Think about the recent personal conversations you’ve had with troubled people. Do any of them sound like these testimonies from Arlene and Greg?1
Arlene “It was really hard to get out of bed in the morning. I just wanted to hide under the covers and not talk to anyone. I didn’t feel much like eating, and I lost a lot of weight. Nothing seemed fun anymore. I was tired all the time, yet I wasn’t sleeping well at night. But I knew that I had to keep going because I’ve got kids and a job. It just felt so impossible, like nothing was going to change or get better.”
Greg “At first I was feeling sad all the time, even though I had no reason to be. Then the sadness turned into anger, and I started having fights with my family and friends. I felt really bad about myself, like I wasn’t good enough for anyone. It got so bad that I wished I would go to bed and never wake up.
“My older brother, who I always looked up to, saw that I wasn’t acting like my usual self. He told me straight out that I seemed depressed and that I should talk to a doctor about it. I hate going to the doctor. I thought, ‘No way am I going in for this.’
“But after a few weeks, I started having problems at work too. Sometimes I wouldn’t show up because I wasn’t able to sleep the night before. When I got fired, I knew I had to listen to my brother and get help.”
The definition of depression today
Of course, Arlene’s and Greg’s testimonies are just snippets from their lives, and although there were some differences in their experiences, both of them had enough similarities to label them “clinically depressed” by the criteria used today. Clinical depression, as I am using it, is a broad term that incorporates a couple of more specific diagnostic labels used by mental health professionals.2 In order for such labels to be applied to someone, a person’s lifestyle needs to be significantly affected by symptoms such as the following:
- Depressed mood most of the day, nearly every day
- Markedly diminished interest or pleasure in all, or almost all, activities every day
- Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day
- Insomnia (inability to get to sleep or difficulty staying asleep) or hypersomnia (sleeping more than usual) nearly every day
- Psychomotor agitation (for example, inability to sit still, pacing, pulling at clothes) or retardation (for example, slowed speech and movements, quiet talking) nearly every day
- Fatigue, tiredness, or loss of energy nearly every day
- Feelings of worthlessness or excessive or inappropriate guilt nearly every day
- Diminished ability to think or concentrate, or indecisiveness, nearly every day
- Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideas with or without a specific plan, or a suicide attempt
- Feelings of hopelessness
Depressive episodes can last for anywhere from two weeks to several years, and with varying degrees of severity. By definition, the presence of these symptoms is not due to the effects of any drugs or a medical condition (for example, an underactive thyroid gland). The presence of the symptoms negatively affects the person’s relationships, work responsibilities, etc.
Notice how broad the range is in these possible symptoms. Some of the criteria are physical symptoms (changes in appetite, changes in sleep patterns, changes in energy levels); some are mental symptoms (thoughts of worthlessness, inappropriate guilt, indecisiveness, thoughts of death). The impact of depression on people’s relationships is also noteworthy.
Because clinical depression is identified by the presence of these symptoms—and because a number of these symptoms have to do with the way people think, react to adverse circumstances, or relate to others—it’s important that we not miss an important logical implication: not addressing pessimistic thinking, guilt, relational problems, etc., will actually sustain depression. Over the years, this simple observation has spurred the development of several treatment strategies in the mental health community: cognitive therapy (focusing on the thinking element), behavioral activation (focused on the inactivity element), and interpersonal therapy (focusing on the relational element). Furthermore, this is important as we think about the pastoral care you might offer to a depressed person.
God’s relationship to people’s experiences with depression
From a Christian point of view, we might wonder, “Where does a relationship with God enter into a portrayal of depression?” What we call “depression” was also experienced by numerous people mentioned in the Bible. For example, compare the following verses from Psalm 102 (ESV) with the criteria listed above:
|THE WORDS OF THE PSALMIST
THE MODERN CRITERIA FOR DEPRESSION
|“My heart … has withered.” (v. 4)
|There is no motivation in the psalmist.
|“I forget to eat my bread.” (v. 4)
|There is no desire to eat.
|“I am like a desert owl of the wilderness … like a lonely sparrow on the housetop.” (vv. 6, 7)
|There is social isolation. (In Leviticus 11:16–18, owls, like other birds of prey, are considered unclean because of their association with carrion.)
|“I lie awake.” (v. 7)
|There is difficulty sleeping.
|“All the day my enemies taunt me.” (v. 8)
|There is a sense of no relief/hopelessness.
|“For I eat ashes like bread and mingle tears with my drink.” (v. 9)
|There is extreme sadness; ashes were associated with mourning rituals.
|“… because of your indignation and anger; for you have taken me up and thrown me down.” (v. 10)
|There is guilt and shame (due to the exile).
Hannah, Elijah, Jeremiah, and many more people mentioned in Scripture might be labeled as depressed if evaluated by mental health professionals today. Yet, contrary to the secular point of view, in these cases the people’s relationship with the Lord was their primary consideration both to make sense of their depressed state and to seek relief from it.
The importance of pastoral care for depressed people
From a biblical standpoint, all of the symptoms associated with depression must be addressed within the framework of a person’s relationship to God. Though “spirituality” has also recently become a point of interest among secular psychologists in the treatment of depression (and other problems), their understanding of it is not helpful to Christians. The secular definition of spirituality simply draws attention to meaning, purpose, or a desire to be in contact with “the divine,” all of which is determined by the individual person. In contrast, in the Bible, spirituality always has to do with a person’s relationship with God, and that relationship touches on all aspects of life: how one relates to others, makes decisions, thinks about the future, deals with sadness, prioritizes care of the body, assesses meaning and purpose in life, addresses guilt, etc. (Note the parallels with the symptoms listed above.) Spirituality is not a separate component of a Christian’s life; it energizes, shapes, and directs his or her life.
Therefore, as a pastor, you can be a significant resource for depressed people in your congregation. You might not be the “lead” person helping a depressed member, but in a real sense, the centrality of their relationship with the Lord means you need to help them think through all of the effects of depression on their lives from a biblical perspective. You can be the person who helps the depressed individual process the mental, relational, behavioral, and physical aspects of depression from a God-centered (spiritual) perspective. That person will most likely also get help from other professionals, but never assume that the involvement of other professionals diminishes the significance of your role! It actually highlights its significance, especially if the others are not Christians. Who else can help the depressed believer understand and respond to the many different effects of depression biblically?
- These names are not those of actual people, but representative.
- The more specific labels used by mental health professionals today are Major Depressive Disorder and Persistent Depressive Disorder (this may also be referred to by an older label, Dysthymic Disorder). Symptoms associated with Major Depressive Disorder tend to be more intense, but of shorter duration, than those associated with Persistent Depressive Disorder. These diagnostic labels come from the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (Washington, DC: American Psychiatric Association Publishing, 2013).