She wrote of a “terrible sense of loss,” “an untold darkness” and crushing loneliness. If she’d consulted a doctor, she might have gone home with a prescription for Prozac or Cymbalta.
But the low feelings that Mother Teresa — now St. Teresa of Calcutta — experienced went untreated by medication, and the depression she described in personal letters is generally ascribed to a difficult but important spiritual journey.
Nuns of the Missionaries of Charity attend a thanksgiving ceremony for the sainthood of Mother Teresa, portrait seen, in Kolkata, India, on Nov. 4, 2016. The low feelings that Mother Teresa experienced went untreated by medication, and the depression she described in personal letters is generally ascribed to a difficult, but important spiritual journey. | Bikas Das, Associated Press
In fact, for centuries, a persistent gloom was commonly thought to be a spiritual malaise, what another Catholic saint, St. John of the Cross, called "the dark night of the soul." Depression was a matter between a man and his God, not a man and his doctor.
Today, however, many people who experience depression turn to their primary care doctor for treatment, and they often return home with a prescription. One in 10 Americans take antidepressants, a rate that many doctors say is alarmingly high given the treatment’s risks, which include birth defects and thoughts of suicide.
We will never know if medication would have helped or hurt St. Teresa in her time of emotional need. With no blood test or brain-imaging procedure that can diagnose depression and illuminate a clear path of treatment, navigating the darkness can be tricky.
Some people discover that a combination of medication and talk therapy is best; some find relief in exercise, exposure to sunlight and changes in diet. Others find nothing works, a condition described as treatment-resistant depression. But both people who suffer from depression and those who treat it say recovery rarely happens with a single solution. They say if you or someone you love is depressed, plan on exploring some side roads on the path to recovery — not just to treat the condition, but to learn from it.
How depression is diagnosed
In her new memoir on depression, New York writer Daphne Merkin asks readers to imagine what cocktail-party conversation would be like if depressed people were honest when someone asks how they are.
“Not fine. Very depressed, in fact. Can barely get out of bed. Have no idea what’s happening in the world lately and don’t much care.”
That’s something 16 million Americans might want to say if they had been able to muster the energy to get to the party at all. About 6 percent of U.S. citizens suffered at least one major depressive episode in 2015, according to the National Institute of Mental Health.
To diagnose depression, doctors use a checklist of symptoms outlined in the Diagnostic and Statistical Manual of Mental Disorders; they include a depressed mood, diminished interest in daily activities, significant weight loss or gain, sleep changes, fatigue and recurring thoughts about death.
If a person experiences five or more of the symptoms on the list every day for at least two weeks, they can be diagnosed with major depressive disorder, often treated with a class of drugs called SSRIs, or selective serotonin reuptake inhibitors. These drugs affect the body's level of serotonin, a neurotransmitter that influences mood, sleep and digestion.
According to the most recent available government statistics, 1 in 10 Americans over the age of 12 have taken an antidepressant in the past year, a rate that rises in certain subgroups. Nearly one-quarter of women in the 40s and 50s take antidepressants, and 1 in 6 seniors do, despite a recent report that the drugs can double the risk of hip fractures in older people.
Recent research has also found that taking antidepressants during pregnancy can double the risk of birth defects in babies. And an elevated risk of suicide in the first months of treatment is why the FDA requires the drugs carry a "black-box warning."
Overall, however, the drugs have been celebrated as "remarkably safe and effective" for most people who use them, according to the Harvard Mental Health Letter. But not everyone who uses them needs them; some researchers believe that only 20 percent of depression may be the result of chemical malfunction since up to 80 percent of depressive events occur in the wake of a major life event.
In cases of like these, depression may be an appropriate and temporary response to a traumatic event such as a death or divorce.
Jim Ellor, a Presbyterian minister and professor of social work at Baylor University in Texas, said it's actually better for people to get through the early stages after trauma or grief without medicine. "They sort of need to go through it," he said.
And Dr. Howard Weeks, an associate professor of child and adolescent psychiatry at the University of Utah School of Medicine and past president of the Utah Psychiatric Association, said, “Taking anything you don’t really need isn’t a good idea, whether it’s Tylenol or Motrin or whatever."
“America as a whole has a tendency to want to use a medication to fix something; that’s one of the reasons we’re getting all these ‘superbugs.’ This also applies to mental-health issues. It’s easier to say, ‘I’m taking a pill. I’m doing something about it.’
"Therapy’s harder than taking a pill,” he said.
Does depression help us think?
Paul Andrews, who teaches evolutionary psychology at McMaster University in Ontario, earned degrees in law, aerospace engineering and evolutionary biology before he began studying the effects of the SSRIs.
In recent years, he has co-authored four studies on the subject, including one that challenged the common understanding of how the drugs work and another that posited that depression is a useful, even necessary, adaptation of evolution.
“We now know that a sad, depressed mood promotes an analytical processing style. When depression is caused by major stressors — your husband is having an affair and wants to divorce you, you’re having a conflict with your parents — your depression is trying to help you think your way through it by analyzing the problem,” Andrews said.
“I don’t mean to say all depressive episodes are adaptive. Our bodies are composed of all these evolved organs, and they can all malfunction. But how often does that occur? Our best evidence says that it’s rare, that most episodes that currently meet the diagnostic criteria (for depression) are responses to stressors,” Andrews said.
In his work, Andrews argues for diminished use of SSRIs because of the effects on the body unrelated to the brain; serotonin levels also affect digestion and blood clotting, among other functions, and he says antidepressants "degrade the overall functioning of the body."
Another study published last year said the medications simply don't work, at least not for children.
A bottle of Eli Lilly & Co.'s Prozac at a company facility in Plainfield, Ind. | Darron Cummings, Associated Press
In that study, published in the medical journal The Lancet, researchers analyzed the outcomes of 34 clinical trials involving 5,260 children and teens. Out of 14 antidepressants they took, only one, fluoxetine (better known to consumers as Prozac) outperformed placebos.
For adults, if antidepressants don't work, one reason could be that they're not addressing the problem, which could be spiritual in nature, said Thomas Moore, a former monk and the author of "Dark Nights of the Soul" and other books on spirituality.
Moore, who lives in New Hampshire and often speaks to medical providers about the need for a spiritual component in health care, likens a clinical depression to a black mood, while a "dark night" — the sort of spiritual travail experienced by Mother Teresa or St. John of the Cross — is more gray.
"It's the sense that the meaning of life has gone away, and there's no sense of purpose. If it touches the meaning of your life, you need a more spiritual response," he said.
A darkness no one else can see
Depression is different from St. John's dark night, which is "the experience of spiritual dryness, even desolation, when the traditional props and practices we use simply do not work," said Gerald L. Sittser, who sank into a debilitating depression a year after surviving a fatal auto accident that killed his wife, daughter and mother.
"It took Herculean strength for me to get out of bed in the morning. I was fatigued all day long, yet at night I was sleepless. I would lie awake by the hour, feeling the torment of a darkness that no one could see but me. I had trouble concentrating. I was apathetic and desireless. I could not taste food, see beauty or touch anything with pleasure," Sittser wrote in his book "A Grace Disguised."
Sittser, now 66 and a professor of theology at Whitworth University in Spokane, Washington, eventually clawed out of the depths of depression with the help of a counselor and a low-dose antidepressant that he took for about six months. "It took the edge off the severity of my loss so that I could function, especially as a father, though in the end my kids and their needs was the best medicine for me," he said in an email.
In 2013, a survey by LifeWay Research, which is affiliated with the Southern Baptist Convention, found that half of evangelical Christians believed that mental disorders like depression can be vanquished by prayer and Bible study. At the time, LifeWay's Ed Stetzer expressed concern that some people see mental illness as a character flaw rather than a medical condition.
While some religious groups have seen depression as a natural consequence of sin, others have viewed it as an important spiritual journey, one that St. John of the Cross said "is not something that happens to spiritual beginners," wrote Tim Farrington in his meditation on depression, "A Hell of Mercy."
Farrington, a 59-year-old novelist who lives in Virginia, first experienced depression as a teenager. A Roman Catholic who studied Buddhism and spent two years at a California ashram, Farrington at first assigned his depression to spiritual causes, but finally found relief in medication, which he continues to take after 16 years. Its main purpose, he says, is to keep him alive.
If there are physical repercussions down the line, he'd still rather be damaged than dead, Farrington said. "You can have your dark night of the soul, but you have to be alive," he said. "Job one is staying alive."
Moore recommends that people who think they are seriously depressed see both a doctor and a spiritual leader.
Although he comes at it differently than Andrews, the researcher in Ontario, Moore shares the evolutionary psychologist's belief that depression can be an important period of growth in some people.
"When you feel melancholy, that generic sadness, it can age you in a good sense. A lot of Americans today are younger than they should be; they don't take their lives seriously enough, and then they're shocked when something really bad happens," he said. If people can patiently ride out their dark night, which can take weeks or years, many can get through it without medication, and "people have a much richer life when they've gone through it."
In fact, most depressive events resolve without any treatment at all, according to a report published in Nature Reviews Neuroscience.
That said, Moore does not discount the need for the medical treatment in severe cases such as Merkin's. And persistant dysfunction — the inability to function at the most basic level at home or work — is a sign that medical treatment might be necessary, Ellor, of Baylor University, said.
“There are still faith communities that will say all one needs is God. I would affirm, as a pastor, that everyone needs God, but there are other professionals that can be helpful to them,” Ellor said.
How to help yourself and others
Hospitalized four times for depression that menaced her through adolescence, young adulthood and middle age, Merkin, 62, believes severe depression is likely caused by both "biological predisposition and psychological triggers."
“It’s sometimes difficult to pick up on severe depression because it masks itself. Depression is not noisy,” she said.
With depression on the rise, especially in teenagers, she has advice for any parents wondering whether the behavior they see is the passing angst of adolescence or something more serious. Keep a vigilant eye on a teen who seems withdrawn and quiet to a troubling degree, appears to have no energy for social activities or school, and constantly isolates his or herself.
Moodiness comes and goes; depression persists. A person struggling with depression doesn't need platitudes or a pep talk, but someone who understands the seriousness of the condition, Merkin said. A gentle suggestion — such as "Would you consider seeing a doctor or taking medication?" — can be helpful, as well as offering to help the depressed person find a doctor and get to an appointment.
"It's important, I think, not to blame the sufferer or make light of his or her suffering by saying things like 'You can pull out of it' or 'Can't you make more of an effort?'" she said.
Depression is both paralyzing and isolating, and chances are, the sufferer has already blamed himself.
“Depressed people turn on themselves very badly; they don’t give themselves a generous hearing. It helps if someone else extends that generosity to you," she said.
Farrington agreed, noting that in the Bible, Job’s friends didn’t provide the most famous of sufferers much help.
“Try, if possible, to keep the pressure off,” he said. “A depressed person has pressure enough. They know they’re not up to speed; they know what they ‘Should Be Doing.’
“To the extent that you can be with them without needing them to be different is a pure gift. Which is the hardest thing you can do for another: to be with them nonjudgmentally.”