Q. Thank goodness for my law partner, without
whom I would have lost my license to practice by now. I have been
unable to concentrate on, or even care much about, my cases for the
past six months - just getting out of bed and into the shower feels
like a huge task. Since I don't feel like talking to anyone, it's
not surprising that I often don't return calls from clients.
It probably won't surprise you that I've been diagnosed with
major depression. I've tried a series of antidepressant
medications, which have either not worked or caused side effects
that I could not tolerate (so that I never found out whether they
would work, since it takes three weeks or more for them to "kick
in"). My friends and family have been talking about recent articles
in Newsweek and The New Yorker suggesting that antidepressants
don't actually work anyhow. I have a "talk therapist" as well -
that doesn't seem to be doing much for me either. Even if it did,
50 minutes a week seems like a drop in the bucket. What else can I
do?
A. We agree with your appreciation for your law
partner - too many lawyers who practice solo are unable to find any
kind of backup when depression interferes with their ability to
function professionally. But let's focus on your concerns about
what is called "treatment resistant depression."
Regarding antidepressant medications: For years, they have, we
think, been "over-sold," when there were always many individuals
for whom they provided little or no improvement, and others for
whom they seemed helpful but far from curative. Nevertheless, they
have been an important part of the professional toolkit. We wish
there were a collection of depression treatments that were
universally powerful and safe - in reality, no form of treatment
helps everyone with depression.
That does not mean that you should give up - most people
experiencing depression do eventually find relief and return to
their previous level of functioning. Some seem to just get better
with time, and some clearly seem to improve after finding the
"right" medication and/or psychotherapist.
The articles that you referenced make the point that a very
large part of the effect of medication treatments (and perhaps
psychotherapies as well) is a placebo effect. No doubt, placebo
effect plays a role, just as it probably does in many medical
treatments. On the other hand, we find it a little hard to believe
that placebo is the only effect, having seen so many
individuals who, for example, got no benefit from antidepressants
#1 and #2 but experienced considerable alleviation of symptoms with
antidepressant #3. Even dogs and cats often seem to benefit from
the same antidepressants. (Is that "placebo by proxy"?)
Even if we accept these conclusions about antidepressants (which
derive from "meta-analyses" of numbers of treatment studies),
consider the following: (1) much of the evidence seems to suggest
that antidepressants offer no significant benefit to those with
mild or moderate depression. Your depression is major and severe;
unless you've already tried virtually every
antidepressant, the chances are still good that one of them would
help your condition; (2) if a big part of the impact of such
medications is that the process of taking them somehow galvanizes
an internal system involving belief and expectation, maybe that
effect can be appreciated rather than dismissed. Even a small
improvement might bring you to the point of being able to get more
out of your psychotherapy (and there are plenty of studies
supporting the efficacy of, for example, interpersonal and
cognitive therapies for depression).
The other major treatment that becomes worthy of consideration
when other treatments have failed is ECT (electroconvulsive or
"shock" therapy). Indications are that ECT is effective more of the
time than any antidepressant. There is, however, a downside; not
only can the application of electrical current to the brain seem
barbaric (calling forth, for many, misleading images from One
Flew Over the Cuckoo's Nest), but more importantly, there are
potential effects on memory and cognition. The extent of these
effects has been argued within psychiatry, loudly and for many
years. (Most ECT patients suffer memory problems temporarily,
around the time of treatment - the controversy is over the extent
of lasting memory loss, which seems to vary greatly among
individuals.)
When it comes to weighing these concerns against profound and
prolonged depression, however, many have found the possibility, or
even the reality, of memory loss to be worth the risk. Among the
best known recipients of ECT who have come to that conclusion are
former Massachusetts first lady Kitty Dukakis (who wrote
extensively about ECT in her book, Shock) and
actress/writer Carrie Fisher (who addresses the matter in her
autobiographical Wishful Drinking).
Feel free to come into LCL to discuss these issues further.
Meantime, not only is your law partner to be commended, but so are
you, for making sure that a colleague is handling the
responsibilities that, for the time being, you cannot.
Questions quoted are either actual letters/e-mails or
paraphrased and disguised concerns expressed by individuals seeking
assistance from Lawyers Concerned for Lawyers.
Questions for LCL may be mailed to LCL, 31 Milk St., Suite 810,
Boston, MA 02109 or called in to
(617) 482-9600. LCL's licensed clinicians will respond in
confidence. Visit LCL online at www.lclma.org.