by Terry Harrell, J.D., MSW, LCSW, Executive Director, JLAP, Introduction by Susan Eisenhauser, J.D., Former Executive Director, JLAP
Volume 23, No. 4. Indiana Trial Lawyers Association quarterly journal, The Verdict. Reprinted with permission.
"I am in that temper that if I were under water I would scarcely kick to come to the top."
- John Keats
When Terry and I attended the 14th Annual Commission on Lawyer Assistance Program's (CoLAP) Annual Workshop in Albuquerque this fall, depression seemed to be one topic uppermost in everyone's mind. A gathering of LAP staff and volunteers from around the country, the Workshop is the place we see what others are up to, spot trends and gauge how Indiana is doing in providing assistance to our impaired colleagues. It became clear that the increasing depression caseload we are seeing here in Indiana is much the same experience as that of other LAPS around the country who provide "broad brush" programs (and many states with "substance abuse only" programs are quickly seeing the need to expand). While confirming what many believe - that depression is at least as prevalent in our profession as addiction - we hope it also shows that we are finally reaching people with our message that help exists. Kathy Cronkite, who has publicly acknowledged her own depression, and that of many other well known individuals, in her book, On The Edge of Darkness: Conversations About Conquering Depression, poignantly refers to "that illuminating moment when you realize you are not alone". This opportunity to talk to you is a part of our reaching out process.
Below, JLAP Clinical Director Terry Harrell gives you a primer on depression. We will undoubtedly cover the topic again in future articles. If you are interested, we can refer you to many wonderful resources, please feel free to call us. In addition to Kathy Cronkite's book, William Styron does a truly superb job of defining his depression in his book Darkness Visible. Finally, the single most often expressed reason LAPs have expanded into the mental health arena is the incidence of suicide among our colleagues. As Terry reiterates below, at JLAP we hope our work will lead to the elimination of suicide as the option chosen by our colleagues. If you or someone you know is suffering from depression, please call us. And know that you are most assuredly not alone.
In an early 1990s Johns Hopkins University study comparing rates of depression among twenty-eight occupations it was found that lawyers had the highest rates of depression and that lawyers were 3.6 times above the average rate of depression for the occupations compared. A study of 801 lawyers in the state of Washington found that 19% of the lawyers surveyed suffered from depression. A survey of 2,570 lawyers in North Carolina revealed that 25% reported clinical symptoms of depression such as loss of appetite, lethargy, suicidal thoughts, or insomnia at least three times a month during the past year. There is no reason to think that lawyers in Washington or North Carolina are significantly different from lawyers in Indiana. In addition, most lawyers who have been in the practice for any length of time can name lawyers they knew or knew of who committed suicide. Our lofty goal in helping educate you about depression is to lower the incidence of untreated depression and to reduce or eliminate the incidence of suicide in our colleagues. By raising awareness we hope attorneys will seek support and treatment and/or encourage their peers to do so. Eventually, we hope to work on prevention strategies so that fewer attorneys have to experience depression at all.
DEPRESSION (di-pres/en) - a lowering of vital energy (Webster's Dictionary)
Depression is a broad term used to refer to a range of different diseases recognized by the medical field. We also use the term to refer to temporary and minor negative feelings (i.e. I'm depressed because the Pacers lost last night or the post-holiday blues.) Depressive illnesses include major depression, the bipolar disorders, dysthymia, cyclothymia, and variations of these based on timing of the onset (i.e. seasonal or post partum), duration of symptoms, or severity of symptoms. These illnesses impact over 19 million adults in America each year. Depression is frequently seen as a complicating factor in heart attack, stroke, diabetes and cancer patients. In fact, depression increases one's risk of having a heart attack. Almost anyone who kills him or herself suffers from a mental disorder, most often a form of depression or substance abuse or both.
The key factor in diagnosing most of these illnesses is the presence of a major depressive episode. To be diagnosed with a major depressive episode your symptoms must last at least two weeks. The symptoms must also appear to be a change from previous functioning. There are people who resemble Winnie the Pooh's Eyre their whole life but are not depressed. The symptoms of a major depressive disorder include:
Thankfully, most people do not experience all of the symptoms. To be diagnosed with a major depressive episode one must experience at least five of the above symptoms and one of the five must be either depressed mood or diminished interest or pleasure in most activities. For one gentleman I know a significant symptom was the fact that he no longer cared whether he watched IU basketball games after being a devoted fan for twenty plus years. If one meets several of these symptoms, but less than five, there are milder depressive disorders that can still be diagnosed. It is important to remember that each person will experience a different set of symptoms with their depression and that the symptoms will look different with different people. No two people will experience depression in exactly the same manner. There are, however, some common themes that do repeat themselves, particularly in lawyers.
In lawyers the most common symptoms are closely related to the work we are trying to do. Reduced ability to concentrate is one of the most bothersome symptoms for attorneys. They may have had trouble sleeping and a poor appetite for some time but attorneys often seek treatment when they realize that their ability to concentrate and get their work done is compromised. When you add together reduced ability to concentrate with fatigue and loss of interest in most all activities it is highly likely that the attorney's work is going to suffer at least in quantity if not in quality. In addition, attorneys in this condition often try to remedy the problem by working longer hours to keep up on the quantity of their work. In doing so they reduce contact with significant, supportive people in their life, reduce the amount of time they spend on exercise, hobbies, and other stress reducing activities, and cut back further on what is most likely already inadequate sleep. In their attempts to solve the problem they are doing the opposite of what they need and falling deeper into the hole of depression.
Many things can cause depression and most often there are multiple causes. Some of the many causes of depression include:
If you are experiencing only a few symptoms of depression you may be able to help yourself by spending more time with family and friends, talking to someone rusted about your feelings, exercising regularly, improving your sleep habits, and watching what you eat and drink. Sometimes these minor symptoms of depression are a warning sign that it is time to reevaluate your priorities and whether your daily life is consistent with those priorities. Talking to your family doctor is always a good idea. Your lethargy and excessive sleep might be due to your new antihistamine rather than depression. Your doctor can also help you evaluate whether you can cope with this yourself or need to seek professional help. Another "in between option" if you live in the Indianapolis area would be to attend JLAP's depression support group. There you could talk to other attorneys who have experienced depression and learn when or if they sought professional help, what worked, and what did not. For more information about the group or if you are interested in starting one in your area please call our office.
Assuming that you and your family doctor have ruled out other health problems and medication side effects and believe that you are depressed my recommendation is that you try therapy and medication. Both work. The literature is clear that either one alone can successfully treat depression. However, if you want to feel better sooner and stay in recovery longer, do both. The medications available today are NOT the psychiatric medications you heard about twenty years ago or even ten years ago. In the last ten years alone medical science has dramatically improved the medications available to treat depression and other mental disorders. On proper medication you will not feel sedated or cloudy headed. If you notice anything unusual, you need to report it to your doctor as an undesired side effect, not something to be tolerated. Medications generally work faster than therapy. Most people who are clinically depressed want to get feeling better as soon as possible and medication can help with that. In addition, people who are extremely depressed often need to start medications before they are able to participate meaningfully in therapy.
Therapy helps the individual to sort out where their depression came from and whether the individual needs to make any lifestyle changes to fight the depression and prevent further episodes. For example, if one of the causes of your depression was a chronic or acute stress of some kind, you will need to eliminate the stress or learn some new skills for managing the stress, or the relief from the medication may be only partial and/or temporary. You may need to reevaluate your own expectations for yourself or others. You may need to address lifestyle issues such as sleep patterns, choice of relationships, use of substances including caffeine, nicotine, and alcohol, or eating habits. Part of therapy will be assisting you in deciding how long to stay on the medication. If you have a strong family history of depression you may decide that it is best to stay on the medication for some time. On the other hand, if you have no family history and your depression occurred during the year that your divorce was final, your mother died, and you lost your job, you might have more of an acute and situational depression and might not be on medication very long. Regardless, the skills you learn in therapy are what will help you to avoid future episodes of depression. This is critical because it is generally accepted in the psychiatric field that if you have one episode of depression there is a 50% chance that you will have a second episode. If you have a second episode of depression there is a 70% chance that you will have a third episode and if you have a third episode there is a 90% chance that you will have yet another episode. Clearly, it is worthwhile to do all you can to treat a first episode of depression to increase the chances that it will be your only experience with depression. Whether you think you are a little down after the holidays or know that you are clinically depressed we hope that you will let us be part of your solution to the problem.
(citations available upon request)