Downcast: Biblical and Medical Hope for Depression is meant to be a guide for the layperson and clinician considering how to approach the treatment of depression as a Christian. We encourage you to purchase a copy for yourself, for your church ministry leaders and for your Christian patients struggling with depression.

It discusses such practical subjects as considering medication, types of psychotherapy, spiritual practices that can help and misconceptions about depression, as well as an interview with Rick and Kay Warren (The Purpose Driven Life) on their personal experience with suicide. It is also a book which seeks to answer the question of how our Christian faith changes our fundamental stance toward depression, in considering the role of lament and crying out to God amidst the suffering of living in a fallen and broken world. And one way we experience that brokenness is in our bodies.

This excerpt from Downcast focuses on the role of the body and a Christian perspective on antidepressants.

                                                                                                                                               

“Or do you not know that your body is a temple of the Holy Spirit within you, whom you have from God? You are not your own, for you were bought with a price. So glorify God in your body.” — 1 Corinthians 6:19-20, ESV

Our bodies matter to God. Depression tends to deny that, and it tells people they don’t matter, their lives don’t matter and their bodies don’t matter. But that is depression’s lie. God certainly paid for lives and our salvation at great cost to Himself. And as a consequence, we are no longer our own. We belong to God. Moreover, He dwells within every believer. Our bodies are not simply our own to use and abuse. This means we are to be stewards of our bodies and care for them, even when we feel worthless and self-destructive.

And this is especially true when it comes to depression. To glorify God with our bodies means to care for our bodies, even as depression seems to drain the body of its vitality. Regardless of what the cause is for depression (see Chapter 3), depression is experienced in the body. People experience depression as physical symptoms, such as difficulty sleeping, change in appetite, lack of energy, moving slowly, difficulty thinking and a dulling of the senses, while food lacks taste and colors appear less bright. So, it makes sense that one way to fight against depression is also through physical strategies involving the body.

In most books about depression, the only two strategies discussed are medication or

psychotherapy. While we spend significant time discussing those two strategies, we also address other  strategies like sleep, diet and exercise that can be helpful; although, for anything more than mild depression, they should probably be combined with therapy (Chapter 6) and/or medication.

Ruts in the Road and Neuroplasticity

The brain is one of the mysteries of creation that we are only just starting to understand through science and medicine. As more knowledge about the mechanisms of the brain is uncovered, researchers are also constantly revising their theories about how it works. As we discussed in Chapter 3, an early theory was that depression was caused by a neurotransmitter deficiency in the brain.

But science has moved ahead to understanding the brain as functioning primarily through connections between neurons, through how the brain gets wired and rewired, in a process called neuroplasticity. The brain is constantly changing and adapting, strengthening the pathways used to make them more efficient and removing the pathways we no longer use.

Why is this important? The way that I (JH) often explain it to patients is that the repeated thoughts of depression or anxiety function like ruts in a road. Repeated thoughts wear those ruts deeper and deeper as we use these particular pathways in the brain over and over. So, it becomes easier and easier to slide down these ruts into depression, and it becomes harder and harder to get out of them and create new pathways.

Fortunately, there are ways to break out of those ruts. One particular growth factor to remember is Brain Derived Neurotrophic Factor (BDNF), a protein in the brain that supports neuron survival, growth and development. One might think of it as fertilizer for the brain. Long-term stress decreases the amount of BDNF in the brain and causes shrinkage of the hippocampus, the area in the brain associated with learning and memory. People with chronic depression have atrophy of the hippocampus and the areas of the brain related to motivation and emotion. Fortunately, increasing BDNF in the brain can stimulate neuron re-growth and development. BDNF can be increased by several strategies, including sleep, exercise, diet, medication, ECT, learning and psychotherapy.

How Medications Work

We’ve named this book Downcast, and in a very real way those who are depressed are cast down. Those with depression find it very hard to break out of this—they lose their sense of motivation and meaning, they tend to interpret everything through black-tinted lenses and they find it very difficult to learn or try something new.

All these aspects of depression have corresponding findings in the brain. People with depression have reduced levels of BDNF, which results in decreased neuron growth and development. Within the brain, there is atrophy of the hippocampus and prefrontal cortex, which are associated with motivation and learning. In contrast, there is overgrowth of the amygdala and nucleus accumbens, which are associated with fear, emotion and sleep regulation.

Understanding how antidepressants work is important. Antidepressants do not work, as was once popularly thought, by fixing a chemical imbalance. In our experience, this misconception has led to many fears about taking antidepressants, such as that they will change a person’s personality or that a person will become dependent on the medication. Rather, recent research suggests antidepressants work by two mechanisms. The first is by increasing BDNF in the brain, which enhances neuroplasticity and can counter the atrophy that occurs with depression. This process takes weeks to occur.

Antidepressants work through a second more immediate mechanism by altering the black tinted lenses by which depressed people experience the world and recall events. Depressed people have a negative bias—they tend to pay attention to and remember only negative information, and they disregard positive information. This bias can be addressed through therapy (which we describe in the next chapter) and can be helped by antidepressants. Several studies have shown that after just one dose of an antidepressant, people are more attentive to faces with positive facial expressions, not just to faces with negative expressions. Although the symptoms of depression do not lift so quickly, what is important is that over time, depressed individuals can learn a new way of perceiving the world and their interactions in it.

The practical takeaway from this is that antidepressants work by helping depressed people learn new ways of perceiving and interacting with the world. In order for antidepressants to be effective, individuals must engage in activities that allow learning to occur. They need to engage in activities such as psychotherapy, exercise and social interaction including attending church, serving others or meaningful work. Antidepressants are not a quick fix, so simply staying at home and taking antidepressants will be insufficient to break out of the cast of depression.

What does the Bible have to say about the use of medication for depression?

Some Christian counselors and pastors teach that Christians should only use the Bible, faith and the Holy Spirit’s power to overcome life’s difficulties, including depression. They usually come from one of two camps: (1) they believe depression is only a spiritual problem, or (2) they believe depression is a physical problem but individuals need to have enough faith for physical healing (and likewise do not seek medical help for other physical ailments as well.)

With regard to the first camp, we hope we have addressed this issue of causes of depression thoroughly in Chapter 3, by explaining that what affects us spiritually also affects us psychologically, sociologically and physically, and vice versa. The second camp might be addressed by challenging them to examine their beliefs about how it is that Jesus works in the world. Does Jesus only work through prayer and miracles?

Consider, for example, when Paul included in his letter to Timothy a brief practical

suggestion: “No longer drink only water, but use a little wine for the sake of your stomach and your frequent ailments” (1 Timothy 5:23, ESV). It sounds like Timothy struggled with gastrointestinal and other medical problems. Paul’s advice to Timothy was not to pray for healing, but to consider taking something medicinal for his health. While we strongly discourage using alcohol to treat medical or psychiatric problems, and Paul strongly discouraged addiction to alcohol (1 Timothy 3:3), few medications were available during that time, so wine was often used as medicine by the Jews and the Greeks. God can work miracles through practical ways. This is the “common grace” He grants to both believers and unbelievers: “…For he makes his sun rise on the evil and on the good, and sends rain on the just and on the unjust” (Matthew 5:45, ESV). We believe antidepressant medication is one of those means of common grace.

What is God trying to say to you through your depression?

This is the fundamental question to consider while taking antidepressants. We have used the fever metaphor repeatedly, and it is true again here. Depression is like a fever, and while for the minority it may be a purely biological cause, for most others depression is a symptom indicating that something deeper is going on in a person’s heart or a situation is making her or him feel deeply unhappy. Antidepressants can “reduce the fever” and give the person time to make the necessary changes in their life.

As C.S. Lewis puts it, “We can ignore even pleasure. But pain insists upon being attended to. God whispers to us in our pleasures, speaks in our conscience, but shouts in our pains: it is his megaphone to rouse a deaf world.”

The pain may be so loud that it is difficult to reflect and make changes. As Michael Emlet, a professor of biblical counseling at CCEF, put it, sometimes medication can “calm the waters of the mind to allow for deep-sea exploration. You can’t have a diving expedition if there is a gale on the surface of the water.”

Taking antidepressants or other medications is only one step toward healing from depression. The next step is much more difficult, since it requires examining your heart. What is God telling you? What have you been deaf to? What is He shouting at you in your pain?