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Treating Depression With Psychiatry and Faith

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I met Aaron Kheriaty, M.D. while I was working on a wire-service story about the Psychiatry & Spirituality Forum at the University of California, Irvine, where he is director of residency training and medical education in the department of psychiatry. My interest in Kheriaty's work was both personal and professional. As a religion reporter, I had frequently investigated intersections of private faith and public life. As a mother, I was trying to figure out how to help my sons, both of whom were struggling, though in the case of one of them, I was unaware of just how deeply.

I submitted that story on Thursday, March 27, 2008. On Friday, March 28, my son Gabriel died by suicide. The first person I called after the police left my home in the early hours of March 29 was Aaron Kheriaty. He ministered to my family twice that day -- the second time bringing a casserole that his wife had made. He also delivered a beautiful homily at Gabriel's funeral and treated my other son in the months afterward.

Needless to say, Aaron became a friend. I was both moved and honored when he included Gabriel in the dedication for "The Catholic Guide to Depression," his new book (co-authored with Monsignor John R. Cihak). In the book, Aaron writes about what it was like for him to walk into my family's tragedy. More importantly, he and his co-author offer a great deal of hope to depression sufferers and their families. The following interview about the book has been edited for length and clarity.

Christine A. Scheller: You explain in the introduction that although the book is a Catholic guide to depression, it could be helpful to other Christians. Why did you focus on Catholics?

Aaron Kheriaty: The concept for the book originated from my publisher, Sophia Institute Press, a Catholic publisher with its own niche market, so they wanted to highlight the aspects of the book that are distinctively Catholic. Also, there are books written by Protestant Christians on depression, but we didn't see much written by Catholics, and certainly nothing written by a Catholic mental health professional. We saw an audience that we could speak to very directly, but as I was writing the book, it was clear to me that any Christian who professes Jesus as Lord could benefit from it as well.

Why did you dedicate the book to your friend Matt and my son Gabe, both of whom died by suicide?

Matt was a close friend who was diagnosed with Bipolar Disorder when I was in medical school. He died while I was in residency training. Watching what he went through with this devastating, complicated and painful illness influenced me in terms of becoming a psychiatrist. At the reception after Matt's funeral, many people asked about his bipolar disorder. They had always known him as a cheerful, upbeat, optimistic, energetic person and were extremely perplexed. I was able to explain a little bit about his illness. That helped not necessarily to make the loss any easier, but at least to gain some level of understanding of what led to his death. That was my first experience, not as a physician, but as a friend.

The second experience was with your family. Not having known Gabriel, but having met you and then having been there with you and your family the night Gabriel died, that also was very formative for me in terms of my own professional development. Walking with you through that and through his funeral, I sort of feel like I know Gabriel and I miss him, even though I never knew him in this life. When I wrote the book, I had in mind people suffering from depression and people like you, people like my old friends who just wanted to know what happened to a loved one and how to make sense of it.

In the foreword, you cite statistics that depression is the fourth leading cause of a disability worldwide. Edward Shorter, in his book 'Before Prozac: The Troubled History of Mood Disorders in Psychiatry,' talked about a change in terminology in which depression replaced anxiety as a leading mental health diagnosis even though symptoms haven't changed much. Is depression on the rise or do we just talk about it differently?

I'm familiar with Shorter's thesis. There may be something to it in the sense that a lot of folks who suffer from depression also have a significant degree of anxiety and vice versa. So there's overlap between these two disorders. His idea is that the treatments that are widely available will color which of the clinical features we tend to emphasize. There may be something to that, but I don't think that alone can account for what we're seeing today, which are rising rates of depression. The epidemiological data here is pretty clear and consistent.

It suggests that for whatever combination of reasons, depression is becoming more common. I cite a few social factors in the book to make the argument that among the contributing factors, the social and cultural ones may account for high rates of mild or moderate depression. I think a lot of that is driven by social isolation and fragmentation. More and more people, particularly elderly people, are alone and their family or social ties have been weakened. Those factors are important and shouldn't be ignored.

There's a powerful story in the book about an elderly women who had suffered both cancer and major depression. She said if she had to choose between going through cancer again or enduring another episode of depression, she would choose cancer. You say many people think depression is nothing more than an intense episode of 'the blues.' Why are they wrong?

One of the things that gets in the way of people comprehending this illness as something profoundly different from everyday emotional experiences is the word depression itself. It's a really pathetic word. I like the old term melancholia, because it suggests something black and weird and foreign. It's not an everyday word that we use in other contexts to describe things that are benign. Depression goes beyond a passing emotional state and really affects the whole body and the whole mind. We have to get past that word and try to explain to people that what their loved one is going through is profoundly debilitating both mentally, and in a sense, even physically. A person feels drained and sapped of vitality and they lack a normal sense of being connected to the world and even connected to one's own body.

Not long after my son's suicide, I watched a series on PBS in which a mental health professional described depression as the feeling of being 'a terrible person.' Is this feeling common in depression?

The sense of irrational self-loathing is unfortunately very common, especially in moderate to severe depression and bipolar depression -- a real dark, nihilistic sense of worthlessness or even self-hatred.

Does the biological aspect of bipolar depression cause this self-loathing or is it working in concert with other social and/or spiritual issues?

It's a little too simplistic to say that the biological factors in depression cause it, but this certainly contributes. We need a well-functioning brain to have clear thinking. That's obvious. What happens with depression is that the person seems to lack cognitive or mental flexibility, so their thoughts become very constricted and it's difficult for them to perceive or consider alternate solutions to what they see as life problems. Relational factors contribute to that, but also the biological lack of vitality will drag a person's thoughts downward.

Another thing that happens frequently is that the person develops what one could consider to be a kind of "phobia." As their energy gets more drained, there's a sense of needing to conserve that energy. There's a sort of "energy expenditure phobia," one could say. So the impulse is to withdraw. That withdrawal -- whether it's social withdrawal or staying in bed all day, or not going to school -- tends to have the opposite effect, draining a person more of energy and vitality. Then they get into a cycle of withdrawal and energy drain.

This is where many of the interventions try to focus. You have very little energy, but if you want more, you need to expend what you have. You need to push yourself; psychiatrists call this "behavioral activation." That runs directly contrary to all the inclinations that the depressed person feels, which is why social supports and a regimented program of recovery can be helpful in trying to pull or push the person out of the withdrawal cycle.

What about altruistic acts that get a person outside of themselves?

Yes, absolutely. The focus of the depressed mind tends to be really turned inward, ruminating on past mistakes and worrying excessively about the future, usually with bleak themes. And so, learning to be mindful and aware and in the present moment can help. Even doing a small act of kindness or service for another person is really important for getting the person mentally out of ruminating on the past, worrying about the future, turning inward, and thinking only of their own pain. This will help them see that even though they feel horrible, they can still have a positive effect on the world.

You say Christians don't always treat depression like the multifaceted problem that it is, but can over-spiritualize it. Is this kind of thinking a hindrance to people getting the help they need?

A lot of Christians come to me pretty reluctantly and oftentimes contrary to the advice of Christian friends or family members, sometimes even a minister who suggests that they shouldn't trust psychiatrists or that medications aren't appropriate because this is really a spiritual problem. I consider that to be unfortunate. Oftentimes it delays the time between the onset of symptoms and appropriate treatment.

I argue in the book that a purely medical model also is not adequate to describe depression. Reducing it to a chemical imbalance in the brain or a biological disease model alone doesn't take into account other important factors, including spiritual factors, behavioral factors, things that the person may be doing (knowingly or unknowingly) that contribute to the depressive episode. I think you can go off the rails easily in both directions, either over-spiritualizing and discounting biological factors and treatments, or taking a purely medical approach. I advocate looking at depression from multiple perspectives, both in trying to understand what's causing it and in finding appropriate treatments for it.

I encourage patients to continue seeking spiritual support from their pastor or spiritual director, to continue praying, continue going to their church or small group, and continue finding solace in the Scriptures. I also try to convey to them that spiritual exercises and practices are perfectly compatible with things like taking a medication and going to psychotherapy. They can all work hand in hand.

Research shows that medication alone is sometimes effective, psychotherapy alone is sometimes effective, but both together are more effective than either one alone. Research also shows that exercise, social interactions, spiritual practices like prayer, meditation and church attendance lower the risk of depression and reduce the amount of time it takes to recover from an episode of depression. Mine is a both/and rather than an either/or approach to treating depression.

How do the sacraments, spiritual direction and the wisdom of the church fathers and saints help a person recover from depression?

One of the principles of Catholic theology is the principle that we call sacramentality. The idea is that in the incarnation, God took on our flesh. He became a man. Because that is a central truth of our faith, we understand that the material world can mediate spiritual realities. As human beings, creatures of both body and soul, we relate to God, among other things, through our senses. There's also the belief in Catholic theology that Christ instituted seven sacraments, including giving the apostles and their successors the task of mediating forgiveness in the sacrament of penance.

The elements there that I think turn out to be most healing both spiritually and psychologically are the fact that if I'm burdened by guilt or by sins of the past, when I go to confession I'm able, in a very tangible way, to hear those words of absolution from the priest who is acting in the name of Christ and the church. Many people who have gone to confession will describe it as a powerful experience -- being able to be able to walk away knowing with a great deal of conviction that they have indeed been forgiven, that the burden they've been carrying has been lifted. I think that's consistent with our psychological makeup as well, because it's very concrete and tangible.

The other thing that I think happens in confession is that we understand that sin not only harms our relationship with God, but it harms our relationships with others, so you have a priest who's there representing not only Christ who forgives, but also representing the church. Many people experience it, I think rightly so, as a sense of reintegration with a community after making a good confession. If they have been alienated or away from the practice of the faith for a long time, they go to confession, they receive God's forgiveness, but they also receive a sense of being welcomed back into the body of Christ and are encouraged to have a sense of responsibility to the church and to other Christians. I think those two elements can be spiritually healing and also psychologically uplifting.

On the flip side, sometimes when people are suffering from mental illness, they fixate on negative aspects of religious belief and/or practice. How do you help someone when their faith becomes a problem rather than an avenue of healing?

The answer to that is rather than encouraging them to think less about faith because their faith has taken a morbid or pathological twist, it's to correct their sense of what Christianity really is. In other words, falling back on a more adequate faith that says we are saved not by our own behaviors, or by our own works. Contrary to popular belief, this is something Catholics and Protestants do agree on. We are saved only through the grace of God that was won for us by Christ on the cross. So the answer lies in giving them a sense of hope that comes from a more adequate understanding of the central truths of Christianity.

Interestingly, Obsessive Compulsive Disorder, which used to be called "Scrupulosity" because it often manifested in moral or religious contexts, was first described in manuals that were used to teach Catholic priests how to deal with penitents in the sacrament of confession. Through pastoral experience, the writers recognized that people could have morbid or unrealistic obsessions about having committed some grave sin that was really a very minor fault. There was a tendency to return to the sacrament of confession over and over again, and confess the same sin, worrying that maybe they didn't do it right last time, or maybe they're not really forgiven. The instructions that were given to priests to deal with scrupulosity were very sound psychologically. They were basically to forbid the person to come back and re-confess. This coincides with modern behavioral therapy for compulsions that is aimed at reducing or interrupting compulsive rituals.

What the person is doing is really a manifestation of a compulsive behavior. Sometimes a skilled pastor or priest will set limits. "You've confessed that already. I refuse to allow you to continue ruminating on this." They reassure the person that they have been forgiven. Now that we have a better understanding of the causes and treatments for conditions like OCD or Scrupulosity, referring the person to a mental health professional to treat that underlying disorder would be appropriate.

An issue we've talked about before is people who are in unhealthy faith communities that exacerbate their suffering.

That's a complicated issue. There are a lot of misinformed Christians out there, both Catholic and Protestant. I don't think this is specific to any one denomination or tradition. You can find people in any community that get confused about fundamental issues, give folks bad advice, and cause a lot of pain and suffering. There's no mental suffering worse than a spiritual crisis where a person is unreasonably worried about their own damnation or inability to be reconciled or united to God. What a horrible form of suffering. It's contrary to Christianity, which I think clearly is about Christ's openness to anyone who even makes the slightest movement in his direction. The parable of the prodigal son illustrates this beautifully. The son hadn't even gotten home yet. The father just saw him at a distance and ran to him. That's the mercy of God.

In the last chapter, you talk about 'divine filiation' and the 'virtue of hope.' Can you describe those two principles?

John in his epistle says that we are truly children of God in Christ. He has adopted us by grace to be his sons and daughters. This is not just one more religious or metaphysical truth among many. I think this truth -- that in Christ we're reconciled to God, that God is a loving father, he's very close to us, that he loves us more than all the fathers and mothers of the world could possibly love their children -- this has to be the foundation for our whole existence as Christians. So rather than seeing it as sort of one more fact to memorize and archive in the "Christianity file" in my brain, or one more religious truth among others, I think of it as the glasses we put on that allow us to see everything in our life with more clarity. It's the lens through which we experience joys, sorrows, pain, suffering.

This idea of being a child of God is so fundamental and life-altering that we have to try to live constantly with an awareness of that divine filiation, an awareness that God is near, that I'm always in his presence. Wherever I am and whatever I'm doing, he's there sustaining me with such profound love and mercy that I can't possibly fathom how much he loves me.

That's something of what I was trying to convey in the last chapter of the book. It gives rise to the three theological virtues that Saint Paul mentions in 1 Corinthians, chapter 13: faith, hope and love. I focus on the virtue of hope because it's the one we hear the least about in terms of preaching. We hear a lot about faith and about love, but less about Christian hope.

Depression is really sort of an affliction of the soul, because very often it strikes precisely there -- it makes it difficult to have hope. Both on a human level and on a spiritual level our basic hopes for this life can be shattered by depression. A sense of a future in this life can be shattered by depression. And also, our hope for union with Christ and for heaven can be eclipsed. I won't say that it can be shattered because hope is given to us by God's grace; it's not something that we manufacture. But our sense of it, our awareness of it, our knowledge and subjective feeling of hope can be eclipsed when we are depressed.

People often feel abandoned by God when they are severely depressed, don't they?

Exactly. And so, we have to sometimes recall that fundamental truth, even when we can't subjectively feel it. We may not be able to feel hopeful, but we can stand with some degree of conviction on the hope of heaven, the hope of union with Christ, the hope that things either now or after this life can be better for us, even infinitely better than what we can imagine.

An abridged version of this interview was previously published at FirstThings.com.