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Spirituality and depression: a case study.

Ann, a 73-year-old widow who lived alone in a small North Carolina town, consulted me because she felt she was too self-absorbed. Ann is a retired social worker and spends much of her time with her 44-year-old schizophrenic son, Fred, who has been repeatedly hospitalized for acute psychotic episodes. About five years after I undertook the care of Ann's son, her older sister became acutely depressed, later suffering a stroke in her early 70s. With the help of a daytime home health aide, Ann cared for her sister while continuing to work full time. Five years after her sister's death, Ann's husband was diagnosed with pancreatic cancer; as with her sister, Ann remained as the primary care giver, providing hospice-type care for her husband throughout his illness. Soon after her husband's death, Ann retired and undertook a number of volunteer activities. She was 64, in good health, and looking forward to a period free from the major care taking activities which had dominated her life, when she unexpectedly experienced a negative change in her mood.

She told me she was having difficulty sleeping and had lost five pounds, a noteworthy loss for her size. Her sleep was not sound, and she was lethargic. Her primary concern, however, was that she had no interest in anything. Yet the lack of pleasure which Ann described was unlike what I usually hear from the seriously depressed. Rather than bemoaning that she experienced no joy from a good meal or time spent with good friends, Ann complained about her sense of lost purpose for living. Referring to the Biblical Caleb who, in his 85th year, said to Joshua, "I am still as strong today as the day Moses sent me out; I'm just as vigorous to go out to battle now as I was then. Now give me this hill country that the Lord promised me that day" (Joshua 14:10-12), Ann remarked that Joshua provided Caleb a challenge: the opportunity to conquer Hebron, not a land grant. Although physically healthy, Ann attributed her lethargy to inactivity and to the self-absorption of taking care of herself as opposed to others. Like Caleb, she needed a challenge.

I tried to reason with Ann, noting that she had devoted most of her adult life to helping others, and she deserved a rest. In my view, she was denying herself the opportunity to enjoy the healthy years she had remaining and was priming herself to experience even more depression when she became frail with advancing age. She had to learn to receive care as well as to give care. Ann understood my logic but replied that it just did not work for her. In fact, "talk" did not seem to work for her; she was a person of action.

Ann's symptoms met the criteria of a major depressive episode of moderate severity, and I prescribed a low dose of an antidepressant medication, Prozac. She began to sleep better, her appetite improved, and she felt her energy return. After about three weeks she began reading again. By usual criteria, Ann experienced a good response to the medication. However, although six weeks later she admitted to feeling much better, she still did not feel like her "old self" and continued to experience a sense of "being burdened by myself."

"I have been a Christian for many years. I don't think I have worked in the church from a sense of guilt, or from a sense that I could earn my salvation, There was too much to do, too many people who needed my help. I always seemed to have more to do than I could do, and that left little time for me. At times I would get myself through a hard day by telling myself that I would get some rest and some space when I retired. In reality, I was rejuvenated by a little reading and some time with my friends.

"When Sam died, I finally had the time to rest and the space to think about myself, to which I had looked forward, yet not thought much about. I grieved Sam's death before he died, so when he died, I was more relieved than anything else. Then one morning, I got out of bed thinking 'this is the first day of the rest of my life.' I considered doing many things, but I didn't accomplish much of anything. What bothered me the most was that I was thinking so much of my future, my good fortune, or my problems.

"I thought that I could learn a lesson by learning to accept the help of others. I began to worry that I didn't really appreciate the grace of God. I understood it but did not feel it. The more I tried to feel God's grace, the more I failed. It was in work, not refection, that I felt His grace. I believe that God gives us work--that is, the opportunity to work--not so we feel that we can earn His grace but to assure us that we have received His grace. It is a gift to be able to work. Now that gift has been taken away, or so it seems. Of course, there are plenty of volunteer opportunities; these seem contrived, however. I need the kind of challenge that had been placed before me most of my life. Sitting here talking doesn't do it. Volunteering at the hospital doesn't do it. And there aren't that many opportunities for an old woman like me to help."

"An old woman?" I protested: this was the first time that she had referred to herself as old. "I do feel like an old woman: I am tired; I feel weak; I can't get up with gusto. My skin is thin and covered with spots, my joints ache, and I am constipated half the time. I feel old. Five years ago, if you had asked me, I would have told you I may be in my late sixties, but I feel no different from I did twenty years before. Not so today. I feel like a 73-year-old; I dress and act like a 73-year-old. See these running shoes? You may think them youthful, but I wear them because they are comfortable and don't slip on the floor.

"You don't seem to understand what I'm feeling--I mean what I feel about myself. You are not alone. My children, except for Fred, say the same that you say: I should be enjoying this phase of my life. Yet I have become so preoccupied with 'me' that I can't enjoy the things and people around me. There isn't much purpose in a life that focuses on 'me.' I, like you, thought this was the time for a well-deserved vacation. I made plans for vacations, bridge games and volunteer work, such as visiting people at church. I wasn't going to simply indulge myself in retirement, but I did want to go to sleep each night without going over in my mind plans for the next day about caring for my son, my husband, or my sister. It didn't work; your textbook descriptions of a good retirement do not seem to work for me. I am missing something, but I am not certain exactly what. Two things do stick out, however: first, I have never been so self-conscious, or, better stated, 'self-centered'; second, I seem to be drifting.

"Self-absorption--self-pity--is not a good thing: when you think about yourself all the time, you assume others are thinking about you as well. You start worrying about what others think. You become the center of attention. Your love for God and for your neighbor fades to the background. You begin worrying about God loving you and being good to you. You think about others and whether they will take care of you. Or you worry that others don't find you interesting or useful. You start doing things with "I" at the center, not others. This is not good.

"I don't want to be a Jonah, just sitting and waiting under a gourd to die (Jonah 2). I see other persons near my age who have maintained their usefulness, or at least they believe they are useful. I have always taken care of people, yet God hasn't left me anyone to care for. I could nurture my anger with God until I squeeze all the bitterness out of that lemon. That's not what I want. I want to be fruitful. I want to be like those fruit trees in Ezekiel (Ezekiel 47:12). I want to be a tree bringing forth fruit in its season (Psalm 1). I want to produce sweet, not bitter, fruit. I want to rid myself of this heavy sense of self."

Ann took up community work, which helped, yet, after recovering from her acute depression, she still wished to see me. We talked about her family and looked toward the future. Ann realized she was not always going to be able to care for Fred; she also realized she would have difficulty accepting help for herself once she truly needed it: "Unless God takes me suddenly, I still must face being dependent on others and being the focus of others. For the time being, however, I can live with this depression as long as I am useful. My life may not be a happy life, but it is a blessed life. I am blessed with eyes that can see others and are once again blind to self. I am blessed with energy to help others."

Ann did not become a flurry of activity; she worked quietly. She continued to experience a mild, depressed mood. Yet she also felt a sense of peace with God. Her family did not recognize the peace as such; rather, they saw her as having returned to her old self and wondered why she wanted to continue to see me. I arranged for her visits in conjunction with Fred's: as long as she expressed interest in her family and was active in providing nursing care, the family took their eyes off Ann: "No one has a clue that I am still depressed. They think I am the Ann of old. But I am not the Ann of old. I hardly get a charge out of anything these days. I am ready for God to take me when he chooses. Don't get me wrong: I am not going to harm myself even though life is truly tiresome. But I don't want to rest. If I can't work, then life is not worth living."

I continue to see Ann about every three months, mostly to monitor her medications. She resisted psychotherapy in the usual sense. She does not want to probe into herself and ask why she has this drive to work. She does not want to explore the possibility that her grief for her husband has driven her to care for someone. Rather, Ann has a great fear of being self-absorbed. At a visceral level, she does not enjoy talking about herself. In her view, she was never the focus of attention during her life (one of many children from a home in which most of the children grew up to be professionals). To ask herself the question, "Am I happy?" never occurred to her until depression overcame her. Rather, she viewed herself as living a meaningful, spiritual life.

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:
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Title Annotation:Special Section: Spirituality/Medicine Interface Project
Author:Blazer, Dan G.
Publication:Southern Medical Journal
Geographic Code:1U5NC
Date:Jul 1, 2007
Previous Article:Eye on religion--working with Seventh Day Adventists.
Next Article:Selected annotated bibliography on depression and suicide.

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