Unless you live in a bubble, is it not a universal human experience to face adversity? The scriptures testify to it certainty, especially for “everyone who wants to live a godly life in Christ Jesus” (2 Tim. 3:12 NIV). So what happens when we encounter trials?
“I found myself in trouble and went looking for my Lord; my life was an open wound that wouldn’t heal. When friends said, ‘Everything will turn out all right,’ I didn’t believe a word they said” (Psalm 77:2 The Message).
So when people are “looking for the Lord” in their times of trouble, shouldn’t we be compelled to reach out with the gospel in word and deed, just like the Apostle Paul did in the New Testament?
God, the human body, and depression
The body is a finely tuned homeostatic mechanism that not only reflects intelligent design, but also reveals a compassionate God who equipped it with systems to respond to every life contingency. As a physician, I marvel at both the body’s complexity and its ability to adapt (sometimes in an instant) to change in our circumstances. The brain’s capacity to mediate emotion in the process of such adaptation is a good example of how fearfully and wonderfully we’re made.
One could think of depression as the body’s “alarm system.” Any alarm system is designed to warn us of some real and/or imminent danger. Imagine, for instance, that you went to bed one night, and an hour later you were suddenly awakened by the deafening scream of your fire alarm. You race down the hall, hustle your children out of the house to safety, and then watch as your home burns to the ground. Wouldn’t you be overwhelmingly grateful that you had a fire alarm that worked the way it was designed?
Like any good alarm system, the symptoms of depression are designed by God to get our attention and warn us of danger to our spiritual, psychological, and physical lives. Therefore, appropriate analysis and therapeutic intervention must address all three of these areas in order to maximize full restoration and healing.
Depression and the brain
Since my training is in the biological sciences, I would like to explain as clearly as I can the essential role of neurotransmitters for the normal functioning of the human brain and emotions. Christians and non-believers alike are subject to the way God has created our bodies to function, just as we are all subject to gravity.
Understanding Depression and the Role of Medication
One of the hardest questions to answer is “When should medical treatment be considered? When has the line been crossed from human emotion to medical disorder?” Dr. Stephen Stahl, M.D., one of the world’s leading authorities on the functions of brain chemistry, has said:
Depression is an emotion that is universally experienced by virtually everyone at some time in life. Distinguishing the “normal” emotion of depression from an illness requiring medical treatment is often problematic for those who are not trained in the mental health sciences. Stigma and misinformation in our culture create the widespread, popular misconception that...depression is...a deficiency of character which can be overcome with effort. For example, a survey in the early 1990s of the general population revealed that 71% thought that mental illness was due to emotional weakness; 65% thought it was caused by bad parenting; 45% thought it was the victim’s fault and could be willed away; 43% thought that mental illness was incurable; 35% thought it was the consequence of sinful behavior; and only 10% thought it had a biological basis or involved the brain.
There is abundant evidence of a complex mind-body interaction. This interaction, interestingly enough, makes it challenging to sort out the origins of change even at the physiological level. We know, for example, that emotional and behavioral changes made in therapy—changes that involve making different choices in life—can prompt changes in brain chemistry just as much as changes in brain chemistry can prompt corresponding changes in emotions and behavior. In other words, psychological causes and brain chemistry are intricately linked to one another.
The average person has moods that, from time to time or for a season, may fluctuate slightly higher or lower than normal. It’s when these moods fluctuate greatly or remain oddly high or low for extended periods that a person might begin to consider depression as the cause. Depression is really part of a spectrum including not only low or depressed moods but also elevated or "manic" moods. The majority of depression is considered "unipolar," which means sufferers only experience periods of depressed mood. But others experience times of being very "up" even to the point of irrational euphoria and significant impulsivity. The treatment for people who have "up" episodes in addition to their depression (called “bipolar”) is different than people who only have depressed or “down” episodes. “Mania” is what physicians call this abnormal state of mood where the euphoria creates significant problems including impulsivity, agitation, irritability, racing thoughts, lack of sleep, and reckless spending.
Differentiating between people who only have a depressed mood versus people who can fluctuate from either a depressed mood to a euphoric mood is very important before starting the treatment process. People who only have unipolar depression (also called major depressive disorder (MDD)) are often treated with antidepressants to lift the mood from depressed to normal. People who have various forms of bipolar depression are typically treated with a "mood stabilizer" to keep them from becoming euphoric, and then an antidepressant medication is added to keep them from becoming depressed again during the next mood swing.
What causes depression?
The symptoms of depression should serve as an alarm system to begin an investigation of the following areas in a person’s life:
A. Genetic factors
B. Environmental factors affecting psychological and spiritual dynamics
C. Other medical issues
Every one of these factors can adversely affect the brain and how it functions at the molecular or hormonal level, causing a deficiency of specific chemicals called neurotransmitters. Neurotransmitters are hormones that “hand off” or “transmit” a signal from one nerve cell to another. In order to function normally, you need to have a full reservoir or “tank” of these hormones in the nerve cell ready to be released and thus communicate the bioelectrical “message” to the next nerve. For our purposes, depression is nearly synonymous with a depletion of these neurotransmitter hormones, much like running out of hot water while taking a shower. If the brain does not have an adequate amount of these hormones, the body’s nerve-messages don’t get delivered, and the body begins to malfunction. Some people inherit a tendency to have low hormone levels because their nerve cells either break down more of the hormones than other people’s do, or their body simply does not make enough of them.
In addition, when people experience significant loss, like a divorce or death of a child, or experience physical or emotional burnout or a number of other factors that create severe stress, the brain works overtime in anticipation of the worst possible situation. In this “full combat alert” state, the mind plays a “what-if” game, expending energy trying to anticipate the worst possible scenario and making early preparation for all of the possibilities. This reaction of the body to these strongly disturbing situations can deplete the body’s neurotransmitters, again increasing a person’s risk for depression.
Medication can lend assistance in all these situations by regulating the level of neurotransmitter hormones, allowing the “message” to be sent from one nerve to the next in a more normal fashion (like having instant hot water for your shower). A common misconception about antidepressant therapy is that antidepressants are habit-forming or force a dependency upon the user, placing them in “bondage” at the hands of the physician or leaving them vulnerable to spiritual manipulation.
Understanding Depression and the Role of Medication
However, antidepressant medications are not addicting like Valium, narcotics or cocaine; these directly stimulate the nerves provide an altered state of consciousness or euphoria. Antidepressants work to regulate the process by which nerves deliver their messages from the brain to the body; consequently, they ARE NOT habit-forming, nor do they manipulate a person’s thoughts or values. It is important to understand this, as misinformation and stigmas in this regard can prevent some from seeking vital medical treatment or even supporting the treatment of others. Many patients use antidepressant medication for a season, only to stop taking it once the patient and his/her health-care team decide it is appropriate and safe to do so. As with any medication, a patient should only stop an antidepressant treatment regimen under the advice of the prescribing doctor.
Some of the confusion as to why certain people struggle with adversity more than others can be answered in the concept of individual variability. Each person is unique, and so physicians must individually assess the potential for significant depression. Some people can go through divorce, lose their job and seem to manage just fine, while others seem to collapse into depression if they get disappointed by not getting a new car. Just like the color of your eyes and hair, there is individual variability in your body’s ability to manufacture or metabolize (break down) the brain’s hormones. If you inherited a tendency to have low levels of these hormones, you will be more vulnerable to experiencing a chain of events that leads to depletion and, therefore, it is more likely that medication can provide relief.
Can significant depletion be caused by long-term emotional stress? Yes. Can significant depletion be caused by an environmental stressor? Yes. Can significant depletion be caused by family genetics? Yes. Therefore, how should the issue of using medications be viewed? As a necessary evil? As something to avoid at all costs? Is medication a panacea that should be given to everyone?
The good news is that 90 percent of people who need it can be helped significantly with their depression once they have found a suitable medication. With this help, they are much more amenable to the work of psychotherapy and open to receive spiritual guidance, which is more likely to bring about lasting change.
When is depression severe enough to consider medication?
Physicians rely on the specific DSM-IV (the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders) criteria in evaluating the following symptoms to make the diagnosis of major depressive disorder (MDD). If a person has at least four of the following symptoms nearly every day for at least two weeks, you meet the criteria for depression:
(1) Depressed mood and feeling of hopelessness;
(2) Loss of interest in daily activities and pleasures;
(3) Inappropriate guilt and feelings of worthlessness;
(4) Appetite changes causing either weight gain or weight loss;
(5) Sleep problems, especially early morning awakening;
(6) Agitation and restlessness;
(7) Concentration difficulties and inability to make decisions;
(8) Fatigue and lack of energy;
(9) Recurring thoughts of suicide, in which life seems empty and not worth living;
(10) Irritability and feeling “stressed out.”
A qualified physician will review the preceding list of symptoms and the potential risk factors on the basis of your genetics, environmental circumstances, and other medical conditions, medications, and history of substance use and abuse. Self-assessment tools like the Beck, Zung, or PHQ may also be used in an attempt to quantify the symptoms, confirm the diagnosis and monitor improvement with therapy.
Don’t antidepressants increase your risk of suicide?
In 2004, the FDA issued a “black box” warning to physicians that antidepressant may cause increased suicidal thinking in young people less than 19 years of age. As a result, physicians became more cautious about prescribing antidepressants, and many people became afraid to start taking them. In 2008, the American Journal of Psychiatry published an article that showed that as a result of the FDA warning, deaths from suicides actually increased 14%. Thomas Insel of the National Institute of Mental Health said, “We may have inadvertently created a problem by putting a ‘black box’ warning on medications that were useful. If the drugs were doing more harm than good, then the reduction in prescription rates should mean the risk of suicide should go way down, and it hasn’t gone down at all—it has gone up.” He concludes by saying, “If I had a child with depression, I would go after the best treatment but also provide close monitoring.”
Gregory M. Knopf, M.D. has been a family practice physician for 30 years and is the founder and medical director of the Gresham-Troutdale Family Medical Center. He is a graduate and Clinical Associate Professor of Family Medicine at Oregon Health Sciences University. Dr. Knopf has a particular interest in the treatment of anxiety and depression. He speaks across the country on the topic, principally for professional audiences, and for the general public and churches as well. He is the co-author of Light on the Fringe: Finding Hope in the Darkness of Depression with Gary Lovejoy, Ph.D. and also wroteA Christian’s Guide to Depression and Antidepressants: Clearing Up the Confusion.
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