The crisis of depression

A pastor's compassionate and proactive intervention can be an important part in ministering to the depressed.

Alan A. Nelson, M.D., is a practicing psychiatrist in Carbondale, Colorado.

As Jane Remington sits down she looks at her pastor, not quite able to hide the hint of sadness in her eyes. She has not been sure how to begin this interview, nor how it will end. A pleasant and regular church member, she has taken an active part in all church activities, especially her work as an effective Bible teacher.

A woman in her mid-40s, Jane has made the appointment to discuss some of the problems she has been having. As they begin to talk, the pastor asks how things are in her marriage. "Our marriage is quite stable," Jane says. "Of course no marriage is perfect, and we may not do too many things together, but we have a good relationship and a firm commitment to each other."

Jane continues. "My life just seems to have had little joy and satisfaction in it lately. My devotional life and study have been good. In fact, I feel I have matured spiritually. But I don't seem to have much energy. I am not sure if it's because of early menopause or lack of good sleep. I have problems dealing with my teenage daughter, and I guess that has bothered me a lot."

After some conversation, the pastor realizes that he has been talking to the open, pleasant woman he has always known Jane to be, but he also senses that there is a significant tiredness in her. As he goes on, a picture forms in his mind of a woman living constantly on the verge of easily being thrown into discouragement, even over small and otherwise insignificant irritations.

The dilemma of depression

If you were Jane's pastor, how would you work with her? Is Jane's problem normal/physical? Is it depression? concealed marital discord? emotional loneliness? All of these thoughts and others might pass through your mind as you listen to Mrs. Remington while you try to decide if you should schedule her (or want to schedule her) for another visit.

The most common psychiatric condition in North America is depression. While there may be, on the part of mental health professionals, a tendency to overdiagnose this illness and overprescribe medications, it is nonetheless the number one clinical problem seen by psychiatrists and psychologists. Since this is the case, pastors need to understand the factors involved in depression.

Pastors vary widely when it comes to their interest in, and ability to deal with, people's emotional difficulties. Some are fearful of encountering emotional distress of any kind, because they cannot understand it or because it may involve "counseling," with which they are uncomfortable. This article is designed to help pastors recognize the symptoms of depression, form a tentative diagnosis, and thereby be better equipped either to deal with a given problem themselves or to make effective referrals. First, however, it looks at the pastor and his or her role as a counselor.

The pastor and the counseling role

Some pastors approach counseling with trepidation. They are afraid it will dominate their ministry, govern their time, and drain their energy. Some pastors resist counseling because of negative experiences they have had in their personal, marital, or professional lives. In fact, their own life may be in such disarray that they hesitate to take on the role of counselor.

Another possible reason pastors may be uneasy with the counseling role is that they may have done some counseling that has left them with a sense of failure, helplessness, and being burned by their interaction. Perhaps their counseling experience resulted in an obviously negative outcome. Maybe it became too emotionally intense or close to the pastor's own personal concerns, or in some other way had a negative impact on the pastor's life. Certainly, most pastors are better equipped to deal with theological issues. They feel safer keeping things within the "religious" arena, away from personal and emotional concerns. For many pastors, conducting a good Revelation seminar or Bible study creates a significantly more rewarding sense of security and sanctuary when compared to the quicksand of counseling. This is not to say that pastors should allow themselves to be distracted from the center of their role, which is the proclamation of Christ and His truth. It is true to say that along with that role, and even as part of it, pastors should have a practical sense of the basics of recognizing significant emotional distress and dealing with people on an emotional level.

Not all pastors should counsel. Individuals have different strengths and talents, and either by temperament or training they may not be equipped to be good counselors. However, all pastors can be trained, or at least become aware of the essential principles involved in early recognition of the emotional/counseling issues among their members so that they can properly decide how to deal with them.

Recognizing the symptoms of depression

We fear and avoid things we do not understand. Therefore the more pastors understand the symptoms of emotional disorder and begin to fit them into discrete categories such as depressive disorders, anxiety disorders, eating disorders, to name just three, the more easily and effectively they will address these issues in their ministry.

Recognizing the symptoms of depression is key to reaching a tentative understanding and subsequent decision about treatment. The symptoms of depression are subtle. Often the depressed individual tries to mask these symptoms. Clinical depression is not just a down mood. Part of being normal is having normal mood changes. Just as the seasons change and the tides come and go, so do our emotions.

What differentiates a case of the blues or a down mood from clinical depression is the intensity, duration, and severity of symptoms. People suffering from a clinical depression feel as though their symptoms just won't go away. They wake up with them in the morning. They want to withdraw. They want to go back to sleep (which "seems" sometimes to provide the only relief from these symptoms). The clinically depressed person does not want to see or be seen by people. There is a corresponding emotional withdrawal and lack of expression in the face. The countenance is, as it were, blunted. The eyes have no sparkle.

Another symptom is lack of energy. The depressed seem tired and ran down. They lack motivation to do things. They lack creativity, interest in hobbies or friendships. As in Jane's situation, they have no joy in living. Often the voice pattern lacks inflection. The pacing of their speech is slow, and their thinking seems laborious and painful. Their mind seems preoccupied with what a therapist calls painful thinking, i.e., thoughts of failure, dread, guilt, fore boding, and discouragement.

If these symptoms are left untreated, they can persist and lead to suicidal thinking. Fifteen percent of patients who have clinical depression will attempt suicide. Thus, a serious depression can be a lethal condition and should be addressed as early as possible. This is one reason pastors should have training in early recognition of depression so that they can be of help to parishioners who may be experiencing depression.

The origins of depression may vary, but symptoms seem remarkably consistent. Depressed individuals feel low self-worth. They are easily annoyed. They feel useless and guilty. They are indecisive. They cannot concentrate. They may experience fatigue, tenseness, and restlessness. An added symptom may be a change in weight, either a gain or a loss.

Depression: risk factors and causes

Five basic risk factors are associated with depression.

Gender. Women are far more likely than men to get depressed or seek treatment for depression. Probably two thirds of clinical depression cases are women.

Age. Older men and women, from adolescence into the early 40s, are more likely to be affected.

Race. Black women relate a higher incidence of depression than do other control groups.

Family history often has its influence on one's vulnerability to depression.

Marital status is also a powerful predictor of the likelihood of depression. People who are divorced, separated, widowed, or never married all have higher incidents of depression. A happy marriage stabilizes an individual's emotional equilibrium.

Despite much talk about the influence of "chemical imbalance" as a major cause of depression, the leading cause actually has much more to do with broken relationships or significant losses and disappointments that are not accepted. Of the most predictable causes of depression, the single most common one cited in research is marital discord and divorce. Any longstanding stress can lead to the erosion of emotional health, fatigue, and chronic worry. Over time, if untreated, this kind of stress can develop into clinical depression.

Some have a genetic susceptibility to depression, with a history of family members having had the problem. These are referred to as "biological depressions," or "chemical imbalance." No blood test or diagnostic instrument can define this chemical imbalance. In reality, when diagnosing "chemical imbalance," a therapist or psychiatrist makes a judgment call when he or she feels that a patient's current symptoms are far beyond that of a mere day-to-day variation of normal mood.

At times, certain physical conditions can mimic the symptoms of depression. Thyroid and hormonal imbalance can cause either depression or symptoms that seem very similar to depression. People with such symptoms need a thorough medical evaluation to rule out any possibility of depression.

Occasionally some may develop depressive symptoms for no clear reason. Their life seems reasonably well balanced, they are in good physical health, and their marriage appears stable. Such instances are called "endogenous depressions," meaning that they come from within and do not result from a clear causative stressor. Such cases typically have a family history of depression. Such patients generally respond favorably to medical management.

Treatment suggestions

In severe cases of depression the most important thing to do is to encourage the person to seek help. Be proactive and encourage your parishioner or loved one to get appropriate professional help.

Refer the individual to a professional appropriately trained in mental health and practicing psychotherapy. A Christian therapist is clearly preferable, but if one is not available, then refer the patient to the most competent, well-rounded, well-balanced counselor you can find. He or she may not share your parishioner's specific religious views, but in most cases will be professional enough to respect these views and not see them as delusional or pathological. It is wise to do some research and referencing ahead of time so that you as a pastor possess a developed, updated list of mental health professionals to whom you may confidently refer your church members.

If a patient has tried to get better on his or her own in several ways and the symptoms still persist, refer such a patient to his or her physician or psychiatrist for a medication consultation. I am a conservative psychiatrist when it comes to medication, and yet I have found most of the new generation antidepressants, including Prozac-type medications, can be beneficial in treating these discouraging and frustrating symptoms.

These medications work by helping the brain to metabolize its own serotonin. Serotonin is an important neurotransmitter that helps the central nervous system with the regulation of mood and emotion. These medications are different from amphetamines or stimulants. They are much safer, are not addictive, and have many fewer side effects than earlier antidepressants. While side effects with these newer medications are few, each antidepressant has the potential for some side effects, and a parishioner needs to be encouraged to discuss this with his or her doctor. Taking medication is not a sign of a lack of spiritual maturity.

Encourage people suffering from depression to remain active. Recommend to them that they choose an activity they enjoy and that they make it a part of their regular routine. Tell them to avoid being alone. Have them seek out family and friends to whom they can talk and who will listen. Counsel them to avoid making major life decisions, such as buying a new house, during this time.

Depression tends to self-criticism. Counsel depressed persons to be easy on themselves, not to expect too much too soon, and to treat themselves with kindness and respect. If they are under medication, encourage them to follow their doctor's orders and to take the medication as prescribed.

Along with medical treatments, the spiritual dimension is important. The pastor can encourage the depressed person to maintain a regular devotional life. As the pastor encourages spirituality, he or she can also foster wise nutrition and the need of keeping appointments with professionals. While depressed persons may have neither the emotional energy nor the spiritual interest in maintaining these activities, pastors can gently turn them toward the need of seeking God and casting their cares upon Him.

God is still the primary reservoir of strength for physical, mental, emotional, and spiritual health. He does promise that He will never leave nor forsake us, even when we go through the valley of the shadow of death. A promise like that is worth holding on to, especially when one is contending with feelings of discouragement or depression.

Your compassionate and proactive intervention can be an important part of your parishioners' healing.

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Alan A. Nelson, M.D., is a practicing psychiatrist in Carbondale, Colorado.

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