(Again, notes not text of a lecture. There would be a lot of fill-in between discrete notes)

IV       Causation

There are three potential types of causation for depression: physiological, environment, or spiritual. Often these three elements will affect one-another.

A         Physical Causes of Depression

There are number of physical diseases and physiological conditions which will either cause symptoms of depression or which are associated with depression.

The Mayo Clinic webpage makes the following statements respecting physical causes of depression:

It’s not known exactly what causes depression. As with many mental disorders, a variety of factors may be involved, such as:

Biological differences. People with depression appear to have physical changes in their brains. The significance of these changes is still uncertain, but may eventually help pinpoint causes.

Brain chemistry. Neurotransmitters are naturally occurring brain chemicals that likely play a role in depression. Recent research indicates that changes in the function and effect of these neurotransmitters and how they interact with neurocircuits involved in maintaining mood stability may play a significant role in depression and its treatment.

Hormones. Changes in the body’s balance of hormones may be involved in causing or triggering depression. Hormone changes can result with pregnancy and during the weeks or months after delivery (postpartum) and from thyroid problems, menopause or a number of other conditions.

Inherited traits. Depression is more common in people whose blood relatives also have this condition. Researchers are trying to find genes that may be involved in causing depression.

https://www.mayoclinic.org/diseases-conditions/depression/symptoms-causes/syc-20356007

Since there are actual physical diseases which can cause depression symptoms (remember depression is a description of symptoms, not the diagnosis of a singular disease), it is appropriate to send someone to a medical doctor for a check-up. For instance, heart attack, stroke and thyroid disease are associated with depression.

Brain chemistry:

This is what most people think of as a physiological cause of depression. There have been theories about the relative levels of neurotransmitters such as serotonin as a cause of depression. But there is no possible way to measure the relative levels of neurotransmitters, particularly between the salient neurons relative to a state of depression.

This “chemical imbalance” theory of depression has largely been set aside. As was explained in a Harvard Medical School article:

It’s often said that depression results from a chemical imbalance, but that figure of speech doesn’t capture how complex the disease is. Research suggests that depression doesn’t spring from simply having too much or too little of certain brain chemicals. Rather, there are many possible causes of depression, including faulty mood regulation by the brain, genetic vulnerability, stressful life events, medications, and medical problems. It’s believed that several of these forces interact to bring on depression.

To be sure, chemicals are involved in this process, but it is not a simple matter of one chemical being too low and another too high. Rather, many chemicals are involved, working both inside and outside nerve cells. There are millions, even billions, of chemical reactions that make up the dynamic system that is responsible for your mood, perceptions, and how you experience life.

https://www.health.harvard.edu/mind-and-mood/what-causes-depression

The article goes on to make a case for physiological elements of depression, but the point is that a simplistic “chemical imbalance” theory is simply inadequate.

B         Environmental causes

Depression can be a response to something in one’s environment. And again remember that depression can refer to sadness, fearfulness even anxiety of a sort.

1 Thessalonians 4:13 (ESV)

¹³ But we do not want you to be uninformed, brothers, about those who are asleep, that you may not grieve as others do who have no hope.

Here we have Paul explaining that death can lead to sorrow and that if not rightly understood can lead to a sorrow without hope.

One of the best tests for determining whether a depression is the result of a environmental cause is to ask when the depression began (learned of this test from Charles Hodges, M.D., excellent book, Good Mood Bad Mood). If you receive a response that the depression began shortly after my dad died, you have good evidence of a response to environment

C         Spiritual Depression

 

There are three types of spiritual depression

1          Depression for unrepentant sin

Ps. 32

2          Depression as a response to a corrective of God

2 Cor. 1:8-10 & 12.

3          Depression

Martyn Lloyd-Jones writes of spiritual depression which comes out a defective theology and thus a misunderstanding of the Christian life.

V         Responses to Depression

The response will be dependent upon the cause.

A         Physical disease

Where there is a diagnosable disease with a discrete treatment, then physical treatment is appropriate.

Aside on antidepressant medication

Antidepressant medication is typically medication meant to affect the “chemical imbalance” in the brain. In private conversation with a well-respected psychiatrist at a major university (he has since deceased), said over dinner, “Sometimes antidepressants work, sometimes they don’t; and we don’t know why.”

There many issues when it comes to antidepressants.

First, if the depression is not physical, then medication is inappropriate.

Second, feeling bad may be unpleasant but it is not necessarily bad. As noted in the citations above for spiritual depression, bad feelings may be means of correction or training.

Consider this passage from Paul:

Romans 5:1–5 (ESV)

5 Therefore, since we have been justified by faith, we have peace with God through our Lord Jesus Christ. ² Through him we have also obtained access by faith into this grace in which we stand, and we rejoice in hope of the glory of God. ³ Not only that, but we rejoice in our sufferings, knowing that suffering produces endurance, ⁴ and endurance produces character, and character produces hope, ⁵ and hope does not put us to shame, because God’s love has been poured into our hearts through the Holy Spirit who has been given to us.

At the end of verse two, Paul identifies the “hope of the glory of God” as the basis upon which we rejoice. The question then arises, who then do I increase hope? He goes on to explain that painful circumstances which could overwhelm us (as explained in 2 Corinthians) are used as a means to increase hope, in the end.

Third, antidepressants are subject to a substantial placebo effect. For mild to moderate depression, the placebo effect of antidepressant medication appears to be the principle benefit, “The combined effect of these and other biases suggests that the benefits of antidepressant drugs for mild to moderate depression (over and above the placebo effect) may not be clinically significant.” https://www.psychologytoday.com/us/blog/doctor-you/201907/its-time-depression-make-friends-the-placebo

For those who suffer “severe” depression, the medical indications are different.

Fourth, antidepressants have serious side effects. For instance:

In the latest and most comprehensive analysis, published last week in BMJ (the British Medical Journal),a group of researchers at the Nordic Cochrane Center in Copenhagen showed that pharmaceutical companies were not presenting the full extent of serious harm in clinical study reports, which are detailed documents sent to regulatory authorities such as the U.S. Food and Drug Administration and the European Medicines Agency (EMA) when applying for approval of a new drug. The researchers examined documents from 70 double-blind, placebo-controlled trials of two common types of antidepressants—selective serotonin reuptake inhibitors (SSRI) and serotonin and norepinephrine reuptake inhibitors (SNRI)—and found that the occurrence of suicidal thoughts and aggressive behavior doubled in children and adolescents who used these medications.

https://www.scientificamerican.com/article/the-hidden-harm-of-antidepressants/

Aside on electroshock

Electroshock therapy has returned as a therapy in cases of severe depression. In a recent conversation, a psychiatrist explained to me that the current theory is that the electroshock causes a “hard reset” of the neurotransmitters and shows some alleviation of depression symptoms following the treatment.  When I see her next, I’ll ask about her current opinion of the treatment.

B         Spiritual depression

Obviously, exploration of unrepentant sin is appropriate and repentance (Ps. 32 & 51) may be the necessary response to depression. A warning here: be careful of insisting on this point, because it could easily cause despondency in a troubled conscience.

Administration of Hope

Ps. 77 Gives a good example of how to perform this work:

Psalm 77:1–10 (ESV)

The first four verses describe a case of serious depression

¹           I cry aloud to God,

aloud to God, and he will hear me.

²           In the day of my trouble I seek the Lord;

in the night my hand is stretched out without wearying;

my soul refuses to be comforted.

³           When I remember God, I moan;

when I meditate, my spirit faints. Selah

⁴           You hold my eyelids open;

I am so troubled that I cannot speak.

At this point, the Psalmist administers a series of questions which force him to realize that he has reason to hope:

⁵           I consider the days of old,

the years long ago.

⁶           I said, “Let me remember my song in the night;

let me meditate in my heart.”

Then my spirit made a diligent search:

⁷           “Will the Lord spurn forever,

and never again be favorable?

⁸           Has his steadfast love forever ceased?

Are his promises at an end for all time?

⁹           Has God forgotten to be gracious?

Has he in anger shut up his compassion?” Selah

¹⁰         Then I said, “I will appeal to this,

to the years of the right hand of the Most High.”

Martyn Lloyd-Jones, taking instruction from Psalm 42-43 explained that our trouble lies that we listen to ourselves rather than preach to ourselves. We allow our feelings to cloud and our judgment and we make our emotional state the truth of our condition. He explains that we must turn this on its head must take ourselves by the hand and tell ourselves the truth:

Psalm 42:5 (ESV)

⁵           Why are you cast down, O my soul,

and why are you in turmoil within me?

Hope in God; for I shall again praise him,

my salvation

 

C         Environmental Depression

1 Thessalonians 4:13–18 (ESV)

¹³ But we do not want you to be uninformed, brothers, about those who are asleep, that you may not grieve as others do who have no hope. ¹⁴ For since we believe that Jesus died and rose again, even so, through Jesus, God will bring with him those who have fallen asleep. ¹⁵ For this we declare to you by a word from the Lord, that we who are alive, who are left until the coming of the Lord, will not precede those who have fallen asleep. ¹⁶ For the Lord himself will descend from heaven with a cry of command, with the voice of an archangel, and with the sound of the trumpet of God. And the dead in Christ will rise first. ¹⁷ Then we who are alive, who are left, will be caught up together with them in the clouds to meet the Lord in the air, and so we will always be with the Lord. ¹⁸ Therefore encourage one another with these words.

 

Understanding the matter correctly as a means of remedying the sorrow of loss.

Romans 8:28–29 (ESV)

²⁸ And we know that for those who love God all things work together for good, for those who are called according to his purpose. ²⁹ For those whom he foreknew he also predestined to be conformed to the image of his Son, in order that he might be the firstborn among many brothers.

Note that “good” is defined in v. 29 as being conformed to the image of Christ (not in getting a new car or a better job or some other possible “good”).