“I tried to kill myself yesterday.” The words tumbled from the mouth of the young woman seated in front of me. I noticed skin staples and a reddened wound under the soiled dressing she removed from her left wrist. She continued tearfully, “I cut my wrist without thinking. I didn't want to live anymore. My father found out I was not paying the car insurance and was spending on marijuana and cigarettes and sodas. I was tired of being yelled at and didn't want to face my dad's disappointment with me.” She was hospitalized under 5150, the California law which provides emergency seventy-two hour hospitalization for mentally ill persons who are a danger to themselves or others, or who are unable to care for their basic needs.
Gentle questioning revealed that a month earlier she had made another attempt to end her life. That time she had tried to poison herself with CO, positioning one end of a garden hose in the tail pipe of her car, and deploying the other end in the car window. “My boyfriend messed with my head. He told me he was having a kid with someone else.” She admitted she was “stoned on marijuana” at the time, and stated her suicidal plan “wasn't working out” because the hose kinked. She drove home and never told her family what she had done.
Finally she mentioned that when she was fifteen she had attempted to hang herself. Living with a depressed and abusive alcoholic mother, she was smoking pot and failing her high school classes. She started to hang herself, but the thought that her two younger siblings might find her stopped her. When she told her mother what she had planned to do, she was told to stop seeking attention with such behavior.
I completed taking the history and performed a mental examination, determining that she had never hallucinated, was not delusional and that she was of normal if underused intelligence. She was inactive physically, and embarrassed that her weight was 215 pounds even though her height was 5' 1''. I formulated a diagnosis: major depression, recurrent, severe and non-psychotic. I dictated a psychiatric examination and treatment plan, then ordered close nursing observation, laboratory studies, and a commonly used antidepressant.
The story I have synthesized is composed from common elements of stories heard on a hospital mental health unit. Such stories are so familiar that they garner no surprise for anyone who cares for troubled people. They may seem far removed from one's normal life, but they are not. As suggested by the title of this week's SS topic, “Hope Against Depression,” depression is an ancient and common scourge of humanity. It has been called “the common cold of mental illness.” The term melancholia, coined by Hippocrates of Cos, means “black bile” suggesting a humoral cause of depression. The term still lives, and is used to describe certain severe forms of depressive illness. Reading the familiar laments of David in Ps. 32, 39, 42, and 51 suggests extremes of despair and hopeless despondency very close to the symptoms of persons suffering from depressive illness today.
A graphic example is the depressed dialogue of David with God contained in Psalm 42.
My tears have been my food day and night,
while men say to me all day long, “Where is your God?” vs. 3.
I say to God my Rock, “Why have you forgotten me?
Why must I go about mourning, oppressed by the enemy?”
My bones suffer mortal agony as my foes taunt me,
saying to me all the day long, “Where is your God?”
Why are you downcast, O my soul?
Why so disturbed within me? vs. 9-11 NIV
The term depression is expressive if imprecise. Its meanings range from economic troubles to sadness to severe mental illness. It is a term used in common parlance to suggest conditions ranging from mild unhappiness like a “bad hair day” to true mental illness. Even within categories of mental disorders there is a range of conditions included with differing symptoms and prognosis. Among these categories are dysthymic disorder, major depression, bipolar depression, and schizoaffective disorder. It may be worth defining two of the most important of these conditions.
Major depression is a condition lasting at least two weeks and requiring either depressed mood or diminished interest or pleasure in almost all activities, most of the time, nearly every day. A variety of other symptoms may also be present, including marked weight loss or gain, severe sleep disturbance, fatigue or loss of energy, agitation or psychomotor retardation (being slowed down markedly), feelings of worthlessness or excessive guilt, diminished ability to think or concentrate, and recurrent thoughts of death or suicide. Five of these nine elements are required to diagnose major depression which can occur with or without psychotic features.
Bipolar disorder is a mood disorder featuring at least one episode of abnormally and persistently elevated, expansive, or irritable mood lasting at least a week. However, bipolar patients suffer mostly from depression, accounting for as much as two thirds of their mood disturbance. The stereotype of the happy manic person having a good time and doing only fun things is far from the unpleasant, disturbed reality such people experience.
Although untreated depression is the cause of untold misery as well as impaired productivity and economic loss, the greatest risk is that of suicide. Death by suicide is a major health hazard, the cause of more than thirty thousand unnecessary deaths in our country annually. It is a greater hazard by far than murder which accounts for about twenty thousand deaths in the U.S. each year. During the Viet Nam war years suicide deaths far exceeded combat deaths. Although a major cause of death among the young, suicide rates advance with age, and are greatest among elderly males. Suicide rates are increased related to all major psychiatric conditions, especially disorders of mood and schizophrenia. More than sixty percent of people who take their lives have major depression.
Chemical dependencies are common among depressed and bipolar patients increasing the already substantial risk of suicide. Suicide is a growing hazard among American military personnel and may be related at least in part to the stresses on family life caused by frequent deployments to Iraq and Afghanistan. It is well known that although women are about four times more likely to attempt suicide, men are nearly four times more likely to complete a suicidal act. Past history of suicidal behavior confers a nearly forty-fold increased risk of suicide.
What can be done to treat this group of illnesses we call depression? A great deal. Although the most severely depressed persons such as my patient quoted at the outset require hospitalization for self-protection and the initiation of treatment, most people do not require such intervention. For most, outpatient treatment is needed, and for most severely depressed people antidepressant treatment is likely to be necessary. Effective antidepressant and mood-stabilizing medication is of recent origin. For example, lithium, first used in Australia in 1949, is recognized as the gold standard of treatment for bipolar disorder though many newer medications are now used. FDA approved in 1970, lithium revolutionized the treatment of bipolar disorder. It has the rare ability to decrease the incidence of suicide as much as ten-fold.
As recently as 1988 fluoxetine or Prozac was introduced, a vast improvement on the tricyclic medications then available because of increased safety and diminished risk of overdose death. Creative combinations of antidepressants and newer “atypical” agents can offer hope to many who fail to respond to single agents. Today we expect chemical miracles to be the rule rather than the exception. Unfortunately such hopes may be disappointed, and we often need to seek non-medical alternative treatments.
Psychotherapy or talking therapy is still very useful, and is often most effective when used with medication. The combination of psychotherapy and medication may work better than either one alone. Bright light therapy may be very effective especially for seasonal or winter depression. Regular exercise may function as antidepressant treatment or as enhancement to other treatments being used. An antidepressant exercise program might consist of vigorous walking for forty-five minutes five days per week. Doing so in early morning light may enhance its benefit. TMS, or transcranial magnetic stimulation, is a newer treatment which has now been used on about 3000 patients in the United States. This FDA-approved treatment is generally very safe, with minimal discomfort and does not require anesthesia as does ECT or electroconvulsive treatment. The latter is still dramatically effective for certain forms of very severe depression as described by Kitty Dukakis in her recent book Shock: The Healing power of Electroconvulsive Therapy.
Are there any advantages to being an Adventist Christian when it comes to preventing or treating depression and other illness? There are many. The practice of a healthy lifestyle is one of the most important benefits even though many of us fall short of the ideal of health advocated by Ellen White. These benefits are confirmed by the Adventist Health Study and include increased longevity and lower incidence of many diseases. In addition to the benefits to health, Christian faith offers a satisfying explanation of the human condition and the human need for redemption and forgiveness. It offers relationship with a benign deity who offers Himself as the answer to human alienation from God and each other which is the result of sin. Belief in a forgiving God who united Himself with humanity, and who accepts and forgives failing mortals changes people and gives meaning to our lives. This transforming interaction between man and God does not confer immunity to accident or disease, but it does place man at the center of divine concern, and for the Christian union with the divine is the hope and ultimate glory of human existence.
A specific disadvantage to some depressed believers is the conviction that a committed Christian life should inoculate one against illness, particularly any mental illness. Why should anyone who believes in God and practices a life of Christian virtue become depressed? Does such depression not suggest a lack of faith or an absent prayer life? Or it is assumed that unconfessed sin must be the source of depression. At one extreme severely depressed Christians may become delusional, convinced that they have committed “the unpardonable sin” also known as “sin against the Holy Spirit.” Reasoning with such a person that if they had truly committed this sin they would be unconcerned rather than guilty and pointing out God's forgiving grace will not be persuasive.
Distinguishing between guilt which is irrational and guilt which represents a violation of the patient's own moral code requires the judgement of experienced therapists who are mature in their own moral and spiritual growth. Such recognition of sin as a human reality will never justify an attitude of criticism or condemnation. Rather it recalls the therapeutic intervention of our master who in a similar situation said “Neither do I condemn you,” then furnished the injunction “Go now and leave your life of sin.” John 8:11, NIV
Conscientious patients may suffer the double sting of depressive illness with the added guilty burden of believing that this illness is a reliable sign that they are unconverted. Well-meaning friends who recommend confession instead of effective treatment are likely to add to the suffering of a depressed Christian. Such “Job's comforters” should be kept away from sick people. Instead of offering the comfort of faith, they needlessly add to the stigma and self-loathing many severely depressed people feel.
Finally I suggest we return to the extraordinary prayers of David, a warrior-chief and poet of dramatic mood variations including what appear to be deep troughs of despondency and depression. Although his moods are expressed poetically, the extremes of sadness and hopelessness which contrast with devoted faith and commitment seem spontaneous and unedited. One could imagine these psalms as the free associations of a patient on the couch instructed to say whatever comes to mind. The intimacy and freedom of his prayers demonstrate a full range of human emotion and also suggest a remarkable relationship with the God he knew well. It is also clear from this poetry that David perceived a link between his sin and his mood. Whether he suffered from diagnosable depressive illness or not his graphic expression of mood may be a model of uninhibited prayer.
“When I kept silent my bones wasted away
through my groaning all day long.
For day and night your hand was heavy upon me;
my strength was sapped as in the heat of summer.
Then I acknowledged my sin to you and did not cover up my iniquity.
I said “I will confess my transgressions to the Lord”--
And you forgave the guilt of my sin. Ps.32: 3-5 NIV
This is a companion discussion topic for the original entry at http://spectrummagazine.org/node/2928