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depressionDr Keron Fletcher

Consultant PsychiatristShrewsbury Evangelical Church

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types of emotion

elation

depression

anger anxiety

normal and helpful abnormal and harmful

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emotions

what is mood?

repetitive behaviours

energy levels

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emotions

feelings

thoughts

LOW

DESPAIRSAD

TEARFUL

BLEAK

NOTHINGMISERYTORMENT

DARK

AFRAID

TERROR

GLOOM DOOMIRRITABLE

ANGRY

HELPLESSUSELESS

WORTHLESS HOPELESS

RECKLESS

SUICIDAL

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reducedabsent

irregularstop

constipationdiarrhoea

repetitive behaviours

diminished interestloss of interest

loss of appetiteweight loss

excessive eating

eating

sleeping

sex drivehobbies

toilet periods

brokenearly morning wakeninginsomnniaexcessive

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what is mood?energy levels

TIRED

LETHARGIC

DRAINEDIMMOBILE

EXPRESSIONLESS

NO SPARK

TENSE

EDGYTREMBLING

RESTLESS PACING

AGITATED

WRINGING HANDS

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severity

• low, anxious, weepy, pessimistic, helpless

• drinking more alcohol, little appetite for food, no interest in sex, no sense of humour, poor sleep patterns, difficulty concentrating

• tired all the time, can’t be bothered

• dark despair, unshiftable misery, impending sense of great doom, terrible guilt, torment

• not eating or drinking, marked weight loss, early morning wakening, constipated, poor memory, poor grooming

• agitated, purposeless activity, strong desire to be dead for benefit of self and others

MILD SEVERE

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biblical examples

• “I cried out to God for help; I cried out to God to hear me. When I was in distress, I sought the Lord; at night I stretched out untiring hands and my soul refused to be comforted. You kept my eyes from closing; I was too troubled to speak. I thought about the former days, the years of long ago; I remembered my songs in the night My heart mused and my spirit enquired.” Ps 77

• “My heart is blighted and withered like grass; I forget to eat my food. Because of my loud groaning I am reduced to skin and bones. I am like a desert owl among the ruins. I lie awake” Ps 102

• “My soul is full of trouble; I am like a man without strength. You have put me in the lowest pit, in the darkest depths. My eyes are dim with grief. I have suffered your terrors and am in despair…the darkness is my closest friend” Ps 88

MILD SEVERE

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causes“ORGANIC”

BRAIN DAMAGE

“FUNCTIONAL”PSYCHOSIS

“NEUROTIC”EXAGGERATED

“PERSONALITY”NORMAL

MEDICAL TREATMENTS

NON-MEDICAL TREATMENTS

head injury, stroke, dementia, tumourmultiple sclerosis, Parkinson’s disease, thyroid problems, medication and otherdrugs particularly stimulants

bipolar affective disorderunipolar depressionschizophrenia

“depression”, stress/fatigue,loss

“depressed”,disappointments,problems

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nature and nurture

• genetic factors

• diseases

• infections

• drugs and alcohol

• exhaustion

• losses

• insoluble problems

• care in childhood

• current relationships

• employment, finances

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dealing with depression - contents

• mild

• moderate

• severe

• spiritual approaches

• carer

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mild depression• symptoms - mostly emotional changes (low, miserable, weepy), few

repetitive behaviour changes (poor sleep, no interest), some loss of energy (TATT – tired all the time)

• often lasts for about 6 months

• usually recovers spontaneously without treatment

• rest, exercise, good diet, planning enjoyable activities

• good emotional support and encouragement

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moderate depression• symptoms - marked emotional changes (guilt, despair, hopelessness, better off

dead), many changes to repetitive behaviours (EMW, weight loss, unable to work, forgetful), marked energy changes (agitation or lethargy)

• requires medication

• “cognitive behaviour therapy” (CBT) helpful, but difficult to obtain

• encouragement, emotional support and help to resolve difficulties that could maintain the condition

• it usually responds to treatment over a 3-6 month period, but can persist for many years.

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severe depression• symptoms - as for moderate depression, plus abnormal distressing beliefs and hearing

voices that say derogatory things, failure to eat or drink - EXAMPLE

• it is an emergency, usually requiring hospital in-patient care

• requires treatment with two types of medication• antidepressants• antipsychotics

• the quickest and safest form of treatment is electroconvulsive therapy (ECT) which is controversial but often life-saving

• other forms of support and help are required

• carers need particular help and support

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severe depressions

• severe depression is regarded as one of the most terrible afflictions that can affect a person

• the degree of distress, anguish and torment is awful to witness

• sufferers may repeatedly make serious attempts to kill themselves in order to escape the horror of their condition or because they believe they deserve to die and the world would be better off without them

• 15% completed suicide rate

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severe depression

• sometimes severe depression fluctuates with abnormally high mood swings

• elation, unshakeable overconfidence and irritability, hypersexual behaviour, copious spending, grandiose schemes, and frantic energy

• this condition is known as manic-depressive psychosis or bipolar affective disorder. It is not to be confused with the “up-and-down” emotional states commonly experienced by many people

• severe depression and manic elation can co-exist at the same time

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Timothy Rogers 1658 - 1728

• look upon your distressed friend as under on of the worst distempers to which this miserable life is exposed.• treat those who are under this disease with tender compassion.• never use harsh language to your friends when under the disease of melancholy.• if you would possess any influence over your friends in this unhappy state of mind, you must be careful not

to express any want of confidence in what they relate of their own feelings and distresses. • do not urge your melancholy friends to do what is out of their power.• do not attribute the effects of mere disease to the devil.• do not express much surprise or wonder at any thing which melancholy persons say or do.• do not tell them any frightful stories, nor recount to them the sad disasters which have overtaken others.• do not, however, think it needless to talk with them. Encourage them to hope for a speedy recovery.• it will be useful to tell them of others who have been in the same state of suffering and yet have been

delivered.• the next thing you are to do for your melancholy friends is to pray for them.• not only pray for them yourself, but engage other Christian friends also to pray for them.• put your poor afflicted friends in mind, continually, of the sovereign grace of God in Jesus Christ.

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spiritual approaches• most common causes of feeling down and tired

• attitudes• relationships• circumstances

• when we start to lose hope we begin to go down, and as we go down we lose hope

• we cannot always change our relationships - despite "If it is possible, as far as it depends on you, live at peace with everyone" (Rom 12:18) we sometimes have to live with opposition, conflict and confrontation

• we cannot always change our circumstances - learn to be contented: "for I have learned to be content whatever the circumstances. I know what it is to be in need, and I know what it is to have plenty. I have learned the secret of being content in any and every situation, whether well fed or hungry, whether living in plenty or in want. I can do all things through him who gives me strength" (Phil 4:11-13)

• however, we can change our attitudes

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spiritual approaches - hope• hope and rejoicing go together• hopelessness and misery go together (hopelessness/attempted suicide) • examples of scriptural links between hope and joy:

• hope and rejoicing are interwoven e.g. "May the God of hope fill you with all joy and peace as you trust in him, so that you may overflow with hope by the power of the Holy Spirit." Rom 15:13

HOPE IN

REJOICE IN

. the Lord eg Ps 31:24, Jer 14:8 . the Lord's mercy eg Ps 31:7 . the Lord's salvation eg Ps 9:2,14 . God's word eg Ps 119:81

. the Lord eg Ps 5:11, Phil 4:4 . the Lord's mercy eg Ps 33:18 . the Lord's salvation eg 1 Thess 5:8 . God's word eg Ps 119:162

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spiritual approaches – remember/think

• prescription: • (a) remember and think about God • (b) cling to God (put your trust in God)• (c) give thanks to God

• a) deliberately put your hope in God, no matter what you feel like, as the counter-argument to feelings

and thoughts of hopelessness

• Ps 42:5 “Why are you cast down, O my soul? Why so disturbed within me? Put your hope in God, for I will yet praise him, my Saviour and my God”

• REMEMBER AND THINK LONG AND HARD about what God is like • his love and tender care (you must understand that the Lord loves you in spite of what you are like)• his sovereignty (he is totally in control of all things, even your current mood!)• his providence (he will provide all that you need)• what he has done, that he can do it all again (forgive, strengthen, equip)• his "compassions never fail. They are new every morning" (Lam 3:22,23).

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spiritual approaches – cling/give thanks

• b) CLING to God (holding on to truth, despite feeling unbelief) and pray • even if it feels that "no prayer can get through" (Lam 3:44) • "My soul clings to you; your right hand upholds me" (Ps 63:8)• so that you can entrust yourself to the Lord

• c) give THANKS AND PRAISE to God • for who he is, what he has done• for the fact that he is with you now and forever• that he is taking you to be with him to share his glory for eternity• this is helpful even when we are downcast, because it is fact, not fantasy, and therefore can encourage us

(give us hope and joy)

• 1 Thess 5:10,11 "He died for us so that, whether we are awake or asleep, we may live together

with him. Therefore encourage one another.."

• 1 Thess 4:13-18 "And so we will be with the Lord forever. Therefore encourage each other with these words."

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spiritual approaches in action• “Has God forgotten to be merciful? Has he in anger withheld his compassion? Then I thought, “To this I will

appeal: the years of the right hand of the Lord Most High” Ps 77:9,19

• “My days are like the evening shadow; I wither away like grass. But you, O LORD, sit enthroned for ever; your renown endures through all generations. You will arise and have compassion on Zion; for it is time to show favour to her; the appointed time has come” Ps 102:11-13

• “I remember my affliction and my wandering, the bitterness and the gall. I well remember them, and my soul is downcast within me. Yet this I call to mind and therefore I have hope: Because of the LORD’s great love we are not consumed, for his compassions never fail. They are new every morning: great is your faithfulness” Lam 3:19-23

• “I heard and my heart pounded, my lips quivered at the sound; decay crept into my bones, and my legs trembled. Yet I will wait patiently for the day of calamity to come on the nation invading us. Though the fig tree does not bud and there are no grapes on the vines, though the olive crop fails and the fields produce no food, though there are no sheep in the pen and no cattle in the stalls, yet I will rejoice in the LORD. I will be joyful in God my Saviour. The Sovereign LORD is my strength; he makes my feet like the feet of a deer, he enables me to go on the heights” Hab 3:16-19

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spiritual approaches in action

• "Be joyful always; pray continually; give thanks in all circumstances (e.g. when you are depressed), for this is God's will for you in Christ Jesus“ 1 Thess 5:16

• "Then I heard what sounded like a great multitude, like the roar of rushing waters and like loud peals of thunder, shouting: "Hallelujah! For our God reigns. Let us rejoice and be glad and give him glory! For the wedding of the Lamb has come, and his bride has made herself ready. Fine linen, bright and clean, was given her to wear." (Fine linen stands for the righteous acts of the saints). Then the angel said to me, "Write; "Blessed are those who are invited to the wedding supper of the Lamb!"" And he added, "These are the true words of God“ Rev 19:6-9

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spiritual approaches in action

• “He had no beauty or majesty to attract us to him, nothing in his appearance that we should desire him. He was despised and rejected by men, a man of sorrows, and familiar with suffering. Like one from whom men hide their faces he was despised, and we esteemed him not…He was oppressed and afflicted…he was cut off from the land of the living…Yet it was the will of the LORD to crush him and cause him to suffer…after the suffering of his soul he will see the light of life and be satisfied.”

• He is able to sympathise with our weaknesses

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for carers

• you are likely to experience helplessness, worry, frustration, anger• suggestions:

• pray and read the Bible with the depressed person if they can manage it• don’t judge, and don’t assume you know the cause or the solution• listen, but also speak – gently, kindly, but questioning false beliefs, giving simple

advice, praising progress• share the load as much as you can• use helpful Bible verses – that reassure the Lord is in control, that the Lord

forgives sin, that he loves his people, that he hears prayer, that he sympathises with our weaknesses, that we will be with him one day – but don’t be insensitive and beat the depressed person with them

• get support for yourself and get breaks if you can