by George Ohlschlager
Major depression, also known as clinical depression, is a complex biomedical, psychosocial, and spiritual disorder (American Psychiatric Association [APA], 2007). Depression may occur by itself or in combination with other physical or mental disorders. Depression co-occurs with anxiety more than 50% of the time and is often misdiagnosed as an anxiety disorder (Sadock & Sadock, 2002). Other common co-occuring disorders include chronic pain, dementia among the elderly, and drug and alcohol abuse.
The term major depressive disorder was selected by the APA to represent a mood disorder in the third version of the Diagnostic and Statistical Manual of Mental Disorders (APA, 1980). Major depression is a disabling condition that adversely affects a personâ€™s family, work or school life, sleeping and eating habits, and general health. In the United States, approximately 3.4% of people with major depression commit suicide, and up to 60% of people who commit suicide have depression or another mood disorder (APA, 2007).
Major depressive disorder is characterized by a pervasive low mood, accompanied by low self-esteem and loss of interest or pleasure in normally enjoyable activities. It is referred to as â€œthe common coldâ€ of mental health, but this benign description belies the fact that major depression is arguably the most seriousâ€”the most adversely life-affectingâ€”mental-health problem people suffer. Major depression can occur not only in adults but also in children and teenagers, who can also receive much benefit from treatment.
Major depression is more severe and debilitating than dysthimiaâ€”a milder and more functional kind of depressionâ€”and more serious than any prolonged grief or sadness. Major depression is also different from the depressive side of a bipolar disorder, and differential diagnosis here is often missed. The key symptoms of a clinical depression are: (a) anhedonia (the loss of pleasure or satisfaction in life), (b) the rise of numerous bodily and physiological problems, (c) presence of the â€œcognitive triad of depressionâ€ (worthless/helpless/hopeless obsessions), and (d) the debilitating impact of the disorder on oneâ€™s relationships, work life, and self-care (APA, 2000).
Many researchers believe depression is caused by chemical imbalances in the brain, which may be hereditary but may also interact with stressful and traumatic events in a personâ€™s life (which is known as endogenous [biologically based] versus exogenous [reactive] depression). Depression sometimes runs in families, but it can also occur in people who have no such family history. Stressful life changes or events can trigger depression in some people. Usually, a complex combination of many factors is involved. Major depression is reported about twice as frequently in women as in men, and women attempt suicide more often, although men are at higher risk for completing suicide (see Barlow & Durand, 2005).
Most depressed patients are treated with a combination of antidepressant medication and psychotherapy or counseling (Hart, 2001; Sadock & Sadock, 2002). Hospitalization may be necessary in cases with associated self-neglect or a significant risk of harm to self or others (suicide is the most common risk requiring hospitalization). A small minority of people who suffer severe depressive symptoms are treated with electroconvulsive therapy (ECT) and other forms of somatic therapy. Increasingly, people use self-help methods, including support groups, exercise, and nutritional supplementation.
Counseling for depression often involves a threefold focus: (a) increasing exercise or physical activity, (b) repairing broken or impaired relationships, and (c) cognitive restructuringâ€”reducing and renouncing worthless/helpless/hopeless thinking, replacing it with worthwhile and helpful self-talk, and renewing hope in Christ. Depression also advances in isolation, so receptivity to and more time spent with others is often essential in breaking the grip of depression.
Biblical and Spiritual Issues.
Depressed persons often believe they are alienated from God. Significant feelings of distance from God are noted rather than closeness to him (Hart, 2001; McMinn & Campbell, 2007). Depressed persons commonly report their conviction that God is angry with them or has somehow rejected and abandoned them for a myriad of different reasons. The social alienation and withdrawal that is characteristic of the depressed is often reinforced and compounded by this acute sense of divine alienation.
In this alienating equation, depressed people often believe they are being punished by God, that the punishment is usually deserved or just (sometimes there is a powerful obsession with having committed the unpardonable sin), and that there will never be a complete reconciliationâ€”God has abandoned them for all time, and hell is inevitable (see Ohlschlager & Clinton, 2002).
Social histories of depressed persons often reveal a family history that is not grace based, but instead is performance oriented and legalistic. The individual often feels flawed and condemned for failing to live up to projected family or religious standards. Rather than continuing to seek the impossible (as does the obsessive perfectionist), the depressed person instead retreats into a world of alienating cynicism that seems, at first, to be self-protecting. This spiritual estrangementâ€”believing in a core alienation in every relationship, including with Godâ€”fuels the hopelessness that may drive an individual to suicide. For if it were true that God had abandoned someone with no hope of forgiveness or reconciliation, what would be the reason for living? Such existential painâ€”a pain that is believed to have no real cureâ€”can be understood to motivate the upside-down logic of suicide, in which death is then viewed as the only escape from unending pain.
Existential therapists believe that de-pressed persons have retreated from or are living in denial of the core challenge of effective livingâ€”to properly reconcile the ongoing paradox of being alone in the universe and yet also being connected to others in a sea of relationships. The spiritual-existential challenge of living, it is argued, is to resolve the competing forces of aloneness and relatedness. Although relationships have proven to be very painful, and those who feel alienated engage in a fragile and frustrating ego defense, it is even more painful to withdraw from every relationship in the hope of avoiding further pain. â€œThe charge [of self-induced alienation] is complex because the human self does not exist in isolation. Depressed people often are alienated from others; they are typically nonparticipant spectators to lifeâ€ (Wetzel, 1984, p. 216).
Often, a newly discovered or rediscovered relationship with God stops the vicious downward cycle of despair and begins to turn a depressed person to an upward healing path. â€œThe reconciliation of aloneness and relationship is the atonement (at-one-ment) of persons and Godâ€ (Wetzel, 1984, p. 217). The gospel tells us that God has supernaturally broken into the realm of alienation and disbelief. When he shows up in a personâ€™s present experiences and proves that he is truly present in love and grace, the person experiences a moment of renewal and relief from the legacy of alienating despair. Contrary to the long-held prejudice among many mental-health professionals about the inherent pathology of religious belief, the power of a healthy and intrinsic religious faith has been overwhelmingly supported in the research in the past quarter century (Koenig, 2007; Hook & Worthington, 2007; Richards & Bergin, 2005).
Deeply held religious beliefsâ€”the resilient operation of an active and intimate faith in Godâ€”has long been shown to be resistant to depression. Moreover, a wide range of depressive symptoms are less likely to occur and are quicker to remit among those who are intrinsically rather than extrinsically religiousâ€”that is, among those who have internalized their beliefs as opposed to living out a rule-regulated religious performance. It is not always clear which factors are causes or which are effects of depression, but depressed persons who are able to make corrections in their thinking patterns often show improved mood and self-esteem (Koenig, 2007, 2001).
Finally, the combination of the proper medicine with good and effectual counselingâ€”which includes renewing and strengthening the clientâ€™s relationship with God in Christâ€”can turn the tide on many depressive episodes in two to four months for many sufferers. However, a significant minority of depressive sufferers may experience abated symptoms in six months by doing little to nothing to change.
American Psychiatric Association. (1980). Diagnostic and Statistical Manual of Mental Disorders (3rd ed.). Washington, DC: Author.
American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.). Washington, DC: Author.
American Psychiatric Association. (2007). Practice Guidelines for the Treatment of Patients with Major Depressive Disorder (2nd ed.). Washington, DC: Author.
Barlow, D. H., & Durand, V. M. (2005). Abnormal Psychology: An Integrative Approach (5th ed.). Belmont, CA: Thomson Wadsworth.
Hart, A. (2001). Unmasking Male Depression. Nashville, TN: W Publishing Group.
Hart, A. (2007). Thrilled to Death: How the Endless Pursuit of Pleasure Is Leaving Us Numb. Nashville, TN: Thomas Nelson.
Hook, J., & Worthington, E. L., Jr. (2007). The God factor: Evidence from outcome studies of psychological treatments. Christian Counseling Today, 15(2), 16-18.
Koenig, H. G. (2001). The Handbook of Religion and Health. Oxford: Oxford University Press.
Koenig, H. G. (2007). Spirituality in Patient Care (2nd ed.). West Conshohocken, PA: Templeton Press.
McMinn, M., & Campbell, C. (2007). Integrative Psychotherapy: Toward a Comprehensive Christian Approach. Downers Grove, IL: IVP Academic.
Ohlschlager, G., & Clinton, T. (2002). Change as Paradox: Overcoming client resistance and fear of change. In T. Clinton & G. Ohlschlager (Eds.), Competent Christian Counseling: Foundations and Practice of Compassionate Soul Care. Colorado Springs, CO: WaterBrook Press.
Richards, P. S., & Bergin, A. (2005). A Spiritual Strategy for Counseling and Psychotherapy (2nd ed.).Washington, DC: American Psychological Association.
Sadock, B. J., & Sadock, V. A. (2002). Kaplan and Sadockâ€™s Synopsis of Psychiatric Behavioral Sciences/Clinical Psychiatry (9th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Wetzel, J. (1984). Clinical Handbook of Depression. New York, NY: Gardner Press.