Section introduction: spirituality, depression & suicide.

The depressive disorders, among all the psychiatric disorders, have been most closely correlated with ordinary spiritual experience. And the burden of depression is increasing throughout the world. (1,2) Patients who struggle with depression find themselves reaching to the very core of their faith traditions. In some faith traditions, even a severe depression is perceived to be an adaptive component, beneficial to the self and to others. For example, in the Christian mystic tradition, St. John of the Cross writes powerfully of the "dark night of the soul" as a key to spiritual growth. (3) One reason for the tight intertwining of depression and spirituality is the blurred distinction between clinical depression and normal problems of living. Major depression, viewed primarily as a biologic illness, has been especially challenged as a diagnosis too narrowly conceived. (4-6)

While some have viewed depression as an integral component of spiritual growth, others have seen it as emotional suffering that is especially open to spiritual interventions. Depression has often been thought to be derived from shame and guilt secondary to alienation from a higher being, generally caused by sin, and only to be alleviated by spiritual exercises, such as repentance or prayer. Though modern psychiatry has done much to temper the view that depression is a spiritual condition rather than an illness, the former view persists. (7)

The interrelationship between a depressed mood and spiritual struggle/growth dates to ancient times. Job, in the Hebrew Bible, cries out in the anguish of his depressed mood, "May the day of my birth perish, and the night it was said, 'A man is born' ... Why is light given to those in misery, and life to the bitter of soul, to those who long for death that does not come ...?" (Job 3:1-20). He challenges those who accused him of some sin that separated him from God or tried to philosophically isolate him because of his severe disturbance of mood. "But I have a mind as well as you; I am not inferior to you ... What you know, I also know; I am not inferior to you ... you are worthless physicians, all of you! If only you would be altogether silent! For you, that would be wisdom." (Job 12:3; 13:2-5). Job's struggle was not an extraordinary experience.

The development of the Jewish faith as it approached suffering did not follow a simple path. A history of persecution through pogroms, culminating in the Holocaust during World War II, has appreciably shaped Jewish thought. (8) Certain elements of the Jewish response to suffering include a stark realism regarding suffering (the refusal to invoke a supernatural solution to cover or abolish the agonizing realities); intense feelings of family and community; involvement in the suffering of others; and a vision of the Day of Atonement. In other words, for the Jewish faithful, suffering brings a more clear view of life.

The belief that depression offers a clearer view of life is also observed in Islam, particulary in Shi'ism, which envisions tragedy and grief as religiously motivated emotions. (9) Typical religious rituals help the community recollect the struggles and martyrdom of the Shi'i imams. Religious grieving recognizes the suppression of the righteous by the world and the sacrifice of the community in striving toward righteousness. Personal emotional suffering is often interpreted as a reflection of the suffering of the entire community of martyrs. Children first learn to grieve as part of a religious activity. The depressed view themselves as more sensitive to the social environment and especially vulnerability to the hurtful aspects of social relations or public events. This concept of depression in no way minimizes social concern for the depressed: the depressed, as in many other faiths or societies, seek care and condolences from the community.

In Hinduism and Buddhism, the individual must detach himself from suffering without letting detachment turn into indifference. (8) A soul liberated from suffering is a soul unified. That unity extends horizontally as well as vertically, and a soul duly liberated leads to a life of submission, gratitude, forgiveness, self-sacrifice, and self-awareness. If one's thoughts are not liberated--that is, if they continue to be attached to sinful desires and egoism--the outcome can be emotional states such as anger, resentment, shame, guilt, low self-esteem, confusion, and loss of a sense of self. (10) The Hindu and the Buddhist patient is rarely self-referred for emotional suffering but usually is brought by the family to the clinician when all other resources are exhausted. Symptoms are therefore often tied to the complex family structure and the family should be included in therapy.

Suffering and melancholy is viewed with ambivalence in Christianity. Although religious melancholy has been an integral part of spiritual growth throughout much of Western Christian history, at the same time it has often been understood as a symptom of stalled spiritual growth. Depression was understood as not merely the self turning inward due to a painful and self-absorbed temperament but was seen as inextricably derived from one's experience with God. Such an understanding led to the search for explanation for suffering and, subsequently, to the problem of theodicy (the difficulty of defending the justice and righteousness of God in the face of suffering). (8)

Stress and fear often lead to depression. One of the ancient interpretations of a depressed mood was weariness in doing good works, or acedia. The Apostle Paul encouraged the Thessalonians to "never tire of doing what is right" (2 Thessalonians 3:13) for fear of slipping into acedia: in other words, sometimes the depressed withdraw from the world out of weariness from its stresses. People suffering from acedia might see the world clearly enough, yet lose hope in God; they would fear God. Jonah, for example, was weary and became angry with the world and with God because the Ninevites repented, and, in so doing, had "cheated" the wrath of God: "It would be better for me to die than to live," he said while watching and waiting upon the city (Jonah 4). The stress of preaching to this sinful nation drained whatever fervor Jonah felt for his godly mission; his anger and depression wearied him; acedia overtook him, and he withdrew from the city. For many, the answer to acedia was the hope found in the events of Jesus's life and Resurrection.

Hope in Jesus did not abolish suffering and depression, however, and the Christian mystic tradition describes its own profound understanding of melancholy, most poignantly put in the "dark night of the soul." (11) This period of desolation and fatigue reflects a disharmony between the self and the world as one grows spiritually. The dark night reflects an exhaustion of the old state and the "growing pain" to the new state of spiritual consciousness. The greatest pain comes from the sense of God's absence (the Divine Absence), which in turn leads to a redoubled desire to unite with God. This sense of God's absence is accompanied by a heightened sense of sin, the loss of old passions for the world, and the recognition that peace and joy cannot be found in the world. Depression serves as a purification of the will and defeat of the person's rebellion against God. To put it more simply, the dark night builds character for the faithful Christian.

In this issue, the focus of the Southern Medical Journal's Spirituality/Medicine Interface Project is on Spirituality, Depression and Suicide. My colleagues and I will address these delicate connections. First, I provide an overview of spirituality and depression from a cross-cultural perspective. Harold Koenig then reviews the empirical studies which assess the association of religious beliefs/activities and depression. Bob Cloninger then reviews the emerging psychobiologic studies that inform us regarding our innate spirituality and happiness. Next, the relationship between spirituality and depression will be addressed from a developmental perspective by Alan Josephsen (adolescents), Michael Bostwick and Teri Rummans (midlife), and David Steffens (the elderly). Susan Dunlap complements the physicians who have contributed to the section with a view from pastoral care. John Peteet focuses specifically on suicide and spirituality, and Diane Meglan, a social worker, follows this with a review of resources for clinicians facing issues of suicide and depression. In the Eye on Religion subsection, Phil Petersen and Alan Nelson present practical guidelines for working with patients from the faith traditions of the Mormons (Latter Day Saints) and Seventh Day Adventists, respectively. The section is brought to a close with the Selected Annotated Bibliography, which focuses on books that, in my view, provide a most helpful perspective to clinicians.

References

1. Kessler R, Berglund P, Demler O, et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA 2003;289:3095-3105.

2. World Health Organization. World Health Report 2001: Mental Health, New Understanding, New Hope. Geneva, World Health Organization, 2001.

3. St. John of the Cross. Dark Night of the Soul. New York, Image Books, 1959.

4. Blazer DG. The Age of Melancholy: Major Depression and its Social Origins. New York, Routledge, 2005.

5. Parker G. Beyond major depression. Psychol Med 2005;35:467-474.

6. Horowitz AV. Creating Mental Illness. Chicago, University of Chicago Press, 2002.

7. Adams J. Competent to Counsel. Grand Rapids, Baker Book House, 1970.

8. Bowker J. Problems of Suffering in the Religious World. Cambridge, Cambridge University Press, 1970.

9. Good B, Good M, Moradi R. The interpretation of depressive illness and dysphoric affect. In: Kleinman A, Good B, eds. Culture and Depression: Studies in the Anthropology and Cross-Cultural Psychiatry of Affect and Disorder Berkeley, University of California Press, 1985, pp 369-428.

10. Juthani N. Hindus and Buddhists. In: Josephson AM, Peteet JR, eds. Handbook of Spirituality and Worldview in Clinical Practice. Washington, DC, American Psychiatric Press, 2004, pp 125-138.

11. Underhill E. Mysticism. New York, Dutton, 1961, pp 380-395.

Dan G. Blazer, MD, PhD

From Duke University Medical Center, Durham, NC.

Reprint requests to Dan G. Blazer, MD, PhD, Duke University Medical Center, Durham, NC 27710. Email: [e-mail]