While the modern approach to describing, diagnosing, understanding and treating depression is for the most part well organised, this approach is a relatively recent phenomenon and depression has of course been around, unchanged, for centuries. This article examines how we understand depression and how it relates to grief.

In the Image and Likeness

In the beginning man was, as we know, made in the image and likeness of God (Gen 1:26). We are all blessed to share the same heavenly Father, styled by Moses “the God of the spirits of all flesh” (Num 27:16). It is His likeness, exemplified so perfectly in Jesus Christ, that we strive every day to live up to. All the descendants of Adam share the same mental, physical and emotional characteristics as their original forebear. In physique, we are all diverse the one from the other, but this is only the wonderful expression of amazing diversity built in to creation by the genius of our Creator. As far as our thoughts are concerned, we know that we struggle every day to “bring into captivity every thought to the obedience of Christ” (2 Cor 10:5). Emotionally, we recognise that all Adam’s sons are capable of the same feelings. While we know that there are clear differences in how some cultures might express emotions, there are no differences in the actual emotions we feel. All of us are born with the same basic set and these govern the emotional ‘flavour’ of our lives. The experiences and learning we undergo help us to modify, hide, or express our emotions but, fundamentally, we are all the same.

Sadness is one of these basic or core emotions, and depression is its extreme extension.

We turn, of course, to the Scriptures and search them for understanding. There are numerous examples of faithful men and women who experienced real sadness and real depression and who received help. David frequently records his anxiety and depression in the Psalms. In Psalm 6:6–7 he wrote: “I am weary with my groaning; all the night I make my bed and swim; I drench my couch with my tears, my eye wastes away with my grief.” This is no overstatement, as many will recognize. Job suffered too, as a result of real and terrible disasters, unlooked for and totally unexpected. He accepted the tragedies that befell him in a way that makes us marvel, not deviating from his utter trust and dependence on his God. “Thy will be done”, was clearly Job’s response (Job 1:20–22). Yet the criticism of his brethren, who totally misunderstood, caused him to cry out and question what he perceived as God’s harsh and unwarranted treatment of him. The great prophet Elijah also, became deeply distressed at the apparent failure of his great work on Mount Carmel and the threats made against him by Jezebel (1 Kings 19).

Some people call it profound sadness, and this obvious and prolonged sadness is one of the key features of identifying depression. One thing is certain, depression is as real a condition as influenza or a broken leg. Described variously as a “black hole”, a “deep pit”, a “thundercloud”, a “thick fog” and so on, depression is one of the most common mental disorders. Many would say that it is the most common. Certainly, it now ranks as one of the most prevalent health conditions of any kind in the western world, with point prevalence rates1 as high as twenty per cent. It is often called the common cold of mental illness.

Diagnosing Depression

In 1 Samuel 21:13 we read of David in the court of Achish, king of Gath. “And he changed his behavior before them, and feigned himself mad in their hands, and scrabbled on the doors of the gate, and let his spittle fall down upon his beard.”

Mark 5 tells us of Legion, naked, living in tombs and cutting himself with stones.

Both look like mental illness. Both demonstrate obvious symptoms, but only one is legitimate. How would we know which one without some sort of guide? And how would we know what to do unless we knew what was wrong?

Although often used indiscriminately to describe any period of feeling low or sad, depression does have clearly defined criteria for it to be correctly identified. While these seem reasonably broad they must also be taken in context. For example, because depression is such a widely used term and its key components are well-known, we can too easily apply the term indiscriminately.

By contrast, depression can easily result from other conditions (such as physical disabilities) so that its symptoms are ascribed to the other condition and we miss the correct diagnosis completely. To illustrate further, some of the symptoms of depression are not unique to depression but are shared with other conditions. We need to acknowledge the possibility of misdiagnosis, or that more than one diagnosis is possible. As an illustration, we could easily diagnose depression when the problem is actually to do with the thyroid gland2; so this possibility needs to be excluded by a doctor before the diagnosis of depression is confirmed.

What this means is that any diagnosis of depression ought not to be given lightly, but given due consideration before being applied. To be sure, most self-help books about mood would include a self-directed checklist of symptoms, as do many websites and pamphlets, but a formal diagnosis should only be made after a proper, formal evaluation by a professional clinician. Getting the diagnosis right is critical, because as the diagnosis differs, so do the consequent treatments. Additionally, checklists and self-help books, while no doubt well-meaning, may lead us into the trap of seeing ourselves in every description, applying every situation to ourselves, and generating street-corner diagnoses which may do more harm than good. While a diagnosis is being established, certain ideas need to be understood.

There are various, in fact nine, recognised types of depression, each with particular characteristics. Of interest to us is what is properly called Major Depressive Disorder (also known as Clinical Depression) and Unipolar Depression. This could either be a single occurrence or a recurring experience. When we understand the breadth and complexity of the depressive disorders, it becomes easier to see why we need to be very careful before we apply the label of “depression”.

Symptoms

While we can experience depression in intensely personal ways, there are only nine key symptoms and we need five or more of them that have been obvious every day for the previous two weeks. Two of them, depressed mood most of the day and most of the time, and loss of pleasure in most things most of the time, are so much more common than the others that we must have at least one of these two to truly have depression. In no particular order, the other seven are: significant weight change or loss of appetite, no sleep (maybe 2–3 hours in total) or excessive sleep (even 16 hours or more) most days, extreme restlessness or obviously diminished movement, extreme tiredness or loss of energy, feeling worthless or extremely guilty most of the time, the inability to think straight, concentrate or make even simple decisions most of the time, and repeated thoughts of death and/or suicide.

These symptoms must cause obvious distress or problems in everyday life, must not be the result of a chemical we’ve taken (such as alcohol or other medication) and can’t be the result of another condition such as hypothyroidism. Lastly, and importantly, is another exclusion, and worth quoting from a medical manual3.

  “E. The symptoms are not better accounted for by Bereavement, ie, after the loss of a loved one, the symptoms persist for longer than two months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.” (italics ours)

Depression and Grief

Depression is a mental disorder, that is to say, something is wrong. If there is a clear explanation for the depression, such as bereavement, that is to say, if we experience these things when grieving the passing of a loved one, nothing is wrong.

As we’ve already established, it is common for people to experience, among other things, sadness, pain, anger, tiredness, bouts of crying, difficulties in thinking and a depressed mood after the death of a loved one. However, it is important to learn to distinguish these normal grief responses from clinical depression. About 20% of bereaved people will subsequently develop major depression, requiring medical or professional intervention. Unpacking the subtleties of the one versus the other is the task of the clinician, but a short illustration will suffice here.

Martin

Martin sits with his GP and describes his last two months. He outlines low or depressed mood, general fatigue and tiredness, poor sleep to the point of insomnia, loss of pleasure in things he usually enjoys, and an inability to concentrate. He says that he struggles to keep up with his job that previously stimulated and challenged him. Now though, he has trouble making even simple goals, has stopped going to cottage classes because he can’t concentrate and just wants to lie down and rest. At nights, he lies awake, tossing and turning till two or three in the morning, finally drifting into three or four hours of unrestful sleep.

From the list above, the GP would note these symptoms and the fact that they had persisted for two or more months, with five symptoms occurring during the same two week period. By all accounts, he is in the middle of a major depressive episode and goes home with a prescription for 20mg of Prosac. Officially, Martin has a mental illness, in itself nothing unusual or embarrassing, but suggesting a certain set of possible outcomes.

If the circumstances were slightly different, and Martin outlined the same symptoms but also mentioned that his wife had died about ten weeks ago, then officially Martin does not have a mental illness, given that this cluster of symptoms is a normal and expected part of the grief reaction. This would be the more likely explanation for his symptoms than the diagnosis of major depressive episode. In the main, his GP would expect him to come through these symptoms over time, with or without medication, to recover more quickly and to be less likely to suffer from major depression in the future.

Establishing the Difference

To Martin, and to the practitioner, the symptoms are qualitatively different in each case. Moreover, Martin does not have the helplessness, hopelessness, worthlessness, restriction or agitation of movement or the excessive guilt that are extremely common in people experiencing major depression. To sum up, symptoms of major depression not explained by the normal bereavement process may include:

  • Continual thoughts of worthlessness or hopelessness
  • Persistent inability to perform day-to-day activities successfully
  • Delusions (beliefs that are not true)
  • Excessive or uncontrolled crying
  • Slowed physical responses and reactions
  • Extreme weight loss

Those Who Help

For those of us supporting a brother or sister through bereavement, it is helpful to understand which symptoms indicate the normal depressive symptoms that are associated with grief, and those more usually associated with major depression. We are of more value when we are perhaps able to discern when to seek professional assistance.

For the bereaved though, there are risk factors that increase the likelihood of us moving from normal and expected depression associated with grief to that of a major depressive episode. Again, it is useful to have an idea of the circumstances that might contribute to the development of abnormal depression. While this is not an exhaustive list, it does highlight the most common risk factors associated with developing major depression.

  • A history of depression
  • A history of alcohol abuse (alcohol is itself a depressant)
  • An inadequate support system
  • Poor (or easily overwhelmed) coping strategies
  • A feeling of being easily overwhelmed
  • Other significant life stresses

Professional Help

In the event that we notice our dearly loved brother or sister suffering the symptoms of depression and assist them to seek professional help, it is helpful to understand what we could expect to be offered. In most cases our first point of contact is with our GP. Most GPs understand enough about depression to recognise it and ask some sensible questions. However, they can usually offer only two choices: referral (see last article) or medication. If they recognise the depression as severe then they will likely and most appropriately refer you to a psychiatrist—a physician trained in mental disorders—or ongoing support.

Many GPs prescribe antidepressants and offer frequent enough check-ups, providing that the depression is of mild to moderate severity. In these cases, the right type of counselling is as effective as medication; so there is a measure of choice. In real terms, medication is generally quicker and counselling is longer-lasting, and so the most robust option is actually a combination of the two. In severe cases of depression, counselling is less effective and medication is the primary and most accepted approach. In most cases of this nature, a GP will defer to a psychiatrist. They may utilise a psychologist to offer specialist therapy alongside the use of medication. A psychologist cannot prescribe medication, and works at changing behaviour through other techniques, particularly by looking at how we think.

Although there is no assurance that medication will work perfectly, we can be assured that most modern antidepressants are extremely good. Unfortunately there is no great science behind which modern antidepressant to use, and so we may need to try a couple before we find the right one. As with many medications, antidepressants merely assist the body by bolstering our stores of various chemicals. Antidepressants do not replace these chemicals, but help those we do have to work more effectively. A typical course of antidepressants would last about six months. If we are prescribed antidepressants, then as is the rule for antibiotics it is critical that we continue to take them as prescribed. These days there is usually little risk in taking too many, but there are great risks in taking fewer than we have been prescribed, or worse, taking them erratically. Often we find that once mood has improved, people believe they are “cured” and stop their medication. Unfortunately, continually starting and stopping antidepressants decreases the overall effectiveness of the medication and makes us more susceptible to prolonged and more severe depression. In addition to medication, two other issues need a brief mention.

Support Networks

There are two basic forms of support networks: structural and functional. Structural supports are those people available to us as supports by virtue of the fact that they fit into our social structure. Our family is the most obvious structural support. Colleagues can be another. Our ecclesias are also structural supports in that there are many people in our circle of acquaintance. In a practical sense, structural supports might offer initial assistance or care, but can quickly fall away and leave one or two people who are prepared to stick with another person’s grief for the coming months. These one or two fulfil the role of functional supports.

Functional supports are what they sound like. They are those people who actually provide the function of support. They may be family members or colleagues, but can equally be professionals, friends or other people. Ecclesial members fill this role also, and for those suffering from bereavement and/or depression, it is crucial that they have solid functional support who can help guide them through the process.

There is an important lesson for all of us here, as it is through our brethren and sisters that God usually works to assist us. We can be confident that their practical assistance is usually given after prayerful request for God’s guidance. In fact, it is necessary to study this aspect of our service in Christ before we ourselves are in dire need. We can learn from the Scriptures the principles of Divine love and compassion and see how the Lord acted out of the same spirit as his Father. Isaiah 40:11 beautifully depicts His loving and tireless care. We need to analyse passages like these and absorb the practical implications for our daily lives. It is a lifetime’s work to develop these qualities, which each of us must learn if we are to be “kings and priests” in the age to come, for compassion is one of the fundamental qualifications for priesthood (Heb 5:1–2). First we discern them in the Word, in the life of the Lord and of such as David, Ruth, the parable of the compassionate Samaritan, the apostle Paul and others, and secondly by observing the way faithful brethren and sisters in our own midst apply them.

Some seem ‘born’ to show compassion and support others, while many of us tend to feel inadequate quite often to the task. However, it is a responsibility we take on in Christ and it is something we must learn to do effectively. We cannot leave this shepherding to others. We cannot plead ignorance, for the Scriptures abound with examples and a meditative study of this Divinely approved method of nurture and comfort will soon reveal to us how we, too, can follow the example of our Lord.

There are things that we can all do. The most basic is that we believe that our brother or sister does need help and, rather than try to talk them out of their problem, reassure them by being at their side to listen—just as we have come to hope that God will listen to us. This will immediately reveal that we do care and are genuinely concerned. Those who are depressed frequently feel that they are ‘beneath’ the attention of even their brethren. This is part of their feelings of diminished worth or self-deprecation. We should try to practise the apostle’s advice to “bear one another’s burdens and so fulfil the law of Christ” (Gal 6v2). A word of encouragement, even if it does not seem to be well received, does help significantly. A brief note, a small practical assistance never goes unnoticed. Our brother or sister may be unable to respond as we think they ought, but this is part of their depressed state, which we hope to retrieve them out of.

Coping Strategies

While we haven’t space to examine coping strategies in real depth, we do need to cover some fundamental principles. As with support networks there are two basic approaches: emotion-focused coping and problem-focused coping. Both have their place, but are useful in different ways.

Emotion-focused coping handles problems by zeroing in on the feelings and emotions that result. For example, having been given a diagnosis of heart disease, many people head into denial, which prevents the initial surge of reactions. In the first instance, this is useful as it can allow us some time to marshal our mental and physical resources. From there though, we need to become problem focused, which works to address problems, because continuing to deny the truth of heart disease will mean we fail to adjust our exercise or diet or lifestyle which will help us to survive.

When we are faced with something as potentially overwhelming as the loss of a loved one, emotion-focused coping is often the first response. This is normal and appropriate. Trouble develops a little later if we continue to use this approach when we need to use more problem focused coping. Often it is the frustration of other people who believe this transition should have happened that leads them to say, “Pull yourself together”. What they are actually saying is that they think we should become problem focused rather than emotion focused.

As with all grief reactions, this is different for all people, and we can’t force people to move more quickly than they are able. What we can do is be aware of the difference in thinking that represents this shift, expressed in people’s actions and language, and help to facilitate it when we can.

What  Next?

What we are trying to do for our brother or sister is to gently lead them to the Father, the source of all comfort and healing. Psalm 55:22 encourages us to cast our burden upon the Lord, while Psalm147:3 reminds us that “He healeth the broken in heart, and bindeth up their wounds.” Further, Philippians 4:13 reads: “I can do all things—through Christ which strengtheneth me.”

This raises three questions. The first two are obviously linked and they are: What can we do to help? and, What can the sufferer do to help themselves? The third is: What does the Bible tell us?

God willing, what to do to help, and a Scriptural viewpoint are, respectively, the focus of our next two articles.