PROBABLY the most common serious mental dis order that clergymen are regularly called upon to help their parishioners cope with is the problem of depression. It has been estimated that it affects, in serious degree, at least one person in eight at some time in his life span.
The Old Testament describes this ancient malady, and it was also familiar to the early Greek writers. Hippocrates ascribed the condition to an accumulation in the body of excessive amounts of black bile, and from the Greek for "black bile" comes our term "melancholia." Modern science has come a long way since then, although much remains to be done in the way of understanding and effectively treating the physical and psychological components of this complex condition.
The minister needs to understand something of the nature of depression, what factors predispose to it, and what factors tend to prevent its development. He needs to know the signs and symptoms that would lead him to suspect its presence in individual members of his congregation. He needs guidelines in deciding when to refer his parishioners to a physician. He needs to know what is reason able to expect from medical treatment, and what is not reasonable to expect.
Above all, the pastor needs to know how to effectively mediate a truly Christian ministry to those depressed persons whom he does not refer. How can he know whether his religious attitude and approach will be truly healing, or whether his efforts will only make the person worse? Unfortunately, the latter often occurs. This makes it doubly important that the pastor know what not to do. The ancient in junction "Do no harm!" applies not only to the physician but also, and equally, to his co-worker, the minister.
Am I saying, then, that the minister's role in depressed cases is merely to stand back out of harm's way and let the physician or the psychiatrist take over? In a few cases, yes; but in the vast majority, no, by no means!
Medical and spiritual treatment for the depressed person is seldom an either/or situation. Depression is a malady of the whole man. The more severe grades of depression will call for attention to physical and psychological and spiritual factors. Although I shall stress the importance of the pastor's knowing when to refer and what to expect from medical treatment so that he can intelligently cooperate with that treatment, I hope to make plain, none the less, my conviction that the keys for liberating the depression-bound person from the deepest levels of his dungeon of despair lie in the hands, not primarily of the doctor, but of the Christian minister.
Symptoms of Depression
Many severely depressed persons will be easily recognized as being depressed. Others will carefully conceal their disease. Some may not even be aware that they are depressed, for acknowledgment, even to themselves, is simply too painful. To a careful observer, and often also to the person himself, certain changes will be evident in one or more areas of the personality. Characteristic are changes in the emotional sphere. Most often there is a pervading sense of sadness and gloom. There may be frequent crying spells. The person may not be conscious of any reason for such crying.
Most normal people commonly experience mild mood swings. The truly depressed person, however, is not down one minute and up the next, nor even down one day and up the next day. There is an on going current of depressed mood that is but little affected by what normally would be bright spots in the day. To the depressed person there are no bright spots---everything is gray, blue, or black.
Usually these changes in the emotional sphere are accompanied by a corresponding alteration in motivation. The person finds himself dropping off those activities that formerly he enjoyed doing. His spontaneity and enthusiasm wane. Nothing really interests him. It is hard for him to get up in the morning. He has to drive himself to keep going. In severer cases he may develop what amounts to a paralysis of the will he cannot even force himself to do things.
This depressed motivational state is probably the commonest cause of generalized fatigue. The person wonders, "Why am I so dreadfully tired all of the time?" Often he concludes that there must be some thing physically wrong with him; so off he goes to visit his physician. His doctor will feel obliged to perform a battery of costly and more-or-less necessary tests. Exceptionally, a genuine "physical" cause will be found. (Or will be present and not be found!) But in the great majority of such cases the real cause of the weariness is psychological. The person is tired of his burden of depression. Often he is tired of life itself. He may or may not realize that, in a sense, he is longing for some escape into sleep, or into oblivion.
In addition to these changes in the emotional and the motivational spheres, the depressed person often begins to show subtle, or not so subtle, changes in the intellectual sphere. His thinking, in certain areas, tends to be distorted. It may become frankly delusional. His self-esteem is unrealistically low. His shortcomings and failures become magnified in his mind to where they completely over shadow and obscure anything of a positive nature. Characteristically he berates himself by thinking or saying, "I'm no good. I'm bad. I'm hopeless."
Often this distorted thinking takes on religious coloring, and in such cases the person may become obsessed with the idea that he has sinned against the Holy Spirit. He may cling tightly to such delusions as "God doesn't love me anymore. I'm beyond pardon." He views his fall from grace with such finality that "all the king's horses and all the king's men" could not convince him otherwise.
In areas other than those touching on his own fancied badness and hopelessness, the depressed per son's thinking may be quite rational and undistorted, although in all areas his thinking may be slowed down. The severely depressed person characteristically thinks slowly, talks slowly, and moves slowly. Technically, this triad is termed psychomotor retardation, i.e., a slowing down of mind and body. In extreme cases he may scarcely be able to speak at all.
Last in our grouping of the common symptoms of depression are changes in bodily functions. Although mentioned last, they are often the first clues to an early recognition of depression. The person may develop various bodily aches and pains, which tend to reinforce his suspicion that he must be suffering from some physical disease. Often there are changes in appetite and body weight, usually downward, but sometimes only upward. There may be a dwindling interest and ability in sexual matters, or contrariwise, there may be a heightened lust for irregular activities.
What is probably the most important and the most frequently present early sign of depression is alteration in the person's normal sleep pattern. Some times there seems to be an increased requirement. Much more characteristic, however, is insomnia, especially of the early-awakening variety. Often the depressed person will awaken at two, three, or four o'clock in the morning and lie awake for hours, unable to get back to sleep, perhaps until just before getting-up time. Less often, there is difficulty in falling asleep, or simply fitful slumber, frequently disturbed by bad dreams. There are, of course, many causes for insomnia other than depression; i.e., by no means everyone who suffers from insomnia has depression; but the fact remains that most severely depressed persons will have insomnia. Often it is the very earliest sign.
The presence of depression, then, can be suspected from the above changes in the emotional, the motivational, and the thinking spheres, or in the bodily functions. We have not directly mentioned suicidal thoughts, statements, or attempts, any of which naturally conveys the probability that the person is depressed. It should be remembered, however, that not all suicidal persons are depressed, although most of them are. Neither are all depressed persons suicidal, fortunately.
Not only should a minister be knowledgeable in how to suspect the presence of depression, but also he should know something about what to expect as to the natural course of the disease. The following points should be helpful.
Barring suicide, almost all depressed persons eventually will recover from any given episode of depression, even without receiving any treatment at all. The catch is that this "eventually" is usually a long time, seldom less than a few months, often up to a year or more, and it may be even longer. Again, this is without treatment. With the benefit of modern treatment, on the other hand, even severe episodes of depression can usually be terminated within approximately six weeks, instead of an aver age of eight to ten months without treatment.
A person who has had one attack of depression is more vulnerable to having another attack at some future time than if he had never experienced a depression. Many, however, experience only one episode in a long lifetime.
The great majority of depression-prone people function quite normally, and even at a superior level, during the long periods of their lives when they are not depressed. A few of them will also at times deviate from normal in the opposite direction, and will experience a high, instead of a low, mood. They will become elated and overactive. They may become so speeded up that they exhaust themselves and everyone around them. Their judgment is impaired and they may recklessly launch into grandiose enterprises. This upward mood swing is called mania. It is felt to be merely a different manifestation of the same manic-depressive condition that most often produces in its victims only recurring episodes of depression, rather than alternating attacks of depression and mania. The latter more regularly requires management by a psychiatrist.
What Causes Depression?
No one single cause for depression has been isolated and probably never will be, for depression is the end result of complex interplay of many different factors. One such factor is heredity, about which little can be done. A tendency toward a manic-depressive condition seems to be inherited by some people, but it is only a tendency that is inherited and not the condition itself.
Much more important as predisposing and causal factors in depression are untoward environmental influences in the earliest months and years of life, especially those pertaining to the quality and consistency of parental care. The foundations of security, proper self-esteem, and satisfying interpersonal relationships are all laid down in infancy and early childhood. Psychological disturbances in these areas at this time of life, more than any other factor, set the stage for the development of serious depressions in adult life.
Before beginning a study of these psychological and spiritual factors, which are so crucial to the pastor's understanding and management of depression, and which will engage our exclusive attention next month, let us first look at the physical, or nonpsychological, components of the picture, for they, too, are important. Knowledge here can help the pastor know what to expect from the more medical aspects of treatment for the depressed.
A basic fact is that certain biochemical changes occur in the brain of a depressed person that tend to prolong his depression and make it worse. These changes have been extensively studied, yet they are but partially understood. It is believed that they are largely responsible for the insomnia and certain other physical symptoms in depression. Most psychiatrists do not believe that these biochemical or metabolic changes in themselves constitute the root cause of depression (reserving this dishonor to psychological factors), but rather that they are the accompaniments of depression, and that via the mechanism of a vicious circle operate to keep the depression going.
Medical treatment then aims at correcting those changes and thus breaking the cycle and allowing more natural restorative forces (e.g., rest, attention to psychological and spiritual factors, et cetera) to return the person to a normal mental state.
Two treatment methods are available for effecting these changes back toward normal brain functioning; one is electric shock treatment, and the other is the use of antidepressant medication. Although obviously they are very different methods, the pat tern of favorable response in each is so similar that it is probable that the way in which they act to normalize disturbed brain function is very similar, if not identical.
What About Shock Treatment?
Shock treatment is the most prompt and effective means presently available for terminating a given episode of severe depression, although it does nothing to lessen the tendency to future attacks. It is especially indicated in the severely depressed patient, who at the time is scarcely reachable for any psychotherapy because of withdrawal and impaired ability to communicate. It is also especially indicated in the acutely suicidal person, where often it proves to be literally lifesaving.
Certain facts about shock treatment should be useful for the minister to know.
Although it is still not known exactly how shock therapy works and there have been scores of theories propounded it is known that no benefit is obtained unless an actual convulsion is produced in the brain. This fact rules out psychological theories, such as those attributing the results to suggestion or to guilt reduction through punishment. In fact, it does not matter how the convulsion is produced. In stead of electric current one can use certain injected drugs or even inhaled gases. As a matter of fact, shock treatment was first discovered by an astute observer noticing that depressed epileptic patients tended to get over their depression following their spontaneously occurring convulsions!
Although usually shock treatment produces some temporary impairment of memory, the forgetfulness is an unwanted side effect, and in no way is it an explanation of what makes the treatment effective. It does not work by making a person forget his troubles.
In competent hands, the method is safer than most other forms of treatment. With modern refinements it is now a gentle, nonviolent treatment. Typically an intravenous sedative causes the patient to fall asleep. A muscle relaxant is then injected; as a result, only a barely perceptible stiffening of the body occurs when the convulsing current is momentarily applied. The patient reawakens a few moments later. Most patients are treated three times a week for a series of approximately six treatments.
There are little or no permanent harmful effects from shock treatment. This has been carefully documented over the past thirty years of very extensive use. There is little or no permanent impairment of remembering ability or of any other mental faculty.
One of the first gratifying signs seen in persons responding favorably to shock therapy (not all depressed persons are helped by shock) is the disappearance of insomnia, and the return of natural, refreshing sleep. This effect is often seen after only one or two treatments. Relief from other depressive symptoms usually follows within a week or two. Follow-up attention to psychological factors then becomes increasingly important.
Antidepressant Medication Often Helpful
The other medical method of treating depression is with the use of antidepressant medications (e.g., Tofranil, Elavil, Norpramine, or Aventyl). They are commonly used in less severe cases, since their effects, although similar, are generally milder, less predictable, and slower in taking effect than shock treatment. Their use may be complicated by annoying, but rarely dangerous, side effects.
When seen to be effective in any particular case, it is very important that use of these medications be regularly continued for several months, even after the depression has lifted. Although in no sense are they habit forming, relapse is liable to occur if the person prematurely stops taking them. This he is very prone to do for a number of "reasons": he now feels fine, spurns any "crutch," begrudges the bother and expense, and very often especially if he is a devout Adventist he has a very understand able bias against taking "drugs."
Here is an example of where an intelligent minister can be a very helpful member of the healing team by encouraging the person to continue taking his antidepressant medication faithfully until his doctor advises him to stop. Meanwhile, the pastor can be giving his attention to those psychological and spiritual factors that are basically responsible for the man's depression, which we shall consider in the next two articles.
(To be continued)