Definitions of depression strongly influence the policy decisions that in turn affect the sufferers. If depression is a “simple organic disease,” then it must be treated as we treat other simple organic diseases—insurance companies must provide coverage for severe depression as they provide coverage for cancer treatment. If depression is rooted in character, then it is the fault of those who suffer from it and receives no more protection than does stupidity. If it can afflict anyone at any time, then prevention needs to be taken into consideration; if it is something that will hit only poor, uneducated, or politically underrepresented people, the emphasis on prevention is, in our inequable society, much lower. If depressed people injure others, their condition must be controlled for the good of society; if they simply stay home or disappear, their invisibility makes them easy to ignore.

U.S. government policy on depression has changed in the last decade and continues to do so; substantial shifts have occurred in many other countries as well. Four principal factors influence the perception of depression—and thus implementation of policy relating to it—at the governmental level. The first is medicalization. It is deeply ingrained in the American psyche that we need not treat an illness that someone has brought on himself or has developed through weakness of character, though cirrhosis and lung cancer at least are covered by insurance. A general public perception persists that visiting a psychiatrist is a self-indulgence, that it’s more like visiting a hairdresser than like visiting an oncologist. Treating a mood disorder as a medical  Treating a mood disorder as a medical illness contravenes this folly, takes away responsibility from the person who has that illness, and makes it easier to “justify” treatment. The second factor to shape perception is vast oversimplification (curiously out of keeping with twenty-five hundred years of not much clarity about what depression is). In particular, the popular supposition that depression is the result of low serotonin the same way that diabetes is the result of low insulin—an idea that has been substantially reinforced by both the pharmaceutical industry and the FDA. The third factor is imaging. If you show a picture of a depressed brain (colorized to indicate rate of metabolism) next to a picture of a normal brain (similarly colorized), the effect is striking: depressed people have grey brains and happy people have Technicolor brains. The difference is both heartrending and scientific-looking, and though it is utterly artificial (the colors reflect imaging techniques rather than actual tints and hues), such a picture is worth ten thousand words and tends to convince people of the need for immediate treatment.

 The fourth factor is the weak mental health lobby. “Depressed people don’t nag enough,” Representative Lynn Rivers (Democrat, Michigan) says. Attention for particular illnesses is usually the result of the concerted efforts of lobbying groups to raise awareness of those illnesses: the terrific response to HIV/AIDS was spurred by the dramatic tactics of the population that had the illness or was at risk for it. Unfortunately, depressed people tend to find everyday life overwhelming, and they are therefore incompetent lobbyists. Moreover, many of those who have been depressed, even if they are doing better, don’t want to talk about it: depression is a dirty secret, and it’s hard to lobby about your dirty secrets without revealing them. “We get blown away when people come to their representatives to proclaim the severity of a particular illness,” says Representative John Porter (Republican, Illinois), who, as the chair of the Labor, Health and Human Services Appropriations Subcommittee, dominates House discussions of budgets for mental illness. “I have to fight off amendments brought to the floor to reflect someone’s excitement about a story he’s been told, earmarking a particular disease for a particular sum. Members of Congress often try to do that—but seldom for mental illness.” However, several mental health lobbying groups in the United States do champion the cause of the depressed, the most noteworthy being the National Alliance for the Mentally Ill (NAMI) and the National Depressive and Manic-Depressive Association (NDMDA).

The greatest block to progress is still probably social stigma, which clings to depression as it clings to no other disease, and which Steven Hyman, director of the National Institute of Mental Health, has described as a “public health disaster.” Many of the people with whom I spoke while I was writing this book asked me not to use their names, not to reveal their identities. I asked them what exactly they thought would happen if people found out that they’d been depressed. “People would know I am weak,” said one man whose record of fantastic career success despite terrible illness seemed to me to be an indication of terrific strength. People who had “come out of the closet” and spoken publicly about being gay, being alcoholics, being victims of sexually transmitted diseases, in one instance being a child abuser, were still too embarrassed to talk on record about being depressed. It took considerable effort to find the people whose stories feature in this book—not because depression is rare, but because those who will be frank about it with themselves and the outside world are exceptional.

I’d recommend coming out about depression. Having secrets is burdensome and exhausting, and deciding exactly when to convey the information you’ve kept in check is really troublesome.

It is also astonishing but true that no matter what you say about your depression, people don’t really believe you unless you seem acutely depressed as they look at and talk to you. I am good at masking my mood states; as a psychiatrist once said to me, I am “painfully over-socialized.” Nonetheless, I was startled when a social acquaintance of mine called me to say that he was going through AA and wanted to make restitution to me for his sometime coldness, which was, he said, the consequence not of snobbery but of a deep jealously of my “perfect-seeming” life. I did not go into my life’s innumerable imperfections, but I did ask him how he could say he envied me my New Yorker article, express interest in the progress of this book, and still think my life seemed perfect. “I know you were depressed at one point,” he said, “but it doesn’t seem to have had any effect on you.” I proposed that it had in fact changed and determined the whole rest of my life, but I could tell my words were not getting through. He had never seen me cowering in bed and he couldn’t make any sense of the image. My privacy was bewilderingly inviolate. An editor from the New Yorker recently told me that I’d never really been depressed. I protested that people who have never been depressed don’t tend to pretend about it, but he was not to be persuaded. “C’mon,” he said. “What the hell do you have to be depressed about?” I was swallowed up by my recovery. My history and my ongoing intermittent episodes seemed quite irrelevant; and that I had publicly stated that I was on antidepressants seemed not to faze him. This is the strange flip side of stigma. “I don’t buy into this whole depression business,” he said to me. It was as though I and the people I wrote about were conspiring to wrest more than our share of sympathy from the world. I’ve run into this paranoia again and again, and it still astonishes me. No one ever told my grandmother that she didn’t really have heart disease. No one says that increasing rates of skin cancer are in the public imagination. But depression is so scary and unpleasant that many people would just as soon deny the disease and repudiate its sufferers.

Still, there is a fine line between being open and being tiresome. It’s a downer to talk about depression, and nothing is more boring than a person who talks about his own suffering all the time. When you are depressed, you sort of can’t control yourself and your depression is all that’s happening to you; but that doesn’t mean that depression has to be your primary topic of conversation for the rest of your life. 

Prejudice, rooted largely in insecurity, still exists. Driving with some acquaintances recently, I passed a well-known hospital. “Oh, look,” said one of them. “That’s where Isabel got herself electrocuted.” And he moved his left index finger around his ear in a sign for crazy. All my activist impulses rising toward the surface, I asked what exactly had happened to Isabel and found, as I’d anticipated, that she had received ECT at the hospital in question. “She must have had a hard time,” I said, attempting to defend the poor girl without being too earnest. “Think how shocking having shock must be.” He burst out laughing. “I nearly gave myself electroshock treatments the other day when I was trying to fix my wife’s hair dryer,” he said. I am a great believer in a sense of humor and I was not really offended, but I did try—and fail—to imagine our going past a hospital at which Isabel might have had chemotherapy and making similar jokes.

Andrew Solomon