We’ve all heard personal stories and the staggering statistics surrounding lawyers and depression. However, many still don’t understand what constitutes clinical depression, why lawyers are so susceptible, what treatments are available beyond medication, and when and where to seek help for themselves or a colleague. The following fictional case studies constitute a must-read primer on depression for all lawyers.

Pierre, Corporate Lawyer

Pierre is an extremely successful corporate lawyer who is well respected by his peers. Although he has always been thought of as gregarious, outgoing and fun-loving, for the past couple of months Pierre has not been feeling quite himself.

He no longer enjoys things they way he used to and he feels a profound sense of sadness just about every day; so much so that he feels utterly hopeless about his future. To make matters worse, Pierre’s previously healthy appetite has evaporated and he often finds himself waking up very early in the morning and unable to fall back asleep. Although Pierre has always enjoyed hockey and weight-training, lately he has found that he just doesn’t have the energy to do much of anything. At work, he has been scraping by and cannot seem to concentrate or make quick decisions, both of which have conspired to send his self-esteem and sense of worth into a tailspin.

His friends, co-workers and family are growing increasingly concerned as he is returning phone-calls and e-mails less frequently, and seems very withdrawn and despondent.

Alia, Real-Estate Lawyer

Alia is a self-employed real-estate lawyer who thus far has enjoyed an accomplished and rewarding career. Although Alia has always been known for being driven, lately her energy seems boundless.

She has taken on an extraordinary number of cases and often works three or four days straight without sleeping or so much as a quick nap, yet she remains completely functional. Recently, friends have remarked that Alia seems to be much more talkative than usual, almost as if she cannot get out the words fast enough. Alia herself has noticed that she seems to have a million thoughts racing through her head at any given time and that she is hopelessly distracted. Although Alia has been generating a lot of revenue through her increased caseload, she’s been prone to wild spending sprees, racking up $17,000 in credit card bills in just the last two weeks.

Both Alia’s friends and family have been put off by her growing sense of grandiosity and irritability and are troubled by her frequent proclamations of being “the best lawyer in the entire world”. Alia’s husband is particularly troubled by these changes in Alia as he remembers her being very subdued and sad only a few months ago. At that time she had seemed inconsolable and had only a fraction of the energy she now possesses.

Rahim, Public Sector Lawyer

Rahim has been a moderately successful public sector lawyer for the last 20 years. In that time (in fact, ever since he was a young child) Rahim does not remember a period where he has been truly happy—he has always felt a sense of sadness about himself even though he has a loving family.

Although intelligent, he suffers from low self-esteem and has always been plagued by poor sleep and low levels of energy. Rahim is functional at work, however, he definitely feels that he has not excelled in his career the way he could have, which he attributes largely to a crippling talent for procrastination about making important decisions, as well as his difficulty concentrating.

Although Rahim feels that he certainly isn’t a miserable as he could be, he feels burdened by a nagging sense of hopeless about his situation and worries that he might get even worse one day.

Defining Depression

Everyone feels sad or blue at one time or another, so it’s important to distinguish between “normal” fluctuations in mood and the profound and debilitating symptoms that characterize clinical major depression, bipolar disorder and dysthymia.

Major Depression

As was the case for Pierre who we met in our first case study, major depression is characterized by a depressed mood almost everyday for a long-period of time (longer than two-weeks) that causes a lot of distress or negatively impacts functioning at home or at work, as well as a significant reduction in interest or pleasure in previously enjoyable activities.

Like Pierre, individuals with major depression often report additional symptoms including dramatic changes in appetite, difficulties with sleep, fatigue or diminished energy, thoughts of worthlessness or extreme guilt, an inability to concentrate.

Of course, a major source of concern surrounding depression is the possibility of the depressed individual committing suicide. It is important to note that some medical conditions, prescription medications or withdrawal from drug or alcohol use can cause symptoms that mimic major depression, so it’s essential that these causes first be ruled out.

Bipolar Disorder

In our second case study, we were introduced to Alia, who as you might have guessed suffers from a mood disorder called bipolar disorder (which is also sometimes called manic-depression). Bipolar disorder has symptoms of both major depression and what is referred to as “mania”.

Just as sometimes feeling a little blue does not mean we are clinically depressed, occasionally feeling elated or energized does not mean we are manic. A bona fide manic episode is characterized by a continuously heightened, exaggerated or irritable mood that is out of the ordinary for that person and that lasts for a lengthy period of time (e.g., a week or two).

As in Alia’s case, someone in the midst of a manic episode will often display a host of other symptoms including a greatly inflated sense of self-esteem or grandiose behaviour, reduced need for sleep, excessive talkativeness, racing thoughts, increased purposeful activity and reckless participation in enjoyable activities that can often get the person in trouble (e.g., spending sprees, sexual indiscretions etc.).

The hallmark characteristic of bipolar disorder is cycling through periods of mania and then depression. Like major depression, a variety of underlying physical conditions, medications and drugs can cause symptoms similar to bipolar disorder, so these must be considered as well.

Dysthymia

In our third case study, we met Rahim who is affected by a mood-disorder called dysthymia. Dysthymia has many of the symptoms of major depression, but typically they are milder (but can be equally as debilitating in some cases).

A characteristic feature of dysthymia is that the person is affected by low-level symptoms of depression for a very long time (e.g., at least 2 years). In fact, some dysthymic individuals report having never felt happy their entire lives.

Individuals who are dysthymic can also be affected from what is called “double-depression”. Essentially, the individual starts out being dysthymic, but then slips into a deeper, major depression, which can sometimes be difficult to treat.

Depression & Lawyers: Some Facts

Unfortunately, evidence suggests that lawyers are at a greater risk for developing depression and committing suicide than other facets of society (you may also have personal experience that supports this). Consider these findings:

• A study conducted by researchers at Johns Hopkins University revealed that of 28 occupations studied, lawyers were most likely to suffer from depression.
• As outlined in Part 1 of this series, data collected from various lawyer and employee assistance programs across Canada indicates that mental health issues consistently top lawyers’ list of complaints. In 2004, roughly two-thirds of calls placed to various provincial Lawyer Assistance Programs concerned mental-illness or psychological difficulties.
• Although depression affects only five to ten per cent of the population at any given time, a recent study in Washington State found that of a sample of lawyers, 19 per cent reported symptoms of depression.
• A similar study conducted by the North Carolina Bar Association indicated that a quarter of those surveyed demonstrated symptoms consistent with depression; 12 per cent indicated that they thought about suicide at least once a month.

Clearly, being a lawyer represents a higher risk-factor for developing depression or committing suicide. The reasons for this are varied and multi-faceted. In a recent article in the CBA-BC’s Bartalk newsletter, Robert Bircher, Program Coordinator for the Lawyers Assistance Program of BC, notes that “the ‘usual suspects’ are long hours, the adversarial nature of law, the focus on billable hours, increased competition for clients, the dehumanization of the practice, focusing on the business aspects of law rather than people combined with a culture of materialism, perfectionism, and workaholism.”

Just as an individual working in a industrial plant would be expected to be well-versed in the proper handling of potentially hazardous materials in their work environment, it is vital that lawyers be well-educated and aware of the symptoms, causes and treatments available for a principle hazard of their profession—depression. In the remainder of this article, we will cover each of these areas in-depth.

Mood Disorders: Contributing Factors

The causes of depression and related mood-disorders are complex and often it is impossible to point to a single cause for any given individual. Indeed, it is often the combination of a variety of factors that will ultimately determine whether an individual will develop depression:

Genetic: To some degree, the potential to develop a mood-disorder is inherited. That said, our genetics are not our destiny. Depression is the result of a complex interaction between your genetic make-up and numerous factors in the environment. So while someone may have a genetic predisposition for a mood-disorder, it is by no means a certainty that they will become ill.

Gender: It is estimated that risk for developing depression is 1.5 to 3 times greater for woman than men. Factors that may contribute to this gender difference include biological (e.g., hormones), cognitive (e.g., coping styles) and societal factors (e.g., role overload). Of course, it may be that men simply do not seek help for depression as frequently, which creates the illusion that they have a lower rate of incidence.

Biological: Although the biological origins of depression are not completely understood, it is generally accepted that alterations in certain chemicals in the brain are, in part, responsible for the symptoms associated with depression. Although many chemicals are probably involved, the neurotransmitter serotonin is thought be one of the most important.

Stress: Research indicates that most depressive episodes are preceded by some sort of stressful event such as a divorce, unemployment or work-related stress. However, the cumulative effects of day-to-day hassles, such as those experienced by practicing lawyers, can also be damaging.

It is thought that stressful events tax both our physical and psychological coping resources. If the stress becomes chronic in nature, this may compromise these resources leaving certain individuals vulnerable to physical and mental-illness, including depression. Individuals who have endured calamities (e.g., serious illness, sexual abuse) early on in life may be sensitized to stressful events that happen to them as adults, making them even more vulnerable.

Cognitive: Depressed individuals perceive events and cope differently than individuals who are not.

For instance, depressed individuals tend to adopt a negative “glass is half-empty” stance when interpreting events in their environment or their own performance. They also tend to employ less-effective coping strategies such as rumination (i.e., thinking or talking about a problem over and over again without taking action) or blaming themselves or others. In contrast, people who are resistant to depression tend to use more constructive problem-solving strategies when coping with stressors.

Personality: Certain personality traits are highly associated with depression. One of the most important appears to be perfectionism (a characteristic of many lawyers), which while helpful in some respects, can often foster frustration and stress in what is inevitably an imperfect world. As well, individuals who score high for neuroticism (as personified by the consummate “worry wart”) appear to be at increased risk for depression. Neuroticism breeds anxiety, which is a risk-factor for depression in some individuals.

Environmental: Although many of us report getting the “winter-blahs”, for some the shorter days of winter are associated with the development of symptoms of major depression. This form of depression, called Seasonal Affective Disorder (SAD), results from reduced exposure to strong sunlight which may upset the neurochemical balance of the brain. Interestingly, exposure to artificial sunlight can lessen these symptoms (see below).

How are Mood Disorders Treated?

Many of the treatments that were described as effective for anxiety in Part 1 of this series are also very effective in reducing or eliminating symptoms of depression. Depression can be effectively treated using a number of different strategies including:

Cognitive Behavioural Therapy (CBT)

CBT is usually completed over the course of 8 to 12 weeks in one-hour weekly sessions with a psychologist.

The goal of CBT is to attack negative thinking and behavioural patterns that often accompany a depressive episode. CBT is hard work; often the client is given homework assignments that help to reinforce what had been discussed in previous sessions.

Although psychological services are not covered by many provincial health care plans, extended health care insurance plans as well as EAPs retained by your firm can help offset these costs.

Interestingly, CBT is just as effective as medication for treating depression (in fact, CBT may be better at preventing relapse) however, it may not work for everyone. CBT is a great first-option for those individuals who would prefer not to take a medication.

Antidepressant Medications

Major Depression & Dysthymia
Major depression and dysthymia can be effectively treated with a variety of medications. Selective Serotonin Reuptake Inhibitors (SSRIs) which include well-known drugs such as Prozac, Zoloft, Paxil and Lexapro are by far the most prescribed class of antidepressant.

It is thought these drugs work by increasing the amount of serotonin that is available within the brain. An even newer generation of antidepressants (e.g., Effexor) prevents the reuptake of both serotonin and another chemical, norepinephrine. It is crucial to note that these types of drugs can take up to 12 weeks to produce noticeable effects, so it is important that the individual be consistent in taking their medication. Common side-effects reported by people taking antidepressants are problems with sleep, weight-gain and a reduction in libido, although most individuals are able to tolerate these drugs without major difficulty.

Bipolar Disorder
Bipolar disorder can also be treated with medication. Sometimes, individuals with bipolar disorder are prescribed a mood-stabilizer such as Lithium rather than an antidepressant as they can sometimes trigger a manic episode.

Lithium and similar medications are effective in reducing the dramatic changes in mood associated with bipolar disorder, as well as greatly increasing quality of life for both the affected individual and their family. In more severe cases, an antipsychotic medication (i.e., a medication that is usually used to treat schizophrenia) may be prescribed depending on the nature of the symptoms.

Electroconvulsive Therapy (ECT)

Although ECT often congers up negative images, it is an effective and safe therapy for depression that is otherwise resistant to standard treatments, or for individuals who are unable to take antidepressants for medical reasons (e.g., the elderly).

ECT is administered over the course of a number of sessions in which the individual is sedated and given a muscle relaxant to prevent injury. The brain is then stimulated to cause seizure-like brain activity (in fact, ECT therapy was first conceived after a physician noticed that epileptic patients had a heightened mood following seizures). A major side-effect of ECT is memory loss around the time of treatment.

Phototherapy

Also called “light-therapy”, this treatment has evolved primarily for the treatment of Seasonal Affective Disorder (SAD). Essentially, the individual is seated in front of a specialized lamp that can be purchased at a pharmacy (it has to be at least 10,000 lux, which is a measure of brightness) for about between 30 to 90 minutes a day while reading a book or similar activity. Some individuals respond very quickly to this type of treatment while others take longer (e.g., a couple of weeks). Light therapy usually continues until spring when the days become longer once again.

Self-Help

As with anxiety, a myriad of self-help books have been written on combating depression (see recommended readings at the end of this article).

As well, regular exercise (cardiovascular activity for at least 30 minutes, three to five times a week) has been scientifically demonstrated to have potent antidepressant effects. It is thought that exercise provokes the release of chemicals that may be related to mood. Anyone who has experienced a “runners-high” after completing a strenuous workout will certainly agree with this. As well, exercise can be an excellent distraction and can go a long way towards breaking the lethargy and fatigue that so often accompanies depression.

While it has been purported that some nutritional (e.g., Omega-3 fatty acids) and herbal (e.g., St. John’s Wort) supplements may have antidepressant effects, you should always speak with your doctor before beginning any such regimen.

While self-help options can be quite helpful and are a good starting point for many individuals, if you feel your depression is severe and limiting your quality of life, do not hesitate to seek additional assistance.

Mood Disorders & Suicide

Although depression is associated with a host of serious physical illnesses including cardiovascular disease, in the short-term, the major health concern arising from depression is the risk of suicide.

About one fifth of individuals affected by a mood-disorder will attempt suicide, and lawyers report having suicidal thoughts at a much higher rate than the general population.

Certain demographic variables may also act as risk-factors. For instance, single people are more likely to commit suicide than those who are married, especially those who have been widowed or divorced. As well, the risk for committing suicide increases with age, for men in particular. Although women attempt suicide more frequently than men, men succeed in killing themselves more often as they typically use more lethal means.

A family-history of suicide and early childhood sexual or physical abuse are also risk-factors. Psychologically, intense feelings of hopelessness will often precede a suicide attempt.

Even though many individuals who commit suicide communicate their intentions beforehand, friends and family are often shocked to learn that their spouse, friend or colleague has taken their own life. This is probably attributable to some of the signs being at times subtle or rationalization on the part of family members (e.g., “he/she would never hurt himself”). Thus, it is crucial to be aware of some of the warning signs of suicide, which include:

• Explicitly communicating their intent or desire (e.g., “I can’t go on living any longer”)
• Social isolation or contemplative withdrawal
• Decreasing performance at work
• Giving away important possessions
• Thanking individuals for trying to help them

It is very important to understand that depressed individuals often commit suicide when they are coming out of their deepest depression; ironically, only then do they have the energy and motivation to carry out their plans. So, while a colleague may seem to be getting better, this is precisely the time where they may be at greatest risk. Suicidal ideations should always be taken seriously. Ultimately, the suicidal individual should be strongly encouraged to seek, or brought to receive professional help such as a family physician, psychiatrist or trained counselor.

When and Where to Seek Help?

As discussed in Part 1 of this series, there is no magic formula for determining when depression has become a problem for you; this assessment has to be made on a case-by-case basis. However, as guiding principle, if your symptoms of depression are causing significant distress or is impairing your normal social or work-related functioning and decreasing your quality of life, you should seriously consider seeking assistance. The following outlets are good places to start:

Family Physician – Your family doctor is a vital resource for dealing with depression, as they are in an excellent position to provide you with information, resources and treatment. When appropriate, your family physician can refer you to a psychiatrist (a medical doctor who specializes in mental-illness).

Clinical Psychologist – An appointment with a registered clinical psychologist can usually be arranged without a referral, however, as mentioned, your provincial health insurance plan may not cover this service (although your group benefits plan may allocate funds for psychotherapy). Clinical psychologists can provide effective, empirically-proven treatment for a variety of anxiety disorders.

Employee Assistance Programs (EAPs) – Your firm may have retained the services of an EAP provider (you can ask your human resources department if you are unsure). You can contact your EAP anonymously to gain access to a variety of services, including counseling and other forms of treatment.

CBA Wellness – CBA Wellness exists to help legal professionals manage personal, emotional, health and wellness challenges. We work with the provincial and territorial Lawyer Assistance Programs, providing expertise and guidance to their staff and volunteers. Our professional development programs and research resources on mental health and wellness give insights into the very real issues facing our profession.

Epilogue

After finally being persuaded by both his colleagues and his wife to seek help, Pierre went to see his family physician who, after a careful assessment, prescribed him an antidepressant that he took diligently every day. Within a month or two of starting this regimen, he noticed that his energy began to return, he was enjoying life again and his mood had lifted dramatically. He was productive at work again and his colleagues were delighted to have the “old” Pierre back. With his doctor’s consent, Pierre eventually stopped taking his antidepressant, but not before engaging in a few cognitive behavioural sessions with a psychologist to give him some concrete tools for dealing with stress and feelings of depression.

Alia was fortunate to have a very understanding social support network. Her friends and spouse recognized that something was wrong and despite her initial resistance, convinced her to see a doctor. Since starting on a mood-stabilizer, Alia has been back to her old self—energetic, but in control. She also attends a bi-weekly group therapy session where she has been happy to learn that there are others contending successfully with the very same disorder. Alia’s career and family life is back on track and she very excited about her future.

Finally, after getting up the courage to confide in a close colleague at work, Rahim elected to contact a psychologist specializing in cognitive behavioural therapy. In addition to his weekly sessions, Rahim has taken up running which he finds gives him a tremendous boost and keeps his spirits high, as well as tries to read a book or two about coping with depression every couple of months. Rahim has been surprised to learn that he can feel happy most of the time and, although he wishes that he had taken steps to combat his depression earlier, he is feeling great.

Owen Kelly, Ph.D, is a researcher in social neuroscience at the University of Ottawa Institute of Mental Health Research, and the Department of Psychology, Carleton University. He is also a partner in Stress Biometrica, a consulting group specializing in the assessment and evaluation of organizational stress. http://www.stressbiometrica.ca