Living with Depression
Speaking to Texas Baptists, not for them.
Depression is a still commonly perceived as a character flaw–as a sign of emotional weakness. Quite to the contrary, depression is a disease, a serious mood disorder which compromises the depressed person’s ability to function in everyday life.
How long, O Lord? Will you forget me forever? How long will you hide your face from me? How long must I bear pain in my soul, and have sorrow in my heart all the day long? Psalm 13:1-2
Depression is one of the most common and most serious mental health problems afflicting people today. Depression is a still commonly perceived as a character flaw–as a sign of emotional weakness. Quite to the contrary, depression is a disease, a serious mood disorder which compromises the depressed person’s ability to function in everyday life.
Because depression is a disease, Christians should not regard persons who experience depression as faithless, any more than victims of other diseases are so regarded. Depression does affect depressed persons’ spirituality, not unlike other serious illnesses affect spirituality. When we get sick, we sometimes vent our frustrations on God. We ask, “Why did God cause this condition or allow it to happen?” “Why is God angry with me?” “Does God really love me?” Eventually, we may be able to ask, “How can I move closer to God through this illness?” Because they are infected by negative thinking, depressed persons find it especially difficult to see their illness as opportunity for spiritual growth. Their loved ones often grow impatient with the self-defeating inertia and hopelessness which characterizes depression. The first step toward healing and ministry to the afflicted is understanding.
What Is Depression?
Everyone experiences unhappiness, often as a result of a setback or a loss. The painful feelings that follow these events are usually appropriate, necessary, and temporary. When these feelings persist and chronically impair daily life, depression may be at work. Severity, duration, and the presence of other symptoms are factors that distinguish normal sadness from a depressive disorder.
Depression is classified as a mood disorder which occurs in three primary forms: major depression, chronic and usually milder depression (dysthymia), and atypical depression. Other important types of depression are premenstrual dysphoric disorder (PDD), seasonal affective disorder (SAD), and bipolar disorder (manic-depressive illness), which is characterized by periods of depression alternating with episodes of excessive energy and activity.
Major depression is identified by five or more of the symptoms listed below when these occur over a period of at least two weeks and as a change from previous behavior or mood:
- Depressed mood and loss of interest on most days for most of each day. (This symptom is always present in major depression. Irritability may be prominent.)
- Noticeable loss of pleasure most of the time.
- Significant increase or decrease in appetite, and/or weight.
- Insomnia or excessive sleepiness nearly every day.
- Feelings of agitation or a sense of intense slowness.
- Loss of energy and a daily sense of tiredness. Sense of guilt and worthlessness nearly all the time.
- Inability to concentrate occurring nearly every day.
- Recurrent thoughts of death or suicide.
In major depression the symptoms listed above do not follow or accompany manic episodes (such as in bipolar or other disorders). These symptoms impair work, school, and important relationships, including family relationships. Symptoms of depression in children may be accompanied by physical symptoms such as headaches and stomach aches.
Chronic Depression (Dysthymia)
Chronic depression, or dysthymia, is characterized by many of the same symptoms that occur in major depression, but the symptoms are less intense and last much longer–at least two years. The symptoms of chronic depression have been described as a “veil of sadness.” Typically, there are no suicidal thoughts or disturbances in appetite or sexual interest. Possibly because of the duration of the symptoms, patients who suffer from chronic depression do not exhibit marked changes in mood or in daily functioning. They have low energy, a general negativity, and a sense of dissatisfaction and hopelessness. They may also suffer from episodes of major depression.
People with atypical depression generally overeat, oversleep, have a general sense of heaviness, and experience strong feelings of rejection.
Seasonal Affective Disorder
Seasonal affective disorder (SAD) is characterized by episodes of depression during fall or winter, which abate in the spring or summer and which may be replaced by a manic phase. Other symptoms include fatigue, a tendency to overeat, particularly carbohydrates, and to oversleep in winter. Some individuals with SAD have the more common depressive symptoms of undereating and sleeplessness.
Premenstrual Dysphoric Disorder
The syndrome of severe depression, irritability, and tension before menstruation is known as premenstrual dysphoric disorder (PDD). It affects an estimated three to five percent of women in their reproductive years. Persons with PDD experience at least five symptoms of major depression which occur during most menstrual cycles, with symptoms worsening a week or so before the menstrual period and resolving afterward.
The symptoms of grief and depression are so similar that it often difficult to distinguish the two. Grief is considered to be a healthy and important emotional response to a loss and has a limited duration, usually lasting between three and six months. The grieving person endures a succession of emotions that includes shock and denial, loneliness, despair, social alienation, and anger. The recovery period following bereavement, during which the individual becomes reinvolved with life, can last about as long as the period of grief. Normal grief can turn into clinical depression when bereaved persons do not process through their grief to recovery.
Who Becomes Depressed?
Depression is an illness that can afflict anyone, regardless of age, race, or gender. While estimates speculate that about seventeen million Americans develop depression each year, the actual incidence may be much higher since many people fail to seek help.
Women experience significantly higher rates of depression than men. All women are at risk for emotional swings during extreme hormonal shifts, often experienced during the days before menstruation, the postpartum period after delivering a baby, and around menopause. Married women with children have a higher risk for depression than do married childless women, single women, or single or married men. Grandmothers who care for their grandchildren have a very high risk for depression. The stresses and challenges involved in caring for children and the perceived low status and isolation accompanying the role of housewife may contribute to the heightened incidence of depression in women.
A family history of mental illness, especially the mood disorders, such as bipolar disorder, major depression, and chronic depression, appears to predispose a patient to develop depression. Often a combination of genetic, biologic, and environmental factors are at work. Children of depressed parents are at high risk for depression and other emotional disorders.
How Depression Impacts Everyday Life
While all of us share these experiences and feelings from time to time, depressed persons live them as routine:
- Experiencing hope, joy, and happiness is rare or nonexistent.
- Crying, either at nothing or something that normally would be insignificant, is all too frequent.
- Getting up in the morning requires a lot of effort.
- Carrying on a normal conversation is a struggle.
- Smiling feels stiff and awkward.
- A sense of isolation acts as a barrier between you and the larger world.
- It’s easy to forget and difficult to concentrate. Worry and anxiety overwhelm good sense.
- The senses seem dulled—food tastes bland, music is uninspiring, and beauty is invisible.
- Negative thinking rules—the glass is always half empty, things are never getting better life always lets you down.
- Your space is a mess.
- You avoid even friends whose company you normally enjoy.
- Every initiative requires great effort.
- You put off things that need to be done.
- It’s been a while since you really laughed.
- You don’t feel like you can handle your job anymore, even though nothing has changed. You wake up in the middle of the night and can’t go back to sleep.
- During the day you sleep a lot to escape from life.
- It takes you a whole weekend to do chores that used to only occupy a morning.
- You’ve lost interest in sex or even physical affection.
How Serious Is Depression?
In addition to the primary effects of adversely affecting the patient’s ability to function in all areas of life, depression causes other significant harms. Depression plays a major role in most suicides. Depression also exacerbates existing medical conditions and may even predispose people to disease. Studies indicate that depression may have adverse effects on the immune system, blood clotting, blood pressure, blood vessels, and heart rhythms. The health of elderly people who are depressed when admitted to the hospital is likely to decline, and they are less likely to fare as well during recovery as are elderly patients who are not depressed. Many studies have shown strong associations between depression and an increase in the incidence and severity of strokes and heart attacks.
Some studies have linked past and current major depression with bone loss in women and impotence in men. Severely depressed people are at high risk for alcoholism, smoking, and other forms of substance abuse.
What Causes Depression?
Traumatic events, such as a sudden loss of a loved one, abuse, or even natural events such as earthquakes, can cause severe immediate or delayed depression. Many people are able to cope with these losses and traumas and eventually move beyond them without becoming chronically depressed. People who develop acute or chronic depression after loss may have predisposing factors that make them more vulnerable to depression.
Neurotransmitters. Neurologic factors appear to play a primary role in major depressive episodes. Depression is linked to abnormalities in neurotransmitter levels (chemical messengers) in the brain most importantly, serotonin, acetylcholine, and a group of neurotransmitters known as catecholamines (dopamine, norepinephrine, and epinephrine). The degree to which these chemical messengers are disturbed may be determined by other factors such as light or genetic susceptibility. Researchers have linked depression to a defect in a gene which regulates serotonin.
Hormones. The role of hormones in depression is not clear, but female hormones play roles in premenstrual dysphoria, postpartum depression, and SAD. These forms of depression recede or stop after menopause. Researchers are looking at certain steroidal hormones in the brain that regulate progesterone and activity in areas of the brain that control reproductive hormones. Low levels of these steroids may play a role in depression.
Changes in Brain Structure. Brain scans have shown that a particular area of the prefrontal lobe which influences emotional control and regulates serotonin production is less active and considerably smaller in elderly depressed people than in those who do not suffer from depression.
Medications. Many drugs, such as beta-blockers, corticosteroids, antihistamines, analgesics, and anti-parkinsonism medications, can cause depression. Withdrawal from many medications can also cause depression.
Sometimes the level of dysfunction may be serious enough to warrant hospitalization in order to provide protection from further deterioration or self-harm. Most cases of depression can be treated in an office setting by psychiatrists or other psychotherapists. Patients can locate a mental health professional by asking their doctor for a referral or contacting one of the mental health organizations.
The patient should describe symptoms briefly over the phone to any prospective therapist to get a sense of whether he or she will suit the patient’s needs. An advanced degree does not necessarily guarantee quality therapy. Since depressed persons’ confidence in their therapists is a critical component in recovery, patients should be persistent in seeking the right therapists for their needs.
Most adult patients with major or chronic depression are given a trial period of an antidepressant. Some form of psychotherapy is also usually recommended. The combination of antidepressants and therapy appears to be more effective than either treatment alone for most patients, possibly because patients are more likely to take their medications regularly when they are also undergoing therapy.
Helping Depressed Persons
Be present. This means not responding in kind to depressed friends’ and family members’ irritability and not giving in to their self-imposed isolation. Continue to speak, visit, phone, and write even though the friend or family member invests little in the communication. If they are willing to do so, allow depressed persons to share their feelings. While respecting space, boundaries, and privacy, be persistent in your presence and support.
Listen and encourage. Listen to expressions of feelings without invalidating the feelings. Because depression is characterized by negative thinking and feeling, the depressed person’s feelings may be based on a sense of reality which you do not share. While it can be helpful to share your own sense of reality with the friend or family member, it is not helpful to criticize their feelings, even though you think these feelings are not based on fact, are overly pessimistic, and wrongly held. Honestly sharing your own feelings and perceptions in a spirit of love can serve to mitigate the depressed person’s negativity. Dismissing or attacking depressed persons’ communications will make them reluctant to share feelings with you in the future and severely limit your opportunity to minister to them.
Be patient. Depression is a chronic condition. Even when your depressed loved one is receiving helpful drug and counseling therapies, depressive thinking, feeling, and acting tends to undercut therapeutic strategies. Patients are, for example, usually encouraged to exercise, but depressed persons are even more reluctant to exercise than other patients who receive this advice from their doctors. Many therapeutic strategies, in fact, run counter to depressive thinking and acting by design. Depressed patients are told not to stay in bed, to get out of the house with friends and loved ones, and to engage themselves in doable, constructive activities to help change the patterns of depressive thinking and acting. We should not be surprised when patients fail to follow up these suggestions.
Be positive. Encouraging depressed loved ones to act on the advice of their therapists is most constructive when it is positively received. Offering to exercise with your loved one, to take them to lunch, and to collaborate with them on how to remember their medications are more effective than repeated verbal reminders.
Allow God to minister through you. Loving unconditionally, practicing patience, being present over the long term, and returning negativity with positivity are Christian virtues made possible by the Holy Spirit. Only God can grant the strength and resources which enable us to see past the distorted appearances of depression to the reality of the Reign of God in Christ.
Helping Yourself through Depression
Ask for and get help. Depression is a serious disease which requires serious, professional treatment. The good news is that depression is successfully treated with medication and psychotherapy. The bad news is that most depressed people don’t get help. We shouldn’t think of depression as a minor condition which will go away whether treated or not. Depression can be chronic, progressive, and fatal. Depression is always destructive. If you believe that you may be depressed, talk to your doctor, see a counselor, tell a trusted friend or family member.
Be patient with yourself. Remember that depressive symptoms work against all of the good help you may receive. You may not be able to act on every worthwhile suggestion. Get support for following through on therapies, especially with taking medication as prescribed.
Get involved in a regular exercise program. Choose activities which are relatively enjoyable and exercise as often as possible. Exercise helps in many ways: getting you out of the house, improving sleeping and eating patterns, releasing endorphins in the brain which act mood elevators.
Eat nutritious, well-balanced meals. You may not want to eat anything, or you may have an urge to overeat. Avoid extremes and follow a regular eating schedule.
Engage in enjoyable pastimes: reading, listening to music, crafts, sports, and other hobbies. Keep a journal. No one ever has to read it, but the act of writing down your thoughts can be healing. After a while, you can read your notes from weeks earlier to see that things do actually begin to improve.
Stay involved. You may want to hide, but push yourself to stay involved with people and with church. Evaluate other groups you attend. Only go to the ones that give you a lift and move you forward. Nudge yourself to go to lunch with a friend at least once a week, for example.
Be open. Do not waste a lot of emotional energy trying to keep your depression a secret. You don’t have to announce your issues in the newspaper, but don’t isolate yourself. More people have experienced depression than you might think. Through your openness others can identify with you and be helped by the witness of Christ in your life.
Be persistent. Depression habituates against all of the above suggestions. Following through is often a matter of pressing through negative feelings toward positive actions. With the help of medication, therapy, support of friends and loved ones, and the presence of God, we persist toward healing.
Trust God. Depression makes you feel that God is absent, but the clear assurance of scripture is that God is present to the most desperate feelings. Continue in prayer and worship, and you will find God in the darkness.
Save me, 0 God,
for the waters
have come up to my neck;
I sink in deep mire,
where there is no foothold;
I have come into deep waters,
and the flood sweeps over me.
I am wearied with my crying;
my throat is parched.
My eyes grow dim
with waiting for my God.
“Living with Depression” is one of fourteen articles in the Getting Well: Christian Perspectives on Health, Sickness, and Ministry series. Getting Well deals with major health and biomedical issues.
Christian Life Commission