This is a two-part series on depression. Part Two is "Understanding Depression and the Role of Medication" by Dr. Gregory M. Knopf, M.D.

Depression, Preachers, and the Pastorate by Gary H. Lovejoy, Ph.D.

According to the World Health Organization, depression is the fourth leading cause of disability in the world, behind only heart disease, cancer, and automobile accidents. It is predicted to become the second leading cause by the year 2020. What's more, the incidence of depression is increasing at an alarming rate in every demographic and age group. In fact, among women it is the number one cause of disability. In all, 19 million Americans suffer from some level of depression. And yet, mysteriously, very little is mentioned about it in the average church today, apart from an occasional illustration intended to underscore some other more important point. This relative silence on the topic is particularly ironic in view of the historical fact that depression occurred surprisingly often among God's servants in the Bible. Indeed, some of God's greatest acts of redemptive history were done through servants who either were depressed at the time or became so during the course of their responsibilities. So when we add our apparent reluctance to speak about depression to the fact that there are many sitting in the pews who are languishing in that very emotional state, unaware that the Bible actually speaks to their problem, we have a communication gap that profoundly affects the witness of the Church.

So why do neither the clergy nor lay people seem inclined to discuss such a vital issue burdening our brethren? Why is it, too, that 80% of the people who are struggling with depression (and this includes pastors) fail to seek treatment of any kind? For starters, studies have consistently shown that a majority of people view depression as a sign of personal weakness and so are embarrassed to even admit it to themselves. Moreover, the physical symptoms of depression (e.g., fatigue, loss of interest in things, various aches and pains, insomnia, etc.) allow people to remain in denial by attributing their emotional malaise to some low-grade virus or some other physical ailment. Worse still, many believers see depression as not merely a personal weakness, but as evidence of spiritual deficiency. Unfortunately, this belief is often reinforced when they are told they need to pray more and have greater trust and faith in God in response to their tearful disclosure of their intransigent mood state. When their depression still fails to lift, they are convinced all the more that they are beyond any divine help, much less any human help. People are actually leaving churches—and sometimes the faith—because of the stigma and spiritual confusion associated with depression.

Pastors are in an even more difficult place because they live in the so-called “glass bubble.” They are always expected to be on their game and, above all, are supposed to demonstrate the model of godly living which, in their minds, certainly doesn't include depression. I have counseled with many pastors, missionaries, and church leaders over the years who initially felt they were a complete disappointment to God (not to mention themselves) because they couldn't get past the emotional pitfall of depression.

Many of them had come to see me as a last resort, since their regimen of prayer and biblical study, which they had so often recommended to others, had failed to relieve them of their own suffering. Listen to what one pastor had to say about this:

“Some pastors struggle with the appropriateness of receiving help that isn’t exclusively theological or specifically Scriptural in approach. Others are so used to being the ones giving help that they find it difficult to receive any. And, of course, some question the ministry of Christian therapy altogether. I was a member of the second and third groups, especially the third. “The Scriptures are my therapist,” I would say, “and they don’t charge me a hundred dollars per hour for the service.”

Certainly the Bible contributed much to my recovery. Its comforts were amazing; its instructions of insight incredible. But being forced by my circumstances to ask for help from an able counselor changed my entire outlook. Without that wonderful man’s prayer, honest questioning, and practical help, I don’t know how long it would have taken me to heal—or if I ever would have. I continue to find strength and guidance from the Word of God, but in it I read about the importance of Christian community in discerning the deep things of the Spirit. In my experience with depression, the Bible was good, even excellent. But it was the Bible in partnership with a gifted, discerning therapist that God used to loosen me from the hands of this unrelenting monster called ‘depression.’”

As this pastor rightly noted, it is not that prayer and Bible study aren't helpful—most certainly they are. But the experience of depression in these pastors, serving like it did as a persistent emotional alarm system, kept signaling that something was wrong, something to which they very much needed to pay attention. For many, it had to do with some issue or experience that had deeply injured them in the past—and often was continuing to injure them in the present. Ignoring it had only made their lives more debilitated.

It is precisely for this signaling capacity that we use the analogy that depression is to the psychological self as pain is to the physical self. No one likes or seeks pain. Indeed, we have a multi-billion dollar industry designed to find medical ways to eliminate it, or at least to reduce it. Yet the experience of pain is perhaps the most valuable sensory system we have, because it alerts us that something is wrong in our bodies and requires our attention. It is, in effect, the body’s own alarm system, warning us to take immediate action to correct a problem endangering our physical health. The experience of pain is, by design, deliberately negative in order to get our attention. And I think we would all agree that it does a good job in doing just that!

In a similar fashion, we might think of depression as performing the same function as physical pain, only in this case safeguarding our emotional health. Like any alarm system, it is designed ultimately to protect us, even if it too is highly unpleasant when activated. Depression, therefore, is a signal intended to alert us about taking care of an unprocessed or unresolved problem that will otherwise continue to damage our mental health. We may not immediately know how to identify the problem with any degree of accuracy. But that's why it is often wise to consult a Christian professional to help sort out the different issues causing the despair.

It is in this sense that we must understand depression as our ally, not as our enemy. It is itself not the problem, but rather a signal pointing to the problem. As such, we see God’s loving hand in providing us with an internal alarm system that is ultimately designed to protect us from the consequences of ignoring changes we need to make in order to function in an optimal way. When we acknowledge this reality, we are finally in a position to grow in the ways God intended. We cannot always change what we face, but it is certain that nothing will change if we refuse to face it.

One of the sticking points for some Christian leaders is the near-universal experience of low self-esteem among those struggling with depression. Just talking about the importance of self-esteem in the believer strikes some as uncomfortably similar to the narcissism inherent in New Age spirituality. But the truth is that a healthy self-esteem is at the heart of God's desire for us to see ourselves through His eyes of love. He sees us as having inestimable worth (Psa. 8), a fact that was dramatically demonstrated by the Cross. If we were without value to Him, then His redemptive work on our behalf would be utterly senseless. But because we are highly valued, there is inherent logic in every action of grace God has taken to rescue us from our ill-begotten state.

God isn't just loving; He is love (John 4). We were created in His image, and since that which is created in His image must be lovable or it would violate His own character, we must therefore bear that same stamp of love. To be sure, there is a difference here between our person and our behavior. The latter is certainly not always lovable; indeed, it all too often leaves the indelible footprint of sin.

But it is our person that is the subject of God's unfailing love and the impetus for His desire that we see ourselves through his eyes. As A.W. Tozer once put it, “God never had bad thoughts about anybody, and He never has bad thoughts about anybody.”

Incredible as it may seem, when we actually see ourselves from God's perspective, we are at long last liberated to reach out to others in humble service without constantly worrying about whether we will be accepted. Instead of thinking less of ourselves, we are now free to think of ourselves less. Is this not the love that Christ bid us to demonstrate?

Of course, none of this is true for depressed people who have low self-esteem. They are typically imprisoned by a host of lies about their own person that keep them forever preoccupied with self (e.g., by incessantly telling themselves how stupid they are, how hopeless they are, how inadequate they are, how worthless they are, and so on). With the mantra, “What will others think, and will they love me?” running through their heads, they are terrified by the possibility of rejection or abandonment, however remote that outcome might be. As a result, they cannot serve others without at least some form of subtle manipulation, even if it is merely placating others in their desperate attempts to achieve some kind of positive recognition for their efforts.

Anything less constitutes that dreaded experience that confirms to them their own sense of worthlessness. You can see, then, that underlying much of depressed person’s behavior is the compulsion to identify virtually any emotional payoff they can find that will, at least temporarily, anesthetize them from feeling unlovable or inadequate. Regardless of all the Christian admonitions about selfless giving, their world is instead inevitably (and painfully) all about them.

You might be asking at this point, “But what about the biblical notion of denying yourself and taking up your cross? Doesn’t that suggest that the desire for higher self-esteem is spiritually misdirected?” At first glance, it might seem so; but upon closer examination, there is actually a major difference between denying your selfish ambitions—which Jesus taught—and the self-denial of emotional impoverishment, which is often taught in dysfunctional homes of origin. The first focuses on our tendency to revert back to our sinful nature, while the second is centered on a proclivity for self-condemnation. The first keeps our eyes on Jesus, but the second keeps our attention trained on our self-hatred. The important thing is that it is denial of self that opens our minds to God's storehouse of delights, where our deepest desires are fulfilled (Psa. 37:4). But self-denial inflexibly closes our minds to any possibility of a better life.

Selfish desire has never been a part of God’s plan. But, for an entirely different reason, neither has self-denial. The former is the case because it is a transgression of God’s law, the latter because it is the product of irrational thinking. Ironically, self-denial is far more compatible with the non-Christian, Far Eastern monastic lifestyle in which self-imposed deprivation has been, both philosophically and culturally, a common way of life for nearly 3,000 years. The only difference is that, with those who struggle with low self-esteem, it means more emotional than material deprivation, though it can mean both. The significant point here is that it refers, in one way or another, to the legalistic notion that engaging in such deprivation (including putting yourself down) is something laudable, as if it successfully passes for humility.

Yet, contrary to expectations, self-denial doesn’t lead to the spiritual growth people hope for, but rather leads to a wrenching battle with spiritual emptiness. Worse still, self-denial emotionally drives a wedge of fear (mainly of failure) into our God-given peace of mind. While there is no doubt that selfishness invokes God's anger, the same is not true of self-hatred. Instead, it arouses only His sadness. Though we may condemn ourselves, Jesus made it plain that condemnation of our person is not the verdict of His creation (Jn. 8:3-11). The great delusion occurs when we attribute our sense of rejection to God instead of correctly attributing it to our own projection. In the end, this is but another example of the final fruits of self-deception.

So it is incumbent upon each one of us as believers to encourage one another to emerge from the closet of our emotional struggles and false beliefs without fear of condemnation or discrimination. We must cultivate a Christian community that plays a healing role in believers’ lives, one that is notable to the secular world for a love that holds nothing back. Indeed, it must be a love that stands quite apart from the environment of judgmentalism that sometimes mars the Christian witness.

To be biblically sound is to be psychologically accurate. To abide in Scripture is to live in the promise of God's purpose for our lives, a purpose that confers upon us the dignity of our creation. As theologian Haddon Robinson has pointed out, God does not love us because we are good, but because we are precious. It is confusion on this matter that prompts us to depart from God's appreciation of our value. Is it any wonder, therefore, that we are correspondingly predisposed to depression?

Gary H. Lovejoy, Ph.D. co-authored Light on the Fringe: Finding Hope in the Darkness of Depression with Gregory Knopf, M.D. and has been conducting his private counseling practice for over 30 years. He earned a master’s degree in religious education from Fuller Theological Seminary and completed his doctorate in psychology while attending United States International University. He continues an active practice with Valley View Counseling Services, LLC in Portland, Oregon. Dr. Lovejoy was a professor of both psychology and religion at Mt. Hood Community College for 32 years. He has conducted numerous seminars on depression and has been the keynote speaker at many family camps, couple’s retreats and college conferences. Contact Dr. Lovejoy at or (877) ITL-3762.

Understanding Depression and the Role of Medication

Gregory M. Knopf, M.D.

This article is part of a two-part series on depression. Part One is "Depression, Preachers, and the Pastorate" by Dr. Gary Lovejoy, PhD.

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, has said:

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 dynamics
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 depression.

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 habit-forming, 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 prescribing doctor.

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 to everyone?

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 living;
(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.”

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.



06/22/2017 3:46am

I know that all of us are familiar with depression, but only few have the deepest understanding of this sensitive matter. Some people think that it is a simple state of a person that doesn't require so much attention. It is, and it should be given more attention. We should thank Dr. Gregory M. Knopf for discussing essential things we need to know about Depression and its branches.


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