Depression and Cognitive Behavioural Therapy

by Chris Williams and Ben Wiffen


At any one time, one in six people in the UK struggle with a mental health problem, and one in four will be unwell over the course of a year.1 Overall, around one in three GP consultations involves mental health problems in some way.2 Depression is the most common of these, with between 8% and 12% of the population meeting diagnostic criteria for depression in the course of a year.3 Anxiety disorders are also common, and individuals regularly present with a mixture of low mood and anxiety.


These common mental health conditions have a significant impact on the lives of those who experience them. Whilst many manage to hold down jobs and maintain a high level of functioning, many others may experience difficulty in staying at work, maintaining relationships and in family life.

What is a Depressive Disorder?
All of us can feel sad or low in mood from time to time. Usually such changes are in response to external events, and low mood improves quickly. It is when symptoms worsen and last for a significant time that a diagnosis of a depressive disorder is made. The criteria for this diagnosis are outlined i Box 1.

Changes in thinking are common, with the person with depression adopting negative views of themselves, their situation and of the future – Beck’s so-called negative cognitive triad.5 Another distressing feature is hopelessness, which is the strongest predictor of suicide. Engagement in activity is often affected with reduced activity and increased avoidance.

BOX 1: DIAGNOSTIC CRITERIA FOR MAJOR DEPRESSIVE DISORDER FROM THE DSM-IV4

  • Depressed mood or a loss of interest or pleasure in daily activities for more than two weeks
  • Mood represents a change from the person’s baseline
  • Impaired function: social, occupational, educational
  • Specific symptoms, at least five of these nine, present nearly every day:
    1. Depressed mood or irritable most of the day, nearly every day, as indicated by either subjective report (eg feels sad or empty) or observation made by others (eg appears tearful)
    2. Decreased interest or pleasure in most activities, most of each day
    3. Significant wight change (5%) or change in appetite
    4. Change in sleep: insomnia or hypersomnia
    5. Change in activity: Psychomotor agitation or retardation
    6. Fatigue or loss of energy
    7. Guilt/worthlessness: Feelings of worthlessness or excessive or inappropriate guilt
    8. Concentration: diminished ability to think or concentrate, or more indecisiveness
    9. Suicidality: Thoughts of death or suicide, or has suicide plan

The Causes of Depression
A range of factors can be involved in the aetiology of depression. Stressful life events (especially around bereavement, debt, relationship issues or unemployment) are a causal factor of some. Physical illness (such as ischaemic heart disease, stroke, diabetes, thyroid problems, folic acid/vitamin B12 deficiency and cancer) may also lead to depression in others. Other background factors which may be related include a genetic predisposition, personality, upbringing and earlier life events, loneliness, lack of access to support, alcohol and drug, though this is far from an exhaustive list.

In reality, a combination of interacting factors tends to be involved, which can often be best combined in a psychological ‘formulation’. This attempts to summarise the core problems, and brings together how they relate to each other. A formulation should also look at what factors have contributed to the problem in the first place, have kept symptoms going, and point to interventions based on this assessment. This approach allows a more nuanced and relevant understanding of a person’s situation and difficulties than a single diagnostic statement would allow.

How do Christian Faith and Depression Interact?
Christians are not immune from depression and anxiety. There are a number of interactions between the two, and many studies have investigated the extent to which religious belief correlates with various mental health problems.6

On the one hand, for those struggling with depression, faith can be a source of great support offering hope, comfort and purpose in suffering, social support and regular activity. Some may take comfort in God’s promises from the Bible, and prayer may feel like a valued opportunity to communicate with someone who truly loves and understands them.

However, for others, there can be a perception within Christian settings that one should present as unwavering happiness, or a need to present oneself oneself as ‘fine’ and without problems. Indeed, to some people, in spite of the lessons of the Bible (eg the book of Job, many of the Psalms and the life of Jesus and the apostles), it may feel as though admitting that one is sad or scared may be seen as an indicator of weakness of faith, or a lack of prayer. Some may have been told this by Christians around them.

In such circumstances, faith can have a negative effect on depression, as not only are people experiencing depression, but they are also made to believe that their depression is in some sense their own fault, a weakness in their faith, or a result of specific sins in their life. Whilst specific sins may indeed be present and activities that are worsening the situation can be tackled, a key element in resolving the person’s situation is an understanding of the abiding love and forgiveness of the God of grace. Sometimes false guilt can occur, where the person condemns themselves for small failures that do not reflect objectively present sin.

There may also be other specific parts of Christian life that are affected by depression, and cycles that Christians could find themselves in. For example, the person may may lack the motivation or concentration to pray, or complete personal Bible study. Struggling with these things may lead a Christian to feel that he or she is failing in their faith or is not ‘good enough’ as a Christian, leading to a further reduction in their mood. A vicious circle is formed.

A Christian with depression may find there are specific hurdles associated with church attendance. Some typical examples might include a perceived expectation to chat to others after the service. They might wrongly anticipate the thoughts of others, with unhelpful predictions such as ‘they’ll know I’ve not been for a couple of weeks – they’ll think I’m a bad Christians’ or a ‘catastrophising’ think style with a thought like, ‘I might start crying, and everyone will look at me and think I’m crazy’. Consequently, a Christian may avoid going to church altogether, thus forfeiting the potential social and spiritual support this could provide.

Christians may also think that their depression may require a different treatment approach than what someone who is not a Christian may require. Sometimes Christians believe that a secular health profession would not understand the specific challenges that a Christian might face, particularly when core symptoms may relate to feeling distant from God or unable to pray. Consequently, they may tend to seek Christian support for their depression rather than consulting a secular health professional. Many church leaders and members may be equipped to support someone with depression, but it is likely that the majority have not had specialist training in this area. Consequently, the depressed Christian may miss out on receiving an evidence-based intervention such as antidepressant or talking therapies that could benefit them. All accredited CBT practitioners should respect and work with the beliefs of their clients.


continued…
Read more: to part 2


Christian Medical Fellowship (CMF) Files No. 53, 2014