Session on Church's care for depressed patients

Below are papers read at the session "Church's care for depressed patients" of the XXVII International Educational Christmas Readings
January 26, 2019, Moscow (continuation)

Depression and the Notion of Sadness and Despondency in Patristic Literature

V.G. Kaleda

Your Eminence, dear fathers, brothers and sisters!

We have gathered today to discuss perhaps one of the most pressing problems challenging psychiatry and our society, i.e. the problem of depression. About 550 million people globally suffer from depression, and we have about 9 million people with this disorder in Russia. Severely depressed prevail among those who commit suicide. It is not by chance that experts of the World Health Organization (WHO) call depression the number one enemy. We face this problem not only in psychiatric facilities and hospitals for general medical conditions, but also in our daily lives, observing it in our relatives, friends and acquaintances. Sometimes depression occurs at the most unexpected moments of our lives, in the most unlikely situations, or it appears in people whom we have always perceived as strong in spirit. According to the WHO, depression is a mental disorder that manifests itself in a pathologically low mood. The key words are "pathologically low mood", because normally each of us experiences our own emotions, reacts to certain events in our lives: rejoices when something positive happens and gets upset because of some negative events. Our Lord Jesus Christ was also saddened, grieved and wept, when His friend Lazarus had died. You can find many other examples, for instance, in the lives of saints, when people reacted in a certain way to sorrows in their lives. Here we talk about depression as a pathologically low mood with a pessimistic assessment of oneself, one's own situation, and the reality around. It is as if the person is looking at everything through blue glasses: everything in his/her life, everything that has been and will be, is perceived with extreme pessimism. This state is accompanied by motor and ideational, i.e. thinking, inhibition and self-accusation thoughts.

The criteria for depression include low spirits, which last at least two weeks and in which the person stays most of the day. People lose interest in usually pleasant for them activities and do not enjoy them any longer. Sleep disturbance manifests itself with early awakening and difficulty falling asleep, however sometimes the person in depression may sleep all day long. There is a decrease of the activity level, self-esteem, energy, and vitality; whereas fatigue, constipation, and other somatic and vegetative disorders are on the rise. The state is characterized by loss of weight, a significant loss of appetite and refusal to eat, and reduction of appetence. The person may experience an unusual and unreasonable sense of self-condemnation and excessive guilt. In severe cases, the state is characterized by anti-vital and suicidal thoughts.

Depression is one of the most common psychiatric disorders, and there has been a clear trend over the past decades towards its spread, with an increase in the number of depressed patients. At the same time, professionals have begun to pay more attention to this problem and to realize that lingering bad mood does not appear simply because the person has got upset or is sad about this mental disorder. As a result of this changed approach, this disease is diagnosed much more often. Over the past decades it became a leading problem in psychiatry. While psychiatric research in the 1960s and 1970s focused more on schizophrenia, now it puts emphasis on affective disorders.

According to the statistics, women are more susceptive to depression. For example, about 20% of women suffer from postpartum depression. It would seem strange, that such a happy event in a woman's life as the birth of a child could be dimmed with a sudden depression. However, it is caused by a number of endogenous changes that develop in her body.

It should be noted, that from 4 to 18 per cent of the population have a history of depression at some age, according to some psychiatric data. The most vulnerable groups are adolescents and 60+ people, when more than 60 per cent of the population suffer from depression. Depression is not only a sad, downbeat and dreary mood, as many believe. It is a mental disorder, with a triad of symptoms: low spirits, inhibited thinking, and motor retardation. Traditionally, a depressive person will have a hypomimic (masklike) face, with an air of sadness, eyes full of tears and anguish. They move slowly, with the minimum gestures, stooped-shouldered, low and slow speech. This is how classic severe depression manifests itself. However, there can be a so-called smiling depression, when the person with severe mental suffering smiles, often snickers at himself, and this mask makes it very difficult to see his severe mental suffering. Often this mask of smiles and self-irony hides suicidal thoughts and intentions. Patients in a depressed state say that they physically feel sadness, joylessness and sorrow, and with this they point at the heart area. This phenomenon was described as precordial yearning by psychiatrists back in the 19th century. Psychic pain is experienced physically; it is a synesthetic sense of pain. Depression leads to apathy, loss of desire to do anything, ideas of self-accusation, self-effacement and sinfulness. In this state of mind, the person can come to confession, repent of his sins, and the priest would perceive it as a positive moment, as a deep sense of contrition, which every Christian should have. However, it is a depressive state that lies behind this external feeling of sinfulness. The person loses the meaning of life, life becomes aimless. Anti-vital thoughts come to the person's mind at the initial stage, the desire to fall asleep and never wake up, then there come suicidal thoughts and intentions, and in some cases such persons attempt suicides. They lose their ability to perceive the world around, the events, and to react to them, stop feeling taste and smell, feel weak. Such a person reacts irritated to events around him.

During depression, the person speaks of mental (ideational) inhibition: thoughts flow slowly, the person says that his head is empty, he finds it very difficult to think, put elementary thoughts together, go to a shop and say simple words to the shop assistant. He needs to think every phrase over before pronouncing it; it is difficult to participate in a conversation on simple household topics.

The motor component of depression is manifested in the person's physical weakness. A young man should seem to be full of vigour and energy, whereas he cannot force himself to get up in the morning, go to classes, or work, or church. Along with that he experiences melancholy, feels broken and powerless. Depression cannot but affect the spiritual sphere. Believers speak of the so-called petrified indifference. St. Siluan the Athonite gave a classic description of petrified indifference: man turns to God, prays, but feels no answer, as if knocking on a closed door. Man partakes of the Sacraments, but does not participate emotionally in them. They feel cold in their hearts and cannot read spiritual literature. There are patients who cannot take the Communion in this state: they say, they do not feel anything after the Communion and therefore cannot come up to the Chalice. Some people lose faith in God's mercy, begin to repine against and blaspheme God, and reject the cross the Lord has given them.

Depression has different degrees of severity. There exists a so-called mild depression, a kind of sub-depression when the symptoms I have listed are not that much pronounced. Such depression does not have a serious impact on day-to-day work or social activities. In general, only the closest relatives and the priest during confession can feel that the person is in the state of sub-depression. A moderate degree of depression is already characterized by more or less distinct difficulties in performing social and household duties, and work. When we talk about severe depression, the feeling of anguish and hopelessness reaches such a degree of severity that the individual is unable to carry out any activity.

It seems as though the person in a sub-depressed state becomes deeper. He understands that many things and events in his life are nothing but vanity and add to the hectic atmosphere. So, he turns to God, thinks more seriously about his spiritual life, becomes aware of his sinfulness and unworthiness, and seeks spiritual growth and improvement.

The person in a severe depression feels as if he is at the bottom of a very deep abyss, he is unable to feel anything, perceive support from those who love him or hear the priest's words. The person seems to be in a long tunnel, where there is almost no light. In this state, suicidal thoughts and actions often come to people's minds, even to those believers, whose families have always been churched. Even they do not always cope with the severity of depression.

Speaking about the origin of depression, the following types should be named:

• Endogenous depression with genetically induced, biological roots;
• Psychogenic depression, caused by psychogenic factors;
• Somatogenic depression, accompanied by general medical conditions;
• Constitutional depression, related to peculiarities of the man's personality structure.

Endogenous depression includes bipolar affective disorder, recurrent depressive disorder, schizophrenia, schizoaffective psychosis, organic and atrophic brain condition, depression associated with the woman's reproductive cycle (postpartum, involutional, etc.).

All modern psychiatrists point out in their studies that believers are more stress-resilient: they easier take stressful events that come into their lives, and see them as God's will or connivance. There is a saying in Russia - "The Lord has stopped by " - when some misfortune would happen. The Lord has stopped by so that we could think about our lives, in particular, about the meaning of our existence. Victor Frankl said that religion gave the spiritual anchor of salvation to the man with such confidence that they could not find it anywhere else. Studies show that true believers are more likely to endure difficult life situations and have less reactive depression.

There is a constitutionally depressive personality type. Such people initially perceive everything pessimistically and tragically, they lack the ability to experience a carefree joy. They always see the reverse side of things, everything seems somehow poisoned or spoilt. Such people are extremely sensitive to negative aspects of life and always expect the worst. Hypochondriacal fears and punitive thoughts lie in wait for them day after day. It is not rare that a depressive Christian worldview is formed.

Unfortunately, when these people come to church, they very often perceive life in the Church in a depressive manner, thus creating a depressive perception of our church life. They try to perceive Christianity not as a joyful fullness of life in Christ, but rather as a depressing religion.

It is common to distinguish the following main types of depression, depending on the predominance of certain components in the structure thereof: melancholic, anxiety, anesthetic, dynamic, apathetic, dysphoric, cenesthopathic-hypochondriacal and metaphysical.

Melancholic (or dreary) depressions are characterized by the prevalence of a depressed mood with intellectual and motor retardation. Such patients complain of overwhelming desperate sadness, which is often accompanied by painful physical sensations in the upper abdomen and in the heart area. The patient is not pleased with anything, believes her/himself a failure, a burden on the loved ones; the past is seen as a chain of errors; the person feels hopeless and desperate. Patients are inhibited, can stay in bed or sit without moving all day long. Speech is quiet and monotonous.

Anxious depression is accompanied by anxiety, agonizing anticipation of an impending misfortune, disaster. Patients are in a state of tension and feel restless - they "cannot sit or lie down", they are constantly in motion. In some cases, on the other hand, they can sit still for a long time, and only continuous movements of their fingers and hands will reveal their inner tension.

The so-called anesthetic depression is characterized by a dominating loss of emotional reactions to things around. The patients complain of a lack of emotional resonance along with an agonizing sense of inner devastation and loss of all senses, including sadness. They say they have "stiffened", "petrified", "grown dull". There is a sense of change in the perception of the world around - it has lost colour and is perceived as if "through a dim glass".

Adynamic depression is characterized by weakness, defatigation and pronounced difficulties in fulfilling physical and mental work while maintaining the desire for activity. The patients complain of the lack of physical strength and energy, feeling unrested, and powerless.

Apathetic depression is dominated by complaints of the lack of desire and drive to any activity. At the same time, patients do not feel sad and anxious, and they have no ideas of self-reproach.

Dysphoric depression is characterized by episodes of frustration, irritation, anger, aggressiveness and destructive tendencies (so-called "irritable weakness") against the background of depressed moods. At the same time, an insignificant reason may trigger irritation.

In cenesthopathic-hypochondriacal depression (somatized depression, "depression without depression", latent depression), the main complaints are about unpleasant, painful feelings in different parts of the body. The patients focus on their physical health, with the depressed mood being in the background or perceived as a natural consequence of bodily ailments. There are certain signs that signal about this type of depression: the patient persistently turns for treatment to different kinds of doctors who, despite the use of modern diagnostic methods, do not find any particular ailment in the patient (some very vague diagnosis, like vascular dystonia, may be identified); despite failures of treatment, the patient stubbornly goes to doctors.

Meta-physical (existential) depression (more typical of teen-age) is a special kind of depression characterized, first of all, by a sudden dip in philosophical reflections and speculations about the meaning of life, etc. Such reflections can lead a person to a "reasonable" conclusion about the inevitability of death, futility of life and lack of understanding shown by the others, eventually leading to suicide plans.

Besides, there is also the so-called ironic depression, when the patients smile and are ironic about their condition and helplessness. At the same time, the smile on the patient's face does not mean that their disorder is insignificant and does not exclude the formation of suicidal intentions.

From the point of the highest risk of suicide, dreary, anxious and anesthetic forms of depression are the most dangerous. Clinical observations suggest that such forms of depression are the most difficult to withstand. The words by St. Isaac of Syria about despondency that "it nurtures the soul on hell" seem to be most appropriate.

Depression is significantly affected by the age of the patient. Thus, in preschool children depression is manifested in the forms of reaction typical of this age - vegetative system and motor disorders. Children become motor retarded, refuse to eat, lose weight, and sleep poorly. They often cry, become withdrawn, and lose interest in games. Depressive conditions in children of primary school age are characterized by behavioral disorders, problems with academic performance, enuresis, loss of appetite and weight, constipation. In some cases, children show irritation, tendency to aggression and to absenteeism from school classes. Along with this, typically they seem not to complaint on the feeling of yearning and anguish.

In adolescence, depression is characterized by severe attention focusing problems, difficulties in concentration and comprehension, increased fixation on their appearance, anti-vital thinking with the loss of meaning in life and a high incidence of suicidal thoughts and intentions. Sleep disturbances, appetite disorders, headaches, constipation, and numerous hypochondriacal complaints are also noted. Boys are characterized by irritability, whereas girls are tearful and apathetic.

Depression at a later age is characterized by inhibition, anxiety, new or deeper cognitive impairment, including memory impairment, a pronounced hypochondriacal component with the fixation on own's physical conditions, as well as poor sleep, appetite, weight changes, constipation, etc.

Modern studies show that 20% of cases of depression last more than 2 years, and in 17% of cases depression may last for a lifetime. In these cases, they usually speak about the so-called prolonged and chronic depression.

Unfortunately, depression, including long-term chronic depression, is often not perceived as an illness in our society. This results in patients being criticized and reproached for lack of character and "unwillingness to help themselves", instead of providing psychological support. However, influence on the person's will, which deprives him/her of the ability to take action to improve his/her condition, is part of the depressive state itself.

The first and most important thing that a priest must understand is that any depressive state is not just sadness as a healthy person's healthy reaction to everyday troubles of life, but a mental disorder.

Thinking about causes of depression, we should remember what Hippocrates said 24 centuries ago, "We need to know that ... frustration, sadness, discontent and complaints come from the brain... It makes us crazy, and we are overwhelmed by anxiety and fears, either at night or as the day comes".

Today, the following factors are traditionally identified when considering causes of depression: biological, psychological, social and spiritual. The model of depression implies four components: bio-, psycho-, social, and spiritual ones.

Biological components have been studied well and presented in a large number of brain studies, and they stand out in various affective states. There are research methods, EEG in particular, to capture the level of depression.

The social factor of depression contributes to its spread among people of certain professions - caregivers working with the elderly and sick, nannies caring for small children (11.3%), public catering (10.3%), medical doctors (9.6%), the unemployed (12.7%). Scientists, architects and engineers are least affected by depression (4.3%).

Depression is more common among family members of depressed patients. Approximately 20% of relatives of the depressed are also depressed, while relatives of healthy people fall ill in 7% of cases. The risk of depression is 2-4 times higher among single and divorced individuals, than among married people. Divorced and single men are at a greater risk, than divorced and single women.

The Holy Fathers often wrote about "grief and sorrow". When we talk about sorrow in our routine lives, we usually mean the thymic component - sad and sorrowful state of mind. But the Holy Fathers meant not only sad mood, but rather the state of grief and despair, when sadness exceeds the maximum degree. This leads to despondency and powerlessness.

Depression was comprehensively described in detail by the Holy Fathers. St. Abba Dorotheus wrote about grief, mental severity and pain, about exhaustion, uneasiness, anxiety, oppression; St. John Cassian of Rome about despair; St. John Chrysostom about the loss of spirit, powerlessness.

When the Holy Fathers describe despondency, they speak of the state of laziness and boredom (St. Theodoretus, bishop of Cyrus), loss of courage (St. John Cassian of Rome), apathy, numbness, negligence, carelessness, drowsiness (Cyril of Scythopolis), heaviness of the body and mind that urges the man into sleep, even though s/he is not actually tired (St. Athanasius the Great), loss of appetite, aversion, vexation and loss of energy (St. Theodoretus of Cyrus), about the fact that the man loses taste for life, finds all things vulgar and commonplace, does not expect anything else (Palladius of Helenopolis). Psychiatry, today, uses the concept of anhedonia - loss of the ability to enjoy anything. All of this is embraced by the concepts of "sorrow" and "despondency", described by the Holy Fathers.

Surprisingly, but we find the description of causes of depression in writings by the Holy Fathers:

• Deprivation of the desired (in a broad sense) as a psychogenic factor;
• Anger (St. Evagrius Ponticus, "Sorrow is a consequence of angry thoughts"; St. Maximus, "Remembrance of wrongs is associated with sorrow");
• Sorrow can be ungrounded (St. John Cassian the Roman);
• Because of the influence of demons.

Psychiatrists of the 21st century call unreasonable sadness endogenous depression, when the cause is at the biological level, and depression occurs without any triggering factor. The Holy Fathers understood that. We can only admire and be amazed at what the Fathers realized so many centuries ago. St. John Cassian of Rome did not try to attribute these states to any other hidden reasons - the influence of demons, loss of the desired, or some sinfulness. The Holy Fathers honestly admitted that they saw no reason for such depression. Unfortunately, in modern literature, which can be found in Orthodox Churches, priests do not see this and are eager to assign such things to the impact of demons or something else. We need to turn to the Holy Fathers, who described all these conditions.

In many, although not all, cases depression has a spiritual cause. This is due to the passions of sadness and despondency and, thus, is subject to spiritual healing.

In case of endogenous depression, medication steps in the foreground along with spiritual healing, no doubt.

Speaking of reasons for referral to a psychiatrist, it should be noted that there is no need to refer immediately all patients with depression, for example, with a mild degree, to a doctor. People should be referred to psychiatrists when they have developed moderate to severe symptoms of depression, with anti-vital and suicidal thoughts, intentions, or attempts; when the person feels that God has forsaken him/her, and loses hope for the mercy of God; when they lose faith.

When we talk about treatment of depression, we believe that psychotherapy can help, and we shall talk about this in more detail today.

Currently there are many therapeutic methods for those who need it: psychopharmacotherapy, light therapy for seasonal depression, phytotherapy - for mild forms of depression. There is music therapy: King David can be called the first music therapist since he played the lute to King Saul, who was in severe depression. There is bibliotherapy when the person turns to reading the Holy Scripture. This is a very important method for an Orthodox Christian. In severe cases, electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS) are used. There is a whole range of modern antidepressants with different mode of action and indications for prescription.

One of the morning prayers offers amazing words when we turn to the Holy Virgin Theotokos and ask her, "Banish from me, thy humble, wretched servant, despondency…" Indeed, despondency, sadness, depression belong to the most difficult spiritual and mental states of the man. Therefore, we must remember Apostle Paul's words, "Rejoice always; pray without ceasing; in everything give thanks; for this is God's will for you in Christ Jesus" (1 Thessalonians 5:16-18).