First published Jan. 13th 2008.

Disclosure–This is an intensely personal subject for me. I suffer from Major Depression, I have had to come to a knowledge of this thing both as a patient and a physician and as a committed religious person. In my journey, I have gained a LOT of perspective and at a painful price. Ironically, I think the biggest reason I still use the Doc pseudonym for posting is the stigma this problem might create for me as a physician. My particular story is to come in a later post when I am in a more soul baring mood.

Who is to blame for depression? Ourselves, God, the devil, our genes, our culture, our loved ones, our experience, our brain? The question is perplexing and has loud advocates in all camps. Everyone wants to fit it into their boxes and have their own solutions. In my experience each is incomplete. A condition arising at the seat of consciousness, with devastating consequences for our families, our relationships, our work, our personal happiness and yet leaving no marks is difficult for us as humans to reconcile. However reconcile it we must, because Depression carries with it a mortality in the form of suicide.

Evidence clearly shows depression tends to occur in families. Does this indicate a genetic cause, or are the families just dysfunctional?

Evidence clearly shows depression is triggered by stressful life events. In the grieving process all the symptoms of clinical depression are present in the average person for up to a period of years, depending on our bond with the loved one. In other words in this circumstance, major depression is normal. Is it due to our poor coping skills or just our lot in life? Is it even a “disorder”?

Depression is experienced after a stroke independent of other disability? Is this the smoking gun for a purely biological cause, making it a purely medical problem?

One symptom of depression is an overwhelming sense of guilt. Is this a result of our sins, our conscience, our religion, our biology, or our culture? Which do we work to fix? Are these things really bad? The questions can go on and on.

Here is the framework I have come up with for understanding depression. It requires a multipronged approach in which medicine, therapy and spiritual reconciliation all play vital roles.

Problem #1- the monster

Depression is a state of mind with physical consequences. We lose our ability or sleep (or sleep too much), we lose our appetite (or eat too much), we lose the ability to feel pleasure, we lose ability to concentrate, we lose energy, our very thinking or movements can be slowed.

From a neurological perspective, depression is an emotional response which can be triggered by certain cognitive and emotional pathways, or by brain damage (as in stroke). There are certain genes that make this response stronger, hence the familial tendency. The pathways are self reinforcing, meaning that with use the connection in the wiring tends to get stronger and easier to trigger over time. This means as we are depressed, we begin wiring our brains to continue to be depressed. Depression is a vicious circle. It takes a normal physiologic and psychological response and turns it into a monster. This is where medicine steps in and frankly is often quite necessary to make any progress fighting off this response. It effectively quiets the monster.

Problem #2- the circuitry

The problem then is learning to rewire the pathways. We live with a tiny voice in our head triggering automatic thoughts thousands of times per day. In depression, these thoughts are excessively self critical. These thoughts makes us ill, causing a physical and emotional reaction. Once medication is working, the only way we can ever fix this is to change these thoughts and that takes work. Cognitive psychologists work hard with patients to challenge these thoughts with logic. This can be very effective with practice.

The temptation arises when working with the religious to get patients to forego their faith, seeing it as THE cause. This is something deep and personal. Any psychologist who would try to get his patient to abandon his faith in an effort to treat the guilt is making a huge mistake IMHO.

Problem #3- the wounded soul

While abandoning our faith is clearly not the answer, there is no doubt that simplified religious beliefs can be part of a faulty thought process. The temptation for the religious is to ascribe to sin, to being the “fault” of the depressed. This can only strengthen the inner critical voice shouting in the patient’s head. It actually can worsen the problem. This is precisely why we become tempted to blame the religious views themselves.

What I have learned in my life is that understanding of God progresses through various levels. On the lowest, God is a being to be feared. He is full of wrath and vengeance that will be taken out on our evil selves. Terror is the motivating force, which really pushes us away, leads to what can only be described as a dysfunctional relationship.

On the second level, God is a being we obey out of commitment. We have a duty to follow him. Guilt is still a natural consequence because perfectionism is a natural hazard in this mindset. We can never be perfect. Our sense of duty will remind us of our shortcomings continually and the guilt circuit is set in. We will always fall short in one way or another. Eventually burn out will set in.

The highest level, where healing and redemption can really set in is a relationship of Love. Love is a motivating, life affirming power. It is a gift of the spirit and a side effect of truly coming to know God. In short it is the ultimate result of the atonement, making us at one with God, and become as God. We begin to comprehend the depth of his feelings for us, his vision for us and our potential.

I like how David Littlefield describes this at his blog. He delineates how behaviors are shaped by values which are shaped by beliefs which are shaped by relationships. A critical part of reshaping our thinking, in my experience, is the atonement of Jesus Christ. In a very real sense our thoughts can be reshaped, our self image redeemed and ourselves healed through the change that occurs in our soul through the miracle of forgiveness and the power of his redeeming love.