Depression: Looking Up from the Stubborn Darkness (22 page)

She battled well. She sought help, enlisted prayer, read books, and was tough on herself, but it didn’t make any difference in either her mood or productivity. She would have stayed that course, except family and close friends were pleading with her to try medication. As a way to love those close to her, she heeded their advice.

So far, it hasn’t made any noticeable difference, but it might. The first medication she was given left her mentally disorganized and fuzzy, so it was quickly changed. The second medication seems to be neither helping nor hurting. Her psychiatrist will give her another month and then consider adding a new medication.

Depression involves the whole person, body and soul. The soul or heart is always busy interpreting painful circumstances and sorting out basic allegiances. The body just feels sick.

Following Scripture’s lead, matters of the heart are the priority.

Physical training is of some value, but godliness [spiritual training] has value for all things, holding promise for both the present life and the life to come. (1 Tim. 4:8)

The heart is the real battleground during suffering, and it deserves your utmost attention. As you learn how to put your hope in Christ, your work reaps eternal benefits. But that isn’t all. Since you are a hybrid consisting of both physical and spiritual, your physical body can respond to your spiritual growth. In other words, as the Spirit, Scripture, and wise people guide you, you might feel lighter (2 Cor. 4:16–18). Your pain won’t have the same devastating power.

Most current thinking tends to miss the spiritual essence of depression. (Keep in mind that this doesn’t mean that there is always a spiritual cause of depression. It means that depression is always accompanied by questions about God, ourselves, hope and meaning.) Modern approaches specialize instead in physical treatments, and they, too, can lighten the physical experience of depression such as the lethargy, problems concentrating, and even the emotions themselves. The basic rule is this: physical treatments can possibly alleviate physical symptoms, and when depression is raging most people would be delighted to take the edge off some of the physical symptoms; but physical treatments don’t treat the guilt, fear, self-loathing, and other distinctly spiritual symptoms.

Antidepressant medications are the best known and most popular of the physical treatments, but there are hundreds of proposed physical aids, and many of them can change the physical experience of depression. They will not give you hope, but they might make you feel less miserable.

There is broad agreement that antidepressant medication can make some people feel better. In fact, there are times when the reduction in depressive symptoms can be dramatic. That is its major advantage.

But there is much we still don’t know. For example, we don’t know why it helps. The most popular hypothesis is that depression is related, in part, to a lack of the brain chemical serotonin. Many of the new medications, called serotonin reuptake inhibitors (SSRIs), make this chemical more available in the brain. If these help, that would seem to establish the presence of a specific chemical imbalance. But there are well over fifty neurotransmitters in the brain; they are found over large areas, and their interactions with one another defy present analysis. The truth is that the biological theories remain theories.

When medication helps, we don’t know why. The brain is simply too complex, and our knowledge of its mechanics is too primitive. This year, serotonin is the favored neurotransmitter. In previous years it was dopamine. In future years it will be another brain chemical. There remain many unanswered questions.

• We don’t know why medication helps some people.
  
• We don’t know why it
  doesn’t
  help others.
  
• We don’t know why, for any individual person, some medications are more effective than others.
  
• We don’t know why medications that are chemically different have similar effects.
  
• We don’t know why antidepressants seem to be equally effective with seemingly unrelated problems, such as obsessive thoughts and compulsive behavior.
  
• We don’t know why it can take up to a month before people notice a difference.
  
• We don’t know why antidepressants often lose their effectiveness over time.
  

At this point, the most apt analogy for how these medications work is aspirin. Aspirin can alleviate symptoms, but it doesn’t necessarily treat an underlying cause. In a similar way, antidepressants can help, even though a medical exam will not reveal a “chemical imbalance.” There are no blood tests to verify that a chemical deficiency is the cause of depression.

Should you take medication? Most likely you already are. If you aren’t, just make an informed decision.

Medication vs. no medication.
It is unclear whether medication is any more helpful than counseling. (And it is unclear whether counseling is any better, overall, than talking with a wise friend.) Even in cases of severe depression, careful analysis of the evidence does not always demonstrate the superior effectiveness of medication over secular counseling.
¹
You would expect
at least
similar results when you allow Scripture to guide you.

Side effects.
Any medication can have side effects. Antidepressants are no different. Overall, their side effects are not severe, but some people have such difficult reactions that they stop taking the medication. Dry mouth and difficulties in sexual functioning are among the more common side effects.

Long-term use.
Although people have taken antidepressants for many years, we still aren’t certain about their long-term effects. We know that some antidepressants lose their effectiveness over time— the so-called “poop out” effect. Also, there is increasing evidence that antidepressants are mildly addictive in the sense that you have to withdraw from them carefully. The problem with this process is that it is difficult to distinguish between the consequences of cutting back on medication and the depression itself. As a result, when you stop medication, you might mistakenly think your feelings of depression are returning when you are actually experiencing withdrawal symptoms.

Guidelines.
If you are already taking medication, are you feeling better or worse than you felt before you started? If you are no different or worse, talk with your physician to discuss a change.

If you are depressed and not taking medication, you could try medication immediately, or you could delay that decision. Once you start medication, you tend to stay locked in to it.
²
If you decide to wait, use the time to “take your soul to task” and relearn the gospel. Try to jam it into every nook and cranny of your life until you notice real hope. Many people also suggest that regular exercise is helpful. These steps may alleviate your pain more than you expect. Another benefit of postponing medication is that it is easier to figure out what is helping if you introduce one “treatment” at a time. For example, if you started medication at the same time you started seriously considering your own heart, you wouldn’t know if any improvements you experienced were from spiritual changes or medication.

Some depressed people are highly suicidal or passive in the extreme. These men and women, without doubt, are struggling with essential heart issues and you should persist in offering creative expressions of the gospel. Usually in such situations, however, families also pursue medical treatments in an effort to try
everything
reasonable to help. The main concern is if the depressed person has considered overdose as a suicidal plan. Since antidepressants can be lethal in large quantities, families should restrict the amount accessible to the depressed person.

When in doubt, get counsel from other pastors, counselors, physicians, or lay people who have biblical wisdom and experience with depression.

Easily overlooked in the discussion about medication is the fact that depression can be caused by a number of medical problems. In most cases, no treatable medical diagnosis can be found, but if your experience of depression is not clearly tied to particular circumstances, then consult a physician for a medical exam (table 21.1).
³

In this list of medical problems, post-partum depression is one of the most recognizable. In minor and temporary forms, it is very common. Many women experience the blues after delivery because they have just experienced a physical upheaval and the body needs time to adjust. People who go through major surgery experience the same thing. Some women, however, experience depression that is more severe and long-lasting. The causes are unclear. Antidepressant medication might help, and women should be open to considering it. Also, since secular non-medical help, encouragement, and direction have been helpful for these women,
⁴
you would expect biblical help, encouragement, and direction to be even more helpful.

Since depression is so common, and since there are no definitive medical cures, possible treatments have proliferated. Some of the more common include sun-mimicking lights (for those with a seasonal rhythm to their depression), herbal treatments, exercise, diet, megavitamins, and drugs not originally developed to treat depression. More technical procedures include repeated transcranial magnetic stimulation and electroconvulsive therapy (ECT). ECT is of special interest because, after a time of decline in the 1970s and 1980s, it is once again a popular treatment for severe depression.
⁵

The question with these physical treatments is not, “Is this treatment right or wrong?” The question is, “Is this treatment wise?” The guidelines of wisdom apply. For some treatments, such as moderate changes in diet and exercise, the risk and expense are minimal, so they do not demand extensive deliberation. But some of these treatments have higher risks. Therefore, wisdom calls for a careful investigation of the treatment, prayerfulness, and seeking counsel from an experienced, wise group.

We can be thankful that we live in an era when there are ways to alleviate the physical pain of depression. Still, it is worth examining the culture in which these treatments have emerged. For example, one feature of present-day thinking is that we still put our hope in medicine. Therefore, not only can medicine become idolatrous to us, but any treatment that comes with the veneer of medical science is likely to intensify a placebo effect. By that I mean that a medical treatment can change the experience of depression not because it is a successful treatment in itself, but because we have put our hope in that treatment, and our hope is what revises our experience of depression.

We also live in a culture that assumes we are only physical beings. Given that assumption, medication and other physical treatments are seen as the only possible ways to help. But we are also spiritual beings, and fundamentally so. We all live in the presence of God. When we recognize our spiritual core, we find that there are places in our lives that go deeper than any medication can reach.

Finally, our culture no longer sees any value in hardships. Although we all know that hardships have refined our character and matured us, we still try to escape suffering when it comes. This certainly isn’t to say that we should pursue hardships or continue in pain when there are safe means to alleviate it, but hardships simply feel different when we know that God uses them to refine and change us.

With these issues in mind, be careful. Choose wisely.

Discussions about medications and other physical treatments tend to provoke strong and sometimes extreme responses. If you have been hurt by medications, you oppose them. If you have been helped, you advertise them. Scripture, as is its custom, takes a third position that encourages wisdom, opens our eyes to larger issues in the culture, and keeps its focus on the heart.

Rose has had lots of help. She sees a psychiatrist. She meets with a counselor. She knows that her pastor cares and prays for her. But if she had to choose who was most helpful for her, she would say her family and friends. When she started descending into depression, is was the love of family and friends that softened the landing and inspired her perseverance.

This chapter speaks first to the person who is depressed, then to family and friends.

Depression can be hard on relationships. If you are depressed, you need relationships but you isolate yourself. You want help but you reject most counsel. You get encouraging words from others but you don’t believe them. And if family or friends get frustrated, you say you predicted it all along. You act as though you were just waiting for them to get frustrated with you, perhaps even hoping for it. You believe you are worthless, and you seem bent on proving it.