Newsweek Gets It Wrong: The Debate About Antidepressants

I yearned to get better; I told myself I was getting better.  In fact, the depression was still there, like a powerful undertow.  Sometimes it grabbed me, yanked me under; other times, I swam free. – Author, Tracy Thompson.

One study estimates that 19% – - or about 200,000 of this country’s 1 million lawyers – - suffer from depression.  This isn’t just some statistic; this is about people – folks who happen to be lawyers for one reason or another.

Just what are these people supposed to do about their depression?  Many if not most law students, lawyers and judges that I know have taken or are currently taking antidepressant medications. And they seem to be in the majority of people in this country who do so.

The ranks of the medicated are swelling.  The number of Americans taking antidepressants doubled in a decade, from 13.3 million in 1996 to 27 million in 2005. One in ten Americans are prescribed these drugs making them the most prescribed medications in the country.  By comparison, 18 million people take Lipitor for high cholesterol. 

The biggest reason lawyers take these drugs?  Like everyone else, they’re hoping want to feel better, but equally if not more importantly, attorneys want to return to their pre-depression levels of productivity at work.  A profession that doesn’t suffer fools well and demands a lot out of mere mortals.

But is medication effective in treating depression and achieving this objective?

Late last week, I was walking down an icy sidewalk minding my own business.  I could see the usual cast of characters in my peripheral field of vision; clusters of lawyers yucking it up on their way back from lunch, a judge lost in his own thoughts and a corporate lawyer I know (not particularly well) who once told me privately that he takes antidepressants, his lawyer wife  did as well and  five other lawyers in his firm did.  I guess he felt comfortable telling me this because of my public disclosure about my own struggles.  I often feel like a priest in a confessional; I hear about lawyers most private of struggles.  Then, like such disclosures never happened, the curtain is opened and we each walk our own ways.

Walking by a newsstand late last week, I noticed the current cover story of Newsweek Magazine which read, “Antidepressants Don’t Work:  The Debate Over the Nation’s Most Popular Pills”.  The large print seemed to stick a proverbial finger in modern psychiatry’s eyeball and toss the question –along with people who suffer with depression- up in the air. 

The article focused on a recent study which concluded antidepressants essentially worked no better than placebos (sugar pills).  Oh, just great, I thought. What am I, who have taken medication for the past eight years, supposed to do now?  Start popping M & M’s instead of Cymbalta?

The writer of the Newsweek piece concluded

“If placebos can make people feel better, then depression can be treated without drugs that come with serious side effects, not to mentions costs.”

This conclusion is the latest in a long line of recent books leading the charge against the use of medication to treat depression. Charles Barber, in his book Comfortably Numb: How Psychiatry is Medicating a Nation, argues that antidepressants are doled out like Halloween candy in this society.  The motive: the big money made by the pharmaceutical industry.  This is an appealing take because Big Pharma is commonly portrayed as the villains in the popular press; guys in black hats and white lab coats stuffing greenbacks into their pockets.

In an article written for Salon, Barber wrote:

“One has to wonder:  Are we really that miserable?  Manipulated might be a better word for the miserable.  If we were to pick one factor that explains the dramatically increased number of antidepressants that now runs through our collective bloodstreams, it would be direct-to-consumer advertising, otherwise known as television commercials for drugs.” This point is well taken, but not surprising.  Pharmaceutical companies are in the business of making money.  Does such a motive make Lipitor any less effective?  Should commercials about it deter us from taking this drug?  I don’t so.

In fairness to Newsweek, they ran an accompanying piece which tried to give the other side of the coin.  It was penned by psychiatrist, Robert Klitzman who framed the question about the study’s conclusions in this way:

“What should we make of the [study]?  First, some facts: antidepressants have been shown to work for serious major depression.  Most evidence shows they are effective for dysthymia: milder but chronic depression that continues for two years or longer.  The question is whether they work for milder depression that may be shorter or less intense.  That’s important, since major depression affects almost one out of five people [in this country] at some point in their lives.  And most people with depression do not have severe forms of it.”

The response to Newsweek’s take on the study was sharp and quick.  In an Op-Ed in the New York Times, Judith Warner wrote this biting retort:

“Happy pills don’t work, the story quickly became, even though, boiled down to that headline, it was neither startling nor particularly true. Yet in all the excitement about ‘startling’ news and ‘sugar pills,’ a more nuanced and truer story about mental health care in America was all but lost.  The story begins to take shape when you consider what the new study actually said:  Antidepressants do work for very severely depressed people, as well as for those whose mild depression is chronic (dsythymia). However, the researchers found, the pills don’t work for people who aren’t really depressed – people with short-term, minor depression whose problems tend to get better on their own.  For many of them, it’s often been observed, merely participating in a drug trial (with its accompanying conversation, education, and emphasis on self-care) can be anti-depressant enough.”

As the article also points out, most people receiving antidepressants aren’t getting them from well-trained psychiatrists, but family doctors who don’t screen well for depression. One wonders how much training they get on  how to probably diagnose depression and whether they can keep up on all the research on the topic.  The result: we are, in some sense, an overmedicated nation; a country too quick to give sad or unhappy people pills that they shouldn’t be taking and don’t need. 

That conclusion, however, does not mean that these medications don’t work for many (though not all) people suffering from true clinical depression.  My take is that a family doctor who treats urinary tract infections and constipation shouldn’t be doling out Lexapro to a patient that he has spent 5 minutes with. Perhaps the problem isn’t just pharmaceutical companys bent on making a quick buck, but family doctors under managed care who don’t have any time to spend with patients and don’t know much about depression and the various medications used to treat it.

People feel ashamed and stigmatized by going to psychiatrists, but it could be a game-changer for many:  either you don’t have depression and shouldn’t be on medication or you do and you could finally get relief from some of depression’s more devastating symptoms.

There is no doubt that exercise, psychotherapy and some form of community and support will help people whether they are suffering from some transitory upset/sadness in their life (by the way, this helps people with depression too). However, for many people afflicted with clinical depression, it’s unlikely that they will have a real shot at containing or overcoming their depression without short-term or long-term use of medication. They won’t be able to muster the energy, commitment and motivation to engage in the other healthy stuff; to go for a walk, to work out their distorted and negative self-beliefs about themselves with a good therapist or join a support group.

Depression has a terrible undertow; its riptides are often unforgiving.  We need as many weapons in our arsenal to deal with it. People with transitory sadness or disappointments don’t need to become patients; they need to connect with other people or change their lives – maybe both.  Therapy or just working it out by themselves with supportive friends and family may be all they need.

Walking in Bigger Shoes

Lawyers are an earnest, disciplined bunch.  They love evidence – the “show me the money” approach to life.  They’re hard-bitten pessimist, yet love the latest self-improvement projects pitched to them by the legal establishment.  You know — graphs, charts and the Oprah-like cattle call to “Change Your Life in Five Easy Steps!”  The goal of all these books and slogans is Happiness, as if it were a commodity for sale.  There was a snappy piece yesterday in the New York Times Review of Books entitled, “The Rap on Happiness.”  It’s a great take on this country’s obsession with finding the veritable Oz of bliss.

“The real problem with happiness is neither its pursuers nor their books; its happiness itself.  Happiness is like beauty:  part of its glory lies in transience.  It is deep but often brief (as the poet Robert Frost would have it), and much great prose and poetry make note of this.  Frank Kermode wrote, ‘It seems there is sort of a calamity built into the texture of life.’  To hold happiness is to hold understanding that the world passes away from us, that the petals fall and the beloved dies.  No amount of mockery, no amount of fashionable scowling will keep any of us from knowing and savoring the pleasure of the sun on our faces or save us from the adult understanding that it cannot last forever.”

Lawyers walk in shoes that are too small for them, living lives that are too confining, unimaginative and which fail to challenge them to be their best.  They need to switch from pinching wing-tips to cushy loafers.  This switch gives a vital bounce to their steps rather than a lugubrious gait. The opposite of depression isn’t happiness; it’s vitality. It’s like a Swordfish bounding out of the ocean’s waves in defiance of gravity or B.B. King playing a blues riff on his guitar.  They have a vibrancy that can’t be contained; they express themselves in a space where great stuff happens.

Part of the equation involves not so much pills or therapy, as the lifting up of our individual imaginations.  Putting aside what’s possible in a concrete sense ( you know, the mortgage or student loans), have you ever looked out your office window and imagined the life you’d like to have?  This is not the same as rumination; a constant churning of negative thoughts in our cranium which a depressive is prone to.

Rather, it’s an exercise in lively engagement with our Self. To engage in this effort, we have to pop our life’s stick shift out of “Neutral”, the frozen state that depression and/or anxiety can keep us stuck again.  Locate the “Drive” on your shift and engage.

In this exercise, it might be helpful to think about the choices we make in a different way.  Not in a self-recriminating way, but in a fashion that moves us in a constructive direction. We need to separate the wheat from the chaff in our lives; to decide what reduces or enlarges our spirits.  Quality questions can help in regard.  Not the common lament of depressives, “What the hell is wrong with me?”  That’s a dreary question that goes nowhere because the answer we give ourselves is – - “Everything!”  James Hollis, Ph.D., in his wonderful book, “What Matters Most: Living a More Considered Life” offers us a keen approach ourselves to view ourselves:

“Ask yourself of every dilemma, every choice, every relationship, every commitment, or every failure to commit, ‘Does this choice diminish me, or enlarge me?’  Do not ask this question if you are afraid of the answer.  You might be afraid of what your soul will require of you, but at least you then know your marching orders.”

Incline your inner ear.  Listen to your response to this challenging question.  Enlargement of one’s self isn’t so much about happiness, as meaning. Deep down, we all want a life of purpose; where we feel our lives have a point, or many points of light for that matter.  You don’t have to look far.  It’s right beneath your bouncing feet.

Turning Your Life Around

 

Lawyers often sense that their lives have gone off track; they just don’t know how to fix them.  They’re hit by daily demands that make it difficult to find their true north.

There are the demands that hurtle at them from the lives they occupy – the boss that’s yammering for more billable hours, families that feel upset by all the hours they spend at work or you-name-it-crap from this frenzied world.

Then there are the demands that emanate from somewhere inside of them; the part of themselves – their true selves – that wants a life with less stress, more meaning and a sense of connectedness to other people.  While they pine for such a life while looking outside their law office windows, such reverie gives them a brief respite from the grind.  But after the moment has passed, there’s an abiding sorrow.  A sense that something has been lost that can’t be found.

Perpetual stress can keep lawyers from ever dealing – in a constructive and persistent way – with what they really want in life. They check their Blackberry’s more than check in with themselves. They don’t really know what they want most of the time; they just know that it’s not this.  Emotional pain may be leaking out of them; for some lawyers, this has been going on for years.  The pain might be mitigated in healthy (e.g. exercise) or unhealthy (e.g. drinking, drugs) ways.  But, it will not go away – until they turn around and face themselves.

Lawyers need to become conscious of the choices they’re making during their waking hours.  Of course, there’re exceptions, but the majority of lawyers have choices.  They aren’t victims that are being forced to stay at their jobs.  They’re choosing to stay at their jobs and do the work they’re paid to do. 

Most lawyers, however, just don’t see it this way.  They feel stuck in their jobs and lives with few viable alternatives.  As odd as it may sound, they feel like victims.  Friends of mine who aren’t lawyers scoff at my observation:  “Lawyers victims?  Give me a break.”  Nonetheless, it’s true on an emotional level for many lawyers.

Lawyers can feel this way because (a) the “golden handcuffs” in which they’re just making too much money to quit; (b) they’re in too much debt; (c) they’d rather complain than face the abject fear that comes with making tough changes; or (d) they’re simply paralyzed by stress, anxiety or depression.

However, by turning from a stuck-victim status to a choice-maker posture they can begin to awaken to their true potential. They might have to make small changes in their lives or maybe a closet full of whoppers.  Perhaps they’ll have to go back to the drawing board of their lives and sift through and separate what’s really important versus what’s trivial. This will take time; let nobody fool you on this one.  People in our country are basically impatient; we want relief from our distress NOW.  But, meaningful and realistic changes never seem to unfold this way. That’s just the facts-o-life. 

Turning your life around may come down to this:  What are you willing to do to change your life?  Lots of people — not just lawyers — know that their lives aren’t working.  The same group approaches their lives with all the right intentions of changing it for better.  Most, however, will not change despite the chorus of voices from within telling them to do so.

I had a friend who would call me once a month and lament how unhappy he was.  I’d listen for thirty minutes and then he, having discharged his discomfort, would say goodbye only to repeat this weather pattern about thirty days later.

Finally, six month in this telephonic waltz, I said “Tom, what are you willing to do to change your about life?”  The question must have stunned him like a taser because there was silence –  a dead silence — on the other end of the line.  He evaded the question, said we would have to get together soon for lunch and hung up.  Tom never called again.

Tom didn’t really want to change – - he wanted to bitch, a common past-time for many lawyers.  He wanted my sympathetic ear to appreciate just how much he’d been screwed over by opposing counsel, an irate judge or his cranky wife.  I had sympathy for Tom, but also a good deal of frustration because I realized that I wasn’t really helping him.

I would ask you the reader:  “What are you willing to do to change your life” Are you willing to the feel the free floating anxiety that’s inevitable if you are to start changing your life?  The longer the discontent goes on, the bigger the changes will have to be.  The longer we delay, the bigger the kick in the pants from Life to wake us up.

Yes, work is only a part of life and many lawyers no doubt find outlets of meaning and joy along other avenues.  However, as Gregg Levoy, author of Callings:  Finding and Following an Authentic Life, such sizing up of our days miscalculates the energy and time we must invest in our daily jobs:

“Work is merely one of the arenas in which you play the game – the one the Gods are watching from the press-box atop Mount Olympus while sipping mint juleps.  It is only one of the arenas in which you express your humanity, search for meaning, play out your destiny and dreams, contribute your energies and gifts to the world and spend your precious nick of time.  It is also an arena in which you spend two-thirds of your waking lifetime and it is legitimate to love your work!  Life is a thousand times too short to bore yourself.  If someday your life does flash in front of your eyes, the very least you want it to do is hold your interest.”

Rear-ended by Depression

The abject pain of clinical depression is magnified expontentially when one considers that sufferers usually blame themselves for their plight. “What’s wrong with me?” is a common refrain.  Most people with depression feel “bad” to their core.  They can’t always articulate why this is so, but they know that they can’t shake their own self-condemnation.  There is no place to hide from it, no true rest for the weariness it brings.  We lay awake at night and hope that tomorrow it will be better.

I had a conversation last week with a mental health professional who asked me, “What in the world do lawyers have to be depressed about?  They’re rich and powerful.  Lawyers should stop complaining and realize how good they have it.”  Yet a lack of gratefulness has little to do with depression.  I used to recite a list of things I had to be grateful about – and there were many – but it all fell on depression’s deaf ears.

When others tell us to “snap out of it,” we may buy it hook, line and sinker and even believe that they know what they’re talking about.  Well-meaning friends may try to reign in our sorrow by suggesting that they can identify with our suffering.

In her book about her own depression, An Unquiet Mind:  A Memoir of Mood and Madness, psychiatrist, Kay Redfield Jamison writes:

“Others imply that they know what is it is like to be depressed because they have gone through a divorce, lost a job, or broken up with someone.  But these experiences carry with them feelings. Depression, instead, is flat, hollow, and unendurable.”

Such attempts by others, even when well intentioned, always brought about a deep sense of loneliness in me.  I had, like most people, gone through my fair share of difficult experiences in life like losing a job.  But this experience – this blast furnace of melancholy – was not that.  We get over losses in our lives, we adapt.  We can’t just “get over” depression.

There is a sense that we have been rear-ended by depression; out of seemingly nowhere, our lives are crashed into and changed forever.  In a very real sense, we will never be the same.  Some will recover from their depression, many will not.  That’s not a very popular thing to say, but it’s been my experience from talking with hundreds of lawyers from around the country who I’ve been privileged to share with.  For many, recovery will be an on-again off-again sort of affair.  They will have to work hard to recover and make lots of effort to stay healthy.

Part of the reason why too many lawyers don’t get better is simple:  most don’t get any form of treatment for their depression.  A study by the National Institute of Mental Health revealed that as many as 80% of people in this country get no form of help whatsoever.  Looking out a window, I wonder how high the rate is for lawyers.  It’s most likely a mixed bag.  While it’s true that people from a higher socio-economic class tend to get treatment – mostly because of their access to good medical care – most attorneys still don’t because of the stigma associated with mental illness.

Such shame – dumped on people from others and the self-inflicted variety – is particularly deep for lawyers.  This is so because of the myths surrounding their internal world.  Lawyers feel like they’re supposed to be veritable Supermen able to bend steal and solve all manner of a clients’ problems without wrinkling their power blue suit. If they’re in pain, they’re told to “suck it up.”  We live in a nation of winners where, deep down, many feel like losers.

This sort of mentality, in part, explains the epidemic rates of depression in the law.  Studies have concluded that lawyers suffer from depression at a rate of twice the national average or about 20%.  This means that 200,000 out of the one million lawyers in this country suffer from depression.

What’s a depressed lawyer to do?  First, one must stop blaming oneself.  This is tough because most people with depression have been living with this cognitive distortion for a long time – maybe their whole lives – and this corrosive self-talk promotes the viscous cycle that is clinical depression.  If one can’t stop blaming oneself for having depression, it’s tough to get better.  Little by little, we need to learn to let that bullshit go and start walking a healthier path.

The poem, The Journey, by Mary Oliver, captures some sense of this path for me.  I hope it will for you.

One day you finally knew

what you had to do, and began,

though the voices around you

kept shouting

their bad advice – -

though the whole house

began to tremble

and you felt the old tug

at your ankles.

“Mend my life!”

each voice cried.

But you didn’t stop.

You knew what you had to do,

though the wind pried

with its stiff fingers

at the very foundations,

though their melancholy

was terrible.

It was already late

enough, and a wild night,

and the road full of fallen

branches and stones.

But little by little,

as you left their voices behind,

the stars began to burn

through the sheets of clouds,

and there was a new voice

which you slowly

recognized as your own,

that kept you company

as you strode deeper and deeper

into the world,

determined to do

the only thing you could do – -

determined to save

the only life you could save.

One Nation Under Medication

Clinical depression’s analogy to illnesses like heart disease or diabetes has been helpful to de-stigmatize it in our society.  It is a physical illness, regardless of its causes, and requires medical care and treatment.  But, in a very real sense, it’s much more than that.

Heart disease and diabetes do not affect our minds, personalities and emotional worlds like clinical depression.  Taking antidepressant medication, unlike other meds to open sinus congestion or plaque-filled arteries, changes how we see ourselves as well as how others see us.

Much about what drives how we feel about taking medication is driven by stigma; the dark cloud of shame which says that we’re weak or somehow “bad” for taking such drugs.  This nonsense continues despite the fact that 350 million people suffer from depression worldwide and that it’s the leading cause of disability on the planet.

In the book Undoing Depression, Dr. Richard O’Connor captures some of the irony of stigma:

“If [all of the statistics] are true, if depression is as dangerous and prevalent as I’m saying, you may well ask: Where’s the big national foundation leading the battle against depression?  Where’s the Jerry Lewis Telethon and the Annual Run for Depression?  Little black ribbons for everyone to wear?”

Looking back on my journey with medication, it was a rough ride but one in which I am glad I took.  I have been on medication for the past eight years and it controls my depression.  I don’t think that it’s the only reason why I’ve gotten better; I’ve done a lot of healthy stuff to recover too (e.g. psychotherapy, exercise and change in my diet).  But, at least for me, medication brought about a profound stability that I might not have otherwise achieved.

The fact that medication helped me and continues to do so doesn’t mean I don’t have my fair share of ambivalence about taking them; on the contrary.  Besides the unknown long-term effects on our brains from using these potent concoctions, there is also a change of identity that takes place when we start using them.

I sometimes miss the old, pre-antidepressant Dan that was wired and edgy.  When anxiety and depression really lit up  my nervous system, it was as if too much wattage was flowing through the power grid of my body.  The medication seemed to calm things down and even things out.  As I grew calmer, I was able to think through things more clearly – especially my depressive thought habits.  But there’s a struggle which waxes and wanes within me, even as I give the medication its due, about whether becoming a medicated person has been a good thing entirely. 

In his book, “Is It Me or My Meds?” Boston College Professor, David A. Karp writes:

“[P]eople’s self-esteem and sense of integrity are deeply connected to their ability to control their personal problems  The people I spoke with had difficulty accepting the idea that emotional illnesses are no different from physiological problems such as heart disease or diabetes.  It may be comforting to hear that antidepressant medications correct chemical imbalances in the brain just as insulin controls diabetes.  But most of those I interviewed assigned different meanings to mental and physical conditions. When asked directly, they affirmed that psychiatric drugs are far more likely than other medications to make them feel bad about themselves . . . .”

There is no doubt in my mind that we become different people on these drugs; there is the pre-antidepressant person and the post-antidepressant person.

In an article Dr. Karp wrote for the Lawyers With Depression website, he writes:

“While direct-to-consumer advertising has likely fostered an easier acceptance of these pills, most of the people I interviewed who suffer from major depression embark on a psychiatric drug career with great reluctance.  Typically my respondents turn to medications only when desperation leaves them without alternatives. 

This is understandable in terms of the identity line that one crosses by seeing a doctor, or seeing a diagnosis of depression and filling the prescription for anti-depressants.  One person poignantly expressed her identity dilemma by saying that, ‘When I swallowed that first pill I swallowed my will.’  Beginning a regimen of psychiatric medications is part of the traumatic transformation from person to patient; from being a merely troubled person to someone who has mental illness.  Crossing that boundary is hardly an easy step to take.”

I think Dr. Karp captures a good deal of the angst that goes along with taking meds.  Most people I know who take them can identify with what he says.  There is often a sense of shame attached with taking medication because we feel that we should be able to kick depression’s ass all by our sweet old selves.  What that blows up and we are left stumbling on depression’s playing field, we often turn to medication.  In my own life, I felt shame for a period of time.  But as my understanding of depression grew, I knew I didn’t have anything to be ashamed of.  It wasn’t my fault that I had depression, but it was my responsibility to get better.  Medication was part of that for me.