Treatment-Resistant Depression Affects Practice

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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