Understanding Depression and the Role of Medication
Unless you live in a bubble, is it not a universal human experience to face
adversity? The scriptures testify to it certainty, especially for “everyone who
wants to live a godly life in Christ Jesus” (2 Tim. 3:12 NIV). So what
happens when we encounter trials?
“I found myself in trouble and went looking for my Lord; my life was
an open wound that wouldn’t heal. When friends said, ‘Everything will turn
out all right,’ I didn’t believe a word they said” (Psalm 77:2 The Message).
So when people are “looking for the Lord” in their times of trouble,
shouldn’t we be compelled to reach out with the gospel in word and deed,
just like the Apostle Paul did in the New Testament?
God, the human body, and depression
The body is a finely tuned homeostatic mechanism that not only reflects
intelligent design, but also reveals a compassionate God who equipped it
with systems to respond to every life contingency. As a physician, I marvel
at both the body’s complexity and its ability to adapt (sometimes in an
instant) to change in our circumstances. The brain’s capacity to mediate
emotion in the process of such adaptation is a good example of how fearfully
and wonderfully we’re made.
One could think of depression as the body’s “alarm system.” Any
alarm system is designed to warn us of some real and/or imminent danger.
Imagine, for instance, that you went to bed one night, and an hour later you
were suddenly awakened by the deafening scream of your fire alarm. You
race down the hall, hustle your children out of the house to safety, and then
watch as your home burns to the ground. Wouldn’t you be overwhelmingly
grateful that you had a fire alarm that worked the way it was designed?
Like any good alarm system, the symptoms of depression are
designed by God to get our attention and warn us of danger to our spiritual,
psychological, and physical lives. Therefore, appropriate analysis and
therapeutic intervention must address all three of these areas in order to
maximize full restoration and healing.
Depression and the brain
Since my training is in the biological sciences, I would like to explain as
clearly as I can the essential role of neurotransmitters for the normal
functioning of the human brain and emotions. Christians and non-believers
alike are subject to the way God has created our bodies to function, just as
we are all subject to gravity. One of the hardest questions to answer is
“When should medical treatment be considered? When has the line been
crossed from human emotion to medical disorder?” Dr. Stephen Stahl, M.D.,
one of the world’s leading authorities on the functions of brain chemistry,
Depression is an emotion that is universally experienced by
virtually everyone at some time in life. Distinguishing the
“normal” emotion of depression from an illness requiring
medical treatment is often problematic for those who are not
trained in the mental health sciences. Stigma and
misinformation in our culture create the widespread, popular
misconception that...depression is...a deficiency of character
which can be overcome with effort. For example, a survey in
the early 1990s of the general population revealed that 71%
thought that mental illness was due to emotional weakness;
65% thought it was caused by bad parenting; 45% thought it
was the victim’s fault and could be willed away; 43% thought
that mental illness was incurable; 35% thought it was the
consequence of sinful behavior; and only 10% thought it had a
biological basis or involved the brain.
There is abundant evidence of a complex mind-body interaction. This
interaction, interestingly enough, makes it challenging to sort out the origins
of change even at the physiological level. We know, for example, that
emotional and behavioral changes made in therapy—changes that involve
making different choices in life—can prompt changes in brain chemistry just
as much as changes in brain chemistry can prompt corresponding changes in
emotions and behavior. In other words, psychological causes and brain
chemistry are intricately linked to one another.
The average person has moods that, from time to time or for a season,
may fluctuate slightly higher or lower than normal. It’s when these moods
fluctuate greatly or remain oddly high or low for extended periods that a
person might begin to consider depression as the cause. Depression is really
part of a spectrum including not only low or depressed moods but also
elevated or "manic" moods. The majority of depression is considered
"unipolar," which means sufferers only experience periods of depressed
mood. But others experience times of being very "up" even to the point of
irrational euphoria and significant impulsivity. The treatment for people who
have "up" episodes in addition to their depression (called “bipolar”) is
different than people who only have depressed or “down” episodes. “Mania”
is what physicians call this abnormal state of mood where the euphoria
creates significant problems including impulsivity, agitation, irritability,
racing thoughts, lack of sleep, and reckless spending.
Differentiating between people who only have a depressed mood
versus people who can fluctuate from either a depressed mood to a euphoric
mood is very important before starting the treatment process. People who
only have unipolar depression (also called major depressive disorder
(MDD)) are often treated with antidepressants to lift the mood from
depressed to normal. People who have various forms of bipolar depression
are typically treated with a "mood stabilizer" to keep them from becoming
euphoric, and then an antidepressant medication is added to keep them from
becoming depressed again during the next mood swing.
What causes depression?
The symptoms of depression should serve as an alarm system to begin an
investigation of the following areas in a person’s life:
A. Genetic factors
B. Environmental factors affecting psychological and spiritual
C. Other medical issues
Every one of these factors can adversely affect the brain and how it
functions at the molecular or hormonal level, causing a deficiency of
specific chemicals called neurotransmitters. Neurotransmitters are hormones
that “hand off” or “transmit” a signal from one nerve cell to another. In order
to function normally, you need to have a full reservoir or “tank” of these
hormones in the nerve cell ready to be released and thus communicate the
bioelectrical “message” to the next nerve. For our purposes, depression is
nearly synonymous with a depletion of these neurotransmitter hormones,
much like running out of hot water while taking a shower. If the brain does
not have an adequate amount of these hormones, the body’s nerve-messages
don’t get delivered, and the body begins to malfunction. Some people inherit
a tendency to have low hormone levels because their nerve cells either break
down more of the hormones than other people’s do, or their body simply
does not make enough of them.
In addition, when people experience significant loss, like a divorce or
death of a child, or experience physical or emotional burnout or a number of
other factors that create severe stress, the brain works overtime in
anticipation of the worst possible situation. In this “full combat alert” state,
the mind plays a “what-if” game, expending energy trying to anticipate the
worst possible scenario and making early preparation for all of the
possibilities. This reaction of the body to these strongly disturbing situations
can deplete the body’s neurotransmitters, again increasing a person’s risk for
Medication can lend assistance in all these situations by regulating the
level of neurotransmitter hormones, allowing the “message” to be sent from
one nerve to the next in a more normal fashion (like having instant hot water
for your shower). A common misconception about antidepressant therapy is
that antidepressants are habit-forming or force a dependency upon the user,
placing them in “bondage” at the hands of the physician or leaving them
vulnerable to spiritual manipulation. However, antidepressant medications
are not addicting like Valium, narcotics or cocaine; these directly stimulate
the nerves provide an altered state of consciousness or euphoria.
Antidepressants work to regulate the process by which nerves deliver their
messages from the brain to the body; consequently, they ARE NOT habitforming,
nor do they manipulate a person’s thoughts or values. It is
important to understand this, as misinformation and stigmas in this regard
can prevent some from seeking vital medical treatment or even supporting
the treatment of others. Many patients use antidepressant medication for a
season, only to stop taking it once the patient and his/her health-care team
decide it is appropriate and safe to do so. As with any medication, a patient
should only stop an antidepressant treatment regimen under the advice of the
Some of the confusion as to why certain people struggle with
adversity more than others can be answered in the concept of individual
variability. Each person is unique, and so physicians must individually
assess the potential for significant depression. Some people can go through
divorce, lose their job and seem to manage just fine, while others seem to
collapse into depression if they get disappointed by not getting a new car.
Just like the color of your eyes and hair, there is individual variability in
your body’s ability to manufacture or metabolize (break down) the brain’s
hormones. If you inherited a tendency to have low levels of these hormones,
you will be more vulnerable to experiencing a chain of events that leads to
depletion and, therefore, it is more likely that medication can provide relief.
Can significant depletion be caused by long-term emotional stress?
Yes. Can significant depletion be caused by an environmental stressor? Yes.
Can significant depletion be caused by family genetics? Yes. Therefore, how
should the issue of using medications be viewed? As a necessary evil? As
something to avoid at all costs? Is medication a panacea that should be given
The good news is that 90 percent of people who need it can be helped
significantly with their depression once they have found a suitable
medication. With this help, they are much more amenable to the work of
psychotherapy and open to receive spiritual guidance, which is more likely
to bring about lasting change.
When is depression severe enough to consider medication?
Physicians rely on the specific DSM-IV (the fourth edition of the Diagnostic
and Statistical Manual of Mental Disorders) criteria in evaluating the
following symptoms to make the diagnosis of major depressive disorder
(MDD). If a person has at least four of the following symptoms nearly every
day for at least two weeks, you meet the criteria for depression:
(1) Depressed mood and feeling of hopelessness;
(2) Loss of interest in daily activities and pleasures;
(3) Inappropriate guilt and feelings of worthlessness;
(4) Appetite changes causing either weight gain or weight loss;
(5) Sleep problems, especially early morning awakening;
(6) Agitation and restlessness;
(7) Concentration difficulties and inability to make decisions;
(8) Fatigue and lack of energy;
(9) Recurring thoughts of suicide, in which life seems empty and not worth
(10) Irritability and feeling “stressed out.”
A qualified physician will review the preceding list of symptoms and
the potential risk factors on the basis of your genetics, environmental
circumstances, and other medical conditions, medications, and history of
substance use and abuse. Self-assessment tools like the Beck, Zung, or PHQ
may also be used in an attempt to quantify the symptoms, confirm the
diagnosis and monitor improvement with therapy.
Don’t antidepressants increase your risk of suicide?
In 2004, the FDA issued a “black box” warning to physicians that
antidepressant may cause increased suicidal thinking in young people less
than 19 years of age. As a result, physicians became more cautious about
prescribing antidepressants, and many people became afraid to start taking
them. In 2008, the American Journal of Psychiatry published an article that
showed that as a result of the FDA warning, deaths from suicides actually
increased 14%. Thomas Insel of the National Institute of Mental Health said,
“We may have inadvertently created a problem by putting a ‘black box’
warning on medications that were useful. If the drugs were doing more harm
than good, then the reduction in prescription rates should mean the risk of
suicide should go way down, and it hasn’t gone down at all—it has gone
up.” He concludes by saying, “If I had a child with depression, I would go
after the best treatment but also provide close monitoring.”
What if I choose not to use medication and just “tough it out?”
Depression’s impact is not limited to the sufferer; it can drastically affect
relationships with others, especially loved ones. The brain’s neurotransmitter
activity affects cognitive and emotional functioning, impacting a person’s
attitude, motivation, perception of others, and ability to respond
appropriately. Depressed patients often express that “everything is more
difficult to do” and “nothing seems fun any more.” And because cognitive
ability can be impaired by your mood, the depression can even prevent a
person from seeing how their mood is affecting other people. If you think
you might be suffering from depression, talk to those closest to you—those
you trust intimately—and ask if they perceive any difficulty in your mood or
relationships. It might surprise you how much your behavior has affected
those around you and how obvious the condition is to others.
There is even some evidence that over extended periods of time, if
people remain depressed as a result of low brain neurotransmitter levels,
actual shrinkage in the hippocampus (deep part of the brain) can occur,
which could potentially be associated with increased likelihood of
Alzheimer's-type dementia. There is evidence that when neurotransmitter
levels are low, this causes low levels of BDNF (brain-derived neurotrophic
factor), which causes nerve cells in the brain to shrink and eventually die.
Raising levels of neurotransmitters with the use of antidepressants also
increases the brains level of BDNF and encourages the "regrowth" of
damaged nerve cells.
More than 60% of people who committed suicide suffered from a
major depressive disorder. About 8% of people with major depressive
disorder will die by suicide. Note the following risk factors for suicide:
• Diagnosis of a chronic depressive disorder
• Past history of suicide attempts or suicidal thoughts
• Family history of suicide
• Depressive episodes requiring hospitalization
• Change from inpatient to outpatient status
• Severe worrisome anxiety symptoms
• Panic attacks (recent history)
• Severe loss of pleasure in life
• Alcohol abuse: moderate or worse
What about counseling? Does it work?
Multiple studies have proven that counseling and psychotherapy plus
medication are more effective than either one alone. For many people,
counseling and psychotherapy alone can lead to healing and resolution of
depression. But just like getting on the “right” medication, finding a skillful
counselor who can help you resolve emotional, relational, and spiritual
issues may take time. You may want to check out the web site for the
American Association of Christian Counselors at www.aacc.net to find a
Christian counselor in your area.
I firmly believe in the “integration” paradigm when considering the
subject of depression and personally see on a daily basis the change in
people’s lives—whether it be from spiritual transformation, Christian
psychotherapy, or use of medication—often in combination, since each area
affects the others.
How does God view those who are depressed?
God is intimately involved in the process of our healing and wholeness. His
desire is for our good, and He does not use depression to punish us. As result
of His movement in our lives, He gives us the privilege of helping others.
More insight on this topic can be reviewed in my colleague’s article from
The symptoms of depression are very common; they are not due to
emotional or spiritual weakness. Depression is evidence that brain hormones
(neurotransmitters) are depleted. Depression will affect you in every way:
your body, your mind, your emotions, and your spirit. Therefore, assessment
and treatment must address each of those areas. There can be multiple
triggers, inciting events, and genetic or medical conditions involved, so steps
should be taken to restore those levels with proper therapy and medication
after an accurate diagnosis as to the cause is made.
Most people are more aware and open about the physical symptoms
than the psychological symptoms of their depression. There is no blood test
to make a diagnosis of depression, but a careful professional assessment can
be highly accurate. Many Christian people feel ashamed that they need to
take antidepressant medication because they feel they have disappointed
God by their choices or behavior. Some people are afraid antidepressants are
"addictive,” which they are not. Depression is a highly treatable condition,
but it can be very difficult or impossible to "fix yourself" with sheer
willpower. The vast majority of people suffering with depression can be
dramatically helped with appropriate antidepressant medication and
counseling/psychotherapy, as needed.
Be patient to find the right therapy regimen and/or antidepressant that
works the best for you. Remember most medications will have a few
nuisance side effects, but most disappear or diminish with time. God could
choose to heal someone instantaneously, but in my experience He more
often uses available medical therapies as well as effective spiritual
counseling and psychotherapy to accomplish full restoration. God truly is the
What would happen if, rather than avoiding those who are hurting or
“in a bad place,” we were actually “compelled” to come alongside them with
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encouragement to seek help by considering an evaluation for counseling or
medical treatment, accompanied by participation in a Christian group or
fellowship? There is nothing greater in life than to see others find freedom
and wholeness in Christ!
Gregory M. Knopf, M.D. has been a family practice physician for 30 years and is the founder and medical
director of the Gresham-Troutdale Family Medical Center. He is a graduate and Clinical Associate
Professor of Family Medicine at Oregon Health Sciences University. Dr. Knopf has a particular interest in
the treatment of anxiety and depression. He speaks across the country on the topic, principally for
professional audiences, and for the general public and churches as well. He is the co-author of Light on the
Fringe: Finding Hope in the Darkness of Depression with Gary Lovejoy, Ph.D. and also wrote A
Christian’s Guide to Depression and Antidepressants: Clearing Up the Confusion.
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