Have you been there? Have you ever been in ‘a real downer’? I have. That may surprise some of you. After all, many people think that Christians shouldn’t feel depressed, and if they do, they must be failures! This certainly is a big stick with which I have seen many Christians beat themselves. It made them feel worse and made the ‘dark pit’ they were in feel even darker and deeper. Yet I can not find any example of such action in the Bible, even though it deals with many people who were depressed. Rather than ‘beating people up’ God dealt with individuals in loving ways.

Personal experiences

My ‘downer’ was several years ago but is still very fresh in my mind. It lasted about four to five months and I’ll be honest: I felt wretched. It was the cumulative effect of being let down and ‘slapped in the face’ several times in unexpected ways. Each episode on its own appeared insignificant, and still does, but so many things hitting me in one go were sufficient to knock me over. It is important to remember this when dealing with people who are depressed, as what appears a trivial stimulus to you, may in fact be ‘the last straw’ for them.

How did I deal with my situation? Not very well when I look back on it. Like many professionals, and indeed Christians, I covered it up to those around me, for fear of losing face and making myself vulnerable. I kept telling myself I wasn’t supposed to feel this way. Every morning when I went out to work I put on my mask of ‘all is well in the world’. To everyone else I seemed my usual jolly self, but inside I felt thoroughly miserable and as soon as I got home again the mask came off and I could stop the pretence. I remember sitting in church on some occasions wanting to scream out ‘are you all as happy as you make out to be, or does anyone feel as bad as I do?’ What were the main things that brought me out of this? Well, firstly I tried to assess my feelings and reactions to situations. This is not easy when on occasions you feel yourself spiralling down and find it difficult to remember what made you start feeling low in the first place. Secondly, I never stopped reading my Bible or going to church, even though my heart wasn’t in it. I made a promise to my Dad when I was nine years old that I would read my Bible every day and I’m certainly glad he asked me to make that promise. It’s important to keep reading God’s word and meeting with his people, even though you don’t feel like it, because these are very often the means of keeping yourself sane and allowing God to speak to you. No matter how bad you feel, don’t spite yourself by cutting off some of your routes to recovery. For me it was a process. I didn’t suddenly wake up one morning and feel on top of the world. It took time. If you’re feeling low you need to allow God and time to restore you. Similarly, if you know of someone who’s feeling low be patient with them.

Christian case studies

To hit a downer is not a particularly modern phenomenon. The psalmist who wrote Psalms 42 and 43 knew what real anguish was. However, he also knew where his help lay. In 1 Kings 19, Elijah hit rock bottom and asked God if he might not die. However, God dealt graciously with him and met his needs. Even Moses hit rock bottom when the burden of leading the Israelites was too great for him (Nu 11:10-15). He wanted to die as well, because he couldn’t take the strain any longer. Does this sound familiar? Even this great hero of the faith was so depressed that he wanted to die. Yet later in the passage we see how God lovingly dealt with him. God didn’t make him feel worse or give him a hard time. Instead he gave Moses exactly what he needed - more men to help and share the burden. These are the actions of a loving and understanding God. We would do well to learn from the example of the great Master and Healer.

Many prominent Christians in history have also been dogged with feelings of depression, anxiety or obsessional behaviour. I share their names with you not to knock them, but to encourage you. They include Martin Luther, John Bunyan, William Cowper (hymn writer), Lord Shaftesbury (the great human rights reformer), Gerard Manley Hopkins (poet), Christina Rossetti (poet and hymn writer-check the name under some of the well known Christmas carols!), Amy Carmichael (missionary), JB Phillips (theologian) and CS Lewis. I urge you to read their stories in the book ‘Genius and Grace’.[1]

What causes depression?

Why do people get depressed? It’s probably a multifactorial thing. Let’s look at some of the factors.

1. Genetics. Identical twins reared apart show 60% more concordance for depression than dizygotic twins.
2. Biochemistry. There are excesses of 5-hydroxytryptamine receptors in the frontal cortex of brains taken from suicide victims.
3. Endocrinology. Approximately one third of depressed people do not have normal cortisol suppression in the dexamethasone suppression test.
4. Biography. Adverse life events are important (eg job loss, divorce).
5. Psychodynamic reasons. Freud said that depression mirrors bereavement, but the loss is of a valued object and not a person. Others support the idea of learned helplessness.
6. Vulnerability factors. Physical illness, pain, lack of intimate relationships.
7. Spiritual factors.

All these factors may allow depression to arise and persist. So be on the look out for them. I was always taught as a student to ‘treat the cause’! Look for what might be underlying the depression and treat it if possible. This will aid a more satisfactory recovery.

Depression is common

Depression and its associated feelings are very common. Each year, it is estimated that 40% of the population have feelings of depressed mood, unhappiness and disappointment. Of these 20% will experience a clinical depressive syndrome, in which low mood is accompanied by sleep difficulty, change in appetite, hopelessness, pessimism, or thoughts of suicide.2 It is estimated that GPs fail to diagnose over half of those patients with a major depressive illness3 and often fail to treat adequately those whom they do recognise. 80% of patients with a new diagnosis of depression (or anxiety) present solely with somatic symptoms.4 The more I practise as a GP, the more I see this. All too often a patient comes in with a physical illness but digging a little deeper in the history reveals an underlying depressive problem. It is essential to listen to the patient and look for clues which are sometimes carefully hidden.

I remember dealing with a patient some years ago now when I was working as a locum. To all intents and purposes, she was the run of the mill ‘tired all the time’ patient. I’d never met her before, but there was something about her and her body language, which I couldn’t quite put my finger on. When I began to probe a little deeper she burst into tears. There was a lot of turmoil in her private life and in fact her spiritual life as well. That consultation ended up being a very long one, but well worth me running behind in my surgery to deal with. We were able to look at some the big issues in her life and plan a strategy to help her.

I sometimes ask, ‘do you have any church connections?’ just as a feeler to see if the patient has any spiritual input at all. In this case, the patient replied that she had lost touch with her church, but that her mother had been encouraging her to go back again. The patient couldn’t believe that I was also touching on the same issue. It made her sit up and think that here was some positive action she could take. She left feeling more positive and was definitely intending to find herself a new church. Without that gentle (and I stress gentle) probing the real issues would not have been confronted by her. Nor would she have had some initial plan of action. Instead, she could so easily have left my room only to have her blood count and thyroid function checked. Both perfectly reasonable things to do, but the real problem wouldn’t have been faced.

Diagnosing depression

Be aware also that depression can often be accompanied by and masked by anxiety.[4] In this case treatment of anxiety alone is insufficient and may appear to worsen the depression. It is useful to have a checklist of questions to improve accuracy of diagnosis, the Research Diagnostic Criteria.5 A major depressive illness exists if the patient has a low mood for over two weeks with impaired social functioning and a positive score on at least five of the following:

• change in weight or appetite
• change in sleep pattern
• lethargy
• objective evidence of psychomotor agitation or retardation
• loss of interest in usual activities
• inappropriate self-blame
• inability to concentrate or make decisions
• recurrent thoughts of death or suicide

A score of only four or a low mood for between one and two weeks makes the diagnosis probable, but not definite.

Another question I use frequently to give me an idea of ‘where the patient is at’ is asking them to score their mood on a scale of zero to ten, zero being ‘absolutely terrible’ (suicidal) and ten being ‘great, couldn’t be better’. This a quick way of gauging the patient’s mood and one I find quite effective. It also leads easily into asking that awkward question ‘have you ever thought of harming yourself or taking your own life?’ This is difficult to ask at the beginning, but when dealt with sensitively I find most patients are very honest. It is essential to know if the person/friend/patient is at risk.

Caring for depressed patients

How do we manage patients in this situation? Here’s a quick check-list.

1. Listen. This is a skill which comes with practice. Being a medic doesn’t automatically mean you’re a good listener. You need to work at this and become comfortable with pregnant pauses, or a patient crying their eyes out in front of you. Patients need to be listened to. If you don’t you may misdiagnose them. Learn to be at ease. There are various types of ‘listening skills’ which are elaborated further in the article ‘Doctor as Counsellor’.[6]
2. Show concern. This may sound obvious, but is often lacking in many a consultation. Try and put yourself in the patient’s shoes.
3. Express hope. Explain the nature of the illness and make it clear that the hopelessness that they may feel is part of the illness and not an accurate assessment of the situation.
4. Provide a free booklet on depression.
5. Explain your treatment plan and check that you have the patient’s agreement. This aids compliance.
6. Suggest someone in the family comes to the next appointment to ensure that everyone concerned understands the nature of the illness.
7. Explain that you need to see the patient regularly. How regularly depends on the degree of the depression.
8. Prescribe anti-depressants for all but the mildly depressed (and not really for those who are reacting appropriately to a recent crisis, or for whom being miserable is a way of life!).

The role of anti-depressants

Some people feel very strongly that all depression is as a result of some particular sin or other spiritual problem and are therefore against the use of anti-depressants. This may be the case for some. As a consequence of the Fall we can become both physically ill and prone to mental distress and disorder. When a patient is very ill and lacking objectivity, it is often not appropriate to talk about spiritual things. Once the balance of their mind has been restored and they are able to think more clearly it may be the time to mention spiritual issues, or refer them on to a Christian counsellor. But in the early stages it is helpful to prescribe an anti-depressant to allow the healing process to begin and enable the patient to get to the point where they can begin to face up to the big issues and cope better with them. To me, it’s a bit like treating a person with a broken leg: you put them in a plaster and give them crutches to allow the bone to mend. As it does and the person is better able to cope with their mobility problems, you remove the plaster and take away the crutches at the appropriate times. You’d never dream of telling them just to get on with it. So too, people need anti-depressants to enable them to get to the point where they can cope. Then, when the time is right you remove the ‘crutches’ of the anti-depressant.

It is important to make this clear, as many patients fear going on to an anti-depressant in case they become addicted. With many of the newer anti-depressants on the market now, this is less of a problem. One should choose carefully the treatment that will suit the patient’s age and medical history. I find it helpful to explain to my patients about the possible side-effects of treatment, as this aids compliance, especially if you advise that for the majority of patients these effects resolve within a few weeks with particular drugs. If patients know what to expect they usually stick with it.

Use the Bible with sensitivity

Whilst I mentioned the role of God’s word in my recovery, I would warn against being tempted to ‘throw’ glib verses at people, just to make them (and yourself, for that matter) feel better. I think this can be one of the most uncaring and hurtful actions that you can take. For example, I remember dealing with a Christian man who was really quite depressed and had been for some months. But what made his depression worse were his Christian friends and his church. No-one had a grasp of how he felt, rather they thought that he shouldn’t feel like that. So week after week they would give him ‘a wee verse’ to cheer him up. These ill-thought actions only made his depression worse. The book of Job may teach us how to avoid being an unhelpful ‘comforter’. There is a time and place for using God’s word, but it must be in a caring manner. Often a hurting person just needs to know there is someone there for them.

Coping with depression in ourselves

As a medical student, you should be aware that you are about to join a profession that has a higher than average incidence of suicide and alcoholism than the general public. There are a lot of stressed-out doctors and you need to be prepared to face this stress because it will hit you all too quickly! Warning signs include: drinking alcohol before facing work/patients; minimising every contact with patients/colleagues, so that you do the bare minimum that will suffice; inability to concentrate on the matter in hand with your thoughts entirely taken up by the workload ahead; irritability; inability to take time off without feeling guilty; feelings of liexcessive shame or anger when reviewing past debacles (to avoid mistakes it would be necessary for us all to give up medicine - so don’t beat yourself up!) and emotional exhaustion.

What should you do if you think you are falling into this situation?

1. Recognise that you are stressed. If you can’t see it, take it seriously when a friend or colleague points it out.
2. Confide in someone you can trust and whom you feel is well fitted to help you.
3. Give your mind time to rejuvenate itself.
4. Look at the potential causes and then try and take control: learn to prioritise, don’t arrive late, spread out your paperwork and don’t allow it to mount up, take time out for yourself: to be quiet, to feed, to rest, to go to the toilet, to exercise and relax ! If all this fails consult your own GP or other such professional for help. Remember the BMA has a confidential help-line. Use it if needed.
5. Last, and by no means least, make sure you take time every day to be quiet with the Lord, to read his word and to talk to him. He has been there before you and he knows what you’re going through.