cbaReport-Nov12 - page 12

November 2012 CBA REPORT
balanced Living
he first time I saw Dan Luka-
sik’s documentary “A Terrible
Melancholy: Lawyers with De-
pression” was at the CBA’s CLE seminar
on “Depression, Stress, and Anxiety
in the Legal Profession,” in September
2010. As a psychiatrist, this was my first
experience with CLE, prompted by an
invitation from Joy Lawrence-Slater to
join Dan Lukasik by speaking about
medical aspects of depression. I was
moved then by Dan’s message and by the
mission of this man who single-handed-
ly has taken on the cause of promoting
awareness of depression among lawyers
The second time I saw Dan’s docu-
mentary, in May 2012 at the American
Psychiatric Association’s annual meeting,
where I had arranged for Dan to give his
workshop to a group of psychiatrists, one
member of the audience asked him to
add to his movie tips on how to find good
treatment for depression. Dan told him
he’s unlikely to make another movie, but
I took his cue. Here’s a start on a tip sheet
for anyone looking to get the most effec-
tive treatment for major depression.
Essential components of a
comprehensive treatment plan
Shopping for good treatment for
major depression can be trickier than
buying a car. It’s not so hard if you have
relatively “simple” depression, most of
which can be well treated by a skilled
primary care clinician with medications
or counseling. But if you have com-
plex depression, that is, either multiple
episodes, or partial response to adequate
treatment, or other illnesses that com-
plicate the treatment of depression, then
it helps to know what you’re looking for.
You want to know what effective treat-
ment consists of. And you want to know
the essential elements of comprehensive
treatment planning for complex depres-
sion. If
Consumer Reports
could evaluate
the qualities of comprehensive treatment
for depression, these are the criteria they
(and you) should look at:
• Medications
• Therapy
• Knowledge of your illness
• Daily self-management plans
• Exercise
• Sleep management
• Behavioral activation
• Relaxation/Mindfulness practice
• Symptom monitoring
• Relapse prevention plan
. Antidepressant medica-
tions, though not essential, are often
the starting point for treatment because
of the ease of access to them through
primary care clinicians. Medications
and therapy are the two pillars of the
treatment plan for depression, but for a
substantial number of patients either one
alone may not be sufficient for effective
treatment. Because the full response rate
to a trial of a single antidepressant is
about 60 percent, many people have to
try more than one. And a full trial may
take several months with careful dose
adjustment and monitoring. Since we
have more than 20 antidepressants to
choose from, most people can find one or
a combination that works.
Therapy specifically de-
signed to relieve depressive symptoms
and prevent relapse usually requires an
hour a week for two to three months,
sometimes more. Cognitive therapy and
interpersonal therapy for depression have
been well studied and are as effective as
medications for relieving the symptoms
and better than medications at prevent-
ing relapse. Combining medications and
therapy is generally more effective than
either alone, but access to good therapy is
more difficult to find than good medica-
tion management. When negotiating
with a therapist, ask specifically for
therapy for major depression.
Knowledge of your illness.
complex depression deregulates your
biology, psychology and your social life,
sometimes for many months or years,
you have to understand how depression
works in order to achieve effective treat-
ment. Depression, like cancer, diabetes
and heart disease, will run your life if
you don’t learn how to manage it. That
means asking lots of questions, studying
self-help books, searching the internet,
attending self-help groups, watching
documentaries—anything that will make
you an expert on your illness. Aim to be
as clever about your depression as some
people are about their diabetes or heart
Daily self-management plans.
people who do not get well with the first
or second treatment with medications
or therapy, and many of their clinicians,
overlook the fact that recovering from
any severe chronic condition is a part-
time job. It’s not enough to work on your
By Lawson Wulsin, MD
What is Good Treatment for Depression
and How to Find It
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