^Depression as a general phenomenon has often been referred to as “the common cold of psychopathology”; an extreme of this condition – Major Depressive Disorder (MDD) – serves to be a much more severe form of depression, indeed, it is “one of the most common, debilitating, and deadly psychiatric conditions.”

In order to best understand this disorder it is necessary that one understand multiple aspects of it, to include: the symptoms associated with the disorder, its etiology, its prevalence, and the various modalities used to treat the disorder.

Furthermore, as the Christian counselor seeks to understand the disorder, it is also necessary that the Biblical and theological issues and critiques relating to the disorder also be addressed; this is especially true because as A.W. Tozer once noted “because we are the handiwork of God, it follows that all our problems and their solutions are theological.”

Symptoms

 The symptoms of MDD are varied and not confined to a single area of functioning, rather, there are “emotional, motivational, behavioral, cognitive and physical symptoms of depression; it is a holistic phenomenon.” As laid out by the American Psychiatric Association in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, there are nine primary symptoms of MDD.

When the individual has MDD these symptoms will be present during the same two-week period, will occur most of the day, nearly every day, will not be attributable to the physiological effects of some substance or to a medical condition, and will cause clinically significant distress in functioning.

The first of these symptoms is a depressed mood, expressed by such things as feeling sad, empty, and/or hopeless. It could be said in this state that depression feels like a mere absence of everything, of an empty pain that feels not merely like pain but like meaningless pain.

The second of these symptoms is anhedonia, or a loss of interest or pleasure in most to all activities. One of these previous two symptoms must be present in order for an individual to have MDD.

Apart from these two, at least four of the other associated symptoms must be present in order to diagnose with MDD. These other potential symptoms include such things as a significant amount of weight loss despite not dieting, or weight gain of more than 5% body weight in a month; a marked decrease or increase in appetite may also suffice. These also include insomnia or hypersomnia; fatigue or loss of energy; a lowered ability to think or concentrate; feelings of worthlessness or inappropriate guilt; psychomotor agitation or retardation; and recurrent thoughts of death, such as suicidal ideation (even without a specific plan) or a suicide attempt. One way of describing a person in this state is that they “view the world through gray-tinted glasses.”

In the Christian realm there are also spiritual symptoms which one may observe. Thus the symptoms of depression can express themselves as being compounded by a feeling that God is angry with them.

Causes

There are a number of theories regarding the causes of MDD. Sometimes the disorder seems to arise out of nowhere while other times it seems to have a trigger. Because of this it is often difficult to ascribe a specific cause to a depression. According to the DSM-5, the risk factors related to this include temperamental, environmental, genetic, and other factors.

The main temperamental risk factor associated with MDD is neuroticism, which cause individuals to be more likely to develop a depressive disorder in reaction to stressful events in life.

The main environmental factor which plays into MDD is the presence of stressful life events – this is especially so in terms of childhood experiences, which research indicates plays a large role in the development of cognitive processes. Examples of such life events would include the loss of a parent before age 5 (which has been associated with an increase in depression as an adult), some sort of abuse, or living in an environment where the child’s self-esteem was constantly threatened and/or a negative worldview communicated.

Other environmental factors include such things as the lack of a support system, systems which “have been shown to mitigate the effects of negative stressors”, as well as a significant amount of stress in the individual’s life which can result in a chemical imbalance which may then trigger a depression.

The main genetic factor associated with MDD is that having a close family member who has had MDD increases an individual’s chances of developing it themselves; it has furthermore been found that there is a higher prevalence of MDD in females than in males.

Finally, the presence of any other non-mood disorder can play into an individual developing depression, with substance abuse, anxiety, as well as borderline personality disorder being the most prevalent, along with other medical conditions. Of these other factors that may play into the development of depression, while mild symptoms of depression have been associated with conditions such as diabetes, asthma, and heart disease, it has been found that obesity does not play a significant role in causing depression.

Apart from these risk factors, there are also other elements which have been linked as contributors to depression, such as the biological element. As stated by Yarhouse et al., few clinicians today “would deny that there are usually biological foundations for problems of mood.” One of these biological elements is the influence of chemical hormones and neurotransmitters, for instance, a decrease in serotonin or norepinephrine will result in the feelings that rare labeled as depression.

A potential cause of this decrease are the thoughts of the individual, for “it is now believed that thoughts stimulate chemical hormones.” Because the chemical balance of the body plays such a large role in the way an individual feels, serious depressive symptoms can also be “direct results of poor choices about chemically controlling our mood states” such as is present with abuse of both legal and illegal medications and drugs.

The cognitive element also plays a role in the etiology of MDD. A major cognitive element present in both major and minor depression is negative self-talk, and there are at least three different misbeliefs or types of negative self-talk that individuals repeat to themselves or ruminate over as a way of devaluating themselves; these include the beliefs that they are no good, that their daily life is no good, and that their future is hopeless. This sort of self-talk “can and does create and maintain feelings which are so miserable they may lead to suicide attempts.”

While engaging in this sort of negative self-talk the individual will often reinterpret their own personal history so that those things which were good – or even average – become seen as “terrible and deserving of infinite guilt.”

These sorts of cognitive patterns often become immune to attempts at logic, and it is debated whether or not these patterns are the primary causes of depression or results of a “synergistic combination of stressors and vulnerabilities.”

In being immune to normal logic, depression also shows a logic of its own so that the afflicted individual is unable to distinguish between loving actions, hurtful ones, and indifferent ones. Regardless of whether this sort of rumination is the cause or the effect in relation to depression, it has been shown by Vanhalst that the most harmful component of rumination was often the uncontrollability of it.

This negative self-talk is generated in a variety of ways and can perhaps be narrowed down to five major cognitive errors.

These errors include: selective abstraction, where the individual focuses only on certain elements of an experience to describe the entire thing; arbitrary inference, where the individual draws a conclusion without evidence or in the face of contrary evidence; overgeneralization, where the individual draws a conclusion based upon only a single incident; personalization, where the individual relates events to themselves even without evidence that the events are so linked; and dichotomous thinking, where the individual classifies events into either/or and all/none categories despite the possibility of there being other options.

From the Christian perspective it should also be noted that sin can be a cause of depression. Despite this, one can’t automatically attribute one core sin as being the cause of a depression. This sort of connection should not be made lightly, especially since in Christian circles depression is usually seen as a moral failing anyway, even when it may not be.

Thus, while sin may be a contributing factor in a depression, other factors should always be taken into consideration.

Prevalence

According to the APA the prevalence of MDD within the United States is approximately 7%, where 18-29 year olds have a threefold higher rate than those over 60 years of age, and females have a “1.5- to 3-fold higher rates than males beginning in early adolescence.” More specifically, the prevalence of depression has be shown to be between 3-8% in adolescents (with a lifetime prevalence of 14%), and a prevalence of 17% in adults, where approximately 40-70% of those who experienced as adolescents also experiencing it as an adult.

This recurrent nature increases with each additional onset, such that approximately 60% of those who develop have one episode will experience a second, “70% of those with a second will suffer a third, and 90% of those with three or more episodes will experience further, often many more, recurrences.” Beyond this, it is also noteworthy that there are symptoms of depression “underpinning many acute psychological disorders.”

Treatment 

Recently it is becoming more understood that depression is something that needs to be treated holistically and in an interdisciplinary way. This treatment uses one or more of multiple types of interventions, to include: suicide prevention, biotherapies, psychotherapies, and family involvement. Suicide prevention is the most pressing treatment needed if there is a risk, as 15% of those with severe depression will eventually commit suicide (this in itself accounting for 60% of suicides). This can be accomplished through such things as getting the client merely to agree not to kill themselves, by breaking the pattern of ruminations through hospitalization, and to assign task once this pattern is broken.

Biological treatments are a major tool in the treatment of MDD, which includes everything from serotonin reuptake inhibitors to mood stabilizers to electroconvulsive therapy (ECT). According to Maxmen et al., 78% of individuals improve through use of ECT, 60-70% with the use of antidepressants, and 23% improve simply through the use of a placebo (p. 363). ECT is usually only used with the most severe cases of depression, such as those which do not responds to any sort of medication.

Because depression includes cycles of negative self-talk and ruminations, its treatment should go beyond mere medication to also include counseling for change in beliefs and behavior. Cognitive approaches to psychotherapy are one of the more effective treatments, especially as it is this sort of approach which is most directly able to target the negative self-talk as well as the irrational attitudes and beliefs, selective memory, pessimism, guilt, and shame associated with depression. This approach has been shown to have successful results of 50-60%.

For the Christian, part of this approach may include correcting the misbeliefs which plague the depressed individual.

Thus it can be asserted that the individual is indeed a creature of worth and value, created in the image of God. It can be shown that even a depressed person can find meaning in activities, because the daily life of the Christian comes from God. It can finally be shown that the Word of God says that the future is not hopeless, but that there is hope in Christ.

The goal of this is to change the way the individual perceives the problem, which then may result in a reevaluation of the problem; in this way “experience has been altered through the change in meaning.” Once the experience has been altered through this change in meaning the individual may begin to find some sense of hope.

Strategies along the behavioral line focus on helping the individual to develop social skills and reinforcing non-depressive actions. This development of social skills is especially important – as noted earlier – the lack of support systems is a possible contributing factor to depression. The development of social skills may go a long way in correcting this, and as is noted by Larry Crabb: “because our worst problems began in community, that’s where our answer lies.”

Rather than seeing themselves as “damaged selves needing repair,” the individual needs to see themselves as “isolated souls who can find life only through connection with God and with other people.”

These behavioral strategies can also include helping the individual to set and achieve goals that they themselves set, which because they are set by the individual are more likely to succeed.

In the same vein as this development of social skills in order to create support systems is the need for family involvement. This is especially important because the family members may also feel drained through involvement with the depressed individual.

The involvement of the family serves three primary functions, to include: supporting the individual, supporting the family, and treating the family. In this the family should be shown the limits of what they can do to help the individual, but should also be educated and involved in the treatment process, thus “by helping the family help the patient, the therapist helps the family.”

From the Christian worldview there are a few other noteworthy nuances to treatment. One of these is the potential to deal with the problem of sin, which may be one of the causes of the depression. It is likely that many of the false beliefs and the negative self-talk that the individual is engaging in is based upon a non-Biblical worldview, and correcting this worldview may be a step in the right direction for the individual, along with helping the individual to get beyond certain sins in their life.

Beyond this, more drastic measures may be necessary, and in some circumstances deliverance from demonic influence may be in order and may be helpful for the individual.

While major depression is one of the more common and more serious disorders that individuals deal with, there is much about it that is understood and also much that can be done about it. Through the use of suicide prevention, biotherapies, psychotherapies, and family involvement, many individuals will be able to overcome the disorder.