Science in Christian Perspective

Depression: 
Biochemical Abnormality or Spiritual Backsliding?
WALTER C. JOHNSON
132 Pine Street
Hanover, Massachusetts 02339

From: JASA 32 (March1980): 18-27.

Of all the ills which afflict humanity mental depression is one of the most common and universal, involving people of all ages, all occupations, and all strata of society. Indeed if is the opinion of many authorities thatmore human suffering results front depression than from any other illness affecting mankind.

According to Dr. Nathan Kline there are at least four million case's per year in the United States alone. Possibly as many as eight million individuals per year suffer from this malady', and less than one third of all cases receive' any form of treatment. 'there are 22,000 known cases of suicide in this country per year, but these figures most likely are a tremendous underestimate of reality. Many Cases are not reported because of uncertainty. For instance', in relation to automobile accidents some instances are not reported for religious or other reasons. Probably in actual fact 50,000 to 70,000 suicides occur each year. Apart front the successful suicidal attempts there are probably a quarter of a million unsuccessful attempts or suicidal gesture's in this country per year.¹

Depression is an affliction which produces titan symptoms, but as Dr. Nathan S. Kline points out in his hook
Front Sad to Glad, one universal symptom which is common to every sufferer is a lack of pleasure and enjoyment.² Although a mood of sadness is generally a feature of this type of illness, an obvious feeling of depression need not be experienced. One can feel a loss of joy and happiness in place of the more obvious feeling of depression. Usually the patient experiences a sadness and gloominess of mood which in a mild case may present itself as a loss of normal cheerfulness accompanied by a general lack of interest and zest for life.
In a severe case of depression the patient will he over-whelmed by a feeling of deep gloom and abject miser.
Fie may feel that life is no longer worth living, and may contemplate or even attempt suicide in order to escape from his hapless and unbearable condition of anguish. lie may even have a terrible foreboding of some awful doom falling on himself or his loved ones. A very depressed individual has even been known to kill spouse and children to prevent them from suffering some awful fate, afterwards attempting suicide himself.

A depressed person may experience difficulty in concentration, and may not he able to retain the information which he has read in a book or magazine, or has heard on the radio or television. He may also show a general loss of interest in his hobbies, his recreation, his work, people, and ideas that once meant much to him. lie may experience a decrease in love and affection for family, friends, and even for God. For the individual who is a Christian it may he extremely difficult to read the Bible, to pray, and to show love and devotion to the Lord.
Depressed patients frequently exhibit a loss of self esteem, and a feeling that they are utterly worthless. They may also express feelings of guilt, and in the case of a person who is a Christian, may have lost their assurance of eternal salvation. The patient may even feel that he is guilty of the unpardonable sin and has indeed committed the sin against the Holy Ghost so that he is irrevocably and eternally damned to everlasting punishment. Argument and reasoning, and even pointing out the precious promises in the Word of God such as justification by faith and the eternal security' of the believer, is of no avail when the sufferer is in this wretched and unhappy condition. However when adequate treatment has been given he will then become amenable to spiritual exhortation and counseling.

Depressed individuals are frequently tired and exhausted, and in severe cases there may be evidence of psychomotor retardation which is characterized by a general slowing down of responses, thinking processes and movements. The patient may have a feeling of utter emptiness inside, and occasionally the retardation attains such severity that he may be unable to engage in conversation, becoming mute yet presenting an appearance of abject and total misery. Sometimes a depressed patient may be very anxious, tense and frightened, and may even present an outlook of severe restlessness and agitation.

In many cases of depression the sleeping pattern is altered and often the patient suffers from a lack of sleep. Frequently, however, he has no difficulty in getting off to sleep at night, but awakens in the early hours of the morning. Very often a depressed individual will sleep excessively, taking refuge in his bed rather than facing the world. Many patients suffering from depression feel worse early in the morning, but tend to experience a certain amount of improvement in their mood as the day progresses.

Occasionally a depressed person may hear hallucinatory voices which are generally of an accusatory nature consistent with the patient's feeling of guilt, self depreciation and worthlessness. Complaints of various physical symptoms are extremely common in depression including loss of appetite, alterations in bowel functions, nausea, headaches, abdominal cramps, pains in the chest, and various other aches and pains. Sometimes the physical symptoms may so overshadow the depressive mood that the latter is overlooked, and the patient's condition is misdiagnosed.

In severe cases of depression bizarre delusions of a hypochondriacal nature may sometimes occur where the patient may allege that his intestines have rotted away and his blood has decayed. Nihilistic delusions where the patient may actually deny his own presence or allege the absence of a vital organ can also occur in such cases. One patient suffering in this fashion once said to me, "I have no body."³

Depression can wear many faces and present many symptoms, and the question that usually follows this descriptive account is whether depression consists of only one type or whether there are various different kinds of depression arising from different causes, and requiring Uifferent types of treatment.+ However most authorities in the field of psychological medicine would share the opinion that there are different types of depression, but there would be disagreement about the best and most accurate manner of categorizing these conditions. Indeed a new classification of mental illness including mood disorders is now being contemplated by the Task Force on Nomenclature and Statistics of the American Psychiatric Association (DSMIII)⁵

According to this new classification, mood disorders are divided into unipolar and bipolar varieties. A patient suffering from a bipolar disorder (manic-depressive illness) experiences manic episodes in which he is elated, overactive and overtalkative in addition to periods of depression. The individual who is the victim of an unipolar mood disorder suffers from either episodes of depression or manic behavior but not from both. In the manic phase of manic depressive illness the patient is overactive, overtalkative and demonstrates excessive energy. His mood is generally one of cheerfulness and elation, but he is frequently irritable and may become angry and bad-tempered, particularly if any attempt is made to thwart his plans or to interfere with his activities.

In addition to being excitable, overactive, garrulous and talkative, the manic individual flits rapidly in his thoughts, conversation and activities from one topic or project to another. He may plan a host of different projects one right after another, but may fail to complete any one of them properly. As a result of his excessive energy he appears to be tireless in his activities. Usually he needs much less sleet) than is normal, awakening several hours before his usual time, his excessive energy unabated. When the disturbance of sleep is particularly severe, he may actually continue being active for days without obtaining any sleep, and in spite of this may not be tired at all.

As a result of his elation and joyous exaltation ideas of grandeur may develop, sometimes accompanied by fleeting delusions of wealth and power. Businessmen suffering from this condition have been known to embark on very risky and venturesome business speculations, sometimes losing thousands of dollars in the process. 1 recollect the ease of a housewife who used to suffer from repeated manic episodes in which she would order lavish amounts of new clothes and other commodities from nearby shops in an extravagant fashion, much to the dismay of her husband. Another case involves a middle aged woman suffering from mania who ordered approximately one thousand dollars worth of furniture, and arranged for it to be delivered to her apartment despite the fact that the apartment was already fully furnished.

In very severe attacks of mania the patient may be extremely noisy, singing and shouting, and may become very destructive, tearing personal clothing and bed linens into shreds; he may also become very angry and even violent as a result of relatively minor provocation. I can remember one manic patient who became so angry that she threw a chair at me, but fortunately she missed her target.

In unipolar manic illness the patient is liable to have recurrent attacks of mania separated by periods of normality, whereas in a bipolar disorder he may experience recurrent aberrations of mood, sometimes characterized by phases of manic elation and overactivity. At other times it is characterized by bouts of depression separated by periods of time in which he can appear quite normal. In some instances the individual suffering from a disorder of mood may plunge from a state of manic elation directly into a condition of severe depression or vice versa.

Classifying Mood Disorders

A very convenient manner in which to classify mood disorders is to divide them into Primary Affective Disorders and Secondary Affective Disorders.

A Primary Affective Disorder is an affective episode which could occur in an individual who has had no previous history of any psychiatric illness except perhaps previous similar affective episodes.

Secondary Affective Disorder occurs in an individual who has had a pre-existing illness such as hysteria, anxiety neurosis, obsessive compulsive neurosis, alcoholism, schizophrenia, chronic brain syndromes, drug addictions, character disorders, etc. It also includes depression secondary to organic medical illnesses such as influenza, infective hepatitis and infective mononucleosis, and also as a side effect of certain drugs such as reserpine and methyl dopa which are used in the treatment of hypertension, certain hormones such as birth control pills, cortieostcroid preparations and other medications.

Primary affective disorder is divided into bipolar (manic depressive illness) and unipolar varieties. Unipnlar depression has been further subdivided as a result of the work of Winokur and others into Depression Spectrum Disease and Pure Depressive Disease.

Depression Spectrum Disease is of early onset occurring in females tinder forty years of age. These patients have a family history characterized by increased rates of alcoholism, sociopathy and depression. There is a considerable amount of alcoholism among male relatives, but there is more depression in female than in male relatives.

Pure Depressive disease occurs in males aged over forty, and in the family history of these patients depression occurs more equally in male and female relatives. There is also no familial increase in alcoholism above the average expectation.⁹

Causes of Depression

There is still much discussion and debate regarding the causes and nature of depression. Even today there remains considerable disagreement among mental health experts concerning the relative importance of biological factors in comparison with psychological influences in the production of depression. Many Bible-believing Christians including numerous ministers, Christian workers, and pastoral counsellors are of the opinion that depression is predominantly, perhaps entirely, due to spiritual problems such as a sinful life pattern, unconfesscd sin, and/or a faulty relationship with God. It is my purpose to discuss and evaluate these three different viewpoints in the light of present knowledge, and to offer conclusions about the causation of depressive illness which are both scientifically reasonable and are also in accord with the teaching of the Bible.

Many psychiatrists are proponents of a medical model of emotional disorders, regarding them as analogous to hypertension (high blood pressure) or diabetes mellitus, and believing them to be caused by aberrations in the functioning of the brain.

Indeed for many years diligent efforts have been made to search for specific abnormalities of the brain in individuals suffering from mental illness. Postmortem examinations performed on patients who had suffered from emotional disorders revealed no such abnormalities, not even when sections of brain tissue were viewed under the microscope. The exceptions were in cases where the mental symptoms were associated with an organic brain syndrome caused by such conditions as brain tumors, syphilis of the nervous system, alcoholism or arteriosclerosis (hardening of the arteries).

In consequence of these negative findings it has been realized that the problem is of a much more subtle nature and appears to be biochemical. The emphasis for research in biological psychiatry is now being focussed mainly on two areas: the biochemical aspects of mental illness and the genetics of emotional disorders.⁷

Biochemistry of Mental Illness

During the past 25 years there has been much scientific research directed towards the biochemistry of mental illness and the biogenie amine or eatecholamine theory of mood disorder has been developed. According to this theory a deficit of hiogenic amines located in specific areas of the brain is associated with depression, and an excess of such substances is found in mania. The biogenic amines include norepinephrine, dopamine and serotonin, and act as neurotransmitters facilitating the passage of a nerve impulse or signal from one nerve cell to another.

The brain consists of about ten billion nerve cells or neurones, and billions of electronic circuits formed by the nusnerous interconnections of these nerve cells. This marvellous organ has been likened to a very elaborate and complicated electronic computer with the individual nerve cells comparable to vacuum tubes or transistors such as have been used in the mechanism of electronic computing machines⁸

Nerve cells or neurones are found in numerous shapes and sixes, but each nerve cell has a cluster of fibres called dendrites sprouting from one end of the nerve cell. Each neurone also has a cell body containing a nucleus and a long cable-like fibre called an axon leading from the opposite end of the cell body from the dendrites. The axon terminates in a number of branches which end in very close proximity to dendrites of adjoining neurones. Between the axon of one nerve cell and a dendrite of another nerve cell is an infinitesimally tiny gap, perhaps only about 1/50,000 of a millimeter wide, called a synapse.⁹

When a dendrite receives a signal from an adjoining nerve cell a disturbance is created in the cell by altering the ratio of sodium to potassiumo. As a result of this disturbance an electric current is triggered off, and this current flows down to the terminations of the axon where are situated tiny sacs of one of the biogenic amines. As soon as the electrical impulse reaches the end of the axon, minute packets of this neurotransmitter substance are released into the synapse where they activate a dendrite of an adjoining nerve cell so that an electrical impulse is generated in this neurone. In this way the nerve message or signal is transmitted to the next nerve cell. Meanwhile most of the neurotransmitter substance is absorbed back into the neurone whence it was emitted, and is recycled.

One single nerve cell may transmit signals to tens of thousands of other neurones. A delicate switch system is attached to each of the nerve cells so that any individual cell is switched on or off at any given instant. The biogeoic amines or neurotransmitter substances act as the 'on" part of the switch mechanism by facilitating the passage of the nerve signal across the synapse from one nerve cell to another. Certain substances function as the "off" portion of the switch, some of these compounds destroying the neurotransinitter and others blocking the action of the biogenic amines.¹⁰

In manic illness where there is an excess of hiogenic amines the nerve cells fire excessively and too frequently so that the patient manifests symptoms of excessive energy, excitement and overactivity. In depression on
the other hand, where there is a deficiency of hiogcnic an9ioes, too many nerve cells are switched off and the patient shows evidence of decreased energy, an unhappy mood and other signs of depressive illness.¹¹

There is much evidence to support the biogenic amine theory of mood disorder. It has been noted that antidepressant medications increase the levels of available biogenic amines in the brain, and in experimental animals, those treated with drugs which raise the concentration of these substances in the central nervous system, become much more alert and active. Certain drugs such as reserpioe, which reduce the level of biogenic amines in the brain, are liable to cause symptoms of depression in man, and produce lessened activity and sedation in experimental animals.¹²

Evidence is being accumulated to suggest that there are at least two biochemical subtypes of depression. One type is characterized by low urinary MFIPC levels (3 methoxy 4 hydroxy phenyl glycol-a metabolite of norepinephrine), and indicates a possible deficiency of oorepinephrine in the central nervous system. This type of depression tends to respond well to imnipramine and desipramioe, but not to amitriptyline.

The other biochemical type of depression is associated with normal or increased NII-IFC levels together with a. reduced concentration of 5 hydroxy-indole acetic acid (a metabolite of serotonimn) in the cerebro spinal fluid. This type of illness tends to respond well to amitriptyline and not to innpransioe and desipransioe.

It appears that there are other biochemical derangeinents present in patients suffering from depression in addition to the disorder related to biogenic amines. There is evidence of a disturbance in the metabolism of sodium and potassiuns. These substances are intimately involved in the electrical activity of the nerve cells. Most of the sodium found in the nervous system is located in the spaces between the nerve cells, whereas the bulk of the potassium is found within the neurones. There is some evidence that there is an increase in the concentration of sodiumss within the cell in depression and also in mania. It appears that the concentration of potassium in the cell is decreased. ¹³ These changes affect the metabolism of the nerve cell, and the transmission of the electrical signal along the nerve fibre itself.

It has been observed that many depressed patients, particularly those who are severely depressed or suicidal, secrete an excess of This is a fatty wax-like steroid substance produced by the cortex of the adrenal glands. It has important effects on various metabolic processes in the body, and these effects are designed to enable the individual to meet stressful situations including psychological and emotional stress. ^15,27 The production of cortisol by the adrenal glands is controlled by delicate and intricate mechanisms involving the pituitary gland and the hypothalamus. Certain nerve cells in the hypothalamus produce the biogenic amine norepinephrine w'hich inhibits the secretion of the corticotropin releasing factor. The corticotropin releasing factor which is secreted by the hypothalamus stimulates the production of the adrenocorticotropic hormone (ACTH) by the anterior lobe of the pituitary gland. ACTH in turn activates the secretion of cortisol by the adrenal cortex. As there is a relative deficiency of biogenic amines in depressed individuals, this braking action upon the secretion of the corticotropin releasing factor is weakened and an increased amount of cortisol is manufactured by the adrenal cortex.¹⁶

A number of studies, involving both twins and families have indicated the presence of a definite hereditary and genetic basis for the development of depressive illness. Studies of identical twins have shown that in situations where one twin develops a depressive illness the other twin has approximately a 60% chance of becoming a victim of the same disease. According to Dr. Nathan Kline when there is a history of severe depression in one parent there is approximately a 10% to 15% chance that the same affliction will appear among the children. The fact that there is a genetic tendency to mood disorders is strong evidence of the presence of a biological malfunction in these conditions.¹⁷

Beyond Brain Biology

I have attempted to describe briefly the current theories relating to the biological basis of mood disorders. In my opinion these theories are fairly well substantiated. However, the brain is an exceedingly complex organ, and although there has been an explosion of new discoveries in recent years relating to its functions there is much that still remains mysterious. From a scientific point of view we know very little about the relationship between the electrical and chemical changes which take place in the myriads of nerve cells of the brain, and the phenomena of consciousness, mind and spirit. Nevertheless we do know that biochemical changes in the brain influence mood and personality, and even affect our appreciation of God's love, the enjoyment of our fellowship with the Lord Jesus, and our own personal, daily walk with Him.

It is an established fact that the limbic system is intimately connected with emotion. The limbic system includes parts of the frontal and temporal lobes of the brain, thalamus and hypothalamus, together with the nerve pathways connecting these different areas. The different portions of the limbic system have connections with numerous other parts of the central nervous system. Areas of the limbic system have been stimulated in conscious patients submitting to brain surgery under local anesthesia. Feelings of anxiety and fear have been evoked when certain areas have been stimulated by an electric current, whereas stimulation of certain other areas have induced feelings of joy and even elation."' It appears that a function of the bingenic amines, by means of their role as neurotransmitter substances, is to influence the normal variation of emotional expression in the daily lives of healthy human beings. There is an appropriate experience and expression of such feelings as grief, sadness, or joy.

Many psychiatrists ascribe depression as almost entirely due to psychological causes. They adhere to the theories of psychoanalysis as the explanation for the causation of mood disorders. Sigmund Freud, the father of psychoanalysis, in his paper "Mourning and Melancholia" (1917), compared melancholia or depression to
normal grief. He postulated that depression could occur in reaction to a vaguely perceived or even imaginary loss. The studies of Sigmund Freud and Karl Abraham (1924) led to the conclusion that a combination of an experience of loss in early childhood and a recent loss in adult life, were of prime importance in the causation of depressive illness. Melanie Klein (1934) held the view that the predisposition to depression was dependent upon an unsatisfactory mother-child relationship during the first year of life. The failure of the mother to show sufficient love to the child, was in her opinion, a potent factor in setting the stage for depressive illness in the future.

Generally speaking, psychoanalytic theory indicates that depression originates in faulty early childhood relationships. The infant suffers a loss or deprivation of maternal love and this traumatic experience renders his developing personality vulnerable to future stressful situations, particularly those in which another loss of some kind is involved. The anxiety and misery produced by the rejection and lack of love on the part of the mother produces much anger and resentment in the infant, who being unable to express his rage openly against the parent turns his anger in against himself. This unresolved anger produces depression. Feelings of guilt, rejection, inadequacy and worthlessness develop out of this unsatisfactory early childhood situation, and the child's personality becomes weakened, vulnerable and excessively sensitive to emotional stress. Although these feelings may become buried in the unconscious mind of the child, they may be reactivated strongly by some loss in adult life or even in later childhood so that a severe depressive illness is precipitated.

The types of losses which are reported to be able to trigger off episodes of depression include bereavements, divorce, separation from loved ones, aging, loss of health, retirement, financial reverses, loss of friends and loss of self confidence and self esteem. Bereavement not infrequently triggers off a depressive illness, and even the anniversary of a loved one's death can aggravate or reactivate the symptoms of depression.

Not only does there appear to be ample evidence that depression can occur in infancy and early childhood, but clinical data have been collected which seem to indicate that such children are liable to become more vulnerable and more sensitive to subsequent losses when they are older, and react more frequently by developing a depressive illness. R. A. Spitx described the development of symptoms of severe depression arising in 19 out of 123 infants who had been separated from their mothers and placed in a nursery. Not only did these babies show weepiness and loss of interest in their surroundings, but in addition their rate of development was slowed down.¹⁹

Engel and Reichsmann described the case of the infant, Monica, who had been born with a congenital atresia or narrowing of the esophagus. In order to enable the baby to obtain nourishment, an artificial connection had been produced surgically between the stomach and the exterior of the abdomen, and a tube had been inserted into the stomach for feeding purposes through the surgically constructed opening in the wall of the abdomen. Because of the presence of this tube the mother was not able to coddle her baby or even to hold it. After the age of six months the child became very fretful and cried for long periods of time. The infant failed to gain weight and became extremely withdrawn and depressed. However, after a few months in a hospital where a doctor and one of the nurses were able to spend a considerable amount of time with the baby, her depressive symptonis subsided, but thereafter she remained liable to suffer from episodes of depression .²⁰

John Bowlby claimed that complete separation of an infant from its mother produced prolonged and devastating effects including anxiety, an insatiable need for love and affection, strong feelings of anger and vengefulness, and consequent depression and feelings of guilt. lie postulated that a loving, close and continuous relationship with the mother was essential for the emotional well being of the infant and young child.²¹ However many workers have presented evidence that does not entirely agree with Bowlby's conclusions. From the information that they have collected they have come to the conclusion that favorable events and situations of childhood or later life mold alleviate the psychological injury sustained during infancy, and that the ill effects of emotional deprivation during babyhood are not necessarily permanent and irreversible.²² in other words a Supportive and loving relationship provided in later childhood, adolescence or even beyond that time can have a beneficial effect upon the personality of an individual who has been emotionally hurt by a lack of love and affection during infancy. When the Lord Jesus Christ conies into the life of such a person the impact of Cod's eternal, unchanging, and infinite love brings healing and an increase of emotional stability.

States of depression resembling those observed in human infants have been produced under experimental conditions in baby monkeys. In these experiments the infant monkey has been separated from its mother or from other monkeys which were a significant source of security. Separation of rhesus monkeys for one or two periods of six days each at the age of approximately six months caused depressive symptoms resembling those shown by human infants under similar circumstances. As long as two years later these monkeys still showed some manifestations of their original depression though not as severely as at the time when they were separated from their mothers. The animals which had been twice separated from their mothers showed more pronounced effects than those which had been separated only once. Repeated short term separation of baby monkeys from their mothers produced a marked arrest of social developmerit and led to extremely immature behavior.²³

Correlating Emotional and Biological Causes

I have sought to demonstrate the role of emotional deprivation in early childhood and subsequent losses later in childhood and in adult life in the production of depression. How can these findings he reconciled with the modern biological theories of the causation of mood disorders? At first sight it would appear that these two different points of view are contradictory, but in my opinion it can be demonstrated adequately that these contrasted approaches to the causes of depression are not only reconcilable but also complementary towards each other.
Experimental studies with laboratory animals have shown that factors in the environment can produce a definite effect upon the brain. For example a series of experiments on rats was conducted a number of years ago at the University of California in Berkeley. In these experiments one group of rats was placed in an enriched environment in which the animals had ample opportunity to interact socially with their peers, and in which various suitable toys and playthings were provided. Another group of rats was kept socially isolated, each animal in the group being placed in a single cage without any toys. The different cages were sufficiently far apart to prevent any social interaction. The animals which had been provided with the enriched environment demonstrated a higher intelligence as shown by performance tests than the rats which had been subjected to the impoverished environment.

After a while the animals from both groups were killed and their brains were examined. It was noted that the cerebral cortex of the rats which had been exposed to the enriched environment was thicker and the nerve cells, although they had not increased in number, had formed a niore complex network of interconnecting nerve fibres. It was also observed that these brains contained a higher concentration of the enzymes cholinesterase and acetylcholinesterase than was found in the brains of the rats which had been subjected to the impoverished environment.²⁴

In his book From Sad to Glad Dr. Nathan S. Kline describes some experiments with rats. They were placed in specially constructed cages and there given a mild electric shock. The animals thrashed around wildly, trying to escape from this most unpleasant experience, and eventually touched a bar or ran across a barrier quite accidently. Contact with the bar or harrier automatically turned off the electric current. When the rats were exposed subsequently to the same situation they continued to thrash around until they eventually managed to touch the bar or trip the harrier. This continued to happen more frequently until they finally learned to turn off the electric current almost imediately.

Further experiments were performed in which the animals were placed in cages that were contrived in such a way that random electric shocks were administered and no matter what these rats did they were unable to escape from it. At first they ran around frantically trying to escape, but after a while their efforts to obtain relief became more and more feeble, and they eventually gave up the struggle, lying down passively and silently. They manifested a behavioral state corresponding quite closely to a condition of depression. Even when the electric shocks were not being administrated these rats remained listless and apathetic with impaired appetites and with a loss of interest in sex.

Finally another research worker carried the experiment a stage further with different rats. After he had induced chronic patterns of depressive behavior in these animals in the manner already described, he killed them and performed autopsies. He discovered that the level of norepinephrine, one of the biogenic amines which serves as
a neurotransmitter in the central nervous system, was abnormally low. In this connection it must be remembered that a deficiency of biogenic amines in the central nervous system is an important feature of depression in human beings.²⁵

It appears, therefore, that psychological and environmental stress, provided that it is sufficiently prolonged and severe, may alter the biochemistry of the brain in such a manner that a deficiency of biogenic amines and other biological abnorrnalties that are characteristic of depressive illness is produced. Thus it may be seen that a psychological approach to depression is not necessarily antagonistic to a biological view of this condition; indeed both viewpoints are complementary to each other.

Depression as a Spiritual Problem
Many Christian people including numerous ministers and pastoral counsellors are of the opinion that depression is purely a spiritual problem, and is the direct result of the sufferer's sin.

Dr. Jay E. Adams believes that depression is the result of the counselee's sin, and that the sole remedy of the problem is to bring him or her to repentance by the effective use of the Word of God. In his volume, The Christian Counselor's Manual, he states that almost anything can be at the root of the counselee's depression including hormonal changes, financial loss, feelings of guilt over a specific sin, self pity resulting from jealousy or unfortunate events in the life of the individual, had feelings arising from resentment and worry, and circumstances which are merely the consequence of ordinary negligence. He is of the opinion that the depression does not result directly from any one of these factors but arises out of a faulty, sinful response to the problem. Because of this sinful response, additional problems, including a burden of guilt, are added to the original problem. The additional complicating problems may again be met by a further inadequate sinful response and the victim of this situation may plunge into a downward cycle of repeated patterns of sinful reactions to his circumstances. The end result of this vicious cycle is a state of despair, hopelessness, guilt and deep depression.

Dr. Adams insists that this cycle can always be reversed at any point by biblical action in the power of the holy Spirit, and that the hope for the depressed individual lies in the fact that the depression is the result of the counselee's sin. He tends to characterize the manic phase of manic depressive illness as a faulty sinful attempt to overcome the depression and bases these conclusions on the fact that beneath the elated and euphoric facade there lurk feelings of sadness and misery. He expresses the idea that a depressive phase in manic depressive illness generally precedes a period of elation and the patient generates manic symptoms in order to obtain relief from the misery of depression.²⁶

Dr. Tim LaHaye emphasizes "spiritual therapy" for the relief of depression and states that most miserable or depressed people are not conscious of the fact that their misery emanates from the absence of God in their
lives. He categorically states that the primary causes of depression are spiritual.²⁷

Both Adams and LaHaye correctly point out that the spiritual dimensions of man's nature are virtually ignored or denied by the vast majority of psychiatrists, psychologists and other mental health workers whose evaluation of the nature of man is generally based upon the philosophies of secular humanism. They have rightly emphasized the necessity for and the importance of sound biblically oriented spiritual counselling in helping the depressed individual, but in my opinion they have grossly oversimplified the issues by assuming that the cause of depression is always of a spiritual nature. At the same time they deny or play down psychological and biochemical causes despite the fact that the evidence for the operation of these factors is virtually overwhelming.

In my own psychiatric practice I have treated many patients suffering from depression, and a significant number of these individuals have been people who were totally committed to the Lord and seeking to live lives of complete dedication and surrender to Him. If mood disorders were invariably and wholly caused by a condition of alienation from God, one would expect an improvement in the mental condition of such an individual as soon as he had entered into an experience of conversion or, in the case of an erring Christian, as soon as he had confessed his sin and surrendered his life completely to the Lord Jesus Christ. This, however, is not necessarily the ease.

After conversion to Christ, two female patients of mine temporarily developed symptoms of manic excitement, and one man who had a history of perverse and obscene sexual behavior went into a psychotic depression from which he recovered eventually. In the cases of these patients it may well have been that the emotional impact of their conversion experiences and the accompanying joy born of a new personal knowledge of Christ, together with the sense of relief arising from the forgiveness of sins was too much for their biologically unstable nervous systems so that the man was plunged into a state of suicidal depression and the two female patients were launched into a flight of manic excitement and elation.

I would also like to emphasize, as further evidence that problems of a spiritual nature are not the sole causes of depression, that a treatment program based upon a theoretical framework which ignores the biological and psychological factors operating in the production of depressive conditions is liable to end in disaster. In other words if, as a result of the mistaken notion that all mental illness is caused by a faulty relationship with God, spiritual therapy alone is employed to the exclusion of medical and psychological modes of treatment, the patient's emotional condition may fail to improve. He may become worse, or even be driven to an ever deepening despair, possibly terminating in suicide. This type of reasoning is not only unscientific, as we have already seen, but is also unscriptural. In the account of the healing of the man who had been blind from birth (John 9) we are told that the disciples asked the Lord Jesus the question, "Master, who did sin, this man, or his parents, that he was born blind?"²⁸ Let us note carefully our Lord's reply, "Neither bath this man sinned, nor his parents, but that the works of God should he mademanifest in him "²⁹ In this statement our Lord clearly teaches that disease, and this includes mental illness, is not necessarily caused directly by the sin of the individual who is afflicted.

It is true, however, that mental illness, in common with every other kind of sickness, is ultimately the result of the sin committed by Adam and Eve in the Carden of Eden. With the fall of man sin first entered the world, and with it came death, both physical and spiritual, sickness, sorrow and all the manifold afflictions and evils which beset mankind. Nevertheless mental illness occurring in a particular individual is not necessarily the direct coosequence of that person's sin, although in some instances that individual's sin may he an important factor in the genesis of his emotional breakdown. It is important for us not to go to the other extreme of denying that sin plays any part at all in relation to the development and perpetuation of mental illness. I am firmly convinced that a wrong relationship with Cod, backsliding, grieving the Holy Spirit and unbelief or an attitude of rebellion against Cod, including a refusal to receive Jesus Christ as Saviour and Lord, are all significant factors which have a definite bearing upon the incidence of mental and emotional suffering and breakdown.

Depression in Non-Christians

In addition to those individuals who deliberately and wilfully reject the claims of the Lord Jesus Christ, there are many men, women and young people who are either totally ignorant of the way of salvation or who have been robbed of any faith and confidence in the Bible by apostate clergymen who have abandoned sound doctrine and who preach theological liberalism from their pulpits. Others have been successfully brain washed by high school teachers and university professors who are steeped in the teachings of secular humanism, atheistic existentialism, Marxism or other antiChristian philosophies. As a result of this type of indoctrination countless individuals have been intellectually confused and have been plunged emotionally into a state of utter hopelessness and complete despair, not knowing the purpose of their existence, where they come from, or where they are going.

Dr. Francis A. Schaeffer in his excellent volume, The God who is There has ably pointed out that much of the modern philosophy, art, music, and literature, and the so-called New Theology, whether it be the "God is dead" theology, neoorthodox or Christian existentialism, is an expression of deep despair. "To live below the line
of despair," says Schaeffer is in a real sense to have a foretaste of hell now, as well as the reality in the life to come. Many of our most sensitive people have been left absolutely naked by the destruction These thinkers
do not have a unified philosophy which encompasses science, the material universe on the one hand and faith and human experience on the other. To them there is an unbridgeable chasm between concepts which are rational and logical such as the facts of science and the whole body of established knowledge on the one hand, and faith and experience on the other hand. To move from the realm of the former to that of the latter involves an irrational leap of faith. The realm of the rational and logical including man is meaningless and purposeless, and the realm of faith and experience is vague, illusory and uncommunicable according to these modern thinkers. The effect of these dreadful concepts, with their attendant loss of hope, upon the human personality can lead only to despair, deep and unrelieved gloom, and possibly in some instances suicide.³⁰

Ensnared by the teachings of science, falsely so called, many educated persons including myriads of our young people believe that the universe came about by chance and that man is the end product of a blind godless evolutionary process. The late Bertrand Russell, English mathe-matician-philosopher and a militant atheist and pacifist gave expression to utter pessimism and the blackness of deep despair stating that man ". . . his origin, his growth, his hopes and fears, his loves and his beliefs, are but the outcome of accidental collocations of atoms. No fire, no heroism, no intensity of thought and feeling, can preserve an individual life beyond the grave; all the labours of the ages, all the devotion, all the inspiration, all the noonday brightness of human genius, are destined to extinction in the vast death of the solar system, and that the whole temple of Man's achievement must inevitably be buried beneath the debris of a universe in ruins ³¹

Jean Paul Sartre, exponent of atheistic existentialism, paints a picture of man which can be described by three words: anguish, abandonment and despair. Man he says, is constantly forced to snake decisions without any guidance and with no guarantee that anything he does is correct because, continues Sartre, there is no Cod. Man is placed in an unsoluble dilemma resulting in deep and undying anguish. He is abandoned without a purpose and with no a priori values. Furthermore, according to Sartre, man is reduced to despair because he is free, yet without hope, since to will something is not necessarily to achieve it. Finally, when he dies all his efforts may have been in vain.³²

Socialism, political liberalism and Communism have devalued the unique importance of the individual human being making bins subservient to the collectivist state, so that in these days of increased government control and intervention there has arisen an increasing depersonalization of the individual rendering him little more than a cypher or a social security number.

In addition to the false and evil philosophies, which I have briefly outlined, unregenerate and unsaved human beings are assailed by terrible anxieties and the possibilities of impending doom which threaten our society and hang over it like the Sword of Damocles. Many thinking individuals today are troubled because of the possibility of a nuclear war which could devastate civilization, the dangers of increasing pollution of the earth's atmosphere and waters, the population explosion with its accompanying threat of famine and starvation, and the prospects of a Communist dominated one world government with its accompanying terrors. '['hiss this existential despair and loss of hope can trigger off a depressive illness in the same manner as other kinds of losses. If the individual concerned has already experienced a previous loss such as lack of parental affection in early childhood or if there is already a biological predisposition to depression the intensity of his suffering is likely to he much more severe.
Similarly the guilt and unhappiness resulting from a broken relationship with Cod due to uneonfessed sin, and the burden of guilt arising from sins and transgressions of the past in the life of the unconverted individual can generate symptoms of depression or aggravate an already preexisting depressive mood. I believe that the emotional tension associated with these spiritual problems can cause biological changes in the brain, especially in relation to hiogenic amine metabolism which can further enhance the state of depression, plunging the sufferer into a vicious circle of deepening misery. In this case the individual may not respond to spiritual counselling alone but may also require treatment with antidepressant drugs.

While I cannot agree with those Christian counsellors who attribute all mental illness to sin in the life of the believer or a state of alienation from Cod in the case of the unconverted individual, I must emphasize very strongly that any treatment program which neglects the spiritual dimensions of the human personality and fails to take into account the tremendous healing which God brings to bear upon the emotionally disturbed person who submits his life to Him is to say the least, extremely deficient and inadequate.

Treatment of Depression

As far as the treatment of depressive illness is concerned, about 95% of patients can he relieved of their symptoms by physical methods of treatment which include electric convulsive therapy, antidepressant drugs (the tricyclics and monoamine oxidase inhibitors) and in a few specific cases lithium carbonate.

The advent of the antidepressant medications about twenty years ago has sharply reduced the need for electric convulsive therapy (ECT), but this mode of treatment is still useful in severely suicidal patients or in persons who for some reason do not respond to antidepressant drugs. The biggest disadvantage is the temporary impairment of memory which generally occurs as an undesirable side effect of the treatment particularly if the electrodes are applied to the head bilaterally. Unilateral ECT, in which the electrodes are applied to the side of the nondoniinant cerebral hemisphere, is in my opinion about as effective as the bilateral treatment, but also has the added advantage of producing much less memory impairment. In studies of animals it has been demonstrated that experimental electric shock treatment, acutely administered, has caused an increase in the turnover of biogenie amines in the brain.

The tricyelic antidepressants, which include imipramine (tofranil) and amitriptyline (elavil) are the drugs most frequently chosen to he used, particularly in severe endogenous depressions. They operate by blocking the reuptake of the neurotransmitter into the presynaptie neuron thereby increasing the concentration of hingenie amines at the synapse." Biochemical studies suggest that patients with low urinary MFIPC concentrations (norepinephrine deficient group) respond best to insipramine or desipramine, whereas patients with normal or high urinary concentrations of this metabolite are more successfully treated with amitriptyline.

The monoamine oxidase inhibitors which include isocarboxazid (marplan), phenelzine (nardil) and tranylcypromine (parnate) are the drugs chosen in atypical depression associated with anxiety, phobic and hysterical symptoms, and also in depressive illnesses including endogenous depressions, which have failed to respond satisfactorily to tricyclie antidepressants. Certain foods such as cheese, pickled herring, lima beans and others, and certain medications should he avoided by patients being treated with monoamine oxidase inhibitors as they may cause an acute and sudden rise in blood pressure. However if these foods and medicines are avoided, monoamine oxidase inhibitors are relatively safe .³⁵ The nsonoansine oxidase inhibitors exert their antidepressant effects by the inhibition of the enzyme monoamine oxidase. As a result of the inhibition of this enzyme there is an increase in the concentration of hiogenie ansines in the brain.

Small subgroups of depressed patients require lithium carbonate combined with a tricyclic antidepressant or a monoamine oxidase inhibitor for the successful treatment of their illness. Patients who have failed to respond to ECT and to both types of antidepressants administered separately, have sometimes responded to combined antidepressant therapy (trieyelies and mnouoamine oxidase inhibitors used together). Finally in relation to antidepressant drug therapy it must he remembered that there is generally a two to three week time lapse before therapeutic effects are manifest.

In addition to biological forms of treatment a supportive type of psychotherapy, together with more specific biblical counselling in patients who are amenable and open to spiritual truth, is in my opinion usually sufficient. More extensive psychotherapy should be reserved for the depressed individuals in whom neurotic or characterolugical factors represent a major aspect of their illness. Many patients cannot afford the money or time to indulge in prolonged and frequent psychotherapy sessions, nor are there enough therapists to go around as far as this type of treatment is concerned. If all the psychoanalysts in this country were to treat nobody except depressed patients they would he giving therapy to less than 1% of such cases.

In the process of psychotherapy the following areas may require attention: (1) Explanation of the nature of the patient's illness including the use of drugs and ECT together with their side effects. (2) Discussion relating to the handling of every day problems, preferably in the light of Scripture. (3) Discussion and exploration of such issues as true and false guilt, anger, poor self esteem and feelings of rejection.

The patient needs to be assured of the love and concern of his therapist. If he is a Christian he should he assured from the Bible of his imputed righteousness in God's sight; yet if there is uneonfessed sin ruining his fellowship with the Lord, he should be encouraged to repent and confess that sin.³⁶

Finally the Christian therapist most always bear in mind that it is not enough to treat the biological and psychological aspects of depression; he must do more than that. He most treat the whole man and that includes the spiritual dimension of the depressed individual. If possible the patient should be led to a saving knowledge of the Lord Jesus Christ and thence to a life of total commitment and victorious Christian experience.

REFERENCES

¹How To Win Over Depression by Tim Lahaye. Chapter 1, p. 16. Zooderv an 1974.
²From Sad to Glad, by Nathan S. Kline M.D. Chapter 1, p. 18. Putnam 1974.
³Cornpanion to Psychiatric Studies, Volume 2. Editor: Alistair Forrest. Chapter 9, "Affective Disorders," C.W. Ashcroft, I.M. Blackburn and ILL. Cundall, p. 201. Churchill Livingstone, Edinburgh and London 1973.
⁴From Sad to Glad by Nathan S. Kline MD. Chapter 3, pp. 48-49. Putnam 1974.
⁵Depression, edited by Gene Usdin M.D. Chapter 4, Pp. 52-53, Classification of Mood Disorders by Robert L. Spiteer M.D. and Jean Eddicott, Robert A. Woodruff Jr. KID. and Nancy Andceasoo Ph.D. MD. Bronner/Mazel Publishers New York 1977.
⁶Winokor, C., Cadoret, B.J., Dorzab, J. and Baker, M. Depressive Disease: A Genetic Study, Archives of General Psychiatry, 24:135, 1971.
⁷Understanding Mental Illness: A Layman's Guide by Nancy Andressen Ph.D., M.D. A,tgsburg Publishing House Minneapolis, Minnesota, 1974. Chapter 3, pp. 48-50.
⁸Only a Machine or Also a Living Soul?" by Walter C. Johnson M.D. Journal of the American Scientific Affiliation December 1970.
⁹A Primer of Psychobiology: Brain and Behavior by Timothy J. Taylor Ph.D., W. H. Freeman and Co., San Francisco 1975. Chapter 2, p. 27.
¹⁰From Sad to Glad by Nathan S. Kline M.D. Chapter 5, pp.96-911. Potuaos 1974.
¹¹Understanding Mental Illness: A Layman's Guide by Nancy C. Andrea. and Ph.D. KID. Augshurg Publishing House Minneapolis, Minnesota 55415. Chapter .3, p. 50.
¹²Neuropsychopharachology: A Series From Roche Laboratories No. 6, "Models of Affective Disorders," Hotfmao-LaBoche Inc. 1977.
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¹⁴Neuropsychopharmacology. A Series From Roche Laboratories No. 6, "Models ,f Affective Disorders," Hoffman-1,sBoche Inc. 1977.
¹⁵ Human Physiology. The Mechanisms of Body Function by Arthur J.Vander, James H. Sherman and Dorothy S. Luciano 2nd. Edition McGraw-Hill Book Co. Chapter 15, "Defense Mechanisms of the Body," pp. 500-501.
¹⁶Dpression, edited by Gene Usdin MD. Bruneer Mazel Publishers, New York 1977. Chapter 6, ¹⁷Psychoneuroendoermology; Fundamental Concepts and Correlates in Depression" by Robert "I'. Rubin MD and Kenneth S. Kendler MD. pp.125-128.
¹⁸From Sad to Glad by Nathan S. Kline M.D., Putnam 1974. Chapter 12, pp. 222-223.
¹⁹  Spiz, R. A.,"Hoispitalism, An Inquiry into the genesis of Psychiatric Conditions in Early Childhood," Psychoanalytic Study of the Child 1.53, 1945.
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²⁰Engel, CI,. and heichsmaou, I", 1956) "Spontaneous and Experimentally Induced Depression is an Infant with a Gastric Fistula: A Contribution to the Problens of Depression," Journal of the American Psychanalytic Association 4, 428.
²¹Bowlby, J. (1953) Child Care and the Growth of Love, Penguin Books.
²² Companion to Psychiatric' Studies, editor Alistair Forrest, Vol. 2, Chapter 9, "Affective Disorders," C.W. .Ashcroft, EM. Blackburn and RI.. Condall, p. 227. Churchill Livingston Edinburgh and London, 1973.
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²⁴Brain Changes in Response to Experience" by Mark B. Borosenwig, Edward L. Bennett and Marion Cleeves I)iansens, February 1972. Readings From the Scientific American. The Nature and Nurture of
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²⁵From Sad to Glad by Nathan S. Kline KID,, Chapter 4, "In Search of Causes, A Medical Detective Story," 'p. 52-85, Putnams 1974.
²⁶The Christian Counselor's Manual by Jay E. Adams, Presbyterian and Reformed Publishing Co. 1973. Chapter 33, "Helping Depressed Persons."
²⁷How to Win Over Depression by 'Vim LaHsye, Zondervan Publishing House, Grand Rapids, Michigan 49508, 1971. Chapter 4, "Is There a Core for Depression?"
²⁸5John 9:1-2
²⁹John 9:3
³⁰The God Who is There by Francis A. Schaeffer, Intervarsity Press, Downers Grove, Illinois 60515. 1968. Chapter 5, pp. 46-47.
³¹Beyond Science by Densis Alexander, Chapter 4, p. 141. A.J..Holman Company, Philadelphia and New York 1972.
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³⁵A Neglected Modality in Psychiatric Trestnscut-The Klonoansine Oxidase Inhibitors- by Walter C. Johnson MD. Diseases of the Nervous System, Vol. 36, No. 9, pp. 521-525, September 1975.
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