Depression and the Christian
Depression is common. Most readers will know of someone who is or has been depressed. And yet it is difficult to write about the subject. This is partly because of the danger that a depressed person may misinterpret what I write, but largely because of the reluctance of many people to face up to the fact that Christians become depressed. Sadly there is still a stigma attached to admitting that one is suffering from depression. Many Christians think that, since there appears to be no apparent physical cause for a mental illness such as depression, it must have a spiritual cause and therefore a spiritual cure. This results in people being afraid to admit they are depressed in case they are thought to be ‘backslidden’ and therefore failures, and this leads to a downward spiral into a deeper depression. I hope what I have to say will dispel misunderstanding and help people to face up to the reality of depression and seek appropriate help.
The Bible teaches that the physical and spiritual elements of our natures act as a unity. We cannot separate out various parts of our experience and say that this is purely physical, that is purely mental, the other is purely spiritual. Thus in an illness which has a very definite physical cause, such as an accident or an infection, there are always mental, spiritual and social dimensions which are affected and need care. It should not surprise us that in an illness classified as primarily mental there will be physical, spiritual and social elements that need attention. We are fragile creatures and liable to dysfunction in any part of our nature, which affects the whole of our being. Brain research continues to throw light on the close connection between mind and brain. This has led to deeper understanding of the nature and treatment of depressive illness.
What is the difference between feeling down or sad and being clinically depressed? Most of us go through times when we feel sad and our mood is low. But usually we pick up again fairly quickly and feel times of happiness and even joy. In clinical depression (a depressive illness), the mood stays low for at least two weeks (usually a lot longer) day after day without respite, and the person loses interest and satisfaction in the things that he or she usually enjoys. There are several physical and mental symptoms which are usually present and point towards the diagnosis.
Emotional changes include low mood (usually lowest in the morning), loss of pleasure in usual activities, sadness (with weeping or being unable to do so), and diminished awareness of and ability to show affection. There may be loss of assurance in religious faith, loss of satisfaction or persistence in prayer, and hopelessness leading to a feeling that life is not worth living.
Changes in thinking may include self-dislike (“I hate myself ”); self-blame (“It’s all my fault, I always do the wrong thing”); aspects of oneself are thought to generate repulsion in others (“Nobody likes me, I’m horrible”); self-consciousness can induce ‘ideas of reference’, when others are thought to be saying or thinking things about the patient (“I know what they’re saying about me”); excessive guilt with no hope of forgiveness; suicidal thoughts may be expressed or concealed. Decision-making, reading, thinking and planning, all become slowed or may cease altogether. Past failures are dwelt on, leading to a negative way of thinking about oneself and anxiety about the future.
Physical Symptoms may include changes in appetite, weight loss or gain, changes in sleep pattern, typically with early morning waking in severe cases. Backache, headache and other pains may be the symptoms first mentioned to the GP, who should always be on the lookout for a depressive illness in patients with rather vague physical symptoms.
The foregoing symptoms are accompanied by changes in behaviour. There may be a slowing down of activity or there may be agitation. There is progressive withdrawal and inability to face people. Thus Christians may stop going to church and may give up other activities which they usually enjoy. Bible study and prayer are neglected because of lack of concentration and enjoyment. There might also be unhelpful activities, such as drinking too much alcohol, which may give a temporary lift but then leads to further depression. In severe depression there may be depressive delusions which may include ideas of personal worthlessness, of having committed the ‘unforgivable sin’, and of having no money, no friends, etc. There may be self-harm, and suicide may be contemplated or attempted.
Needless to say depression not only is associated with these changes to the person but also affects relationships with other people and with life situations and these in turn can have an adverse effect on the depressed state. The more depressed a person becomes, the further he feels from God and this makes the depression worse.
Some unfortunate individuals, who suffer from manic depression (bipolar illness), instead of returning to normality after an episode of depression, become hypo-manic. This is a psychiatric emergency and often requires hospitalisation for control and stabilisations (sometimes under a compulsory order). It is characterised by ceaseless activity and talking and irrational, irresponsible and unfeeling behaviour which is very disruptive in the home. The patient talks non-stop, will not let you get a word in, is often abusive and dismissive and is absolutely convinced of his own rightness. He may embark on hare-brained schemes and get into a lot of trouble, financial and otherwise. Lithium Carbonate is effective in treatment
What Causes Depression?
We may distinguish between predisposing factors and provoking factors. While there is growing evidence of a genetic factor in some types of depression, there is no such evidence in most depressive illness. Anyone may develop a depressive illness. Some personality types predispose to depression. People who have a low view of themselves and lack self-esteem are more prone to develop depressive illness.
Among provoking factors may be loss events, such as bereavements, loss of physical health or bodily functions, loss of job or livelihood, and broken relationships. Some physical illnesses, such as infectious hepatitis (jaundice), glandular fever and other viral illnesses are commonly followed by depressive illness. Stressful social circumstances, especially when the person has little support, may also lead to depression.
Childhood and teenage depression is becoming more commonly diagnosed and may be associated with bullying, abuse in the home, and low self-esteem. Students who feel depressed should seek help early, because if left until near exam time it will lead to great disruption of studies. Postnatal depression is more serious than the common “baby blues” which are due to the hormonal changes immediately after childbirth. Depression is not uncommon in old age and may be mistaken for the effects of dementia. Such patients improve dramatically with small doses of antidepressants.
What Changes Occur in the Brain in Depression?
Research has shown biochemical abnormalities in the brain associated with depressive illness. Messages are passed from one nerve cell (neuron) to another by chemical transmitters called monoamines such as noradrenaline and serotonin (5-hydroxytryptamine or 5-HT). In depression, there is depletion or blockage of these neurotransmitters leading to a delay in neurotransmission and therefore blockage in processing of information. Whether this biochemical imbalance is the cause or the result of the depressive illness, there is no doubt that it is present and responds to physical treatments such as anti-depressants and electro-convulsive therapy (ECT). The various antidepressants act by increasing the amount of neurotransmitter available and therefore enabling the thought processes to return to normal. This leads to a lifting of the mood of the patient.
What Treatment is Available for Depression?
While some mild depressions may eventually get better by themselves, the course of the illness may be shortened by good treatment – anti-depressants, some form of psychotherapy or counselling and general supportive measures. The attitudes of the doctor and other health-care professionals involved are of extreme importance to give reassurance and hope to the patient, as are also the attitudes of family, friends and church.
Antidepressants, which work by counteracting the biochemical abnormality in the brain, have revolutionised the treatment of depression. They need to be taken for at least two weeks for their effects to be apparent and continued long after the depression has lifted, perhaps for up to a year. If one antidepressant fails or has unacceptable side effects, another may be used and the dosage can be altered as required. Support is necessary to help the patient persevere with treatment despite possible side effects and delay in response in the early stages. Side effects usually diminish as the patient improves. Patients can be reassured that antidepressants are not addictive. In normal doses they do not raise the mood in non-depressed people. They can, of course, be abused, as some people attempt to get a ‘kick’ from misuse of these pills in high dosage. As with any powerful medicines, they should be taken only under the supervision of a doctor.
Christians can be reassured that there is no stigma attached to taking medication for depression. As they begin to feel better, they will begin to recover their interest in prayer and Bible reading, but they should be encouraged to take their medication for the recommended length of time.
Sometimes ECT is necessary (especially in severe depression) and this is not the terrifying ordeal it used to be, as it is carried out under anaesthesia and does not lead to permanent loss of memory or faculties. ECT is thought to help depression by increasing the effectiveness of 5-HT in the brain. It is the treatment of choice in the severely depressed patient who is suicidal. It is usually administered to inpatients twice a week and the number of treatments required depends on the response of the depression. Again Christians should be reassured that there is no stigma attached to this physical treatment for an illness which they may think of in purely mental or spiritual terms.
There is a wide variety of psychotherapeutic and counselling approaches. One that is widely used by psychiatrists, clinical psychologists and mental health teams is cognitive behaviour therapy (CBT). While traditional psychotherapy since Freud has concentrated on the role of the subconscious and early childhood experience, CBT concentrates on current unhelpful, negative thinking patterns and behaviour which are associated with depression. The self-help book I recommend at the end of this article explains this approach, in which five areas of one’s life are examined (life situation, thinking, feelings, physical symptoms and behaviour) and pointers given to dealing with problems in each area. While this may be helpful in prevention or in a mild or early depression, in a more severe depression medication will be necessary to raise the mood before the patient can concentrate enough to benefit from such therapy.
What about alternative or complementary or herbal remedies? Many people are turning to these. There is some evidence that a herbal remedy from St John’s Wort has antidepressant properties. Much more research needs to be done. Remember that herbal remedies contain powerful biochemical compounds and may have side effects and also interact with other medication. So a doctor’s advice should be sought before trying these remedies.
Professional Help Available
General Practitioners are usually the first professionals approached, and they should be able to reach a diagnosis and start treatment. They may refer the patient to a psychiatric hospital if the problem is severe, or they may enlist the help of a Community Mental Health team, which may include a psychiatrist, psychiatric nurses, clinical psychologists, occupational therapists, social workers and psychotherapists. These are all trained in mental health and can help to treat people in the community rather than in hospital. Many Christians are afraid that their faith may be ridiculed or even blamed for their condition by secular professionals. But this should certainly not happen. We must also recognise, however, that some Christians’ beliefs may be unbalanced and may indeed be contributing to their illness.
Support from Minister and Congregation
Things to avoid in trying to help depressed people:
Don’t say things like: “Pull yourself together”, “Don’t be so emotional”, “Take your mind of your problems by doing something else”. The depressed person is incapable of taking your well-meaning advice.
Avoid criticising depressed people as they feel such criticism deeply and it will only confirm their negative feelings about themselves and make them feel worse.
Do not be put off by the seeming unresponsiveness of the depressed person. If you stay away, this will reinforce his feelings that the church doesn’t care and you think he is unworthy of your attention.
Do not attempt to carry out intensive psychotherapy or counselling without training. By all means learn and put into practice the principles of good pastoral care. Some of the qualities needed are: good listening skills, unconditional acceptance, warmth, empathy and confidentiality.
Do not ignore any expression of suicidal feelings. These must always be taken seriously and the person advised to seek help at once.
Some Ways of Helping the Depressed Person:
Encourage others not to stigmatise those who are depressed. Encourage openness and willingness to share information for prayer rather than taking part in criticising, ignoring, ostracising, gossiping about or otherwise hurting the person.
During the severest phase of the illness maintain regular contact by visiting for encouragement to take and persist with treatment, and to pray with the person. If he has the idea that the problem is spiritual and does not want to see a doctor, gently explain that it is the depression that is causing the feeling of a low spiritual state and that once he gets treatment, his spiritual state will improve. Assure him that you are willing to get a phone call from him at any time, just for a chat. The depressed person tends to isolate himself, because of feelings of unworthiness and inability to cope. Reassure the Christian that as he begins to improve he will regain his ability to concentrate on reading and prayer, and also his assurance and joy. Encourage him to be honest and tell God in prayer all that he feels, however negative it may be. The psalms are helpful here.
In the recovery phase help the person to pick up the threads of normal life again. Help him to start or restart personal Bible study and prayer. Offer to accompany on walks outdoors. The exercise helps to encourage sleep, which is beneficial in helping the mental filing process disrupted by the depression to improve. If the person has been unable to go out to face people, offer to accompany to go shopping or attend church for the first time. Sometimes it’s better to go to a different supermarket and even a different church for the first venture out, before facing more familiar territory. Avoid an over-effusive welcome or embarrassment at seeing them in church after a long absence. Encourage the person to be ready to cope with well-meaning but insensitive questions (“You’re a big stranger, where have you been?”). Reassure the over-conscientious that they will not immediately be expected to resume full duties and responsibilities in the church.
As full recovery approaches, encourage to take more responsibility, but avoid overloading the conscientious. Encourage contact by telephone. Encourage to stay on medical treatment even though they may feel back to normal. Treatment may be needed for up to a year or more. Encourage to admit to feeling unwell at any time and to seek treatment for any recurrence of the depression.
On full recovery encourage the person to review his life before the illness and identify possible causative factors in personality and life-style so that danger signals may be recognised and future attacks prevented or dealt with as early as possible.
Remember the family of the depressed person has to undergo considerable disruption and stress and they need pastoral care too!
I hope I have said enough to dispel the doubts that many Christians have about medical treatment for depression and to give more understanding of how to help those who suffer from this very distressing and disabling condition.