Depression & Mood Problems

QUESTION:

I have passed the Bar Exam and been sworn in. I have a job, and yet I am still finding it hard to get passed my anxiety and general sense of feeling physically unwell. I’ve gone to doctors to see if there was any physical reason for feeling so poorly, but generally I seem to be healthy.

Is there any resource for someone who has made it past all of the hurdles and yet still is struggling to recover and return to an emotional balance afterwords. I feel very alone in this feeling. I should be happy, now I’m just feeling lost. I tend to be a self-helper type, but I can find no accounts of anyone with my particular circumstances.

ANSWER:

There is so often a discrepancy between how we think we “should” feel and how we actually feel. Our feelings, as it happens, don’t comply with the external rules we try to apply.

Anxiety can be elicited by a myriad of sources, both external and internal. Getting over one hurdle while facing another (e.g., “Yay, I got into the elite college I wanted, but … oh, now I have to perform academically”) certainly does not erase it. You were wise to check out any possible physical/medical issues, but the mind and body are so closely linked that anxiety is commonly experienced somatically. The very high rates of depression/anxiety symptoms among lawyers (whether or not they’ve passed the bar yet) can serve as a reminder that you are far from alone.

Why not call or email to arrange an appointment to take a closer look at all of this with one of our licensed clinicians at LCL? It’s Free & Confidential. Find more on scheduling here — a review of measures that might help you feel better would follow an appointment.

QUESTION:

A long time friend and classmate of mine is a very good lawyer with a very active mental health issue. He is a manic depressive, has been hospitalized in the past for his mental health issues and for self medicating. For the last 6 years or so he has been compliant with his medication regimen and built up his practice. But since this past summer he has been in a downward spiral. I believe he stopped taking his medication. He has quickly lost a considerable amount of weight, is rambling a lot, disheveled and smoking a lot of marijuana. I’m afraid he is going to end up ruining his reputation and end up the respondent in a mental health commitment hearing. He will not listen to anyone. Does he have to hit rock bottom and end up committed to a mental health unit to get help or is there a way of getting him help prior to involuntary hospitalization? Any advise would greatly be appreciated. Thanks.

ANSWER:

Unfortunately, it is not at all unusual for people with bipolar disorder to convince themselves that they no longer need their medications, and, also unfortunately, this is a chronic illness that does not go away. Often, people miss some of the qualities of a manic state (such as high energy, quickly-developing ideas, great expectations and confidence) and hate to give it up.  In all these ways, there is significant overlap with addiction, and with the risk of relapse. Cannabis is a frequent choice when people decide to medicate themselves; while cannabis does appear to have therapeutic properties for some conditions, it is not at all a treatment for bipolar disorder.

As with addiction, one can attempt to intervene, which typically involves several of the people closest to the individual who conceptualize his condition in the same way and give him the same message including a strong push toward getting help and continuing to use it. LCL staff would be glad to talk and brainstorm with you about that — call (617) 482-9600 or email drjeff@lclma.org. Otherwise, he may indeed need to run into some kind of consequence that he cannot ignore. We are all very fortunate to live in a free society, but one down-side is that we have no significant power to control or restrain the behavior and choices of others, even when they make awful choices.

Involuntary hospitalization can be an option for someone with bipolar illness, but only when his behavior becomes imminently dangerous or he is clearly way out of touch with reality. If you happen to know who his treatment provider is, the most direct way to make that happen would be a call to the provider (who will not be able to disclose information to you but can acquire information from you).

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I am a 3L who has struggled with depression for years, though I have a difficult time admitting it. I sought therapy through my undergrad a few times, but that did not seem to help and I stopped. I tried last year to go through my law school’s related university’s health center, which including some talking and medicine, but I stopped that as well. I know that I need to seek help again in the future, but I’m not sure where to go at this point, particularly as my health insurance is through my parents (cheaper while in school) and I cannot discuss this with them (but they pay close attention to bills and our health insurance often sends them information instead of me (and vice versa) – not that my parents pry or such, but it is likely that they will find out about it and be concerned, so ask).

Do I have to disclose this on my MA bar application? If I do, does it become public record with the rest of the application? Is there any way to stop it from becoming public record?

Our understanding is that the Massachusetts bar application does not ask about mental health/treatment history (unlike some other states).  It is also our experience that, whenever the Board of Bar Examiners or the Board of Bar Overseers became aware that someone has a mood/behavior problem, their concern about it is largely to ascertain that the person has gotten or is getting appropriate treatment.  So there is no reason not to get the treatment you need.  (Whether it is a public record we don’t know, though we’ve never heard a client complaint about this – the BBE and SJC would be better sources for that question.)

It’s important that you seek assistance for your depression, not only to improve the quality of your life but to minimize the chances that it will affect your career.  To the extent that you have not latched onto treatment in the past (whether because of your own reticence, a therapist who was not a good match for you, medication that did not work for you, etc.), we would encourage you to come meet with us at LCL (confidentially, of course), and use us as your consultant and troubleshooting partner until you find a treatment approach that is helpful.  You need not limit yourself to services provided through your university’s counseling service.  If your health insurance is under your parents’ policy, it is quite possible that they could receive statements showing the name of a provider that you see – it’s worth calling the mental health number on your insurance card to ask about that.  If there is no way to prevent that relaying of information, then perhaps you and we can brainstorm ways to explain the treatment to them in such a way that it would not trigger undue worry for them.  Certainly, law school presents such a high level of stress that one can easily make the case that every law student would do well to get psychological support in balancing their personal needs with their academic demands.  At LCL, we provide evaluation and consultation, but not ongoing therapy – but at least for these services, we are free (supported by a small piece of Massachusetts lawyers’ annual license fee) and don’t submit claims to health insurance.

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 6 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 3 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?

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 seem often 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 down-side; 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

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Can S.A.D. be diagnosed in individuals with learning disabilities, with severe communication difficulties?

Seasonal Affective Disorder is essentially depression that appears or becomes more severe during months when the days are shorter and there is less exposure to sunlight. It is usually possible to diagnose depression based on observed symptoms, such as significantly lowered energy/motivation, decreased capacity for pleasure, sense of hopelessness or other obvious signs of worsened mood.

For more information on S.A.D., click hereto see our Winter 2003 newsletter.

I am a 45 year old solo practitioner suffering from what I think is seasonal winter depression. My mood gets better in sunnier, warmer weather. With each passing winter though, the depression gets worse. I try and stay in the light, but it does no good. It is becoming harder to get motivated. Some days are alright, but some times it is a struggle to get through the day. Because of my life experiences, especially in the law, it is hard to believe that anyone would genuinely want to help. I have received very little help from people over the years. It is usually me doing the helping. Seeking help is frightening and a risk. Plus, it is embarrassing not being able to overcome this problem on my own. I would love to feel better if it is possible, but it does not seem possible. I am very familiar with the law regarding privilege and confidentiality, 51A’s, etc. yet have witnessed the lengths some individuals will go to get information on others. I have seen lawyers convince courts to release or make available sensitive medical/ psychiatric/ psychological information. I have represented good intentioned people that have sought help from social service agencies and have witnessed their dilemmas worsen. Although I may benefit from help, I am afraid that if I seek help, despite the privilege and confidentiality rules, my case will not remain confidential and my situation will become even worse. Is it possible to get help using only a first name? How can confidentiality be maintained if medication is indicated? Health insurance companies routinely share medical information and are allowed to do so. Thank you.

· If do you have seasonal depression (also known as Seasonal Affective Disorder), you may benefit from self-treatment with a Light Box. A typical light box is made of metal, about 2 feet long and 1 foot high, and priced from $300 to $500. ;The light is produced by white florescent bulbs and passes through a UV filter as a plastic screen that spreads the light evenly. The user faces the box for 20 to 90 minutes a day during the depressive season, typically while reading, making phone calls, etc. Among the sources of light boxes are www.sunbox.com, www.apollolight.com, and www.biobrite.com. If this type of treatment is going to help, the effects will be noticed within 2 weeks.

· Your disappointing experiences in asking for help may be related both to realistic matters, such as the adversarial culture of lawyers, but probably also reflect your own personality features and expectations. Someone who starts out with a fragile sense of trust, for example, often finds experiences that seem to confirm that others cannot be trusted. This itself might be a fruitful area to explore in therapy, including by taking that interpersonal risk with the therapist and working through any reactions.

· We have heard from some lawyers who handle such matters that they feel no medical records are truly private. Of course, we are all aware that confidentiality becomes secondary in cases of likely harm to others, child or elder neglect, etc. For what it’s worth, however, none of our three clinicians have ever been forced to disclose clinical information without the client’s consent other than rare mandated reports involving child abuse/neglect.

At LCL, we do agree to see people who withhold their last names, and we would guess that some psychotherapists in private practice would do the same. But, as you suggest, this approach would not work when it comes to prescriptions, or to using health insurance. Concern for privacy is probably the main reason that many people do not use their health insurance for mental health services. (Most use their real names, but the information does not routinely go anywhere other than the therapist’s own files.)

Feel free to arrange an evaluative appointment with us, anonymously if you like, to discuss these dilemmas further.

I’ve always tended to “see the glass as half-empty,” but I’ve come to realize that, in the past year, I’ve really become quite depressed. It’s gotten to the point where I drag myself to the office, and I have missed filing deadlines on my clients’ behalf because I just can’t concentrate. I asked my primary care doctor for a referral to a psychotherapist or counselor, but he told me that now, in the age of Prozac, talking therapy is unnecessary. Is that indeed the state of the art?

It’s not the state of the art, but it may reflect the state of medicine and of managed care. There have been conflicting and confusing research findings for year as to the effectiveness of both psychotherapy and antidepressant medications, but the preponderance of evidence and clinical experience is that both are usually (and about equally) helpful. Clearly, some individuals do better with one than the other, and most (if clinically depressed) get maximal benefit from a combination of the two. Medication treatment appeals to managed care and others because it may be faster and less labor intensive (i.e., less epensive). Proponents of “talking therapy” note that its benefits go beyond symptom reduction, and that its results continue after treatment ends, often not the case for medication. In some cases, managed care organizations have rewarded primary care physicians who keep costs down by minimizing referrals to specialists. This may be a short-sighted solution, since people with untreated or inadequately treated depression, stress, anxiety, etc. tend to develop somatic symptoms and drive up other medical costs.
At Lawyers Concerned for Lawyers, we often see the impact of depression on practice, particularly in neglectful or sloppy handling of cases. We wish that more attorneys would talk to us when the problem first appears, and before it spawns negative consequences. We usually recommend a comprehensive plan of attack, often including both psychotherapy/counseling and medication evaluation, as well as addressing environmental, family, or work related factors contributing to the lawyer’s mood. We can also provide a consultation for those who would like a second opinion.

I am a 32-year-old assistant district attorney and am very happy in what seems to be a promising career. In fact, for the most part I am a happy, well adjusted person — that is except for the winter months. It seems like from December to April, I am chronically irritable, fatigued and unmotivated to do anything. I also constantly crave starchy foods and gain at least seven or eight pounds each winter. It’s tough to get out of bed, even on the weekends. I’m already dreading the fall. Care to comment?

Assuming that your situation is as straightforward as you say, it sounds like you have a classic case of “Seasonal Affective Disorder,” now conceptualized in the mental health field as clinical depression with a “seasonal pattern.” Symptoms like the ones you describe are very common with this type of depression. However, depression with a seasonal pattern can share any of the symptoms of depression, including the symptoms associated with Bipolar Disorder (depression that “cycles” from manic to depressive states, formerly called Manic Depression).

Seasonal pattern depression is thought to be caused by the prolonged darkness of winter, a time when the melatonin level in the body is high, causing a kind of hibernation. In the spring, when melatonin levels drop, a person “reawakens,” becoming more energized and motivated.

The good news is that you don’t have to wait for spring to feel better, as there are new treatments ranging from light therapy to antidepressants (both prescribed by a doctor), often with talk therapy. As with classic depression or Bipolar Disorder, you should seek help by talking with your primary care doctor or mental health professional. LCL also can assess your condition and make a referral. We recommend that you initiate treatment before the arrival of winter’s darker days as you will have a better opportunity to head off a severe episode of seasonal pattern depression.

I am a sole practitioner with an estate planning practice that I have done for over ten years. I also had my first baby three months ago (at age 41!). Although I have wanted this baby for years, postpartum depression hit me about a month after she was born. I couldn’t stop crying, couldn’t sleep, and felt totally out of control. In the last two weeks, I have started to feel better through therapy and antidepressants, but still can’t concentrate and get organized enough to take care of my cases. I have a lawyer friend who offered to help me but frankly, I am too embarrassed to take her up on the offer. I have a full time nanny so telling my friend I need more help would be mortifying. What should I do?

Postpartum depression (PPD) is a particularly paralyzing condition, not only because of the depression itself, but also because of the shame it induces in the mother, who has gotten societal messages all her life that a new baby should be a time of great joy and closer family life. In reality, having a new baby — under the best of circumstances — throws off whatever equilibrium a family had and introduces new physical, emotional and often financial demands. The mother is also further thrown off because of hormonal shifts. If PPD strikes, the situation becomes even more extreme, even life threatening in some situations.

However, PPD is nothing to feel ashamed about. It is a medical problem just as diabetes and the flu are medical problems. I suggest you take advantage of the assistance your friend can offer as soon as possible. One, keeping the PPD a secret will perpetuate the shame and two, allowing your friend to lighten the burden will accelerate the recovery process, as it will reduce the worry and pressure associated with being unable to perform your best. If you still can’t bring yourself to confide in your friend, discuss this with your therapist, who can help you work through your shame.

In the meantime, you deserve a lot of credit for seeking out help; most women with PPD attribute their condition to being a “bad mother” versus to a medical problem. As such, many women never do get help and others only after months of unnecessary despair.

Over the past several months I am constantly exhausted regardless of how much sleep I get. I was managing on my own for awhile (barely) but when I found myself being short with clients and getting into hostile confrontations with opposing council, I decided to talk with my doctor. She put me on Zoloft and said that my symptoms and behavior changes were symptoms of depression. Is this really true?

Depression has many symptoms and irritability or moodiness is one of them. However, just because someone is irritable does not mean they are depressed. To make the diagnosis of depression, irritability would have to be associated with other symptoms. Feelings of sadness or despair, tearfulness, loss of interest in normal activities, change in appetite (marked by weight gain or loss), change in sleep habits, mood swings and chronic feelings of exhaustion are some possible symptoms. Also, while many people with depression do experience sadness or despair, others may experience “anhedonia,” a loss of the ability to experience pleasure. This may explain why you don’t feel gloomy or sad and yet can still have depression.

When these symptoms are evident, it is a good idea to do what your doctor did, arrange for an evaluation with a mental health provider who can make a differential diagnosis. Treatment for depression can consist of psychotherapy and/or medication, and lifestyle changes, for example, adding aerobic exercise, a balanced diet and relaxation techniques. Also, because alcohol itself is a depressant, it is wise to use it very moderately, if not avoiding it altogether. The good news about depression is that it is a very treatable condition.

I have a lawyer friend who recently lost a major case which was devastating to him. I also know he stopped taking his antidepressant medicine about a month ago, as he didn’t think it was helping. However, since losing this case he seems more depressed than ever. I’m getting worried that he’ll do something foolish. What should I do?

When people are depressed they are not always capable of accurately appraising the reality of their situation and often need feedback from those they can trust. I would recommend that you share your concerns, using specific examples, and suggest that he seek further assistance. If this fails and he continues on a downward spiral, then offer more concrete options like going with him to a therapist or LCL. If you are worried that he is at imminent risk of hurting himself, you can bring him to a local emergency room for evaluation. If he were to refuse, you can call the police so that they can escort him there. Just as importantly, I would recommend that you call LCL for support in figuring out how to proceed.

Law is a second career for me. I am fortunate to work in a mid-sized firm comprised almost entirely of pleasant colleagues, doing work that is most often in synch with my own values – yet I seem to be quite unhappy much of the time, especially at work (and much less so when on vacation). How can I understand this, and what can I do about it?

Your question is so global (as is, perhaps, your unhappiness) that we can only choose one or two avenues of response out of many (which would, of course, include the various approaches to treating depression that we have discussed in previous columns). It does appear, from what systematic study exists, that lawyers have a much higher rate of depression than the general population, and that this decline in mood begins with (rather than precedes) law school. We have to admit that, at LCL, we see a skewed population of lawyers who are probably less content than average, and we would love to hear from readers who feel happy with their careers and can offer some thoughts on what factors contribute to that contentment. (Please email us – if you’d prefer to do that anonymously, click on “Q&A” and then “Submit a Question Anonymously” on our web site, www.LCLMA.org).
One interesting perspective on the level of unhappiness in the legal profession comes from psychologist Martin Seligman, whose name is most closely associated with the movement known as “positive psychology.” He focuses in part on the role of pessimism, which he defines as a “tendency to interpret the causes of negative events in stable, global, and internal ways.” The pessimist might see global warming, for example, as an inevitable, gradual march toward the end of life as we know it, while the optimist would view the climate crisis as a serious setback that can and will be overcome. Whether or not the optimistic stance is more accurate or realistic, it is “better for you” in that it is associated with positive mood and constructive behavior.
Ironically, however, pessimism may be a plus when striving to succeed in the field of law! That finding, based on a study of University of Virginia law students, may be a function of how useful it is for lawyers to be able to anticipate negative twists and turns that others would not consider. Hence the dilemma that characteristics which may be useful in the practice of law can be quite counterproductive when it comes to enjoying the practice of law or developing an affirmative view of one’s life as a lawyer.
Seligman and his colleagues note that unhappiness is also fostered by a combination of high demands and low “decision latitude” (voice/impact in the process in which one is engaged) that often typifies life for associates at a large law firm, not to mention the “zero-sum game” of our legal system’s adversarial process. Those obstacles can only be addressed at a systemic level, and let’s not hold our breaths waiting for change. But there may be ways that you as an individual can develop more positive ways of defining your work and career. Feel free to come in and brainstorm with us.

I graduated college cum laude, and still had plenty of time for side activities like my a cappella group and partying with friends. I guess I have a pretty good memory and was able to make the most of those pre-exam and pre-paper all-nighters. Although law school was more demanding, I had some inspiring professors and really got into the subject matter. So I was not prepared for what I am facing now, a few years into working for a mid-size law firm. Nowadays, I go through months at a time when I can’t seem to concentrate. I spend hours staring at the computer monitor, with nothing happening in my head, trying to salvage some cogent thoughts from the sludge in my brain. Too much of the time, I end up doing on-line shopping or read the day’s news, or I find an excuse to escape the office altogether. I walk around wondering when my lack of productivity will be discovered, but I can’t call attention to myself or I could lose the job. Needless to say, my self-esteem is at an all-time low, and I can’t even enjoy anything I do on weekends. What do I do?

Turns out that there is a down-side in the lives of those clever, talented kids who get through school without having to study much – you were “deprived” of the experience of learning to “plug away” at tasks little by little, including those that you initially found incomprehensible or insurmountable. Intellectual sharpness and the ability to catch onto many things quickly are certainly assets, but the acquired skill of plugging away may be equally or even more valuable in the long run.

We’re sure this doesn’t come as news to you, but large or unfamiliar tasks only become manageable when broken down into very small steps. If you are tackling an area that is new to you, the early steps may involve research (including asking others), and sub-steps like (1) get the title of one relevant article or precedent, (2) read the first paragraph until it makes sense, etc. Or, (1) Decide who’s best to ask, Fred, Joyce, or Irene; (2) Leave voice-mail for that person.

These steps must be broken down into units so small (depending on how frozen you mind feels) that there is no chance you can’t do it. People are often surprised how they “get rolling” after pushing themselves into the first few steps. One step after another is the essence of plugging away, along with persistence, e.g., coming back to it in an hour.

Examine, also, what you’re saying to yourself about the process in which you are engaged. (Not that you literally put these things into words, but it helps to find words in order to do battle with unhelpful beliefs.) For example, you could be telling yourself, “If it doesn’t come naturally to me, I can’t do it.” Then think about a realistic alternative thought to keep repeating to yourself as a substitute, e.g., “This is new to me, and it may not be easy, but all the evidence suggests that I have the brain power to figure it out in time – I have learned and mastered harder things.”

Your mental paralysis can also, of course, be viewed as depression, and it is easy to see how circular the process can become – the more depressed you feel, the more you want to withdraw from the project at hand, the less you accomplish, the more you view yourself as ineffective, the more depressed you feel, … The small-steps and thought-challenging approaches described above may help you break out of that cycle, and there are other approaches that could also be helpful, including ones that are more obviously clinical. Wherever, whenever, and however you do it, you can find a way to interrupt the cycle and begin to create a greater sense of efficacy. Once that happens, you are on the way toward a more satisfying professional life.

We have not even touched upon the question of other psychological conflicts that may be at work, contributing to the ways that you have felt stuck. It would be well worth evaluating the situation clinically – for example, at LCL, or with a recommended therapist, or with an in-house employee assistance program if your firm has one. (Sometimes involvement with the EAP can be somewhat protective of your job while you are in the process of addressing the problem.)