Theresa’s father beat her so badly she had to crawl out of the house. Theresa’s grandfather told her mother to go away and hide herself, that if she was ever seen in the county again, if she ever tried to contact Theresa, he’d get her put in jail. “My daddy was twenty-two then, so he’s the big jerk—but they used to tell me that she was a slut, that I was gonna be a slut like her. And my daddy used to tell me that I ruined his life just by being born,” Theresa told me.
Early on, Theresa was diagnosed with an inoperable benign tumor, a hemangioma, located between her rectum and her vagina. She was sexually abused by close relatives every night from her fifth birthday until she was nine, when one of the perpetrators married and left the house. Her grandmother told her that men lead the family, and that she should keep her mouth shut. Theresa went to church and to school, and that was the circumference of her life. Her grandmother believed in strict discipline, which meant daily attacks with whatever household objects came to hand: whippings with extension cords, beatings with broom handles and frying pans. Her grandfather was an exterminator, and starting when she was seven, Theresa spent a lot of time under houses trying to catch blacksnakes. In eighth grade, Theresa took an overdose of her grandmother’s heart medication. Doctors at the hospital pumped her stomach and advised therapy, but her grandfather said none of his family needed help.
In eleventh grade Theresa went out on her first date, with a guy called Lester, who had “kinda touched my soul, because we could honestly talk to each other.” As Lester was dropping her off at home, her father came in and went berserk. He was just five foot one, but he weighed over three hundred pounds, and he sat on top of Theresa (who is four foot nine and at that time weighed one hundred five pounds) and banged her head on the ground for hours, until the blood flowed through his fingers. Theresa’s forehead and scalp are still covered with scars so extensive it looks as if they came from burns. He also broke two of her ribs, her jaw, right arm, and four toes that night.
As Theresa told me this story, her nine-year-old daughter, Leslie, was playing with a pet dachshund. These many details seemed to be as familiar to her as the Passion is to a churchgoer. But they did register: Leslie would become aggressive with the dog at the mention of any real horror. She never cried, however, and she never interrupted.
After the big beating, Lester invited Theresa to move in with him and his family, “and for three years it was great. But then he really wanted me to be like his mother, not work, not even drive, just stay at home and wash the treadmarks out of his underwear. I didn’t want that.” Theresa became pregnant and they married. Lester proved his independence by “running around” while Theresa took care of the baby. “Lester had liked me because I had a mind,” Theresa said. “He’d liked it when I’d told him things. I’d gotten him to listen to good jazz, away from all that Lynyrd Skynyrd stuff. I’d talked to him about art and poetry. And now he wanted me at home, and with his mother because it was her home.”
A year later, just after Leslie was born, Lester had a massive stroke that destroyed most of the left side of his brain. He was twenty-two, a heavy-equipment operator for roadwork, now half-paralyzed and unable to speak. Over the following months, before the doctors discovered his underlying complaint—a form of lupus that causes blood clots—another blockage destroyed his leg, which was subsequently amputated; other clots damaged his lungs. “I could’ve left,” said Theresa.
Leslie stopped playing and looked up at her, a blank, curious stare.
“But Lester was the love of my life, even if we’d been having some rough times, and I don’t give up on things too easy. I went to see him at the hospital, and he had one eye closed and one open. His face had started to swell and his features had dropped on one side. They’d taken the bone off the left side of his head because the swelling was so bad, just sawed off his skull. But he was tickled to see me.” Theresa went and stayed at the hospital, teaching him to use a bedpan, helping him to pee, beginning to learn the gestures with which they now communicate.
Theresa paused in her account of this. Leslie came and handed me a photo. “That’s your second birthday, isn’t it, honey?” Theresa said to her gently. In the picture, a giant, good-looking man, bandaged like a mummy, hooked up to monitors, was hugging a tiny little girl to him. “That was four months after the stroke,” Theresa said, and Leslie solemnly took the photo away again.
Lester came home at the end of six months. Theresa got a job working full-time in a factory, cutting out children’s clothes. She had to work close to home so she could go back and forth every few hours to check on Lester. The day she got her driver’s license, she showed it to Lester, and he wept. “Now you can leave me,” he gestured. Theresa laughed, recounting this. “But he found out otherwise.”
Lester’s personality fractured. He would stay awake all night, calling Theresa once an hour to help him defecate. “I would come home and make dinner and do the dishes and wash a couple of loads of clothes and clean the house up, and then I’d fall asleep, sometimes just collapse right there in the kitchen. Lester would call his mom on the phone, and when she heard his breathing on the line, she’d call back and the phone would wake me up. He’d have refused to eat dinner, and now he’d want me to make him a sandwich. I was trying to be all sunny and perky the whole time, not to make him feel bad.” Lester and Leslie fought a lot over Theresa’s attention; they’d scratch each other and pull each other’s hair. “I began to lose it,” Theresa said. “Lester wouldn’t even try to do his exercises, and he lost more and more mobility and he got enormous, fat. I guess I was in a selfish period and I couldn’t sympathize with him like I should’ve done.”
The stress caused Theresa’s hemangioma, which she had managed to ignore for some time, to expand, and it started bleeding heavily through her rectum. Theresa had become foreman, but her job still involved eight to ten hours of standing every day. “That, and the bleeding, and taking care of Lester and Leslie—well, I guess I should be able to deal with pressure, but I kind of wigged out. We’ve got a Remington twenty-two-inch pistol with a nine-inch barrel. I sat on the bedroom floor and I spun the barrel and I put it in my mouth and clicked. Then I did it again. It felt so good to have that gun in my mouth. Then Leslie knocked on the door and said, ‘Mama, please don’t leave me. Please.’ I laid the gun down then, and I promised I’d never go anywhere without her.”
“I was four,” Leslie said proudly. “After that, I came and slept with you every night.”
Theresa called a suicide hot line and talked for four hours on the phone. “I just bawled. Lester was having a staph infection. Then I had kidney stones. That was so physically painful I told the doctor I was gonna rip off his face if he didn’t help. When your body really goes, your mind wants the time off too. I couldn’t eat; I hadn’t slept in like a month, I was so wired, so hurting, and bleeding so I was total
ly anemic on top of it. I was walking around hateful.” Her doctor took her to meet Marian Kyner. “Marian saved my life, no question. She taught me how to think again.” Theresa started on Paxil and Xanax.
Kyner told Theresa that there was no power forcing her to do all the stuff she did, that it had to be worth it to her. One night shortly thereafter, when things with Lester got out of hand, Theresa calmly put down her frying pan. “Come on, Leslie,” she said. “Get a couple of your clothes, let’s go.” Lester suddenly remembered that Theresa had the power to abandon him, and he fell on the floor weeping, begging. Theresa took Leslie out and they drove around for three hours, “just to teach Daddy a lesson.” When they got back, he was penitent, and their new lives began. She arranged for him to get Prozac. And she explained the toll their life was taking on her. The doctors told Theresa that to prevent further bleeding from her hemangioma, she was not to walk or exercise or move unnecessarily. “I still lift Lester out of the car, and I still lift his wheelchair. I still clean the house. But Lester had to learn independence pretty fast.” For health reasons, Theresa had to give up her job.
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