Depression: how churches and GPs can work together
We want to draw together in a helpful way what we have learned in recent years in Britain about the causes and treatment of depression and anxiety, as they affect Christian people.
We also want to suggest ways churches and medical professionals can work together and show that, with appropriate treatment, most Christians can he helped back to active and useful lives.
It needs to be said at the outset that we both reject the central aspects of the current ‘anti-psychiatry’ movement in its Christian and in its secular variants. An example of this, from an evangelical Christian viewpoint, was Nancy Lambrechts’ article, ‘The Depression Industry?’, in the July issue of EN.
A secular version of these views can be found in Dr. Joanna Moncrieff’s book, The Myth of the Chemical Cure, published earlier in 2008. Both attack the ‘chemical imbalance’ model of depression.
Our reasons for not agreeing with these ‘anti-psychiatry’ views will be found in the paragraphs that follow, but several of the points we make here were also well-made in the letter from Dr. Klaus Green (EN Letters, August 2008).
A real medical condition
The first building block of our argument is to say that serious depression and anxiety disorders are real medical conditions that are faced by Christians and need to be viewed as such. We accept that, as in other areas of medicine, there may be a tendency to over-diagnose but one responsible Christian medical writer, Dr. Nick Land, has written ‘one in four people will have a significant episode of mental illness at some time in their life’.
While no one — to our knowledge — has separately studied the mental health of Christians in today’s evangelical congregations, there is no reason to think that the incidence of mental health issues will be significantly less in our churches. Indeed, because our evangelical churches — quite rightly — provide environments that are caring and supportive, individuals with mental health issues may be attracted to them. If this is so, it would follow that the incidence of mental ill heath in our congregations may be greater than in the wider community. It follows that those in pastoral charge are likely to have to deal with more than one serious ongoing mental health issue within their church memberships at any one time.
Mild and severe
There is a significant difference between people presenting with mild depression/anxiety and moderate/severe clinical depression. The large majority of GPs and practising NHS psychiatrists recognise and treat people coming to them with symptoms of depression on this basis. In my own practice and, more widely, GPs in the NHS are well aware of the dangers of over-diagnosis and consequent over-prescribing. Formal treatment, including anti-depressant drugs, will normally only be given in more severe cases and usually alongside other supportive therapies and advice.
Depressive illness is certainly a complex condition with different facets but we cannot agree with Nancy Lambrechts and others that ‘the medical model’ is inappropriate when seeking to help Christian sufferers. Recognising that depressive illness can strike Christians, just as can long-term physical illnesses like epilepsy or diabetes, can help remove the stigma of guilt and shame that may prevent individuals from seeking medical support.
It follows that Christians facing psychiatric illness should not be put off seeking appropriate professional help because of unhelpful approaches that suggest it is ‘all in the mind’. In our experience — and this covers at least four evangelical church congregations — many fine Christians are actually reluctant to seek and ask for help in this area. But we see no biblical basis for thinking that, because an individual may have a strong faith and be committed to serve God, he or she should be able to cope with mental health issues without appropriate medical help. Often one of the first tasks of those in pastoral charge, when speaking with someone with depressive illness, will be to encourage them to seek appropriate medical help.
It is not true to say that a ‘conclusive and certain diagnosis …is virtually impossible’. In the day-to-day experience of thousands of experienced GPs, including those in my own practice, this is not so. Clinical depressions/anxiety disorders are complex; they vary in severity and in the range of symptoms but they can be diagnosed and assessed with a large degree of confidence. Diagnostic tools we use would include a Beck Inventory and a Personal Health Questionnaire (PHQ9) test, both of which will usually give a good assessment of the extent and seriousness of the patient’s depression. Medical researchers who have mapped and studied clinical depression over the last 40 years have enormously advanced our understanding in this complex and difficult area. These tests build on this work.
Taking a standard listing of symptoms such as this one from the American Psychiatric Association, ‘major depressive illness’ can be identified as follows:
At least one of these symptoms:
* Low mood
* Marked loss of enjoyment
Together with at least four of these:
* Significant change in appetite and a loss of at least 5% of normal body weight;
* Sleep disturbance;
* Agitation or feelings of being slowed down;
* Loss of energy or feeling fatigued almost every day;
* Feelings of worthlessness, low self-esteem, tendency to feel guilty;
* Loss of the ability to concentrate;
* Thoughts of death ….
Source: American Psychiatric Association, list cited in Gilbert (1997), p.7.
Range of treatments
A range of helpful treatments that includes both the use of anti-depressant drugs or talking therapies do exist both for depression and for a range of other psychiatric conditions, such as acute anxiety states. In my GP practice we use these treatments, singly or in combination, and usually with encouraging results.
The reports in the BMJ in early 2008 challenging the long-term benefits of anti-depressant drugs were insufficiently wide ranging to show conclusively that ‘there is little difference between the drug and the placebo’. The local NHS psychiatrists we refer patients to from my practice continue to use these drugs because they are considered to be helpful in controlling patients’ symptoms. Of course, some patients may be kept on them longer than is absolutely necessary but many will need to take them long-term. We must beware of falling into the logical trap, ‘Wrong use does not preclude proper use’; regrettably many of the ‘anti-psychiatry’ proponents are guilty of this kind of faulty reasoning.
The talking therapies such as Cognitive Behaviour Therapy (CBT) should not be dismissed because the models used (of the way we think and the behaviours we adopt in response to these thoughts) are secular and not specifically Christian. A biblical understanding of common grace means that insights into human behaviour and health are often granted to non-Christians. In our experience as a GP practice, rightly used, the techniques derived from CBT can be very helpful in moderating the symptoms of what are often very debilitating conditions. The recent book by two Christian psychiatrists and an experienced biblical counsellor, I am not supposed to feel like this, is very helpful in this respect. Among other things, the book applies CBT techniques to the context of biblical counselling. It also gives practical guidance as to how those suffering from depression can apply these techniques.
A collaborative approach
The model of pastoral and professional care that we strongly support for those suffering from major depression and/or anxiety states is one where biblically based church leaderships and appropriate medical professionals work together to support and help Christians struggling with issues of mental health. In our experience, most GPs are happy to work with church leaders when issues of the care and support of members of their congregations arise. The issue of medical confidentiality does not need to be a barrier to this co-working.
What is to be avoided at all costs is a model of mutual suspicion or even hostility. Sadly, both our experiences are that the consequences of Christians not seeking early and appropriate medical and professional help where clinical depression is indicated can be very serious. Untreated depression can be debilitating for sufferers and for their families also. In the worst cases, there is always the risk of serious self-harm.
In contrast, by combining a supportive pastoral environment in our congregations with appropriate medical intervention sufferers can very often be helped back, over time, to good health and to taking a valuable place in their churches and their communities.
Dr. Mike Davies,
GP in practice, Twyford, Berkshire
Charles H. Whitworth,
Emmanuel Evangelical Church, Leamington Spa
Joanna Moncrieff, The Myth of the Chemical Cure, 2008, Palgrave Macmillan, p.3.
Paul Gilbert, Overcoming depression: a self-help guide, 1997, Robinson Publishing, p.7.
Nick Land, ‘Psychiatry and Christianity: poles apart?’, CMF Magazine NUCLEUS, July 2002, p.13 (also available on http://www.cmf.org.uk/literature/content.asp?context=article&id=310).
FURTHER READING AND HELP
Nick Land, ‘Psychiatry and Christianity: Poles apart?’ Part 2, CMF Magazine NUCLEUS, April 2003, pp.12-20; this is a companion article to the one cited above. It is also available on http://www.cmf.org.uk/literature/content.asp?context=article&id=378). The two articles together cover many of the topics in our article; written originally for medical students.
Chris Williams, Paul Richards and Ingrid Whitton, I’m not supposed to feel like this, 2002, Hodder & Stoughton, ISBN 0 340 78639 6.
Free website to go with the book above: http://www.feelinglikethis.com — this provides additional support, resources and information on using CBT techniques.
The Christian Medical Fellowship is willing to offer general advice on mental health issues to church leaders and pastors. Contact them at http://www.cmf.org.uk or by calling 020 7234 9660 during office hours.