The essential facts about depression

The essential facts about depression

The anguish completely paralyzed me. I could no longer sleep. I cried uncontrollably for hours. I could not be reached by consoling words or arguments. I no longer had any interest in other people’s problems. I lost all appetite for food and could not appreciate the beauty of music, art or even nature. All had become darkness. Within me there was one long scream coming from a place I didn’t know existed, a place full of demons.1

This paragraph, written by Henri Nouwen, one of the noted spiritual writers of our time, puts the question squarely before us. What do we think about depression and religious vocation? Are they compatible or are they mutually exclusive?

The vocation director holds the responsibility of recommending individuals for admission to the congregation. It is a daunting task, especially since candidates are few and the desire for new members is strong. Therefore, this kind of decision calls for an exquisitely fine-tuned sensitivity on the part of the vocation director to the strengths, limitations and complexities of a candidate, as well as an honest assessment of the strengths and vulnerabilities of one’s own congregation.

When a candidate has a history of depression, the vocation director’s job is even harder. To be prepared for such cases, it helps to rethink our judgments about depression and update our understanding of what we are talking about when we use the word depression. Unfortunately, we have one word that refers to many different occurrences.

A number of years ago, Silvano Arieti, former president of the American Psychiatric Association, wrote the following:

Common is the sorrow that visits the human being when an adverse event hits his precarious existence or when the discrepancy between the way life is and the way it possibly could be becomes the center of his fervid reflection. In some people this sorrow comes and goes repeatedly, and in some others, only from time to time. It is painful, delays actions, and generally heals, often but not always after deepening its host’s understanding and hastening his maturation.2

In other words, a certain kind of “depression” is a normal part of life and some people experience it more frequently than others. More often than not we learn from the experience.

Arieti continues:

Less common, but frequent enough to constitute a major psychiatric concern, is the sorrow that does not abate with the passage of time, that seems exaggerated in relation to the supposed precipitating event, or inappropriate, or unrelated to any discernible cause, or replacing a more congruous emotion. This sorrow slows down, interrupts, or disrupts one’s actions; it spreads a sense of anguish which may become difficult to contain; at times it tends to expand relentlessly into a psyche which seems endless in its capacity to experience mental pain; often it recurs even after appearing to be healed. This emotional state is generally called depression.3

Today, we understand depression to be a medical/ psychological condition that affects body, mind and spirit. Through more sophisticated forms of medical and psychological research, we understand that clinical depression is caused by a complex interaction of genetic, biological and psychosocial factors. It can be assessed along a continuum ranging from mild, to moderate, to a severe, debilitating illness.

The depressive spectrum of diagnoses includes:

  • major depressive episode,
  • depression as part of bi-polar illness,
  • dysthymia (moderate depression) and
  • cyclothymia (moderate type of bi-polar disease).

If these labels were not confusing enough, depression is often seen co-existing with anxiety disorders, eating disorders and addictive patterns. The word depression often appears as part of the descriptive symptoms of various personality disorders. Clinical depression— that is, depression persistent and severe enough to merit a diagnosis—is characterized by the following:

  • A sad mood including a markedly diminished interest or pleasure in almost all activities of the day,
  • Significant weight loss when not dieting, or weight gain, or a noticeable decrease or increase in appetite,
  • Insomnia or hyposomnia (too much sleep),
  • Extreme restlessness or excessive sluggishness nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down),
  • Fatigue or loss of energy,
  • Feelings of worthlessness or excessive or inappropriate guilt,
  • A diminished ability to think or concentrate, or indecisiveness,
  • Recurrent thoughts of death (not just fear of dying), recurrent suicidal thoughts without a specific plan, or a suicide attempt or a specific plan for committing suicide.

Five or more of these symptoms indicate a valid diagnosis of depression. For a full clinical description of the depressive spectrum of diagnoses, see the Diagnostic and Statistical Manual of Mental Disorders DSM-IV published by the American Psychiatric Association. For vocation directors who may not have easy access to the DSM IV, easy-to-read descriptions are found on many informative Web sites such as the following: http://www.surgeongeneral.gov/library/ mentalhealth/chapter4/sec3.html.

A widespread condition

Depression in various forms affects about 19 million Americans each year according to the National Institute of Mental Health. Another thought provoking fact is that 25 percent of women and 10 percent of men are diagnosed with some form of depression. Approximately 50 percent of patients who experience a depressive episode will experience another episode during their lifetime, and the likelihood of recurrence increases with each successive episode. Individuals who receive inadequate treatment, and therefore do not fully recover from an episode, may suffer a relapse. Bi-polar illness indicates that the potential for a manic or hypomanic experience may be part of the depressive picture. (In the manic part of the cycle, the person experiences euphoria, confidence, energy and positive thinking to an exaggerated degree.)

Dysthymia is the less serious but more chronic form of depression. Often beginning early in life and persistent over time, its less severe but long-term course is the major feature that distinguishes it from a major depressive disorder. Dysthymia often becomes entangled with a person’s self-concept or personality. A pattern of dysthymia in childhood or adolescence usually affects personality development, especially the formation of effective coping styles. The resulting personality traits appear to be dependent, passive, or avoidant characteristics in the person. Individuals experiencing dysthymia experience varying degrees of distress or impairment in social, occupational or other important areas of functioning.

Therefore, depression takes many forms. It is a stand alone diagnosis, one side in a bi-polar mood disorder, a long term moderate occurrence (generally two years) that can also cycle between depressed periods and hypomanic periods (cyclothymia), an underlying symptom in other diagnoses such as eating disorders, addictive behaviors and acting out behaviors, and a normal temporary response to loss, disappointment, crisis or failure.

Treatment

Depression in its various clinical forms can be greatly helped by intervention. In clinical depression the chemicals in the brain are out-of-balance. Neurotransmitters in the brain such as norepinephrine and serotonin are not produced in sufficient quantities. Because of this lack, too few messages get transmitted between neurons, and the symptoms of depression occur.

Today a number of medications are available with minimal side effects. Some symptoms diminish early in treatment; others, later. For instance, a person's energy level or sleeping or eating patterns may improve before the depressed mood lifts. If there is little or no change in symptoms after five to six weeks, a different medication may be tried. Some people will respond better to one than another. Since there is no certain way of determining beforehand which medication will be effective, the doctor may have to prescribe first one, then another, until an effective one is found. Treatment continues for a minimum of several months and may last up to a year or more. Some of the most common medications are Prozac, Luvox, Paxil, Zoloft, Wellbutrin and Celexa. Paxil is often prescribed when the depressed person shows a mix of anxiety and depression. This is not an exhaustive list but simply some of the most common medications used today, especially for mild to moderate depression.

Psychotherapy is the companion treatment for depression and dysthymia. Much research has focused on time-limited cognitive behavioral therapy (CBT). The underlying premise of CBT is that an individual can change feelings and mood by changing the way he or she thinks and acts. Depression thrives on distorted thoughts such as excessive self-criticism or guilt, perfectionistic or dichotomous thinking, always anticipating the worst, and attributing unfavorable motives to others. CBT helps the depressed person to recognize these thought patterns as they emerge and to alter them toward more realistic thinking. Both medication and psychotherapy impact the brain but in slightly different ways. Brain scans “showed increased blood flow in the limbic or ‘emotional’ system and decreased activity in certain ‘thinking’ areas of the brain after CBT sessions. Subjects who took antidepressants showed different changes in the same brain regions.”4

A more recently developed form of short term therapy has also demonstrated success in assisting clients with depression. Interpersonal therapy is a form of psychotherapy in which the focus is on a patient’s relationships with peers and family members and the way they see themselves. Interpersonal psychotherapy (IPT) is based on exploring issues in relationships with other people. The goal is to help people to identify and modify interpersonal problems, to understand and to manage relationship problems. Interpersonal therapy combines elements of psychodynamic therapy, cognitive therapy and other techniques.

Lastly, psychodynamically based psychotherapy has also been effective in helping alleviate the symptoms of depression. Although there is currently less research, many individuals would attest that their depression has been helped by insight oriented psychotherapy. However, because it is often a longer term treatment, it is less cost effective than medication or the above mentioned forms of therapy.

Research indicates that medication combined with psychotherapy is the more effective way to treat depression. Recent studies have indicated that in the short run, medication is more powerful at raising energy levels and helping with behavioral symptoms, while psychotherapy helps with the longer term implications and the feelings of being “down” or sad. Statistically, more than 80 percent of people with depression improve when they receive appropriate treatment with medication, psychotherapy, or the combination.

Kay Redfield Jamison, professor of psychiatry at John Hopkins School of Medicine writes of her own experience with medication and psychotherapy:

At this point in my existence, I cannot imagine leading a normal life without both taking (medication) and having had the benefits of psychotherapy. (Medication) prevents my seductive but disastrous highs, diminishes my depressions, clears out the wool and webbing from my disordered thinking, slows me down, gentles me out, keeps me from ruining my career and relationships, keeps me out of a hospital, alive, and makes psychotherapy possible. But ineffably, psychotherapy heals. It makes some sense of the confusion, reins in the terrifying thoughts and feelings, returns some control and hope and possibility of learning from it all. Pills cannot, do not, ease one back into reality; they only bring one back headlong, careening, and faster than can be endured at times. Psychotherapy is a sanctuary; it is a battleground; it is a place I have been psychotic, neurotic, elated, confused, and despairing beyond belief. But, always, it is where I have believed— or have learned to believe—that I might someday be able to contend with all of this.5

Impact of depression on the community

Jamison’s reflections on her struggle to overcome depression show that the effort takes enormous energy. Naturally, in a family or a religious community, an experience of such intensity is bound to affect all the members. And depression visits religious at about the same rate as in the general population. According to data from a medical insurance company, during 2004, in a sample of 12,770 religious, 3,042—or about one quarter—were taking one class of medication for depression. When a member of the local community is depressed, it is stressful for each member of the group. It is not the person, but the illness, which is the source of the difficulty. Sometimes community members are involved in helping the depressed religious find appropriate, trustworthy treatment. Once this step has been taken it is equally challenging to remain supportive. Depression leads individuals to avoid contact with others, to shun normal activity. Community members often find this burdensome.

Communities that are flexible and mature enough to accommodate members who are depressed remember that the person did not ask for this illness. They are aware that it is not a moral or character flaw, and they know the individual often doesn’t have much control over what he or she does, especially in the early stages of treatment. These communities have learned that it is helpful not to take the depressive behavior personally. They know, for example, that a symptom such as withdrawal is probably not caused by something they said or did. They remind themselves of the complexities of depression and remain current about treatment options. They have found ways to support the depressed member: expressing concern, asking how they can help, giving positive reinforcement and encouraging healthy behavior. They pay attention to serious changes in the person, and sometimes, they find their own support groups or therapists. They know that the depressive episode has an end point.

Those who live with a depressed member know that it is equally important to care for their own physical and emotional health during this period of depression. Depression in one member can exacerbate depression in those who live with him or her.

Admission to a religious congregation

Yearning for some form of reconciliation, for a new, fresh beginning to their relationship, (a young woman) looked forward to her father’s driving her to college — a time when she would be alone with him for several hours. But the long-anticipated trip proved a disaster: her father behaved true to form by grousing at length about the ugly, garbagelittered creek by the side of the road. She, on the other hand, saw no litter whatsoever in the beautiful, rustic, unspoiled stream. She could find no way to respond and eventually, lapsing into silence, they spent the remainder of the trip looking away from each other. Later, she made the same trip alone and was astounded to note that there were two streams — one on each side of the road. “This time I was the driver,” she said sadly, “and the stream I saw through my window on the drivers’ side was just as ugly and polluted as my father had described it.6

As vocation directors accompany prospective members, they cannot afford the luxury of looking away, seeing out of one window and allowing themselves to lapse into silence. Rather they need to be able to keep their vision open to both sides of the road, to see the litter and the beautiful rustic stream. Religious who experience depression can be intellectually gifted members of the congregation, contributing these gifts to the ministry of the church. They can be artistically or musically talented, enhancing the prayer life of the Christian community, and they can also be individuals who are often warm, supportive, cooperative, and compassionate members of the community, despite their nagging low self esteem or periods of withdrawal. However, the vocation director must remain aware that this diagnosis merits attention, concern and a need for more information.

While individuals with severe, recurrent episodes of depression will probably not come knocking on our doors, the question becomes most difficult for those presenting themselves with mild or infrequent episodes of moderate depression or dysthymia. The challenge is to assess how this diagnosis impacts critical elements of community life and ministry. Effectiveness in ministry and compatibility in community life is a complex blend of intellectual, relational, personal and spiritual qualities. At the same time, depression in any of its forms is a significant diagnosis capable of dropping a pall over strengths and qualities and accentuating weaknesses, at least temporarily.

A predisposition to depression or dysthymia will not change. Here are some questions the vocation minister and community must answer to make a wise decision: Can the individual and the congregation accept the person’s vulnerability to depression? Does the individual take the necessary means to deal with the depression, namely, medication and therapy? Does the congregation value these means enough to pay for and support them? Some communities may value these means but may not be able to afford this or may choose not to spend their resources in this area. Is the candidate the kind of person who forms good relationships in such a way that the other members of the community want to support him or her through the difficult times? Are the candidate’s relational patterns strong enough to support periods of depression? Are local communities in this congregation capable of supporting a religious during stages of a depressive episode? What is the impact of the depression on the candidate’s spirituality and on the community members’ spirituality?

Because relational patterns are so significant in the assessment process, a major tool for assessing the influence of depression on the viability of a candidate will be the personal experience of the vocation director in relationship with the candidate, as well as the relational experiences of a number of the members of the congregation. However, it is also vital in this case to have the assessment of a trained professional who can make an accurate diagnosis, indicate treatment implications and more clearly evaluate the strengths of this particular candidate in view of his or her depression.

The formation process in a religious congregation is long and arduous. Formation, by its demanding nature, is bound to exacerbate the tendency to depression. Candidacy, novitiate and often the years of temporary profession present critical moments in the final discernment of a vocation. Recent research indicates that growth in spirituality can help alleviate the symptoms of depression and shorten the time to recovery. There is no clear way to know ahead of time exactly how the experience of community living, the demands of ministry, and the spirituality of a particular congregation will help the candidate deal with his or her depression.

Perhaps what is most challenging about considering prospective candidates who carry a history of depression is our own need to excel, to find the very best candidates. We want candidates who are enthusiastic about life, energetic about service and ministry, men and women of prayer and spiritual depth, people who are capable of making and enjoying a wide variety of relationships. Men and women religious who are depressed can be all of the above but maybe not all the time. Their periods of depression challenge us to patience, compassion and deeper spiritual understanding.

A religious vocation is lived by imperfect human beings. Who among us would want to have excluded Henri Nouwen from the seminary and thus deny the church the richness and depth of his spiritual journey and insights as a priest? In the end, vocation ministers need to look closely, with the help of a professional, at the individual before them. Can the community live well with this person? And can this person thrive in the community’s life and ministry?

 ____________________________________

1. Nouwen, Henri J. M. The Inner Voice of Love. Image Books, 1998.

2. Arieti, Silvano. in Severe and Mild Depression by Silvano Arieti, M.D. and Jules Bemporad M.D. Basic Books, 1978.

3. Ibid.

4. Harvard Women’s Health Watch, Harvard Medical School, Vol. 11, No. 12, August 2004.

5. Jamison, Kay Redfield. An Unquiet Mind. Vintage Books, 1995.

6. Yalom, Irvin D. The Gift of Therapy. Perenniel, 2002.

Mary Ellen Moore, SH is a clinical psychologist and a member of the Society of Helpers, an international religious congregation. She works at Claret Center in Chicago as a psychotherapist and supervisor for psychology interns from area professional schools. In her community she has served as novice director, provincial and currently accompanies sisters for their tertianship year.

 



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