A BRIEF DIGEST ON EVERYTHING YOU EVER WANTED TO KNOW ABOUT

DEPRESSION

FOUR SELF-HELP TOOLS THAT MIGHT CHANGE YOUR LIFE FOREVER

FRANK B. MINIRTH, M.D. - DIPLOMATE AMERICAN BOARD OF PSYCHIATRY & NEUROLOGY

"Why art thou cast down, O my soul? and why art thou disquieted within me? hope thou in God:

for I shall yet praise him, who is the health of my countenance, and my God" (Psalm 42:11).

INTRODUCTION

Depression affects everyone, to some degree. Significant, medical-type depression affects over seventeen million Americans annually. The lifetime prevalence approaches a staggering twenty percent. It is more common than coronary heart disease and cancer combined (seventeen million people versus thirteen million people). It can be lethal (i.e., from suicide). The cost is high in the form of pain, family conflict, social withdrawal, work absenteeism, reduced productivity, unemployment, and related alcohol and drug abuse. The economic cost for the treatment of depression is forty-four billion dollars, annually, compared to forty-three billion dollars for coronary heart disease. Depression remains undertreated (less than twenty-five percent receive an antidepressant); yet, it is often more effectively treated than coronary heart disease and cancer. Left untreated, the probability of a more resistant type of depression may increase, with the potential for other life-long implications. The treatment tools are significant today. The benefits for the individual may be great and the cause for Christ may be immeasurable.

In the following pages, one may find some of the therapeutic tools that offer help. First, let's look at the various causes, symptoms, and types of depression, along with some general history.

I. DEFINITION OF DEPRESSION. Depression is a disturbance of mood. It involves a happy-sad axis. One who is experiencing depression may exhibit a sad affect, have painful thinking, develop a variety of physical symptoms, and be anxious. The major types of depression are listed below.

II. HISTORY. The Bible mentions "spirit and soul and body." In the middle ages, there was a demonic emphasis. In the years between 1850 and 1900, there was the idea that depression was "due to medical disease." The next fifty years witnessed a shift to an emphasis on psychological factors as the underlying cause of depression. In the 1950s, "biological underpinnings" were the focus. In 1984, the question, "Can mental illness be explained on the basis of changes within the brain?" was considered. Neuroscientists are at the point where answers to such questions may soon be possible. During the 1990s, the focus has been on the interactions of the biological and the psychological factors. Thus, in the 1990s, we are close to the Biblical emphasis.

III. DIAGNOSIS. Major depressive disorders are more apparent in a two to one female to male ratio. It is defined by experiencing five of the following symptoms during a two week period: decrease of mood, decrease of interests, change in weight, change in sleep, agitation or retardation, decrease in energy, increase in guilt, increase in worthlessness feelings, decrease in concentration, and increase in thoughts of death.

A manic episode will have presenting symptoms such as an abnormally elevated, expansive, and irritable mood for more than one week, increase in grandiosity, decrease in sleep, increase in talking, increase in the amount of thoughts, and increase in distractibility, increase in goal-directed activity, increase in activities with painful consequences (three or more), and marked impairment of occupation, socialization and relationships.

A Dysthymic Disorder is evidenced by a depressed mood that continues for at least two years.

A Cyclothymic Disorder will continue for a two year period and is not as severe, with either an increase or decrease in mood.

A Bipolar II Disorder - Major Depression with Hypomanic Episode diagnosis may be indicated when one or more major depressive and hypomanic episodes have occurred that cause significant distress or impairment to one's functioning.

A Mood Disorder Due to General Medical Condition is characterized by one's mood becoming disrupted when there is direct evidence that the underlying cause is a medical disease.

A Substance-Induced Mood Disorder may be the diagnosis when there is sufficient physical and historical evidence of a disturbance of mood due to substance use or withdrawal.

An Adjustment Disorder with disturbance of mood may be evidenced when one's emotional or behavioral symptoms increase due to an identifiable stressor(s) during a three-month period.

IV. ETIOLOGY - CAUSES.

A. Genetic Factors. Family studies on Major Depressive Disorders (MDD) indicate that fifty percent of those diagnosed with MDD have a first-degree relative who has also been diagnosed MDD. Studies also conclude that identical twins (monozygotic twins) demonstrate a common occurrence of fifty percent, while fraternal twins (dizygotic twins) show a common occurrence of fifteen percent. In studies of Bipolar Disorders, the data indicates that ninety percent will have a first-degree relative who has been diagnosed with a Bipolar Disorder. Sixty percent of monozygotic twins studied and fifteen percent of the dizygotic twins studied were shown to have a Bipolar Disorder common occurrence. A physiological effect known as "kindling" in ongoing depression may make depression more resistant. Chromosome abnormalities in X, 11, or 18 may be present in Bipolar Disorders. In depressive disorders, there are usually imbalances of neurotransmitters such as NE 5-HT, dopamine or GABA.

B. Psychological Factors. As the brain experiences stress, changes in the neurotransmitters may occur. If one should lose a parent before eleven years of age, he or she would be predisposed to depression. Although anger has often been proposed as the cause of depression, this has never been proven. In a variety of animal studies, there are indicators that show learned helplessness may, in turn, lead to depression.

C. Spiritual Factors. There are several possibilities to explore from one's spiritual walk that may influence depression.

1. Sin and Guilt. "I acknowledged my sin unto thee, and mine iniquity have I not hid" (Psalm 32:5a).

2. Lack of Realization. "Why art thou cast down, O my soul?" (Psalm 42:5a).

3. Wrong Perspective. " . . . I saw the prosperity of the wicked . . ." (Psalm 73:3-4).

4. Threat by Man. "Then Jezebel sent a messenger unto Elijah, saying, So let the gods do to me . . . (I Kings 19:2).

5. Loss. "Then Job arose, and rent his mantle, and shaved his head, and fell down upon the ground, and worshipped" (Job 1:20).

6. Anger. ". . . It is better for me to die than to live . . . I do well to be angry . . ." (Jonah 4:8-9); " . . . Why art thou wroth? and why is thy countenance fallen?" (Genesis 4:6).

7. Rejection by Man. "Woe is me, my mother, that thou hast borne me a man of strife and a man of contention to the whole earth! . . . every one of them doth curse me." (Jeremiah 15:10).

V. TREATMENT. There are several factors that need to be considered when seeking treatment. These include:

A. The Setting. What type of clinician is best for one - a psychiatrist, a psychologist, or a counselor? What type of counseling will be most beneficial for one - outpatient or inpatient?

B. Assessment of Safety. Does the setting provide a caring atmosphere where one will be able to express his or her feelings and thoughts with confidence? A place where one might be heard and understood?

C. Psychotherapies. What type of therapeutic discipline will work best for one - Behavioral, Cognitive, Insight, Interpersonal, etc.?

D. Psychopharmacology. Studies have indicated that there is a seventy percent effectiveness rate of depression being lessened with the use of medication. The old Tricyclics (TCAs, such as Elavil [Amitriptyline HC1], Pamelor [Nortriptyline HC1], Sinequan [Doxepin HC1] & Tofranil [Imipramine HC1]) were effective in blocking many neurotransmitters, but there were many possible side effects. Then along came the Monamine Oxidase Inhibitors (MAOIs, such as Nardil [Phenelzine sulfate] and Parnate [Tranylcypromine sulfate]) that have also been effective, but may have many possible side effects. About ten years ago, a new broad spectrum antidepressant series came along known as Selective Serotonin Reuptake Inhibitors (SSRIs). Among the best of the antidepressants are the SSRIs such as Paxil (Paroxetine HC1), Luvox (Fluvoxamine), Prozac (Fluoxetine HC1) and Zoloft (Sertraline HC1) that target one very specific neurotransmitter with possible decreased side effects, but drug interactions may still be a significant concern at times. The SSRIs have been used in a broad array of depressions with specific symptoms such as panic attacks, pain, PMS, eating disorders, anger and OCD. More antidepressants have come along in recent years that, in general, may have less side effects and less drug interaction (such as Wellbutrin, Serzone, Effexor and Remeron). Wellbutrin (Bupropion) is a dopamine reuptake blocker that may be a factor in the sexual area. There is usually no increase in weight and may increase energy, decrease smoking addiction, and increase the focus of depressives with ADHD issues. Effexor (Venlafaxine) is a 5-HT NE Reuptake Inhibitor that is used not only in "regular depression," but also in "resistant depression." Remeron (Mirtazapine) has been proven effective for depression with anxiety and insomnia. It may provide a fast onset leading to an increase in NE and 5-HT presynaptic terminal. It also works by antagonism of the 5-HT2, postsynaptic terminal. Desyrel (Trazodone HCI) and Serzone (Nefazodone) are two similar compounds that may be beneficial to depressives who also have insomnia and anxiety. Serzone, a 5-HT2 antagonist, blocks the reuptake of NE and Serotonin. Vestra/Reboxetine, a norepinephrine reuptake inhibitor, is to be introduced soon. Xanax (Alprazolam), a minor tranquilizer, may help in depression. Augmentations with BuSpar (a 5-HT1A agonist), Beta Blockers (such as Visken), Lithium, and Thyroid may produce added results in depression. There are numerous drugs, some new to the market, that have been effective for Mania. These include Depakote, Lithium, Tegretol, and Neurontin. The older antipsychotic drugs such as Haldol, Mellaril, Moban, Navane, and Thorazine may still be effective in depression with a possible psychotic element, but may have undesirable side effects. In recent years, there has been a wave of new antipsychotic drugs such as Zyprexa (Olanzapine), Risperdal (Risperidone), Seroquel (Quetiapine fumarate), and Clozaril (Clozapine) that are more specific at the site of action, and may have less undesirable side effects and a potential for more desirable results (although any drug can potentially have almost any side effect). Paul Ehrlich, a German scientist in the early 1900s, made a prediction that is coming closer to reality. He stated there will be "a drug would be aimed precisely at a disease site and wouldn't harm healthy tissue."

E. Spiritual. The Bible provides its reader with at least seven men who overcame depression.

1. Below are the Eight R's that lead to Responsible Behavior:

a. Refocus - Maschil, for the sons of Korah - "Why art thou cast down, O my soul? and why art thou disquieted within me? hope thou in God; for I shall yet praise him, who is the health of my countenance, and my God" (Psalm 42:11).

b. Right perspective - Asaph - "My flesh and my heart faileth: but God is the strength of my heart, and my portion for ever" (Psalm 73:26).

c. Refreshment - Elijah - Sleep, Supplements, Scripture, Support - ". . . he lay and slept under a juniper tree, behold, then an angel touched him, and said unto him, Arise and eat" (I Kings 19:5).

d. Repentance - David - " . . . I will confess my transgressions . . ." (Psalm 32:5).

e. Realization of the Big Picture - Jonah - ". . . Thou hast had pity on the gourd . . . should not I spare Ninevah . . ." (Jonah 4:10-11).

f. Realization of God - Job - "I have heard of thee by the hearing of the ear: but now mine eye seeth thee" (Job 42:5).

g. Rejoice in God's Word - Jeremiah - "Thy words were found, and I did eat them; and thy word was unto me the joy and rejoicing of mine heart" (Jeremiah 15:16a).

h. Responsible Behavior - "If you do what is right, will you not be accepted? But if you do not do what is right, sin is crouching at your door; it desires to have you, but you must master it" (Genesis 4:7b, NIV).

2. Observations. Several interesting observations may be drawn from the men above. Since there are so few cases, these observations are not absolute, but certainly interesting. The most important insight is that, in all cases, the emphasis was on the spiritual in treatment. The etiologies were diverse.

VI. FOUR SELF-HELP TOOLS FOR CLIENTS THAT MIGHT CHANGE THEIR LIVES FOREVER. The following are four of the most common tools used by counselors to help clients with depression:

A. Change Your Behavior. Focusing on specific behavioral changes on a daily basis can be helpful. Feelings, to a degree, follow behavior, so one may want to change the daily behaviors. If "Plan A" is not working, one may implement "Plan B." One can list ten new behaviors to be tried daily for one week. Then, ask, "Am I feeling better?" Four words may hold the key to success: daily, specific, minimal, and commitment. The ten-point plan needs to be daily for a week or two in order to have any effect. The plan needs to be specific - generalities usually do not work. A minimal commitment may get better results than asking for something that will occur for only a short period of time. An example of a ten-point plan may look like this:

1. Do a minimum of ten push-ups one time per day - can be more, but must be ten.

2. Spend six minutes of quiet time with God daily - three minutes in prayer and three minutes in memorizing one verse that offers help and hope.

3. Have one phone call per day to someone who can offer support.

4. Read one chapter per day from a helpful book that is behavioral-oriented.

5. From a list of ten options for dealing with a current conflict, pick two per day to actually implement (i.e., a gentle confrontation, a specific request for change from someone, an apology).

6. Add four more of one's own specific, minimal, behavioral plans to implement every day for one to two weeks. A behavioral orientation can be very powerful because it can be simple and concrete enough that everyone can understand it. It can be comprehensive (physical, psychological and spiritual) and therefore, perhaps more likely to get results. A helpful verse from Genesis states, "Then the Lord said to Cain, 'Why are you angry? And why has your countenance fallen? If you do well, will not your countenance be lifted up? And if you do not do well, sin is crouching at the door; and its desire is for you, but you must master it'" (Genesis 4:6-7, NASB).

B. Challenge Inaccurate Thinking. We think four hundred to twelve hundred words per minute. From PET scans, we find that some people think too much. We certainly know we think incorrectly at times, and this inaccurate thinking causes more pain than the actual events in life. Several errors in thinking may occur: Magnification (this is "end of the world" thinking); Personalization (taking the unjust actions by others personally rather than seeing the unjust actions, is more of a statement about the person committing the action); Polarization (seeing others as only terrible or terrific and not realizing everyone is on a spectrum of maturity); Emotional reasoning (I think and feel a certain way, so it must be so); Overgeneralization ("things can never change" type thinking) and Selective Abstraction (looking only at the negative). A new, more accurate belief can repeatedly be offered. Life will be life. Life will be tough at times; but why intensify the pain with inaccurate, negative thinking? Thinking also needs to be limited. One should not be thinking intensely all the time. Thinking needs to be accurate. It needs to be focused on Christ. "And be not conformed to this world: but be ye transformed by the renewing of your mind . . ." (Romans 12:2a).

C. Share Feelings. Feelings need to be shared. Depressed individuals need to talk, talk, talk. Talking gets the emotions out. Without this, they may become like volcanoes ready to explode. It has long been proposed that anger turned inward is the cause of depression. Feelings can be shared with a friend, a counselor, and even God Himself. God has always loved the fellowship of His people - "Go and cry in the ears of Jerusalem . . . I remember thee, the kindness of thy youth, the love of thine espousals, when thou wentest after me in the wilderness, in a land that was not sown" (Jeremiah 2:2).

D. Gain Insight. Insight into one's personality (strengths, weakness, defenses) can help one to change for the better. Insight into how the past may be affecting the present is always in order. Insight into how past abuse, abandonment and low self image may be inappropriately applied today can be invaluable. Insight into unfair transference can be helpful. "Search me, O God, and know my heart; test me and know my anxious thoughts. See if there is any offensive way in me, and lead me in the way everlasting" (Psalm 139:23-24, NIV).

VII. THE CHEMISTRY OF DEPRESSION. In some depressions, there is a significant medical (physiological, biochemical) component. There are chemicals (neurotransmitters) in the brain that have tremendous power from a physiological standpoint. They are a major factor in sadness, happiness, worry, anger, logic, sleep, memory, anxiety, thinking, and even facial expression. These chemicals (neurotransmitters) float between the nerve cells (from the axon of one cell to the dendrite of the next cell). When one considers that there are, perhaps, upward of one hundred billion nerve cells, with each having upward of one hundred thousand synapses, then the total number of synapses would approach infinity. There would, perhaps, be more synapses in one brain than all the stars in the known galaxies. Thus, the power of these synapses and the neurochemistry in them is awesome. We now know from research that these neurotransmitters are altered in mental disorders. To be overly simplistic: if dopamine is altered, then one may be out of touch with reality; if GABA is altered, one may be anxious; if ACH is altered, then one may have memory problems; if norepinephrine is altered, one may be manic high; and if serotonin is altered, one may be depressed, worried, and more irritable. Indeed, in depression, serotonin is often low (as may be norepinephrine and/or dopamine). Antidepressant medications often block the reuptake (and thus metabolism by the mitochondria) of serotonin at the presynaptic nerve terminal. If serotonin (or norepinephrine and/or dopamine) is not taken up and metabolized, then it increases in the synapse; thus the mood lifts, and anger and worry may go down.

Today, we not only know which neurotransmitters produce certain emotions, we even know about neurotransmitter subsystems. For example, there are at least eighteen subtypes of serotonin receptors alone. We even know what the subneurotransmitters do and we have medications that will not only affect specific neurotransmitters, but also subneurotransmitters. The biochemistry of depression has become a science in and of itself.

Several parts of the neurotransmitters have been affected, and thus, the mood of the individual. The midbrain (with the Raphe Nucleus [serotonin production], Locus Ceruleus (norepinephrine production, and Substantia Nigra (dopamine production]) is very important. The limbic system (with the Hippocampus [important in memory], the Amygdala [important in anger], the Nucleus Accumbens [important in additions], and the Hypothalamus [important in eating and endocrine issues]) also plays a significant role. The frontal lobe of the cerebral cortex is, of course, the center for higher thoughts and actions.

The old Tricyclic antidepressants (Elavil, Tofranil, Sinequan, Pamelor, Vivactil, etc.) tended to block many neurotransmitters and tended to have many side effects. The same was true of the old MAO inhibitors. About ten years ago, a new series of antidepressants were produced - the SSRIs or Selective Serotonin Reuptake Inhibitors such as Prozac, Paxil, Zoloft, and Luvox. They were more specific in that they just blocked one neurotransmitter - serotonin. Since then, additional antidepressants have appeared (Wellbutrin, Effexor, Serzone, Remeron). With some of these, the specificity has increased so that even subsystems of serotonin may now be modulated.

Two major factors act upon the neurotransmitters with all of their power on emotions. One is stress, and the tools in Part VI should help. The other is genetics and the medicines above may be extremely helpful.

CONCLUSION

The symptoms of depression are multifactional. The causes are diverse and incorporate generalized current stressors, early life issues, and the choices one makes. The treatments are often excellent. There is much hope today for treating depression. In fact, the treatability of depression is high, whereas the treatability of coronary heart disease and cancer is variable. Why not avail oneself of that help - medically, psychologically, and most of all, spiritually? Why not do something to get well? Aristotle once said that we are what we repeatedly do. This series presents the information that is usually considered among the best scientific and spiritual tools available today that will allow one to understand and change what one does - to go from depression to making happiness one's choice. "Why art thou cast down, O my soul? and why art thou disquieted within me? hope thou in God: for I shall yet praise him, who is the health of my countenance, and my God" (Psalm 42:11).

REFERENCE:

Happiness is a Choice

Frank Minirth, M.D. and Paul Meier, M.D.

Baker Publishing, 1978

KEY:

NE = Norepinephrine

D = Dopamine

5HT = Serotonin

5HT2 = Serotonin Subtype

5HT1A = Serotonin Subtype

TCA = Tricyclic Antidepressants

SSRI = Selective Serotonin-Reuptake Inhibitors

MAOI = Monoamine Oxidase Inhibitors