Selected annotated bibliography on depression and suicide.

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

Saint John of the Cross (1542-1591), a Catholic mystic, was a major figure in the Catholic Reformation A Spanish mystic and Carmelite friar, he worked closely with Saint Teresa of Avila, another well-known mystic in the reformation of the Carmelite order. The Dark Night of the Soul, the best known of his written works, is actually the continuation of a longer work on the journey of the soul toward a greater union with and purification by God. The dark night represents the hardships and difficulties the soul meets as it seeks detachment from the world and reaches for the final light of union with the Creator. The book takes on special significance for the understanding of depression and spirituality in that the "dark night of the soul" has become a metaphor for a spiritual melancholy and emotional struggle that many have assumed must accompany any true spiritual growth. In reality, the book focuses upon a more narrow stage of spiritual growth for mystics in which St. John emphasizes that the mystic, by herself, cannot attain true spiritual cleansing and therefore must passively submit to God, a submission which leads through a period when the soul experiences no pleasure in the things of God or in creation, no sense of being in touch with God, and therefore steeped in melancholy.

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

In this book, the author ponders why--if the basic biology of the brain has not changed fundamentally during the last half-century--humankind has become depressed on an epidemic scale. He focuses upon the social origins of depression, origins that tend to be ignored in current investigations. In one chapter, "Things Fall Apart: Society and Depression in the 21st Century," he describes characteristics of modern society that may blunt spirituality and therefore fuel spiritual melancholy, characteristics of the postmodern critique. These characteristics include loss of hope; loss of story (the loss of one's sense that his life is integrated); loss of language (words lose their meaning); loss of self (loss of a core sense of identity); loss of unity (the challenge of a diverse society); loss of trust (we reflect upon society with suspicion); loss of orientation (liberation from tradition often accompanied by confusion and disorientation); loss of meaning (all explanations are brought under suspicion); and nihilism (believing in nothing, having no allegiances and no purposes).

Blazer DG. Freud versus God: How Psychiatry Lost Its Soul and Christianity Lost Its Mind. Downers Grove, IL, Inter Varsity Press, 1998.

In this book, the author challenges the comfortable accommodation that has occurred between psychiatry and even the most conservative faith traditions. Psychiatry and Christianity have never experienced better superficial relations and this is no more clearly observed than in the diagnosis and treatment of depression. Thirty years ago, people from a religious background would have been much more resistant to antidepressant medications than today. Though not challenging the therapeutic benefit of our modern treatments of depression, the author suggests that a healthy tension between psychiatry and faith traditions should stimulate advances in our understanding of the deepest emotional pains. Why does this not occur? The existential pain and subjective experience of psychiatric illness are of little interest to modern psychiatrists; meanwhile, the philosophical and theological implications of disorders of the brain and modern psychiatric therapies are of little interest to religious leaders. As a result, psychiatry has lost its soul, and religion (in this specific case, Christianity) has lost its mind.

Burton R. The Anatomy of Melancholy, 1st ed. New York, Tudor, 1948.

Few will wish to slog through this massive volume, yet familiarity with Burton's The Anatomy of Melancholy (1621) is important to those wishing to understand spirituality and depression. For Robert Burton (1557-1640), a depressive mood (from which he suffered) was primarily the disease melancholia (black bile) as recognized by the ancients, though he waxed eloquently exploiting many literary genres to describe his experience with the malady. Yet Burton was not one-dimensional: he developed a detailed description of a multi-causal depression. At the top of his hierarchy of causes, he leaves sufficient (though not necessary) room for both God and the devil to work their ways with the moods of men. He also described a specific variety of melancholy which he labeled religious melancholy, a depression that could emerge from an excess of "superstition," leading to excessive solitariness, fasting, and a "diseased imagination." Religious melancholy could also derive from a defect of belief in God and love of God. In the former case, the heart is grieved, the conscious is pierced, and the mind is overwhelmed with terrors; in the latter case, the melancholy was the justly deserved result of the anger of God.

Rubin JH. Religious Melancholy and the Protestant Experience in America. New York, Oxford University Press, 1994

Rubin follows on Burton's exploration of religious melancholy with a focus upon the Protestant experience in America, especially among the colonial Puritans. Those who were most fervent in their devotion to the Christian life, those who longed most for a close relationship with God, were at times obsessed by guilt, terror, and despair, feeling that they had been forsaken by God. This distinctive religious experience was characterized by a grieving over the loss of God's love and a fruitless and often dangerous striving toward conversion--for example, some would fast until they died. During the 19th and 20th centuries, however, a religion of healthy-mindedness emerged, and the melancholy of some Puritans passed out of existence. Depression among evangelical Christians, for example, was seen as a failure to seek God rather than an excessive concern with a close relationship with God. Nevertheless, Rubin relates the fears of some theologians that, when religious life is so focused upon looking inward, the emptiness within could produce dispirited and therefore depressed souls.

LaHaye T. How to Win Over Depression. Grand Rapids, Zondervan, 1974

LaHaye is the coauthor of the Left Behind series which has been among the best-sellers over the past few years. He is a conservative evangelical Christian and probably reflects the views of many (but perhaps not most) evangelical Christians. Given that evangelical Christians represent millions of Americans and these people will frequent the offices of all practitioners, especially in the southern US. Practitioners should be aware of their views, though most of us would not agree with them. In this book, written over 30 years ago, LaHaye posits that depression is something "in the mind" that can be overcome through will power and trust in God through the use of steps similar to those posed by more secular cognitive therapies. Examples of these steps beyond prayer and accepting Jesus are "renew your mind daily," "practice creative imagery daily through prayer," "always be positive," and "forgive those who sin against you."

Lutz C. Depression and the translation of emotional worlds. 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

Lutz suggests that emotions are socially determined. This is an extreme view but one that has relevance to depression and spirituality. The social context surrounding the person provides criteria for judging one's own emotions and those of others. Every society attempts to explain what constitutes behavioral deviance, and the proper responses to it, whether that be therapy or punishment. For example, the appropriate and inappropriate expressions of anger are determined by society. Certain behaviors (such as overt expression of anger) may be unconditionally accepted in some societies yet proscribed in others. These societal influences may be so profound that the society literally influences the actual feeling of the individual. In a society with significant religious inhibitions, a person may not "feel" anger when anger would appear to be a natural response. Those feelings may be turned inward, and the person may instead feel depression (an accepted feeling in the society).

Karp DA. Speaking of Sadness: Depression, Disconnection, and the Meanings of Illness. New York, Oxford University Press, 1996.

Karp is a professor of sociology at Boston College and a sufferer of periodic severe depression. He captures the human face of mood disorders, and, though not specifically written with the spiritual in mind, the book informs the reader of the feelings that emerge during the midst of a depressive episode which can leave the victim questioning the very meaning of her life. Combining his personal experience with a series of interviews with fellow suffers, he describes what depression "feels like," what it means to receive an "official" diagnosis, and what depressed persons think of the myriad of mental health experts--doctors, nurses, social workers, therapists--employed to help them. He especially focuses on the ongoing struggle to make sense of biochemical explanations and metaphors of depression as a disease. He is particularly poignant in his description of how society contributes to the widespread alienation and emotional exhaustion of depression as the medical profession attempts to "medicalize" the experience.

Smith J. Where the Roots Reach for Water: A Personal & Natural History of Melancholia. New York, North Point Press, 1997.

Smith was a psychiatric case manager in Montana when he first experienced a serious and protracted depression. He sought medications and therapy, but none were effective; his medical therapy was a failure, and he never fully recovered from the depressed mood. His depression lead him on a journey during which he learns much about his deepest inner feelings as he copes with melancholy. Along this journey he encountered the writings of many mystics, including Teresa of Avila, Catherine of Sienna, Meister Eckhart, and Evelyn Underhill. All suggested to him that during the midst of severe depression, the consciousness of God vanishes, but when one quits theologizing depression and experiences its depths, then one can achieve a new state of equilibrium. Smith's book is quite different from virtually any other description of the personal and spiritual challenges that are brought by depression. Perhaps his final sentences best summarizes his journey: "And my thanks to our Almighty Creator. For everything, even melancholia."

Kramer PD. Listening to Prozac: A Psychiatrist Explores the Antidepressant Drugs and the Remaking of the Self. New York, Viking Penguin, 1994.

Though Kramer says little about spirituality as it relates to depression, this groundbreaking book is essential reading for anyone wishing to understand the interaction between mood, medicines, and meaning. Kramer notes that we are on the verge of possessing medications that take us "beyond therapy." He focuses on the selective serotonin reuptake inhibitors (SSRI), specifically the one to take us into the new era, Prozac. Some people who take Prozac (and other newer medications) express the feeling that the medications can help them feel "better than ever"--in other words, the medications not only relieve the emotional suffering of depression, but they also can give people the feeling that they actually have experienced a change in their identities. For example, a person who was shy all her life is now much more outgoing. Although the SSRIs actually do not lead to such dramatic consequences in the vast majority of cases, the mere possibility of "designer personalities" has profound implications for those interested in spirituality and depression.

Durkheim E. Suicide: A Study in Sociology. New York, The Free Press, 1951.

Though an old study, the work of Durkheim has as much relevance today as it did over 100 years ago. Durkheim reasoned that since different groups in society have different suicide rates, characteristics of social organization may contribute to preventing suicide in some organization and may even prompt it in others. He classified suicide in three groupings: altruistic (in a tightly bound society, such as that of Japan, a member of that society will sacrifice her life for group goals); egoistic (in a weakly attached society, the impulse toward suicide would not be thwarted for the person could not fall back upon relations in that society--Durkheim viewed Protestantism as egoistic whereas Catholicism was more integrated); and anomic (a society that lacks clear-cut norms to govern aspirations and conduct a person will lose the security that group control and regulation can provide--Durkheim would have characterized much of American society as anomic). Durkheim supported his theories by noting that Protestants experienced higher suicide frequency than Catholics, and the unmarried, higher frequencies than the married.

Koenig H, McCullough M, Larson D. Handbook of Religion and Heatlh. New York, Oxford University Press, 2001, pp 118-143.

Though becoming somewhat dated, this text continues to provide the most comprehensive review of the literature that explores the relationship of religion and health. The purpose of the book is to review for the reader the evidence base supporting this relationship. Chapter 7 reviews the association of depression with religious affiliation, religious involvement, organizational and nonorganizational religious activity, religious salience and motivation, and religious coping. The authors conclude the chapter with a review of adjunctive and accommodative religious psychotherapies. In like manner, Chapter 8 reviews the association of suicide with religious affiliation, religious involvement, and attitudes toward suicide. Readers may be surprised with the expanse of the literature, a literature that is far from conclusive and at times contradictory. That said, the scientific study of religion and depression is moving from its infancy toward maturity; this book stands at an important developmental phase.

Meador K, Koenig H, Turnbull J, et al. Religious affiliation and major depression. Hosp Community Psychiatry 1992;43:1204-1208

The investigators in this study examined the relationship between religious affiliation and major depression among 2,850 adults in the community. Religious affiliations were categorized into six groups: mainline Protestant (27%), conservative Protestant (59%), Pentecostal (4.2%), Catholic (2.4%), other religions (2.6%), and no affiliation (4.4%). The six-month prevalence of major depression among Pentecostals was 5.4%, compared with 1.7% for the entire sample. Even after psychosocial factors such as gender, age, race, socioeconomic status, negative life events, and social support were controlled for, the likelihood of major depression among Pentecostals was three times greater than among persons with other affiliations. Carefully designed studies are needed to understand the complex interactions of religion and mental health.

Ellison C. Race, religious involvement and depressive symptomatology in a southeastern U.S. community. Soc Sci Med 1995;40:1561-1572.

Aspects of religious involvement may have beneficial implications for preventing or reducing depression, and religion may be an especially valuable resource for racial minorities in the United States. These issues are explored empirically using data from a large (n = 2956) community sample drawn in the southeastern US. Findings include the following: 1) frequency of church attendance is inversely associated with depressive symptoms among whites, but not among blacks; 2) absence of denominational affiliation is positively associated with depressive symptoms among blacks, but not among whites; 3) frequency of private devotional activities (eg, prayer) is positively associated with depressive symptoms among both racial groups.

Bosworth H, Park K-S, McQuoid D, et al. The impact of religious practice and religious coping on geriatric depression. Int J Geriatr Psychiatry 2003;18:905-914.

Both religiousness and social support have been shown to influence depression outcome, yet some researchers have theorized that religiousness largely reflects social support. Elderly patients (n = 114) undergoing treatment were examined using a standardized algorithm. Patients completed measures of public and private religious practice to measure religious coping, and subjective and instrument social support measures. A geriatric psychiatrist completed the Montgomery-Asberg Depression Rating Scale at baseline and six months. Both positive and negative religious coping were related to depression scores in treated individuals, and positive coping was related to depression six months later, independent of social support measures, demographic, and clinical measures (eg, use of electro-convulsive therapy, number of depressed episodes). Public religious practice, but not private religious practice, was independently related to depression scores at the time of completion of the religiousness measures. Religious coping was related to social support, but was independently related to depression outcome. The authors conclude that clinicians caring for older depressives should consider inquiring about spirituality and religious coping as well as social support as a way of improving depressive outcomes.

Cloninger CR. Feeling Good: The Science of Well Being. New York, Oxford University Press, 2004.

Though most physicians concentrate on the "disorder" of depression, a branch of psychology has emerged--positive psychology. In this book, Cloninger, a psychiatrist with deep roots in biologic psychiatry, integrates a lifetime of work to explore the science of well-being. His is a massive attempt, from a nonreductive perspective, to integrate extant knowledge across the biopsychosocial model to include the spiritual. He describes a way to coherent living that satisfies these strong basic needs through growth in the uniquely human gift of self-awareness. Though not everyone may agree with Cloninger's approach, anyone who seriously wishes to explore the interface of brain science with spirituality in trying to understand depression (and feeling good, which is not necessarily the polar opposite) would do well to read and absorb Cloninger's exposition.

Dan Blazer, MD, PhD