UNDERSTANDING DEPRESSION - A CHRISTIAN PERSPECTIVE
(an imaginary conversation with Dr Lachlan Dunjey based on similar interviews)
I understand you've been talking about depression now for a long time, how did this come about?
Well I had done a term in psychiatry after graduation and one of the things that I was doing in my general practice was to put some of my depressed patients onto anti-depressants. But then they would sit in their church congregations and be exhorted by their minister to "have more faith and stop the medication", so were stopping their medication and coming back to me with a relapse. I decided that I needed to talk to the ministers and so talked to our minister at the time who arranged for me to present a paper at the Baptist ministers' fraternal. Interestingly, or perhaps predictably, the ministers that I really wanted to hear the message did not come, but otherwise the paper was well received and so from then on I got invitations to go to the churches and talk about understanding depression from a Christian perspective.
Have you spoken often since then?
I usually finish up doing about 10 meetings per year and have had the privilege of taking meetings throughout most of WA and I never get tired of it.
Why do you enjoy talking about depression?
I find it amazing that in the mid-1990s that depression is still not understood by so many in the community, that it is still looked upon as being failure or weakness or inadequacy, and that people don't present because of this feeling and others also discourage recognition and treatment of the problem. It is because of this that we now have a public education campaign over a two year period from Mental Health Week in 1993 - I think this is very timely. It is also the commonest of the problems to afflict the human mind and yet is the easiest to treat and offer hope. Our aim is to strip the illness of its shame. Also by learning about depression, we get to understand more about ourselves and therefore are able to get more out of life and also be in a position of being able to help others - something which I think we all enjoy.
Are we beginning to understand the nature of depression better?
Absolutely. We are learning more about the complexities of brain biochemistry and the newer antidepressants have been "designed" especially to help restore the chemistry back to normal. Despite my belief in counselling (I do it most of every work day) I've become more and more impressed with how dependent our minds and emotions are on our chemistry and of the link between depression and our chemistry. I also find the new "designer medications" very exciting - it's wonderful to see people restored to normal. But let me say very quickly that people don't always need treating with medication, and counselling is always important in the overall management of depression.
But surely spiritual people shouldn't get depressed?
It's a dilemma isn't it! Perhaps Christian people with their higher expectations of themselves actually suffer from more internal conflict and therefore are more susceptible, so we might argue that spiritual people get depressed more frequently. The Bible is very clear that we live in an imperfect world that is subject to suffering, in fact all creation groans to be released. We all have our vulnerabilities under stress, and depression from a medical point of view is no more of a failure than suffering any other disease process like a duodenal ulcer. But I am also aware that some parts of the Christian church would regard any of these illnesses as being an indication of lack of faith. I don't think the Bible teaches us this.
So, are you saying that being a good Christian is not sufficient?
Yes. God undertakes for us in positions of great difficulty and looks after the David Brainerds and the C T Studds, but we are also to be personally responsible, and to put faith into action and develop skills and strategies which are not totally spelt out in the Bible. For instance, to be a good and safe driver it is not sufficient to just be "spiritual" - we are obliged to develop skills in driving and to be personally responsible for this. We are also to take care of our bodies and care of our minds doing whatever we can from a position of personal responsibility. The Bible tells us a lot about marriage but we can also learn a great deal about protecting and nurturing our marriages if we attend marriage enrichment courses. So part of being a good Christian is to exercise Christian responsibility - that means when we are hungry we are to prepare food, and not just pray for manna. It means that when we are sick, we pray to God, commit our way to God, and we also go to the doctor.
You mentioned failure before - why do depressed people feel failure?
There are several reasons. Sometimes it is because there is no obvious cause for the depression - Charles Haddon Spurgeon was a great preacher of the last century who suffered from depression quite severely and had some very good things to write about it. One of the things he said was "this evil will also come upon us, we know not why, and it is then all the more difficult to drive it away. Causeless depression is not to be reasoned with. If these who laugh at such melancholy did but feel the grief of it for one hour, their laughter would be sobered into compassion". The significant phrase being "causeless depression is not to be reasoned with".
Depression can affect anyone - it afflicts people of faith and competence and it is perhaps these people that feel more the sense of failure. These are also the ones perhaps most likely to deny that there is a problem and sometimes the first thing we know is that they have successfully suicided.
But also the loss of self-esteem and failure that people feel in depression is part of the depression. It comes with it - it is one of the significant symptoms that people have.
Have you ever been depressed?
Yes I have, but I didn't recognise what was happening at the time. It wasn't recognised by anyone else and it wasn't until I did a term in psychiatry that I realised that I had had a short episode of depression, which happened to be self-limiting and didn't require any treatment. It was when I was a 4th year medical student and my mother had just died after a prolonged illness and I had just had a tonsillectomy. I remember sitting up in King's Park on my way home from university and feeling miserable. I also remember going to the backyard of our house and writing down my problems in the sand - which at other times was a vegetable patch. I wrote down a list of about 5 or 6 problems and one-by-one committed them all to God and had complete confidence that He would work them all out. But the remarkable thing was that I still felt just as despondent despite this confidence. The Psalmist echoes this I think very well in Psalms 42 and 43 when he says "why are you cast down, 0 my soul?" Its worth looking at that Psalm - he does everything right, prays to God, commits his way to God, confesses his sin and failure, counts his blessings and yet still comes up with the refrain "why are you cast down, 0 my soul?"
Is there a difference between sadness and depression?
Yes. Sadness is logical - it has a cause that you can talk about with someone else and the degree of mood change which occurs is consistent with the cause - as is also the length of time for which the mood change lasts. So there is a difference between the sadness, for instance, between losing the football and someone dying - or at least there should be. Sadness makes sense - depression doesn't. There is something terrifyingly illogical about depression as Spurgeon said "causeless depression is not to reasoned with". Of course people frequently look for a cause and sometimes they might define some very real causes of difficulty, for instance, they might say "I am feeling like this because of my job which I don't enjoy", and then leave that job and find that they feel no better. The tragedy is that sometimes people make significant life decisions while depressed - marriages can break-up, people can shift homes or put themselves at positions of risk when a careful analysis of the situation would leave shown that the depression was not substantially related to these problems. So it is extremely important to tell people who are depressed not to make significant life decisions without adequate counselling.
Can sadness turn into depression?
Yes. Especially when the person hasn't grieved in the way that God created us to do, suppressing grief in an effort to "cope better." This can be likened to the suppression of anger - indeed some have said that depression is "anger turned inwards" and there is some truth in this.
How can we tell the difference between sadness and depression?
Sometimes it is difficult to tell the difference between a normal grief reaction and one which has moved into depression, but one of the helpful things for me is the lack of feelings in depression, in particular the inability to feel love and experience pleasure. Once we are no longer able to get enjoyment with our friends and able to feel pleasure in a game of tennis or a walk in the bush, we are starting to move into depression.
Well, what is depression?
It is most important to realise that depression has many faces, or many masks - as John White well expresses in the title of his book on depression "The Masks of Melancholy". There are the typical depressions where people experience sadness, anxiety, guilt, self-reproach, loss of self-esteem, inability to experience pleasure - and therefore also loss of interest in those things which normally give pleasure - feelings of hopelessness and self-blame, aloneness, worthlessness, difficulty in making decisions and distortion of perspective and judgement. This distortion can lead to the point of wanting to die and even be so severe as to have a mother with a newborn baby wanting to not only kill herself, but the baby as well. Suicide at that point seems to be the only and the right thing to do. There may be changes in behaviour such as withdrawal and agitation. There are also physical changes which occur - in general our body tends to slow down so we experience tiredness and the bowel may slow down resulting in constipation. There can be disturbances of appetite - some may eat more because of associated anxiety but the more severe depressive typically loses their appetite and therefore loses weight. There can be slowing down of such things as sex drive and menstrual function. When our brain slows down we experience difficulty in thinking clearly, difficulty in making decisions, difficulty in concentration, memory disturbance and in an older person these manifestations can be confused with Alzheimer's disease.
Depression can be any combination of these symptoms and varies from person to person.
There are also the atypical ways in which depression can present e.g. dementia, paranoia, fatigue syndromes, pain syndromes, shop-lifting in people for whom this would be quite inappropriate, hallucinations and obsessive or blasphemous thoughts.
Once again, it's important to realise that depression presents in many ways.
You mentioned guilt. Surely that just requires getting right with God?
Guilt is an integral part of depression and is frequently worse in Christians. The Christian people that I see have always done the right thing from a Christian point of view and confessed their sins, and yet their feeling of guilt remains. It is important to reassure them that when their sins have been confessed, that God has forgiven them, that their feelings of guilt are just a part of the depression and that the devil loves to accuse us and capitalize on the bad feelings that we have about ourselves. There is a great difference between God-given guilt which is specific and related to specific events and the non-specific broad guilt of depression. We need to tell people this again and again and again. Unfortunately, this guilt is sometimes aggravated by well-meaning Christians who say "you need to get right with God" or "you need to have more faith". I remember a specific instance in Don Baker's book "Depression" when a well meaning Christian came to visit him in hospital and decided to pray with him, and at the end of his prayer threw in these words "and please forgive him for whatever sin has brought him here". This must have been absolutely shattering.
How can a Christian want to die? Or even kill themselves?
As I said before, this represents a significant change of perspective and is illustrated very well by both Elijah and Job. Job said "why should light and life be given to those in misery and bitterness, who long for death as others search for food or honey?"
The perspective of others having forgotten them and turned away from them also applies to God. So many times in scripture there is the plaintive cry "how long, 0 Lord, will you hide your face from me?"
You mentioned fatigue syndromes - would you like to enlarge on this area?
Well, certainly I see a number of people with extreme fatigue which seems to fit into the pattern of the so-called chronic fatigue syndrome that used to be known as M.E. or myalgic encephalomyelitis, without other obvious manifestations of depression, but who respond to large doses of antidepressants of the stimulating type. But maybe I only see the ones God intends me to see. I don't pretend to be able to effectively treat all people with chronic fatigue syndrome, but the success rate that I get with the people that I see is about 75 percent. Maybe they are the true depressives who simply present with a fatigue-type picture, but I strongly suspect that there is an overlap between the two conditions.
You also mentioned obsessional thought processes - can you enlarge on that?
Yes, I remember seeing a theological student some years ago who came to me with obsessional blasphemous thoughts and he had come to the conclusion after prayer and looking at the issue very broadly including the role of the demonic, that the disorder was a chemical one and he informed me that John Bunyan had similar thought processes. He came to see me because he had concluded that it was chemical and wondered whether or not I could help him! I was delighted to inform him that I could and put him onto a particular antidepressant which is notably effective in this area - he responded superbly, stayed on the antidepressants for some 6-9 months and has never had a recurrence since. This is a typical "case" of what is a less common presentation and John White talks about this problem in his book too.
What causes depression?
Just as there are many faces of depression so there are many causes of depression. Most commonly, several of these causes act together in order to produce the final end-point chemical change, so it can be said to be multifactorial. A good way of understanding this is to compare it with asthma - some people with asthma have a sufficiently significant inbuilt genetic factor as to have asthma most of their life without the addition of factors that are necessary in other people e.g. cold air temperature, infections, pollution or allergies. Depression is similar in that some people have such a strong genetic factor that depression seems to occur spontaneously, but in other people other factors are necessary such as loss, change, conflict particularly with the element of being "trapped" - multiple stress situations, illness e.g. glandular fever, metabolic factors e.g. alcohol, hormonal factors or complex psychological factors in the present or in the past.
It is important to realise that the “end-point" change in asthma, regardless of the cause is a chemical one associated with spasm of the airways - similarly the “end-point" change in depression, regardless of which causes are involved, is a chemical one involving conduction from one nerve fibre to another.
Can you explain that a little more please?
Yes. The conduction of the nerve impulse along the nerve or neuron is an electrochemical one, but across the synapse - the connection between the two neurons - the transmission is chemical and we call these substances neurotransmitters. The common ones we talk about are nor-adrenaline and serotonin. Biochemically, these are what we call "mono-amines" and are in a constant state of manufacture and either destruction or absorption, being taken up by receptor sites in the receiving neuron.
Are you saying that depression always involves a change in our brain chemistry?
Ultimately, yes - but this is on a continuum, that is some people have mild changes and other people have more severe changes. If the change is mild this may correct spontaneously, but if the change is more severe then chemical treatment, i.e. antidepressants, will usually be necessary in order for recovery to occur.
Well what about sin as a cause?
Sin always puts a person into conflict with God and frequently into conflict with themselves. So yes, obviously this can be a cause. But I have yet to meet the Christian person with depression who hasn't already asked for forgiveness, so for Christian people to say to them that their problem must be because they have sinned is a very inappropriate spiritual "pat answer" and should never be said. That is what Job's friends said to Job, and we read at the end of the account that Job has to offer a sacrifice on their behalf for their sin in their accusation of him.
Coming back to the Spurgeon type of ‘causeless depression’ - how do you account for this?
Once again, it's a little bit like the asthmatic with a significant inbuilt genetic predisposition. This person doesn't necessarily require any trigger factors for the asthma to occur. Likewise, some depressives have such a strong hereditary component that no other “cause” is necessary to cause the chemical change with the clinical manifestation of depression.
You mentioned antidepressants. Is drug therapy the only way of treating depression?
No. Depression is treated in many ways by many different people and the effectiveness of these treatments depend on the severity of the chemical change. Such people can be counsellors of many varieties, ministers, social workers, nurses, psychologists, GPs and psychiatrists, and there are many different community support groups and self-help groups that are also beneficial in some people. As I said before, counselling is always important even if it is only from a point of view of a preventing a futuretly amazed at the way I see people's thought processes change, their feelings come back to normal and I see them take charge of their lives and to solve their problems and grow, even without specific input into these areas.
What are the most significant things ordinary people can do for each other when they are depressed?
There are many things that we can do - affirming them that they have taken the right step in seeking help, giving them basic explanations in understanding depression so that they don't feel so much of a failure, reassuring them that they will get better, meeting them at their point of need, loving them, listening to them, giving them hope for the future. These things are all important but the most basic and fundamental thing in helping another person is to simply "be there". We so often feel useless if we are not saying anything, but being there in silence is the most potent thing of all. We frequently disparage Job’s friends but they really were great friends. How long do you stay with a person in silence before you open your mouth? Job's friends sat with him 7 days and 7 nights without speaking, they put ash on their head and clothed themselves in sackcloth as an identification with Job's sufferings. Finally one of them said "who can keep from speaking?". Well I think they did pretty well, but when they did speak, from then on they "blew it" and accused Job of having sinned against God because "God punishes those who sin against him and blesses those who obey him". They were wrong. We too have to be careful of that "irresistible urge to speak". If in doubt say nothing, and we can feel very strong about simply being with a person. It may only be 5 minutes one day and 10 minutes the next day but it is very powerful.
At least the Christian sufferer can have hope and know that God hasn't forgotten him?
But even that can disappear, once again Spurgeon says after reminding himself that God never placed Joseph in a pit without raising him up again "alas, when in deep depression the mind forgets all of this and is only conscious of its unutterable misery..."
Aren't antidepressants addictive?
No. Antidepressants are not related to the tranquilliser or anxiolytic group of medications, nor are they related to the sleeping pill class of agent (hypnotics). Antidepressants actually raise the levels of the neurotransmitter substances in the brain and actually do make a person better - they don't just make them feel better. Antidepressants are not mood elevators in non-depressed people - if they had been, they would have found their way into the drug subculture 30 years ago.
How true is the charge that antidepressants change personality?
Totally untrue. Antidepressants when given to a person in depression, allow their real personality to emerge. In some instances this has not been apparent for some 10 or 15 or 20 years and so it seems like they have a new personality.
I have heard it said that antidepressants shouldn't be given to a person in grief, that it can hinder the recovery process. Would you care to comment on this?
Yes. Antidepressants are not indicated for an uncomplicated grief reaction, but where this is moving into depression then antidepressants are appropriate. Indeed when a person is depressed, giving them antidepressants will actually facilitate the counselling of their grief because of the return of normal emotional responses. So antidepressants do not hinder counselling. Medication also enhances the power of the patient to be able to constructively handle their situation.
Are there different kinds of antidepressants?
Yes, there are the older kinds of medication which are quite effective but have nuisance type side-effects such as dry mouth and constipation but have some advantage in that they are sometimes sedating and therefore help sleep and may also help to reduce anxiety. They can however be hazardous in people with heart problems and certainly they are hazardous in overdose situations. The newer antidepressants do not have a lot of these side-effects and are much safer in overdose. I need to say that the nuisance side-effects can frequently be handled by an alteration in dosage, and tend to alleviate in time in any case. There are also the medications that inhibit mono-amine oxidase - an enzyme that breaks down the neurotransmitters - therefore resulting in an increase of neurotransmitter levels. We had to be very careful with the older agents of this class because of their interaction with dietary factors but the new one which is available does not have these restrictions.
Tell us what you think about cognitive therapy?
Cognitive therapy is that therapy which is based on what we feel being secondary to the way in which we think and therefore seeking to change our thought patterns. As I've said before, if a person is not too severely depressed, then this kind of therapy is quite useful, but if a person is significantly depressed then I believe cognitive therapy to be a very inefficient way of dealing with the situation and possibly making the person feel even more of a failure. I find it intensely fascinating that a person's wrong way of thinking and wrong way of seeing the world changes spontaneously with antidepressants. I am quite convinced that our cognition - or way of thinking - is dependent on our chemistry. My way of looking at the counselling issue is to compare depression with a person who walks along a rough road and breaks a leg. The counsellor gets the person to tell how rough the road was, how much the fracture hurts, how to negotiate the rough patches in future and ignores the broken leg. The doctor on the other hand treats their pain, heals the leg and enables them to run across the bumps, but also how to be careful in future and how to avoid harm. I suppose if the person merely has a muscle strain then the counselling scenario is appropriate, but a broken leg requires definite medical intervention, and so does significant depression. However, I believe counselling to be extremely important in the prevention of a recurrence and also preventive for specific times of life, for instance hysterectomy, mastectomy, retirement.
Where does spiritual counselling come into all this?
I believe that spiritual counselling is not so much directed at the cause (but I would like to come back to that) as much as at helping us to know the value of and tapping our resources. Our resources in God are vast. He is Supreme, He is the King, He knows and understands all about us, He comforts and invites and He is always with us, despite what it looks like. One important area where spiritual counselling should be involved at the cause is in the forgiveness of others, but this can never be applied as a pat answer. Before forgiveness can be extended there needs to be felt appropriate anger, anguish, agony and grief. People of faith need reassurance that they have not failed God, that their depression is not their fault, that their guilt is not real but a result of their depression, and that many people of faith have been likewise affected. We also need to understand that faith is not a guarantee that we will not suffer, but it is a guarantee that God is still with us, will bring us through, and will turn even this to good.
Some people say that getting better is dependent on our rejoicing - what do you think about this?
I agree that rejoicing in the Lord is very important but the question that needs to be asked is "does rejoicing make a broken leg get better more quickly?" Maybe it does slightly but it is certainly not a magic formula and we are still responsible for doing what we can about the problem whether it's a broken leg or depression. Spurgeon says there is a "need for felt affliction" and asks where would be the benefit if God just simply picked us up and took us across every stream. We also need to understand the purpose of suffering - Romans 8 tells us that all creation groans to be released from suffering and "even we Christians groan likewise to be released". Peter tells us that suffering is refining, Psalm 126 tells us that those who sow with tears will reap with songs of joy and Paul tells us that "these light and momentary troubles are achieving for us a glory that far outweighs them all" and then exhorts us to fix our eyes on what is unseen rather than what is seen.
These are mysteries that we do not yet fully understand but it is interesting what John Newton said of William Cowper after his death, Cowper having been depressed on and off for most of his life "the Lord's thoughts and ways are so much above ours that it becomes us rather to lie in the dust in adoration and praise than to enquire presumptuously into the grounds of his proceedings".
Is it possible to have joy in the middle of depression?
Yes, if we accurately define that joy - as Amy Carmichael says "Joy is not jolliness; joy is not gush, but joy is acquiescence to God's will". My definition of joy is "I'd rather be here with You my Lord and my God in the valley, than anywhere else without You" which is a free paraphrase of Psalm 84 "I'd rather be a door keeper in the temple of my God than dwell in the palaces of the wicked".
What can be done to prevent a recurrence of depression?
It is important to answer this question in the context that maybe nothing can be done. This applies to the person with the strong inbuilt predisposition when the depression may come on without the presence of any provoking factor. However, even in this situation it is possible to minimise the severity of the episode by recognising its early stages - and perhaps having others to aid in that recognition - with appropriate seeking of help and managing medication as necessary at a relatively early time. It also means being aware of times of increased vulnerability and, in particular at such times, to practise good stress control and to modify one's own expectations of self and also the expectations of others, to avoid being "locked in" or "trapped". Good stress control involves many things including giving permission to feel appropriate feelings that we have because we are created in the image of God; the avoidance of conflict where possible - or at least dealing with it in a way that is not destructive - and good self-care including legitimate escapes. These and many other aspects of stress control are covered in much more detail in my paper on "Coping and Growing through Stress".
Do you have any comment about the families of those who suffer from depression?
Yes. The pressures on family members can be enormous, particularly if the depression is prolonged. Children can suffer because of the lack of love expressed to them, the negative thinking of the parent as well as negativity and irritability being directly expressed to the children. Many spouses are not understanding of the nature of depression and so education and reassurance are necessary. But even when the spouse has a very good understanding of the nature of the problem, it is still hard (? impossible) not to have some degree of resentment building up over a period of time when it is seen that certain actions could easily have been taken to perhaps help the depression and these actions are not taken. Spouses need an incredible amount of support.
But then, I have also seen the situation many times when a Christian sufferer finally starts to understand the chemical nature of depression and accepts the concept of antidepressant therapy, and the spouse - usually a husband - is still intolerant of the use of medications and sometimes refuses to allow their use. Even if he gives permission for their use, the implication is still there that a "little more faith" would have prevented the episode from occurring. This then brings us back to the issue of Christian responsibility, self-care and stewardship. I have also explored this in more detail in my paper on "Coping and Growing through Stress".
MBBS FRACGP DObstRCOG